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

OBJECTIVES: Restrictive eating disorders (EDs) occur across the weight spectrum, but historically more focus has been given to anorexia nervosa (AN) than atypical anorexia nervosa (atypAN). AtypAN's relegation to a diagnosis in the "other specified feeding and eating disorder" (OSFED) category and paucity of research surrounding atypAN invariably implies a less clinically severe ED. However, a growing body of research has begun to question the assumption that atypAN is less severe than AN. The current review and meta-analysis aimed to provide a comprehensive review to compare atypAN and AN on measures of eating disorder psychopathology, impairment, and symptom frequency to test whether atypAN is truly less clinically severe than AN. METHODS: Twenty articles that reported on atypAN and AN for at least one of the variables of interest were retrieved from PsycInfo, PubMed, and ProQuest. RESULTS: For eating-disorder psychopathology, results indicated that differences were nonsignificant for most indicators; however, atypAN was associated with significantly higher shape concern, weight concern, drive for thinness, body dissatisfaction, and overall eating-disorder psychopathology than AN. Results indicated that atypAN and AN did not significantly differ on clinical impairment or the frequency of inappropriate compensatory behaviors, whereas there was a significantly higher frequency of objective binge episodes in AN (vs. atypAN). DISCUSSION: Overall, findings indicated that, in contrast to the current classification system, atypAN and AN were not clinically distinct. Results underscore the need for equal access to treatment and equal insurance coverage for restrictive EDs across the weight spectrum. PUBLIC SIGNIFICANCE: The current meta-analysis found that atypAN was associated with higher drive for thinness, body dissatisfaction, shape concern, weight concern, and overall eating-disorder psychopathology than AN; whereas AN was associated with higher frequency of objective binge eating. Individuals with AN and atypAN did not differ on psychiatric impairment, quality-of-life, or frequency of compensatory behaviors, highlighting the need for equal access to care for restrictive EDs across the weight spectrum.

OBJETIVO: Los trastornos alimentarios restrictivos ocurren en todo el espectro de peso, pero históricamente se ha dado más importancia a la anorexia nerviosa (AN) que a la anorexia nerviosa atípica (ANA). El hecho de relegar la anorexia nerviosa atípica a un diagnóstico en la categoría de "otro trastorno de la ingestión de alimentos y de la conducta alimentaria" (OSFED) y la escasez de investigación en torno a la anorexia atípica, implica invariablemente un trastorno de la conducta alimentaria clínicamente menos grave. Sin embargo, un creciente cuerpo de investigación ha comenzado a cuestionar la suposición de que ANA es menos grave que AN. La revisión actual y el metanálisis tuvieron como objetivo proporcionar una revisión exhaustiva para comparar ANA y AN en las medidas de psicopatología de los trastornos alimentarios, el deterioro y la frecuencia de los síntomas para probar si ANA es realmente menos grave clínicamente que AN. MÉTODO: Veinte artículos que informaron sobre ANA y AN para al menos una de las variables de interés se recuperaron de PsycInfo, PubMed y ProQuest. RESULTADOS: Para la psicopatología del trastorno alimentario, los resultados indicaron que las diferencias no fueron significativas para la mayoría de los indicadores; sin embargo, ANA se asoció con una preocupación de forma significativamente mayor, preocupación por el peso, impulso por la delgadez, insatisfacción corporal y psicopatología general del trastorno alimentario que AN. Los resultados indicaron que ANA y AN no difirieron significativamente en el deterioro clínico o la frecuencia de comportamientos compensatorios inapropiados, mientras que hubo una frecuencia significativamente mayor de episodios de atracones objetivos en AN (frente a ANA). DISCUSIÓN: En general, los hallazgos indicaron que, en contraste con el sistema de clasificación actual, ANA y AN no eran clínicamente distintos. Los resultados subrayan la necesidad de un acceso equitativo al tratamiento y una cobertura de seguro igual para los trastornos de la conducta alimentaria restrictivos en todo el espectro de peso.

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

OBJECTIVE: The association between eating disorders (EDs) and harmful substance use (substance use that causes psychosocial impairment) is well recognized in the literature, and military veterans may be at heightened risk for both issues due to deployment-related stressors. However, little is known about which ED-related symptoms are associated with harmful substance use in veterans, and whether gender plays a differential role in this relationship. Our aims were to: (1) examine gender differences in ED-related symptoms; and (2) examine whether ED-related symptoms differentially predict harmful substance use in US veteran men and women who had recently separated from service. METHOD: This study was based on a nationally representative four-wave longitudinal sample of post-9/11 veterans (N = 835; 61.2% female). Longitudinal mixed modeling was used to test whether specific ED-related behaviors at baseline predicted harmful substance use at follow-ups. RESULTS: We replicated gendered patterns of ED-related symptoms observed in civilian populations, wherein men had higher weight-and-body-related concerns (including excessive exercise and muscle building) and negative attitude toward obesity, and women had higher bulimic and restricting symptoms. For women, alcohol, drug, and marijuana problems were predicted by higher bulimic symptoms, whereas for men, these problems were predicted by higher restricting symptoms. CONCLUSION: Gender played a differential role in the relationship between EDs and harmful substance use. Bulimic symptoms were the most robust predictor for harmful substance use among veteran women, whereas restricting was the most robust predictor for harmful substance use among veteran men. PUBLIC SIGNIFICANCE: The current study found that veteran women had higher bulimic symptoms (characterized by binge eating and purging) and restricting than veteran men. In women, bulimic symptoms predicted future harmful use of alcohol, marijuana, and other drugs. In contrast, veteran men had higher weight-and-body-related concerns (characterized by excessive exercise and muscle building) than veteran women. In men, restricting symptoms predicted future harmful use of alcohol, marijuana, and other drugs.

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

OBJECTIVE: There is a lack of consensus in defining "significant weight loss" when diagnosing atypical anorexia nervosa (atypical AN) and no guidelines exist for setting target weight (TW). The current study aimed to identify community providers' practices related to the diagnosis of atypical AN and the determination of TW. A secondary aim was to evaluate whether professional discipline impacted "significant weight loss" definitions. METHOD: A variety of providers (N = 141; 96.4% female) completed an online survey pertaining to diagnostic and treatment practices with atypical AN. Descriptive statistics were computed to characterize provider-based practices and Fisher's exact tests were used to test for differences in diagnostic practices by professional discipline. Thematic analysis was used to examine open-ended questions. RESULTS: Most (63.97%) providers diagnosed atypical AN in the absence of any weight loss if other AN criteria were met, but doctoral-level psychologists and medical professionals were less likely to do so compared to nutritional or other mental health professionals. Most providers found weight gain was only sometimes necessary for atypical AN recovery. Qualitative responses revealed providers found atypical AN to be a stigmatizing label that was not taken seriously. Providers preferred to use an individualized approach focused on behaviors, rather than weight when diagnosing and treating atypical AN. DISCUSSION: Lack of diagnostic clarity and concrete treatment guidelines for atypical AN may result in substantial deviations from the DSM-5-TR criteria in real-world practice. Clinically useful diagnostic definitions for restrictive eating disorders and evidence-based treatment guidelines for TW and/or other relevant recovery metrics are needed. PUBLIC SIGNIFICANCE: The current study found variability in how community providers diagnose and determine target recovery weight for atypical anorexia nervosa (atypical AN). Many providers viewed the diagnosis of atypical AN as stigmatizing and preferred to focus on behaviors, rather than weight. This study underscores the importance of creating a clinically useful diagnostic definition and guidelines for recovery for atypical AN backed by empirical evidence that providers may implement in practice.

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

OBJECTIVE: Eating disorders (EDs) are serious psychiatric disorders associated with substantial morbidity and mortality that are prevalent among university students. Because many students do not receive treatment due to lack of access on university campuses, mobile-health (mHealth) adaptations of evidence-based treatments represent an opportunity to increase treatment accessibility and engagement. The purpose of this study was to test the initial efficacy of Building Healthy Eating and Self-Esteem Together for University Students (BEST-U), which is a 10-week mHealth self-guided cognitive-behavioral therapy (CBT-gsh) app that is paired with a brief 25-30-min weekly telehealth coaching, for reducing ED psychopathology in university students. METHOD: A non-concurrent multiple-baseline design (N = 8) was used to test the efficacy of BEST-U for reducing total ED psychopathology (primary outcome), ED-related behaviors and cognitions (secondary outcomes), and ED-related clinical impairment (secondary outcome). Data were examined using visual analysis and Tau-BC effect-size calculations. RESULTS: BEST-U significantly reduced total ED psychopathology and binge eating, excessive exercise, and restriction (effect sizes ranged from -0.39 to -0.92). Although body dissatisfaction decreased, it was not significant. There were insufficient numbers of participants engaging in purging to evaluate purging outcomes. Clinical impairment significantly reduced from pre-to-post-treatment. DISCUSSION: The current study provided initial evidence that BEST-U is a potentially efficacious treatment for reducing ED symptoms and ED-related clinical impairment. Although larger-scale randomized controlled trials are needed, BEST-U may represent an innovative, scalable tool that could reach greater numbers of underserved university students than traditional intervention-delivery models. PUBLIC SIGNIFICANCE: Using a single-case experimental design, we found evidence for the initial efficacy of a mobile guided-self-help cognitive-behavioral therapy program for university students with non-low weight binge-spectrum eating disorders. Participants reported significant reductions in ED symptoms and impairment after completion of the 10-week program. Guided self-help programs show promise for filling an important need for treatment among university students with an ED.

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

OBJECTIVE: The general understanding of disorders related to chronic somatic symptoms (e.g., somatic symptom disorder, functional somatic syndromes) is limited because of current categorical conceptualizations in traditional taxonomies. To improve clinical utility and validity, the Hierarchical Taxonomy of Psychopathology offers an empirically grounded dimensional approach. Therefore, the distribution of persistent somatic symptom distress observed in nature is highly relevant for informing decisions related to classification and treatment. This study analyzes the underlying structure of symptoms associated with the somatoform spectrum. METHOD: Taxometric analyses were used to examine the latent status of the somatoform spectrum, which was measured via a dimensional questionnaire devised as part of the Hierarchical Taxonomy of Psychopathology scale development effort. We generated Comparison Curve Fit Index (CCFI) profile analyses across a clinical sample of psychotherapy outpatients ( n = 487), a community sample of German adults ( n = 451), and a student sample from New Zealand ( n = 549). RESULTS: In the clinical sample (CCFI mean = 0.38) and in the student sample (CCFI mean = 0.36), a dimensional solution was clearly favored. Results in the community sample (CCFI mean = 0.51) were ambiguous. CONCLUSIONS: Across the three independent samples, qualitatively distinct subgroups within the distribution of chronic somatic symptoms could not be identified. Therefore, continuous representations seemed to best represent the structure of somatic symptoms. Implications of these findings for etiology and treatment are discussed.

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

OBJECTIVE: Latines have higher rates of eating disorders characterized by binge eating compared to their non-Latine white counterparts, yet culturally and socially relevant factors related to binge eating in Latines have been largely understudied. The purpose of the current study was to examine how discrimination and acculturative stress were associated with binge eating in a nationally representative sample of Latines. An additional aim was to test the extent to which family cohesion and social support could buffer against the effects of discrimination and acculturative stress on binge eating. METHOD: Participants (56% female, N = 2550) were Latines enrolled in the National Latino and Asian American Study. Structural equation modeling using 1000 re-sampled data sets built from machine learning iterative sampling procedures was used to examine the effects of discrimination, acculturative stress, family cohesion, and social support on binge eating. RESULTS: Results indicated that only discrimination was significantly associated with binge eating. Neither the direct effect of acculturative stress, interaction of family cohesion and acculturative stress, interaction of social cohesion and acculturative stress, nor the interaction of social support and discrimination were significantly associated with binge eating. DISCUSSION: This study highlights the need for mental-health providers to understand and assess discrimination among Latines presenting with concerns of binge eating. Treatments that effectively provide coping strategies to manage discriminatory experiences and reduce binge eating could improve both effectiveness of treatment and retention rates for Latine individuals with binge eating. PUBLIC SIGNIFICANCE: This study examined the association of discrimination, acculturative stress, family cohesion, and social support with binge eating in Latines. Only discrimination was significantly associated with binge eating, highlighting the importance for providers to assess discrimination among Latines with binge-eating concerns and to improve equity, inclusion, and belonging at a societal level. Modifying existing treatments to address coping with discrimination could improve the effectiveness for Latines with binge-eating concerns.

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

OBJECTIVE: The study aim was to elucidate the degree to which hyper-palatable foods (HPF) are consumed during binge episodes compared to restricting episodes, and to test the association between HPF intake during each episode and respective episode frequency. METHOD: This study was a secondary analysis of data from a larger study on eating disorders. The present sample included adults (N = 147, 83% women) diagnosed with sub-threshold (41%) or full-threshold (59%) bulimia nervosa (BN). Foods consumed during binge and restricting episodes were assessed using the Eating Pathology Symptoms Inventory-Clinician Rated Version. A standardized definition of HPF developed previously was applied to foods consumed during binge and restricting episodes. A Wilcoxon matched-pairs signed-rank test was used to test the difference between total caloric intake from HPF (KcalHPF) and percentage of caloric intake from HPF (PercHPF) during binge episodes relative to restricting episodes. Four linear regression models tested HPF intake (KcalHPF and PercHPF) during both episode types (binge and restricting) as predictors of respective episode frequency. RESULTS: There was a significant difference between median KcalHPF (1846.6 vs. 279.6; Z = -13.38, p < .001) and PercHPF during binge compared to restricting episodes (95% vs. 61%; Z = -7.35, p < .001). Regression analyses demonstrated that KcalHPF during binge episodes was significantly associated with binge episode frequency (B = 0.002; p < .001), but not PercHPF (p = .287). DISCUSSION: Results suggest that HPF may be primarily consumed during binge episodes among individuals with BN, and may be associated with greater binge-eating frequency. PUBLIC SIGNIFICANCE: Findings from the current study support an underlying assumption of theoretical models of binge eating, suggesting that highly rewarding, hyper-palatable foods (HPF), may constitute the vast majority of energy intake during binge-eating episodes. Additionally, a substantial amount of energy intake from HPF may occur during restricting episodes among people with bulimia nervosa. Greater HPF intake during binge eating may also be associated with binge-eating severity.

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

OBJECTIVE: There is ongoing discussion about whether sports participation is a risk or protective factor for eating disorders (EDs). Research is mixed, with some studies suggesting that athletes have higher mean levels of ED psychopathology compared to nonathletes, while other studies suggest the opposite effect or no differences. The purpose of the current meta-analysis was to identify whether female athletes reported higher mean levels of ED psychopathology compared to nonathletes. METHOD: Following PRISMA guidelines, we identified 56 studies that reported ED psychopathology for female athletes and nonathletes. A three-level random-effects model of between- and within-study variance was completed for the following outcome variables: overall ED psychopathology, body dissatisfaction, drive for thinness, restricting, and loss-of-control eating. RESULTS: Athletes reported lower levels of body dissatisfaction compared to nonathletes (g = -.21, p < .0001). Athletes and nonathletes reported similar levels of overall ED psychopathology, drive for thinness, restricting, and loss-of-control eating on average. Sport type significantly moderated standardized mean difference effect sizes of ED psychopathology in athletes versus nonathletes. Effect sizes comparing levels of drive for thinness, restricting, and loss-of-control eating in athletes versus nonathletes were larger for studies with athletes participating in aesthetic/lean sports compared to nonaesthetic/nonlean sports. DISCUSSION: Findings from this meta-analysis could inform future ED prevention and treatment in female athletes by providing further evidence that athletes in aesthetic/lean sports may report higher levels of ED psychopathology. Participating in nonaesthetic/nonlean sports may be a protective factor for experiencing less body dissatisfaction. PUBLIC SIGNIFICANCE STATEMENT: The current meta-analysis summarized findings from 56 studies that assessed levels of disordered eating, body dissatisfaction, dietary restricting, and loss-of-control eating in female athletes and nonathletes. Athletes reported lower levels of body dissatisfaction compared to nonathletes, highlighting that participation in sport could have some protective factors. Athletes participating in sports that require weight categories (e.g., judo) and sports that emphasize thinness/leanness (e.g., gymnastics and distance running) had higher levels of disordered eating relative to athletes participating in other types of sports that do not emphasize thinness/leanness (e.g., volleyball and basketball).

OBJETIVO: Existe un debate abierto sobre si la participación en los deportes es un factor de riesgo o protector para los trastornos de la conducta alimentaria (TCA). La investigación es mixta, con algunos estudios que sugieren que los atletas tienen niveles medios más altos de psicopatología de TCA en comparación con los no atletas, mientras que otros estudios sugieren el efecto opuesto o ninguna diferencia. El propósito del presente metanálisis fue identificar si las atletas femeninas reportaron niveles medios más altos de psicopatología de TCA en comparación con las no atletas. MÉTODO: Siguiendo las guías PRISMA, se identificaron 56 estudios que informaron psicopatología de TCA para atletas femeninas y no atletas. Se completó un modelo de efectos aleatorios de tres niveles de varianza entre y dentro del estudio para las siguientes variables de resultado: psicopatología general de TCA, insatisfacción corporal, impulso por la delgadez, restricción y pérdida de control de la alimentación. RESULTADOS: Las atletas reportaron niveles más bajos de insatisfacción corporal en comparación con las no atletas (g = -.21, p <.0001). Las atletas y las no atletas reportaron niveles similares de psicopatología general de TCA, impulso por la delgadez, restricción y pérdida de control de la alimentación en promedio. El tipo de deporte moderó significativamente los tamaños del efecto de la diferencia de medias estandarizada de la psicopatología de TCA en atletas versus no atletas. Los tamaños del efecto que compararon los niveles de impulso por la delgadez, la restricción y la pérdida de control de la alimentación en atletas versus no atletas fueron mayores para los estudios con atletas que participaron en deportes que valoran lo estético/cuerpo magro, esbelto, en comparación con deportes que no valoran lo estético/cuerpo magro, esbelto. DISCUSIÓN: Los hallazgos de este metanálisis podrían informar la prevención y el tratamiento futuros de los TCA en atletas femeninas al proporcionar más evidencia de que las atletas en deportes que dan un gran valor a lo estético o al cuerpo magro, esbelto, pueden reportar niveles más altos de psicopatología de TCA. Participar en deportes que no dan valor a lo estético o al cuerpo magro, puede ser un factor protector para experimentar menos insatisfacción corporal.

Generalized network psychometrics of eating-disorder psychopathology.

OBJECTIVE: As network models of eating disorder (ED) psychopathology become increasingly popular in modeling symptom interconnectedness and identifying potential treatment targets, it is necessary to contextualize their performance against other methods of modeling ED psychopathology and to evaluate potential ways to optimize and capitalize on their use. To accomplish these goals, we used generalized network psychometrics to estimate and compare latent variable models and network models, as well as hybrid models. METHOD: We tested the structure of the Eating Pathology Symptoms Inventory (EPSI) and Eating Disorder Examination-Questionnaire (EDE-Q) in Recovery Record, Inc. mobile phone application users (N = 6856). RESULTS: Although all models fit well, results favored a hybrid latent variable and network framework, which showed that ED symptoms fit best when modeled as higher-order constructs, rather than direct symptom-to-symptom connections, and when the relationships between those constructs are described as a network. Hybrid models in which latent factors were modeled as nodes within a network showed that EPSI Purging, Binge Eating, Cognitive Restraint, Body Dissatisfaction, and Excessive Exercise had high importance in the network. EDE-Q Eating Concern and Shape Concern were also important nodes. Results showed that the EPSI network was highly stable and replicable, whereas the EDE-Q network was not. DISCUSSION: Integrating latent variable and network model frameworks enables tests of centrality to identify important latent variables, such as purging, that may promote the spread of ED psychopathology throughout a network, allowing for the identification of future treatment targets.

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

OBJECTIVE: There are limited data to guide the interpretation of scores on measures of eating-disorder psychopathology among underrepresented individuals. We aimed to provide norms for the Eating Disorder Examination-Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA) across racial/ethnic, gender, and sexual identities, and sexual orientations and their intersections by recruiting a diverse sample of Amazon MTurk workers (MTurkers; N = 1782). METHOD: We created a comprehensive, quantitative assessment of racial/ethnic identification, gender identification, sex assigned at birth, current sexual identification, and sexual orientation called the Demographic Assessment of Racial, Sexual, and Gender Identities (DARSGI). We calculated normative data for each demographic category response option. RESULTS: Our sample was comprised of 68% underrepresented racial/ethnic identities, 42% underrepresented gender identities, 13% underrepresented sexes, and 49% underrepresented sexual orientations. We reported means and standard deviations for each demographic category response option and, where possible, mean estimates by percentile across intersectional groups. EDE-Q Global Score for a subset of identities and intersections in the current study were higher than previously reported norms for those identities/intersections. DISCUSSION: This is the most thorough reporting of norms for the EDE-Q and CIA among racial/ethnic, sexual, and gender identities, and sexual orientations and the first reporting on multiple intersections, filling some of the gaps for commonly used measures of eating-disorder psychopathology. These norms may be used to contextualize eating-disorder psychopathology reported by underrepresented individuals. The data from the current study may help inform research on the prevention and treatment of eating-disorder psychopathology in underrepresented groups. PUBLIC SIGNIFICANCE: We provide the most thorough reporting on racial/ethnic, sexual, and gender identities, and sexual orientations for the Eating Disorder Examination - Questionnaire and Clinical Impairment Assessment, and the first reporting on intersections, which fills some of the gaps for commonly used measures of eating-disorder psychopathology. These norms help inform research on the prevention and treatment of eating-disorder psychopathology in underrepresented groups.

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

Given that eating disorders (EDs) are relatively common in college populations, it is important to have reliable and valid tools to identify students so that they can be referred to evidence-based care. Although research supports the psychometric properties of existing ED screens for identifying cases of EDs, most studies have been conducted in samples of young white-majority women or have not reported the psychometric properties of the screening tool in men. OBJECTIVE: The purpose of the current study was to validate a brief, 10-item screening tool for the identification of EDs-the brief assessment of stress and eating (BASE). METHOD: Participants were college students (N = 596; 68.2% cisgender women) from a large Midwestern university who completed the BASE and SCOFF. The Eating Disorders Diagnostic Survey was used to generate DSM-5 ED diagnoses. We evaluated area under the curve (AUC) for both receiver operating curves (ROC) and precision-recall curves (PRC). RESULTS: Both the BASE and SCOFF performed significantly better than chance at identifying probable EDs in cisgender women (BASE AUC: ROC = .787, PRC = .633, sensitivity = .733, specificity = .697; SCOFF AUC: ROC = .810, PRC = .684, sensitivity = .793, specificity = .701). However, the BASE (AUC: ROC = .821, PRC = .605, sensitivity = .966, specificity = .495) significantly outperformed the SCOFF (AUC: ROC = .710, PRC = .354, sensitivity = .828, specificity = .514) for identifying probable EDs in cisgender college men. DISCUSSION: The BASE is appropriate for student healthcare and college research settings. Because the BASE outperforms the SCOFF in college men, results from the current study are expected to contribute to improved identification of EDs on college campuses. PUBLIC SIGNIFICANCE: The BASE is a new screening tool to identify eating disorders. The BASE performed as well as, if not better than, the SCOFF (particularly in men). Given the need for brief, psychometrically strong, and unbiased ED screening tools in college students, the current study helps address an unmet student healthcare need that we expect will contribute to improved identification of EDs on college campuses.

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

PURPOSE: Emotion regulation (ER) refers to the processes by which individuals influence the onset, intensity, and duration of emotions. Previous studies have examined the effects of adaptive ER and maladaptive ER in isolation, but growing evidence suggests that they should be studied in conjunction. This study examined the interactions between habitual adaptive and maladaptive ER strategies with eating disorder (ED) symptoms and ED-related clinical impairment. METHODS: Students (N = 1377) from a Midwestern American university reported ED symptoms, ED-related impairment, habitual adaptive ER (i.e., cognitive reappraisal), and habitual maladaptive ER (i.e., distraction and suppression). Multiple linear regressions were conducted using the PROCESS v3 macro. RESULTS: The study found that adaptive ER was negatively associated with ED symptoms and ED-related impairment, whereas maladaptive ER was positively associated with both outcome variables. Adaptive ER moderated the association between maladaptive ER and ED symptoms, but not clinical impairment. When habitual adaptive ER was low (< 33.4th percentile), there was no association between maladaptive ER and ED symptoms; however, when habitual adaptive ER was moderate to high (> 33.4th percentile), there was a positive association between frequency of maladaptive ER use and ED symptoms. There was no significant three-way interaction among adaptive ER, maladaptive ER, and probable ED diagnosis, for ED-related impairment or symptoms. CONCLUSION: Results suggest that irrespective of frequency of maladaptive ER, people with low adaptive ER reported elevated psychopathology. Findings point to the utility of interventions to reduce maladaptive ER and increase adaptive ER in ED populations. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

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

BACKGROUND: In the past decade, network analysis (NA) has been applied to psychopathology to quantify complex symptom relationships. This statistical technique has demonstrated much promise, as it provides researchers the ability to identify relationships across many symptoms in one model and can identify central symptoms that may predict important clinical outcomes. However, network models are highly influenced by node selection, which could limit the generalizability of findings. The current study (N = 6850) tests a comprehensive, cognitive-behavioral model of eating-disorder symptoms using items from two, widely used measures (Eating Disorder Examination Questionnaire and Eating Pathology Symptoms Inventory). METHODS: We used NA to identify central symptoms and compared networks across the duration of illness (DOI), as chronicity is one of the only known predictors of poor outcome in eating disorders (EDs). RESULTS: Our results suggest that eating when not hungry and feeling fat were the most central symptoms across groups. There were no significant differences in network structure across DOI, meaning the connections between symptoms remained relatively consistent. However, differences emerged in central symptoms, such that cognitive symptoms related to overvaluation of weight/shape were central in individuals with shorter DOI, and behavioral central symptoms emerged more in medium and long DOI. CONCLUSIONS: Our results have important implications for the treatment of individuals with enduring EDs, as they may have a different core, maintaining symptoms. Additionally, our findings highlight the importance of using comprehensive, theoretically- or empirically-derived models for NA.

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

OBJECTIVE: The purpose of this trial is to evaluate the novel use of an empirically supported treatment for sleep problems for people with residual insomnia disorder following ED treatment. METHOD: Participants (N = 6) will complete a single-case multiple baseline study using Brief Behavioral Treatment for Insomnia (Buysse et al., Archives of Internal Medicine, 171, 2011, 887-895; Troxel et al., Behavioral Sleep Medicine, 10, 2012, 266-279). Participants will complete pre- and post-treatment evaluations of insomnia severity, sleep efficiency, daytime fatigue, ED symptoms, depressive symptoms, and anxiety symptoms. Throughout treatment, participants will complete daily diaries of sleep indices (sleep latency, wake after sleep onset, total sleep time, and sleep efficiency). RESULTS: The primary outcome will be treatment effects on insomnia severity, measured by the Insomnia Severity Index. Secondary outcomes include sleep efficiency and daytime fatigue. Exploratory outcomes include ED-related impairment and symptoms, anxiety symptoms, and depression symptoms. We will provide subject-level graphs of sleep indices and ED symptoms throughout treatment. Additionally, treatment effects will be examined at one- and three-month follow-up. DISCUSSION: Although insomnia treatments have been evaluated in other psychiatric disorders, there has yet to be a study examining behavioral interventions for insomnia in EDs. Results of this study will inform the development and application of interventions for residual insomnia symptoms in this population.

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

INTRODUCTION: Greater use of appearance-focused social media, such as Instagram, is associated with increased body dissatisfaction and eating disorder (ED) symptoms; however, questions remain about the mechanism connecting social media use to disordered-eating behaviors (DEBs). The proposed study evaluates how and for whom exposure to fitspiration or thinspiration on Instagram is associated with DEBs. METHODS: We will evaluate a hypothesized pathway from Instagram use to disordered-eating mediated by negative affect. We will test how individual differences in internalized weight stigma, trait self-esteem, and trait self-comparison moderate the pathway from social media use to negative affect. We will recruit 175 undergraduate women who report engaging in DEBs on average at least once per week over the past 3 months. Participants will complete a 7-day ecological momentary assessment protocol, during which they will report their Instagram use, affect, and engagement in DEBs. RESULTS: Multi-level modeling will be used to assess moderated mediation. Results from this study will provide increased specificity about how Instagram usage is linked to eating pathology and who may be most vulnerable to experiencing distress. DISCUSSION: Information about negative affect from Instagram and engagement in DEBs could contribute to the development of Just-In-Time Interventions for problematic social media use.

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

OBJECTIVE: This study tested the association between food insecurity and eating disorder (ED) pathology, including probable ED diagnosis, among two cohorts of university students before and during the beginning of the COVID-19 pandemic. METHOD: Students (n = 579) from a large Midwestern American university completed self-report questionnaires assessing frequency of ED behaviors, ED-related impairment, and individual food insecurity as measured by the Eating Disorder Diagnostic Scale 5, Clinical Impairment Assessment, and Radimer/Cornell, respectively. Chi-square tests and MANOVA with post-hoc corrections were conducted to compare demographic characteristics, ED pathology, and probable ED diagnosis prevalence between students with and without individual food insecurity. RESULTS: Partially supporting hypotheses, MANOVA indicated significantly greater frequency of objective binge eating, compensatory fasting, and ED-related impairment for students with food insecurity compared with individuals without food insecurity. Chi-squared tests showed higher prevalence of ED diagnoses among individuals with food insecurity compared with those without food security (47.6 vs. 31.1%, respectively, p < .01, NNT = 6.06), specifically bulimia nervosa and other specified feeding and eating disorder. There were no differences in food insecurity before or during the beginning of the COVID-19 pandemic. DISCUSSION: Consistent with prior literature, food insecurity was associated with elevated ED psychopathology in this sample. Findings emphasize the importance of proper ED screening for college students vulnerable to food insecurity and EDs.

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

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

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

OBJECTIVE: Approximately 50% of people with eating disorders (EDs) engage in driven exercise to influence their weight or shape and/or to compensate for loss-of-control eating. When present, driven exercise is associated with a lower quality-of-life, longer hospital stays, and faster rates-of-relapse. Despite the seriousness of driven exercise, most treatments for EDs do not target maladaptive exercise behaviors directly. Given the large proportion of patients with an ED who engage in driven exercise and its effect on treatment outcomes, it is critical to understand what predicts change in driven exercise. The purpose of this study was to test whether ED symptoms prospectively predicted change in driven exercise and vice versa. METHOD: Participants were Recovery Record (RR) users (N = 4,568; 86.8% female) seeking treatment for an ED. Participants completed the Eating Pathology Symptoms Inventory (EPSI) monthly for 3 months. RESULTS: In the full sample, dynamic bivariate latent change score analyses indicated that high levels of dietary restraint and restricting prospectively predicted reductions in driven exercise. Among persons with anorexia nervosa (AN), high levels of binge eating predicted increased driven exercise. Among persons with bulimia nervosa (BN), high levels of body dissatisfaction predicted increased driven exercise. Among persons with binge-eating disorder (BED), high levels of binge eating, purging, and restricting predicted reductions in driven exercise. DISCUSSION: Results highlight changes that may predict increased or decreased driven exercise relative to other ED symptoms for AN, BN, and BED groups. These preliminary findings could inform future research on ED treatment efforts to manage driven exercise.

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

OBJECTIVE: The Criterion B binge-eating symptoms represent five symptoms associated with binge eating. Any three out of five symptoms can be used to meet Criterion B. However, Criterion B symptoms may not be interchangeable in terms of how binge-eating severity is associated with each symptom. Item response theory (IRT) can test how endorsing each symptom relates to the overall level (i.e., severity) of binge-eating measured by Criterion B. We used IRT to identify (a) how each Criterion B symptom corresponded with binge-eating severity in a transdiagnostic binge-eating sample and (b) how well each symptom differentiated individuals with differing levels of severity. METHOD: Participants (N = 219) were adults (80.8% female) with a current ED that included objective binge-eating episodes assessed via semi-structured interview. A two-parameter logistic IRT model evaluated how endorsement of each Criterion B symptom corresponded with the level of latent binge-eating severity. RESULTS: "Eating large amounts when not hungry" and "eating alone" reflected the highest binge-eating severity. "Eating alone" was the best discriminator across different binge-eating severity levels, whereas "uncomfortably full" was the poorest discriminator across binge-eating severity levels. DISCUSSION: Criterion B symptoms were not interchangeable in terms of what level of binge-eating severity corresponded with symptom endorsement. "Eating large amounts when not hungry" or "eating alone" may signify elevated binge-eating severity, whereas "uncomfortably full" and "feeling disgusted/depressed/guilty" were not necessarily indicative of elevated severity. Results suggested that Criterion B may need to be revised to eliminate symptoms that are redundant with other binge-eating diagnostic criteria.

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

OBJECTIVE: Rapid response to treatment, indicated by substantial decreases in eating-disorder (ED) symptoms within the first 4-6 weeks of treatment, is the most reliable predictor of treatment outcomes for EDs. However, there is limited research evaluating short-term longitudinal trajectories of ED symptoms during treatment. Thus, it is difficult to know which aspects of ED psychopathology are slow or fast to change. The purpose of this study was to elucidate three-month trajectories of ED psychopathology during treatment and test whether ED diagnosis influenced the direction and rate of change. METHOD: Participants were Recovery Record users seeking treatment for an ED (N = 4,568; 86.8% female). Participants completed the Eating Pathology Symptoms Inventory once per month for 3 months. RESULTS: Latent growth curve models indicated that ED diagnosis influenced the rate of ED behavior change. Anorexia nervosa was associated with faster reductions in cognitive restraint, excessive exercise, restricting, yet slower reductions in body dissatisfaction, and binge eating. Bulimia nervosa was associated with faster reductions in binge eating, cognitive restraint, excessive exercise, and purging. Binge-eating disorder was associated with faster reductions in body dissatisfaction and binge eating, yet slower reductions in restricting. CONCLUSIONS: Our results have implications for future research by providing initial information about the direction and rate of ED change over the course of treatment. If clinicians and researchers know which ED symptoms are slow to change, on average, across diagnostic groups, treatment protocols could be adjusted to target slow changing symptoms more quickly, and therefore improve ED treatment outcomes.