The mediating role of self-criticism, experiential avoidance and negative urgency on the relationship between ED-related symptoms and difficulties in emotion regulation.

OBJECTIVE: Difficulties in emotion regulation are thought to play a transdiagnostic role across eating disorders (ED). In the current study, we explored with a path analysis the mediating role of self-criticism, experiential avoidance and negative urgency on the relationship between ED-related symptoms and dimensions of difficulties in emotion regulation. METHOD: Participants were 103 female outpatients recruited at a Portuguese ED hospital unit, diagnosed with an ED, aged 14-60 years old (M = 28.0, SD = 10.5), body mass index (BMI) ranging from 11.72 to 39.44 (M = 20.1, SD = 5.4). RESULTS: The path analysis resulted in a model with an adequate fit to the data (SRMR = 0.05; RMSEA = 0.07 [0.00, 0.12], PCLOSE = 0.269; TLI = 0.97; IFI = 0.99; GFI = 0.95). A final model in which the relationship between ED-related symptoms and dimensions of difficulties in emotion regulation was mediated by self-criticism, experiential avoidance and negative urgency, accounted for a variance of 71% for strategies, 57% for non-acceptance, 62% for impulses, 56% for goals and 20% for clarity. CONCLUSION: Results suggest that self-criticism, experiential avoidance and negative urgency, combined, are relevant in the relationship between ED-related symptoms and difficulties in emotion regulation. ED treatment and emotion regulation skills may be enhanced through the inclusion of specific components that target self-criticism, experiential avoidance and negative urgency, as they become prominent during the therapeutic process.

The factorial structure and psychometric properties of the Committed Action Questionnaire (CAQ-8) in a Portuguese clinical sample with eating disorders.

The Committed Action Questionnaire (CAQ-8) is an instrument developed to measure committed action, an adaptive psychological process. The main goal in the current study was to confirm the factorial structure of the Portuguese version of the CAQ-8 in a transdiagnostic clinical sample of participants diagnosed with an eating disorder (ED). Participants were 102 female outpatients (Mage = 28.1, SD = 10.6; MBMI = 20.0, SD = 5.5) recruited from a clinical setting specialized in the treatment of ED. Confirmatory factor analysis (CFA) was used to confirm the CAQ-8's factorial structure. Both first- and second-order models revealed adequate goodness-of-fit indices (e.g. χ2 /df = 1.545, p = .06; SRMR = 0.049; RMSEA = 0.073; CFI/TLI > 0.95). A moderation model revealed that the conditional effect of weight, shape and eating concerns on experiential avoidance was significantly moderated by increased levels of committed action, F(3, 97) = 23.79, p < .001, accounting for 42% of the final variance. The present study supports the usefulness of the CAQ-8 as a measure of levels of committed action with patients diagnosed with an ED.

Emotional processing in recovered anorexia nervosa patients: A 15 year longitudinal study.

OBJECTIVE: This 15 years longitudinal study aimed to examine whether difficulties in cognitive processing of emotions persisted after long-term recovery from anorexia nervosa (AN), and its link to anxiety and depression. METHOD: Twenty-four females, who were tested longitudinally during their acute and recovered AN phases, and 24 healthy control (HC) women, were screened for anxiety, depression, alexithymia, emotion regulation difficulties (ER; only assessed in recovery phase), and completed an experimental task to analyse emotional experience. RESULTS: In spite of significant improvement in alexithymia, anxiety, and depression with AN recovery, some emotion functioning difficulties did not normalize. The occurrence of comorbid anxiety and depression explained the reduced ability to identify, understand, and accept emotions in long-term recovery (relative to controls), but not the increased global difficulty in using ER strategies, which revealed a more stable nature of deficit. With recovery, negative emotions linked to situations addressing food and body weight are felt more intensely. CONCLUSIONS: Managing emotions, especially the negative ones, remains a challenge for individuals recovered from AN. Under this circumstance, maladaptive eating behaviour can serve as an affect regulatory function, increasing the risk of relapse. Emotional education is an important avenue in protecting long-term AN relapse.

Nonsuicidal self-injury, difficulties in emotion regulation, negative urgency, and childhood invalidation: A study with outpatients with eating disorders.

OBJECTIVES: Among outpatients with eating disorders (ED), we compared participants without nonsuicidal self-injury (non-NSSI group), with NSSI over a year ago (past NSSI group) and with NSSI in the previous year (current NSSI group) regarding different variables, and examined whether difficulties in emotion regulation and negative urgency moderated the relationship between maternal/paternal invalidation and NSSI. METHOD: The sample included 171 outpatients (94.2% female; Mage = 28.78, SDage = 11.19). RESULTS: Fifty-four participants (31.6%) had NSSI in the previous year. This group showed higher eating pathology, difficulties in emotion regulation, negative urgency, and maternal/paternal invalidation than the non-NSSI group. Analyses revealed an adequate fit to the data for the model that included moderating effects of emotional awareness and negative urgency in the relationship between maternal/paternal invalidation and increased likelihood of NSSI in the previous year. CONCLUSIONS: Interventions for NSSI and ED should include emotion regulation, impulse control, and validation strategies.

Using hydrodynamic and water quality variables to assess eutrophication in a tropical hydroelectric reservoir.

Few studies have examined the influence of reservoir hydrodynamics on the water quality of its limnological zones. In this study, the relationships between the operational phases and the water quality of the limnological zones were assessed for the Amazonian reservoir Tucuruí. Limnological zones were clustered by means of an artificial neural network technique, and inputs used were water quality variables, measured at twelve stations between 2006 and 2016. Generalized Linear Models (GLMs) were then used to identify the influence of the operational phases of the reservoir on the water quality of its limnological zones. The GLM with a gamma-distributed response variable indicated that Chlorophyll-a concentrations in the riverine and transitional zones differed notably from those observed in the lacustrine zone. Chlorophyll-a concentrations were significantly lower during the operational falling water phase than in the low water phase (p < 0.05). The GLM with an inverse Gaussian-distributed response variable indicated that Secchi depth was significantly lower in the riverine than in the lacustrine limnological zone (p < 0.05). Our results suggest that more eutrophic conditions occur during the operational rising water phase, and that the area most vulnerable to eutrophication is the transitional zone. We demonstrate that the use of GLMs is suitable for determining areas and operational phases most vulnerable to eutrophication. We envisage that this information will be useful to decision-makers when monitoring the water quality of hydroelectric reservoirs with dendritic patterns and dynamic operational phases.

Psychometric properties of the Portuguese version of the Invalidating Childhood Environment Scale.

PURPOSE: The current study aimed to examine the psychometric properties of the Portuguese version of the invalidating childhood environment scale (ICES) in a non-clinical and clinical sample of eating disorder (ED) patients. This study also investigated the between-sample differences regarding invalidating parental behaviors and family styles and explored the associations between invalidating childhood environments and eating pathology. METHODS: A sample of 410 high school and college students and 101 patients with a diagnosis of ED completed self-report measures. Principal component analyses and confirmatory factor analyses were conducted to examine the factor structure of the ICES. The internal consistency and the between-sample differences and associations between invalidating childhood environments and eating pathology were also tested. RESULTS: Principal component analyses and confirmatory factor analyses indicated a two-factor solution for each parent. The ICES demonstrated high internal consistency and was able to differentiate between non-clinical and clinical samples. The perception of parental invalidation was higher in ED patients, and the clinical sample presented higher scores in the chaotic and perfect family styles and lower scores in the validating family style, in comparison with the non-clinical sample. Both maternal invalidation and invalidating styles were significantly associated with a higher ED symptomatology. CONCLUSIONS: The Portuguese version of the ICES revealed adequate psychometric properties. Considering the relationship between invalidation in family and eating pathology, the ICES may be useful in clinical practice, especially among ED patients. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Factorial Validity of the Toronto Alexithymia Scale (TAS-20) in Clinical Samples: A Critical Examination of the Literature and a Psychometric Study in Anorexia Nervosa.

There is extensive use of the 20-item Toronto Alexithymia Scale (TAS-20) in research and clinical practice in anorexia nervosa (AN), though it is not empirically established in this population. This study aims to examine the factorial validity of the TAS-20 in a Portuguese AN sample (N = 125), testing four different models (ranging from 1 to 4 factors) that were identified in critical examination of existing factor analytic studies. Results of confirmatory factor analysis (CFA) suggested that the three-factor solution, measuring difficulty identifying (DIF) and describing feelings (DDF), and externally oriented thinking (EOT), was the best fitting model. The quality of measurement improves if two EOT items (16 and 18) are eliminated. Internal consistency of EOT was low and decreased with age. The results provide support for the factorial validity of the TAS-20 in AN. Nevertheless, the measurement of EOT requires some caution and may be problematic in AN adolescents.

Eating disorders-Related hospitalizations in Portugal: A nationwide study from 2000 to 2014.

INTRODUCTION: Recent evidence suggests that incidence of Anorexia nervosa (AN) has remained stable over the last decades in Western Europe, while decreasing for Bulimia nervosa (BN). It is well-known that most individuals with an ED (Eating disorder) do not seek medical treatment. OBJECTIVE: The present study analyses hospitalizations related with EDs held in mainland Portuguese public hospitals between 2000 and 2014. METHOD: A retrospective observational study was performed gathering all inpatient episodes with primary or secondary diagnosis of ED. Number of patients, gender, mean age at discharge, suicide-attempts related hospitalizations, in-hospital mortality, length of stay, and mean charges were analyzed. RESULTS: There were a total of 4,485 hospitalizations with an associated ED. AN was the most frequent ED (n = 2,806). Suicide attempt-related hospitalizations were most common among patients with BN (10.1% of BN hospitalizations) or AN (5.2% of AN hospitalizations). DISCUSSION: AN has higher in-hospital mortality than BN. We observed a higher proportion of suicide related hospitalizations in BN when compared to AN. Although pica, rumination disorder, and psychogenic vomiting represent a smaller portion of all EDs, this study was the first to describe hospitalization trends for this set of EDs for a 15-year period, to the best of our knowledge.

Problematic eating behaviors and psychopathology in patients undergoing bariatric surgery: The mediating role of loss of control eating.

OBJECTIVE: This study compares different problematic eating behaviors (PEBs; objective [OBE]/subjective [SBE] binge-eating and compulsive [CG]/noncompulsive [NCG] grazing) in relation to the severity of loss of control (LOC) and psychopathology. We also investigate LOC as a mediator between PEBs and psychopathology. METHOD: This cross-sectional study assessed a group of patients before bariatric surgery (n = 163), and a group of bariatric patients 12 months or more after surgery (n = 131). Face-to-face assessment: Eating Disorders Examination for binge-eating episodes; Rep(eat) for grazing. LOC was measured by five questions answered in a 5-point Likert scale. Self-report measures: disordered eating, grazing, negative urgency, depression, anxiety, and stress. RESULTS: OBEs were reported by 26(8.8%), SBE by 29(9.8%), CG by 35(11.9%), and NCG by 36(12.2%) of patients. The different PEBs differed significantly in the severity of LOC (F(3,120)= 25.81, p < .001). Patients reporting OBEs scored higher and patients with NCG scored lower in most measures than patients with other PEBs. Patients with any PEBs scored higher in all self-report measures than those not reporting any PEBs, with statistical significance reached for uncontrolled eating (F(4,288)= 20.21, p < .001), emotional eating (F(4,288)= 23.10, p < .001), repetitive eating F(4,288)= 18.34, p < .001), and compulsive grazing (F(4,288)= 27.14, p < .001). LOC was found to be a full mediator between PEBs and psychopathology. DISCUSSION: There is no evidence that the different PEBs differ in the psychopathology severity, independently of the experience of LOC eating during the eating episodes. We show evidence for the conceptualization of different PEB, including grazing, on a continuous scale of LOC and psychopathology.

Orofacial manifestations in outpatients with anorexia nervosa and bulimia nervosa focusing on the vomiting behavior.

OBJECTIVE: This case-control study aims to evaluate the oral health status and orofacial problems in a group of outpatients with eating disorders (ED)-either anorexia nervosa (AN) or bulimia nervosa (BN)-further focusing on the influence of vomit. MATERIALS AND METHODS: Fifty-five women outpatients with AN or BN diagnosis were invited to participate, of which 33 agreed. ED outpatients and matched controls were submitted to a questionnaire and clinical oral examination. RESULTS: Multivariate analysis identified a significantly higher incidence of teeth-related complications (i.e., tooth decay, dental erosion, and self-reported dentin hypersensitivity), periodontal disease, salivary alterations (i.e., hyposalivation and xerostomia), and oral mucosa-related complications in ED outpatients. Dental erosion, self-reported dentin hypersensitivity, hyposalivation, xerostomia, and angular cheilitis were found to be highly correlated with the vomiting behavior. CONCLUSIONS: ED outpatients were found to present a higher incidence of oral-related complications and an inferior oral health status, compared to gender- and age-matched controls. Alterations verified within outpatients were acknowledged to be quite similar to those previously reported within inpatients, in both of nature and severity, thus sustaining that the cranio-maxillofacial region is significantly affected by ED, even in the early/milder forms of the condition, as expectedly verified within outpatients.

Eating disorders and non-suicidal self-injury: Structural equation modelling of a conceptual model.

Evidence suggests several risk factors for both eating disorders (ED) and nonsuicidal self-injury (NSSI), but the relationships between these factors are not well understood. Considering our previous work and a conceptual model, this cross-sectional study aimed to assess the relationships among distal and proximal factors for the presence of NSSI in ED. We assessed 245 ED patients with the Oxford Risk Factor Interview for ED. Structural equation modelling revealed that both distal and proximal factors were related to the presence of NSSI in ED, disclosing a mediating role of the proximal factors. Stressful life events mediated the relationship between childhood sexual abuse, peer aggression, and both ED and NSSI. Childhood physical abuse was related to ED and NSSI via substance use, negative self-evaluation, and suicide attempts. Findings provided support for the conceptual model and highlight the possible mechanisms by which psychosocial factors may lead to ED and NSSI.

Repetitive eating questionnaire [Rep(eat)-Q]: Enlightening the concept of grazing and psychometric properties in a Portuguese sample.

BACKGROUND/OBJECTIVE: Grazing has been associated with poor weight loss or weight regain in obese patients undergoing bariatric surgery, but research remains scarce and complicated by the use of different non-validated measures. The aim of this paper is to describe the validation of the Rep(eat)-Q, a self-report measure developed to assess grazing, and investigates its relationship with BMI and psychopathology. SUBJECTS/METHODS: 1223 university students and community participants (non-clinical; Study A) and 154 pre-bariatric and 84 post-bariatric patients (Study B) completed a set of self-report measures, including the Rep(eat)-Q (worded in Portuguese), to assess disordered eating, depression, anxiety, stress and impulsivity. Exploratory and confirmatory factor analyses tested the factor structure; internal consistency construct, convergent and divergent validity were also tested. RESULTS: The Rep(eat)-Q scales showed good internal consistency (α ≥ 0.849) and temporal stability (rsp = 0.824, p < 0.000). Factor analyses generated two subscales: compulsive grazing and repetitive eating. Significant correlations (p < 0.05) were found between the Rep(eat)-Q and BMI in the non-clinical population and weight loss and weight regain in the bariatric sample. Generally, the correlations with psychological distress were weak (rsp < 0.4). Strong and significant (rsp≥0.4; p's < 0.05) correlations were found between compulsive grazing and eating disorder psychopathology. Repetitive eating subscale was inversely correlated with cognitive restraint (rsp -0.321, p < 0.05) and directly correlated with uncontrolled eating and emotional eating (rsp = 0.754; rsp = 0.691; p < 0.05). DISCUSSION/CONCLUSION: The Rep(eat)-Q is a valid measure to assess grazing in non-clinical and in bariatric surgery populations. Grazing can be conceptualized on the spectrum of disordered eating behavior, and appears associated with loss of control over eating. Considering the link between grazing and weight outcomes, the Rep(eat)-Q represents a necessary strategy for the systematic screening of grazing.

Putative Risk Factors for Non-Suicidal Self-Injury in Eating Disorders.

Evidence suggests a common association between eating disorders (EDs) and non-suicidal self-injury (NSSI). The present study aimed to investigate the potential risk factors for NSSI among ED patients. We assessed 245 ED patients with the Oxford Risk Factor Interview for ED. The results showed that 33% of ED patients reported NSSI in their lifetime. NSSI appeared to occur more frequently among binge eating/purging type ED patients than among patients with other ED and to be related to a more severe eating pathology. A younger age at the onset of eating problems, more negative self-evaluation, suicide attempts, substance abuse, parents' low weight, family tension at mealtime, parental alcohol problems, childhood abuse, peer aggression, and negative antecedent life events were more common among patients with co-occurring EDs and NSSI than among patients without NSSI. The results may inform the risk assessment and treatment of NSSI in EDs in the early detection period. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Psychometric properties of the Portuguese version of the Yale Food Addiction Scale.

PURPOSE: Rising rates of obesity have been recently associated to the novel concept of food addiction (FA). The Yale Food Addiction Scale (YFAS) is the most widely used measure for examining FA (1) and analysis of its reliability and validity is expected to facilitate empirical research on the construct. Here, we tested the psychometric properties of a Portuguese version of the YFAS (P-YFAS), establishing its factor structure, reliability and construct validity. METHODS: Data were obtained from 468 Portuguese individuals, 278 sampled from non-clinical populations, and 190 among obese candidates for weight-loss surgery. A battery of self-report measures of eating behavior was applied. RESULTS: Confirmatory factor analysis verified a one-factor structure with acceptable fit, with item analysis suggesting the need to eliminate item 24 from the P-YFAS. Internal consistency (KR-20 = .82) and test-retest stability were adequate. Correlation analyses supported convergent and divergent validity of the P-YFAS, particularly in the clinical sample. Both FA symptom count and diagnosis, according to the P-YFAS, adequately discriminated between samples, with classification of FA met by 2.5 and 25.8% of the participants in the non-clinical and clinical samples, respectively. CONCLUSIONS: These findings reinforce the use of P-YFAS in non-clinical and clinical populations. Future directions for extending YFAS validation are discussed.

Adversity, emotion regulation, and non-suicidal self-injury in eating disorders.

The comorbidity between non-suicidal self-injury and eating disorder behaviors suggests that psychosocial factors may play a role in both types of behaviors. This study aimed to assess the presence of non-suicidal self-injury in 66 eating disorder patients and to analyze the associations among adversity, emotion regulation, non-suicidal self-injury, and disordered eating behavior. A total of 24 participants (36.4%) reported non-suicidal self-injury. Patients endorsing self-injury had a higher severity of disordered eating behavior. More difficulties in emotion regulation and a greater number of methods of non-suicidal self-injury were associated with a higher severity of eating pathology. Clinicians should consider these relationships in the assessment and treatment of eating disorders.

Anorexia nervosa versus bulimia nervosa: differences based on retrospective correlates in a case-control study.

OBJECTIVE: This study is the result of two Portuguese case-control studies that examined the replication of retrospective correlates and preceding life events in anorexia nervosa (AN) and bulimia nervosa (BN) development. This study aims to identify retrospective correlates that distinguish AN and BN METHOD: A case-control design was used to compare a group of women who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for AN (N = 98) and BN (N = 79) with healthy controls (N = 86) and with other psychiatric disorders (N = 68). Each control group was matched with AN patients regarding age and parental social categories. Risk factors were assessed by interviewing each person with the Oxford Risk Factor Interview. RESULTS: Compared to AN, women with BN reported significantly higher rates of paternal high expectations, excessive family importance placed on fitness/keeping in shape, and negative consequences due to adolescent overweight and adolescent objective overweight. DISCUSSION: Overweight during adolescence emerged as the most relevant retrospective correlate in the distinction between BN and AN participants. Family expectations and the importance placed on keeping in shape were also significant retrospective correlates in the BN group.

Metabolic profile and psychological variables after bariatric surgery: association with weight outcomes.

PURPOSE: This study aims to examine associations between metabolic profile and psychological variables in post-bariatric patients and to investigate if metabolic and psychological variables, namely high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), glycated hemoglobin (HbA 1c), impulsivity, psychological distress, depressive and eating disorder symptoms are independently associated with percentage of excess weight loss (%EWL) after bariatric surgery. METHODS: One hundred and fifty bariatric patients (BMI = 33.04 ± 5.8 kg/m(2)) who underwent to bariatric surgery for more than 28.63 ± 4.9 months were assessed through a clinical interview, a set of self-report measures and venous blood samples. Pearson's correlations were used to assess correlations between %EWL, metabolic and psychological variables. Multiple linear regression was conducted to investigate which metabolic and psychological variables were independently associated with %EWL, while controlling for type of surgery. RESULTS: Higher TG blood levels were associated with higher disordered eating, psychological distress and depression scores. HDL-C was associated with higher depression scores. Both metabolic and psychological variables were associated with %EWL. Regression analyses showed that, controlling for type of surgery, higher % EWL is significantly and independently associated with less disordered eating symptoms and lower TG and HbA_1c blood concentrations (R (2) aj = 0.383, F (4, 82) = 14.34, p < 0.000). CONCLUSION: An association between metabolic and psychological variables, particularly concerning TG blood levels, disordered eating and psychological distress/depression was found. Only higher levels of disordered eating, TG and HbA_1c showed and independent correlation with less weight loss. Targeting maladaptive eating behaviors may be a reasonable strategy to avoid weight regain and optimize health status post-operatively.

Loss of control eating and weight outcomes after bariatric surgery: a study with a Portuguese sample.

The present study aim is to investigate the frequency of loss of control eating (LOC) episodes in three groups with different assessment times: one before, one at short and one at long-term after bariatric surgery; as well as to explore the association of postoperative problematic eating behaviors and weight outcomes and psychological characteristics. This cross-sectional study compared a group of preoperative bariatric surgery patients (n = 176) and two postoperative groups, one at short-term with <2 years follow-up (n = 110), and one at long-term >2 years follow-up (n = 53). Assessments included the EDE diagnostic interview and a set of self-report measures assessing eating disordered symptomatology, depression, and body image. We found the presence of LOC in 26.7 and 16.9 % of the pre-operative and long-term patients, respectively, and in about 11.8% of the short-term patients. One patient (0.9%) reported objective binge eating episodes at short-time, but subjective binge eating episodes were present in about 10% of the patients in all groups. LOC eating was related with the highest BMIs, the least weight loss, most weight regain, and most psychological impairment in the long-term assessments, but not at short-term. Despite the lower frequencies of disordered eating behavior in the short-term group, patients reporting LOC seem to represent a subgroup of individuals with poorest outcomes after surgery and most psychological distress.

Corrigendum: Severe and enduring' stage in anorexia nervosa: comparing eating attitudes, impairment and associated psychopathology.

[This corrects the article DOI: 10.3389/fnut.2022.867401.].

Severe and Enduring' Stage in Anorexia Nervosa: Comparing Eating Attitudes, Impairment and Associated Psychopathology.

This study aimed to assess differences in eating attitudes, impairment, and related psychopathology at treatment presentation for patients with "Non-severe and enduring Anorexia Nervosa" (illness duration of <7 years) and patients with "severe and enduring Anorexia Nervosa" (illness duration of 7 years or more). One hundred and thirty-nine patients diagnosed with Anorexia Nervosa participated in this study. Participants were interviewed with the Eating Disorder Examination (EDE) and asked to complete several questionnaires at the end of the first treatment appointment. We also explored differences at treatment presentation by considering alternative criteria to define groups, namely a composite of illness duration and clinical impairment (≥16 CIA total score). No differences were found when comparing participants based on illness duration. However, when participants were classified into a different classification scheme: "Non-severe and enduring Anorexia Nervosa" (illness duration <7 years and a CIA total score <16) vs. "severe and enduring Anorexia Nervosa" (illness duration ≥7 years and CIA total score ≥16), significant differences were found in terms of eating pathology, depressive symptomatology, psychological distress, and emotion dysregulation. Further research is needed to better understand the role of illness duration and clinical impairment in informing the course of AN.