A longitudinal network analysis of suicide risk factors among service members and veterans sampled for suicidal ideation or attempt.

BACKGROUND: Suicidal thoughts and behaviors are elevated among active-duty service members (ADSM) and veterans compared to the general population. Hence, it is a priority to examine maintenance factors underlying suicidal ideation among ADSM and veterans to develop effective, targeted interventions. In particular, interpersonal risk factors, hopelessness, and overarousal have been robustly connected to suicidal ideation and intent. METHODS: To identify the suicidal ideation risk factors that are most relevant, we employed network analysis to examine between-subjects (cross-sectional), contemporaneous (within seconds), and temporal (across four hours) group-level networks of suicidal ideation and related risk factors in a sample of ADSM and veterans (participant n = 92, observations n = 10 650). Participants completed ecological momentary assessment (EMA) surveys four times a day for 30 days, where they answered questions related to suicidal ideation, interpersonal risk factors, hopelessness, and overarousal. RESULTS: The between-subjects and contemporaneous networks identified agitation, not feeling close to others, and ineffectiveness as the most central symptoms. The temporal network revealed that feeling ineffective was most likely to influence other symptoms in the network over time. CONCLUSION: Our findings suggest that ineffectiveness, low belongingness, and agitation are important drivers of moment-to-moment and longitudinal relations between risk factors for suicidal ideation in ADSM and veterans. Targeting these symptoms may disrupt suicidal ideation.

Few differences in psychiatric comorbidities and treatment response among people with anorexia nervosa and atypical anorexia nervosa.

OBJECTIVE: Little is known about how individuals with atypical anorexia nervosa (AN) respond to eating disorder (ED) treatment in a partial hospitalization program (PHP), nor how certain factors such as trauma, childhood abuse, psychiatric comorbidity, and suicidal thoughts and behaviors might contribute to poor treatment outcomes. Thus, the current study (1) compares prevalence of these factors between individuals with AN and atypical AN upon admission to an ED PHP, (2) compares PHP treatment response between groups, and (3) investigates whether experiencing these factors impacts treatment outcomes. METHOD: We conducted a retrospective chart review of young adults admitted to a PHP with AN (n = 95) and atypical AN (n = 59). Histories of psychiatric comorbidities and adverse childhood experiences were obtained from initial psychiatric evaluations. ED symptoms were assessed at intake and discharge with the Eating Disorder Examination-Questionnaire (EDE-Q). RESULTS: No significant differences were found at intake in ED symptom severity or prevalence of lifetime trauma, childhood abuse, number of psychiatric diagnoses, or suicidal thoughts and behavior. Symptomatology at discharge also did not differ between groups. Emotional abuse was significantly related to discharge shape and weight overvaluation. No other intake characteristics were significantly related to discharge symptomatology. DISCUSSION: To our knowledge, this is the first study to compare the prevalence of comorbidities for both AN and atypical AN, as well as differential treatment outcomes for these individuals in a PHP. Results add to growing literature suggesting that, other than weight, AN and atypical AN have few properties that reliably distinguish them from one another. PUBLIC SIGNIFICANCE: This study adds to a growing body of literature that raises questions about whether anorexia nervosa (AN) and atypical AN are truly different diagnoses. Our findings suggest these two groups present to treatment in a partial hospitalization program (PHP) with similar ED symptoms, as well as prevalence of lifetime trauma, childhood abuse, suicidal thoughts and behavior, and number of psychiatric comorbidities, and demonstrate similar treatment trajectories in PHP.

Feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program for adolescents with anorexia nervosa and atypical anorexia nervosa at six- and twelve-month follow-up.

This study examined the feasibility and preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program (PHP) for adolescents with anorexia nervosa (AN) and atypical AN (AAN), and described the outpatient services received following discharge. Participants (N = 31) completed anthropometric and self-report assessments at admission, discharge, and six and twelve months after discharge from the PHP. Descriptive statistics explored markers of feasibility. Paired samples t-tests evaluated changes in weight and eating disorder (ED) symptomatology from admission to discharge, admission to six-month follow-up, and admission to twelve-month follow-up. Descriptive statistics and effect sizes compared symptoms at each timepoint between participants with AN and AAN. Results indicated that we were successful at recruiting greater than 50% of adolescents approached for this study. We collected follow-up data from more than 70% of participants at discharge, but did not meet this retention benchmark at six-month and twelve-month follow-ups. The entire sample demonstrated significant improvements in weight and ED symptomatology from admission to discharge, and generally maintained these improvements at six- and twelve-month follow-up. While descriptive statistics suggested that participants with AN and AAN received similar outpatient services following discharge from the PHP, those with AN experienced greater improvement in self-reported ED symptomatology than those with AAN at six- and twelve-month follow-up. These findings provide preliminary support for the efficacy of PHPs in treating adolescents with AN and AAN. Further research with larger sample sizes should investigate whether adolescents with AAN experience poorer outcomes than those with AN following discharge from a PHP.

Machine learning v. traditional regression models predicting treatment outcomes for binge-eating disorder from a randomized controlled trial.

BACKGROUND: While effective treatments exist for binge-eating disorder (BED), prediction of treatment outcomes has proven difficult, and few reliable predictors have been identified. Machine learning is a promising method for improving the accuracy of difficult-to-predict outcomes. We compared the accuracy of traditional and machine-learning approaches for predicting BED treatment outcomes. METHODS: Participants were 191 adults with BED in a randomized controlled trial testing 6-month behavioral and stepped-care treatments. Outcomes, determined by independent assessors, were binge-eating (% reduction, abstinence), eating-disorder psychopathology, and weight loss (% loss, ⩾5% loss). Predictors included treatment condition, demographic information, and baseline clinical characteristics. Traditional models were logistic/linear regressions. Machine-learning models were elastic net regressions and random forests. Predictive accuracy was indicated by the area under receiver operator characteristic curve (AUC), root mean square error (RMSE), and R2. Confidence intervals were used to compare accuracy across models. RESULTS: Across outcomes, AUC ranged from very poor to fair (0.49-0.73) for logistic regressions, elastic nets, and random forests, with few significant differences across model types. RMSE was significantly lower for elastic nets and random forests v. linear regressions but R2 values were low (0.01-0.23). CONCLUSIONS: Different analytic approaches revealed some predictors of key treatment outcomes, but accuracy was limited. Machine-learning models with unbiased resampling methods provided a minimal advantage over traditional models in predictive accuracy for treatment outcomes.

Examining changes in binge-eating disorder network centrality and structure in patients treated with cognitive-behavioral therapy versus interpersonal psychotherapy.

OBJECTIVE: A sizeable minority of patients with binge-eating disorder (BED) do not fully respond to evidence-based treatments. Evidence to guide refinements of treatments is needed. Conceptualizing BED as arising from a network of symptom-to-symptom interactions allows for identification of the most strongly connected symptoms, which could inform intervention targets. This study estimated networks of BED features at pretreatment and posttreatment to assess whether cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) differentially impacted the interrelationships of BED symptoms/features. METHODS: Participants were 392 adults (83% women, 88% white) with BED who received CBT (n = 236) or IPT (n = 156) and assessed at pretreatment and posttreatment. Networks were estimated across timepoints and treatments. Expected influence (EI) was calculated; symptoms with the highest EI have the most strong and frequent associations with other symptoms. We also assessed whether the symptoms with the highest and lowest EI predicted posttreatment remission indicators. RESULTS: In the CBT and IPT networks, shape concern, weight concern, and eating concern had the highest EI at pretreatment and posttreatment. EI significantly increased from pretreatment to posttreatment for some symptoms in CBT but did not change for any symptoms in IPT. Shape concern significantly and positively predicted BED remission indicators in CBT and IPT. CONCLUSIONS: CBT and IPT similarly impacted interrelations among BED features. Pretreatment EI predicted posttreatment remission indicators, indicating that pretreatment centrality could signal meaningful intervention targets. Clinical implications and avenues for future research are discussed including how personalized network analysis may advance the understanding of the clinical utility of centrality. PUBLIC SIGNIFICANCE: Cognitive behavioral therapy and interpersonal therapy for binge-eating disorder, which are two leading evidence-based treatments for binge-eating disorder that are quite different in their models and approaches, similarly impacted interrelations among binge-eating disorder symptoms. In addition, the most strongly interconnected symptom predicted indicators of remission. Studying the interrelations among symptoms may provide new insight on how treatments impact symptom relationships and inform intervention targets.

The impact of between-session habituation, within-session habituation, and weight gain on response to food exposure for adolescents with eating disorders.

OBJECTIVE: Exposure therapy is a promising treatment for eating disorders (EDs). However, questions remain about the effectiveness of exposure to feared foods during the weight restoration phase of treatment, and the importance of between-session and within-session habituation. METHOD: We recruited 54 adolescents from a partial hospitalization program (PHP) for EDs which included daily food exposure. Throughout treatment, participants provided subjective units of distress (SUDS) ratings before and after eating a feared food, and completed measures of ED symptomatology. RESULTS: Multilevel models found that pre-exposure SUDS decreased over time, providing some evidence that between-session habituation occurred. In contrast, the difference between pre-exposure and post-exposure SUDS did not decrease over time, indicating that within-session habituation did not occur. Weight gain predicted greater between-session habituation to feared foods, but did not predict within-session habituation. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes, including weight gain and improvements on the Children's Eating Attitudes Test and Fear of Food Measure. DISCUSSION: Partial hospitalization programs that include daily exposure to feared foods may be effective at decreasing anxiety about foods for adolescents with EDs who are experiencing weight restoration. Further research is warranted to replicate our findings challenging the importance of within-session habituation, and to better understand between-session habituation and inhibitory learning as mechanisms of change when conducting food exposure for EDs. PUBLIC SIGNIFICANCE: This study provides some evidence that PHPs that include food exposure may be useful for adolescents with EDs who are experiencing weight restoration. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes. Further research is needed to determine whether clinicians can disregard within-session habituation when conducting food exposure for EDs, and understand the importance of between-session habituation as a potential mechanism of food exposure.

Gender differences in transdiagnostic domains and function of adults measured by DSM-5 assessment scales at the first clinical visit: a cohort study.

BACKGROUND: Measurement-based care has been called for as best practice in psychiatric care and learning health systems and use of transdiagnostic measures was suggested as part of the DSM-5. Our objective is to examine gender differences in first visit socioeconomic, transdiagnostic, and functional characteristics of a dynamic, real-world measurement-based care cohort. METHODS: Transdiagnostic, functional, and clinical measures were collected from 3,556 patients at first visit in an ambulatory psychiatric clinic. All patients were evaluated at the first visit by board-certified psychiatrists or licensed clinical psychologists. Demographic variables and clinical diagnoses were collected from the Electronic Medical Record. Self-report measures were collected that assessed transdiagnostic symptoms (DSM-5 Level 1 Cross-cutting Measure and Level 2 symptom scales), disability, alcohol use, attention deficit hyperactivity disorder (ADHD) symptoms, depression, anxiety, mania, suicidal thoughts and behaviors, and trauma exposure. RESULTS: Men and women did not differ in age, BMI, household income, high school graduation rate, race, or ethnicity, but women were more likely to be formerly married and less likely to have commercial insurance. Compared to men, women reported significantly higher overall psychopathology on the transdiagnostic Level 1 Cross-cutting measure and had higher depression, anxiety, sleep, anger, ADHD combined presentation, and suicidality severity. Women also had higher disability scores than men. However, men reported higher alcohol, tobacco and substance use, and more risky behavior than women. Trauma exposure differed significantly by gender; men reported more exposure to accidents, war-related trauma, serious accidents, and major disasters and women reported more unwanted sexual contact. CONCLUSIONS: This cross-sectional study of a transdiagnostic, ecologically-valid real-word measurement-based care cohort demonstrates gender differences in socioeconomic factors, trauma exposure, transdiagnostic symptoms, and functioning.

The Impact of COVID-19 on Psychiatric Acuity in a Community Psychiatric Hospital.

ABSTRACT: The COVID-19 pandemic has had extensive impacts on mental health care delivery. Anecdotal observations of inpatient care teams at Pennsylvania Psychiatric Institute suggested increased patient acuity during the pandemic. The authors found no consensus definition for measuring psychiatric acuity in the literature. We performed an interrupted time series analysis to identify whether COVID-19 was associated with changes in several hospital parameters that might reflect our patients' access to psychiatric services and acuity. We found increases in inpatient parameters for length of stay, rates of involuntary admissions, and the incidence of restraints, seclusion, and 1:1 observation orders. Observing these increasing trends can inform mitigation efforts to improve the quality of mental health care treatment and care delivery. We suggest the use of these metrics for objective measurements of psychiatric acuity.

Empirically determined severity levels for binge-eating disorder outperform existing severity classification schemes.

BACKGROUND: Eating-disorder severity indicators should theoretically index symptom intensity, impairment, and level of needed treatment. Two severity indicators for binge-eating disorder (BED) have been proposed (categories of binge-eating frequency and shape/weight overvaluation) but have mixed empirical support including modest clinical utility. This project uses structural equation model (SEM) trees - a form of exploratory data mining - to empirically determine the precise levels of binge-eating frequency and/or shape/weight overvaluation that most significantly differentiate BED severities. METHODS: Participants were 788 adults with BED enrolled in BED treatment studies. Participants completed interviews and self-report measures assessing eating-disorder and comorbid symptoms. SEM Tree analyses were performed by specifying an outcome model of BED severity and then recursively partitioning the outcome model into subgroups. Subgroups were split based on empirically determined values of binge-eating frequency and/or shape/weight overvaluation. SEM Forests also quantified which variable contributed more improvement in model fit. RESULTS: SEM Tree analyses yielded five subgroups, presented in ascending order of severity: overvaluation <1.25, overvaluation = 1.25-2.74, overvaluation = 2.75-4.24, overvaluation ⩾4.25 with weekly binge-eating frequency <4.875, and overvaluation ⩾4.25 with weekly binge-eating frequency ⩾4.875. SEM Forest analyses revealed that splits that occurred on shape/weight overvaluation resulted in much more improvement in model fit than splits that occurred on binge-eating frequency. CONCLUSIONS: Shape/weight overvaluation differentiated BED severity more strongly than binge-eating frequency. Findings indicate a nuanced potential BED severity indicator scheme, based on a combination of cognitive and behavioral eating-disorder symptoms. These results inform BED classification and may allow for the provision of more specific and need-matched treatment formulations.

Preliminary effectiveness of a cognitive-behavioral, family-centered partial hospitalization program for children and adolescents with avoidant/restrictive food intake disorder.

OBJECTIVE: This study explored the preliminary effectiveness of a partial hospitalization program (PHP) for children/adolescents with avoidant/restrictive food intake disorder (ARFID). We evaluated how ARFID symptoms changed from admission to discharge, and collected follow-up data on symptoms and outpatient care following PHP discharge. METHOD: Twenty-two children/adolescents with ARFID (77.3% White, 63.6% female) completed measures assessing ARFID symptomatology at admission and discharge from a PHP for eating disorders. Six months and twelve months following their discharge, participants were contacted to complete study measures again and take part in an interview assessing follow-up care. RESULTS: Paired samples t tests indicated that participants demonstrated increases in weight and decreases in ARFID symptomatology from admission to discharge with medium to large effects. All participants reported receiving some form of outpatient treatment following discharge, with the type of outpatient services varying across participants. Data from the 86% of participants who completed the six-month follow-up and 50% who completed the twelve-month follow-up suggest that participants generally maintained treatment gains following PHP discharge. DISCUSSION: Participants experienced symptom improvements from admission to discharge and appeared to maintain these gains after discharge. These results provide preliminary evidence that PHPs are an effective treatment option for children and adolescents with ARFID. PUBLIC SIGNIFICANCE STATEMENT: This study provides preliminary evidence that intensive, evidence-based PHPs are effective in treating ARFID. Our findings suggest that children and adolescents with ARFID who receive flexible, cognitive-behavioral, family-centered treatment in a PHP for EDs experience improvements in weight and ARFID symptomatology from admission to discharge. Despite receiving variable and nonstandardized outpatient treatment, individuals with ARFID appear to maintain treatment gains 6 and 12 months after discharge in a PHP.

Suicide attempts among people with eating disorders and adverse childhood experiences: Results from a nationally representative sample of adults.

OBJECTIVE: People with eating disorders (EDs) have elevated rates of suicide attempts. A need exists to identify factors that help predict which people with EDs might be at greater risk for suicidal behavior. Adverse childhood experiences (ACEs) are associated with both EDs and with suicide attempts. Thus, the current study examined whether having histories of ACEs and EDs augments lifetime risk for suicide attempts. METHOD: This study included 36,146 adult participants in the National Epidemiologic Survey on Alcohol and Related Conditions-III who completed structured diagnostic interviews and answered questions regarding ACEs and suicide attempts. Weighted means, frequencies, and cross-tabulations were computed for prevalence of ACEs and suicide attempts by ED diagnosis. Multiple logistic regression was used to compare risk of lifetime suicide attempts by ED diagnosis and ACE history. RESULTS: Prevalence of ACEs among people with EDs was 54.1-67.8%. ACE history and ED diagnosis were associated with elevated odds of experiencing a lifetime suicide attempt (AORs = 4.64-6.45 and 3.20-4.06, respectively). There was no ACE history-by-ED interaction on risk of suicide attempt, regardless of forms of EDs. DISCUSSION: ACEs are common among people with EDs and associated significantly with suicide attempts, but ACEs and EDs do not appear to interact to augment risk for suicide attempts. Considering ACE exposure in theoretical models of suicidal behavior in people with and without EDs and in suicide risk assessment and management with people with EDs may prove useful.

Psychological and eating disorder symptoms as predictors of starting eating disorder treatment.

OBJECTIVE: Little is known about the treatment uptake rate for adults diagnosed with an eating disorder through formal assessment. This study aimed to identify psychological and eating disorder symptoms that predict whether individuals with diagnosed eating disorders start treatment after receiving a diagnostic assessment and recommendation to begin treatment. Identifying barriers to starting treatment can inform interventions to improve the uptake of treatment. METHOD: After a diagnostic assessment at an eating disorder specialty clinic, 223 adults were recommended to begin treatment and completed self-report measures of psychological functioning, clinical impairment, and eating psychopathology. Patient attendance was assessed to determine rates and predictors of starting treatment within 3 months of the assessment. RESULTS: Of the 223 patients recommended to begin treatment, approximately two-third started treatment within 3 months of the assessment. Logistic regression identified greater avoidance of eating, greater laxative use frequency, more social eating concerns, and lower weight dissatisfaction as predicting lower likelihood of beginning treatment after assessment. A chi-square test for independence found no significant differences between diagnostic groups on starting treatment. DISCUSSION: Findings identify eating disorder symptoms that predict treatment enrollment after diagnostic assessment and recommendation to begin treatment. Assessing for these symptoms at the diagnostic assessment stage is recommended to address potential treatment barriers. Future research should identify strategies that increase treatment uptake at this stage of the process.

Disordered eating, self-esteem, and depression symptoms in Iranian adolescents and young adults: A network analysis.

OBJECTIVE: The network theory of psychopathology examines networks of interconnections across symptoms. Several network studies of disordered eating have identified central and bridge symptoms in Western samples, yet network models of disordered eating have not been tested in non-Western samples. The current study tested a network model of disordered eating in Iranian adolescents and college students, as well as models of co-occurring depression and self-esteem. METHOD: Participants were Iranian college students (n= 637) and adolescents (n = 1,111) who completed the Eating Disorder Examination-Questionnaire (EDE-Q), Rosenberg Self-Esteem Scale (RSES) and Beck Depression Inventory, Second Edition (BDI-II). We computed six Glasso networks and identified central and bridge symptoms. RESULTS: Central disordered eating nodes in most models were a desire to lose weight and discomfort when seeing one's own body. Central self-esteem and depression nodes were feeling useless and self-dislike, respectively. Feeling like a failure was the most common bridge symptom between disordered eating and depression symptoms. With exception of a few differences in some edges, networks did not significantly differ in structure. DISCUSSION: Desire to lose weight was the most central node in the networks, which is consistent with sociocultural theories of disordered eating development, as well as prior network models from Western-culture samples. Feeling like a failure was the most central bridge symptom between depression and disordered eating, suggesting that very low self-esteem may be a shared correlate or risk factor for disordered eating and depression in Iranian adolescents and young adults.

Correlates of suicidal thoughts and attempts in males engaging in muscle dysmorphia or eating disorder symptoms.

OBJECTIVE: Despite the high rates of suicidality in body dysmorphic disorder and eating disorders (EDs), research on suicidality in a related disorder, muscle dysmorphia (MD), is essentially nonexistent. Thus, this study tested relations between suicidal thoughts and behaviors and MD and ED symptoms in an online male community sample. METHOD: A total of 464 males (Mage = 40.3; 85% Caucasian) recruited from Amazon's Mechanical Turk completed measures that evaluated ED symptoms, MD symptoms, current suicidal ideation, and past suicide attempts. RESULTS: Most MD and ED symptoms were correlated with current suicidal ideation and previous suicide attempts. In multivariate regression models, vomiting and appearance intolerance remained significantly related to suicidal ideation, while hard exercise and lower functional impairment were significantly related to prior suicide attempts. CONCLUSION: Results indicate that appearance dissatisfaction, a core MD criterion, and hard exercise, a common behavioral symptom of MD, are associated with suicidality.

Post-traumatic stress disorder as a moderator of transdiagnostic, residential eating disorder treatment outcome trajectory.

OBJECTIVE: Residential treatment for severe eating disorders (EDs) is associated with primarily positive outcomes. However, less is known about the moderators of treatment response. Comorbid post-traumatic stress disorder (PTSD) diagnosis is associated with increased ED symptom severity. This study investigated whether PTSD moderated outcomes of transdiagnostic, residential ED treatment based upon the Unified Protocol. METHOD: Female patients (N = 1055) in residential ED treatment completed a clinical interview to assess PTSD diagnosis and self-reported ED, depression, and anxiety symptoms, anxiety sensitivity, experiential avoidance, and mindfulness. We tested whether PTSD moderated trajectories of symptom change from treatment admission to discharge and 6-month follow-up using multilevel models. RESULTS: PTSD moderated change in ED symptoms, depression severity, and experiential avoidance. Patients with PTSD showed steeper symptom improvements from admission to discharge. However, PTSD was associated with greater symptom recurrence after residential treatment. CONCLUSIONS: Patients with comorbid PTSD demonstrated more improvement during residential treatment, but experienced steeper posttreatment symptom recurrence.

Comparing the clinical presentation of eating disorder patients with and without trauma history and/or comorbid PTSD.

This study examined whether clinical characteristics among patients presenting to residential eating disorder (ED) treatment differed according to patients' trauma history and current PTSD diagnostic status. Participants (699 girls and women) completed surveys at treatment onset. One-way analysis of covariance (ANCOVA) tests assessed cross-sectional differences between three groups of patients: those reporting no trauma history (No Trauma, n = 185), those with trauma history but without PTSD (Trauma, n = 263), and those with current PTSD (PTSD, n = 251). Relative to the No Trauma group, the combined Trauma and PTSD groups reported greater ED symptoms, anxiety and depressive symptoms, experiential avoidance, anxiety sensitivity, and lower mindfulness. The PTSD group reported greater ED, anxiety, and depressive symptoms, greater anxiety sensitivity, and lower mindfulness, relative to the Trauma group. In sum, ED patients with any history of trauma experienced more symptoms and other psychopathology relative to patients who did not report trauma history. Among patients reporting trauma, those with current PTSD experienced even greater symptom severity. Interventions focused on improving emotional functioning could be especially beneficial for ED patients with trauma histories.

Bridging eating disorder symptoms and trait anxiety in patients with eating disorders: A network approach.

OBJECTIVE: Anxiety is thought to influence the development and maintenance of eating disorders (EDs). However, little is known about how, specifically, anxiety influences ED symptoms and vice versa. Network analysis identifies how symptoms within and across disorders are interconnected. In a network, central nodes (i.e., symptoms) have the strongest relations to other nodes and are thought to maintain psychopathology. Bridge nodes are symptoms in one diagnostic cluster that are strongly connected to symptoms in another diagnostic cluster and are thought to explain comorbidity. We identified central and bridge nodes in a network of ED symptoms and trait anxiety features. METHOD: We estimated a regularized partial correlation network in patients with mixed EDs (N = 296). ED symptoms were assessed with the Eating Disorder Examination-Questionnaire. Trait anxiety was assessed with the Trait subscale of the State-Trait Anxiety Inventory. Items to include in the network were selected with a statistical algorithm to ensure that all nodes represented unique constructs. Central and bridge nodes were identified with empirical calculations. RESULTS: Central ED nodes were dietary restraint, as well as overvaluation of and dissatisfaction with shape and weight. The central trait anxiety node was low feelings of satisfaction. The strongest ED bridge node was avoidance of social eating. The strongest trait anxiety bridge node was low self-confidence. DISCUSSION: Avoidance of social eating and low self-esteem may be routes through which EDs and trait anxiety are linked.

Using network analysis to identify central eating disorder symptoms among men.

OBJECTIVE: The network theory of psychopathology has been described as an "innovative framework" that may "transform" clinical psychological science. Several network studies have identified central eating disorder (ED) symptoms, yet studies have been comprised primarily of women. Using two large samples, we constructed ED symptom networks among men to identify central symptoms. METHOD: Participants were recruited from three universities and using Amazon's Mechanical Turk. Participants completed the Eating Disorder Examination-Questionnaire (EDE-Q), Male Body Attitudes Scale, and Drive for Muscularity Scale. ED symptom networks were jointly estimated among men with (n = 248) and without core ED symptoms (n = 902). Core ED symptoms were defined by (a) scoring above a suggested male EDE-Q clinical cutoff and (b) reporting symptoms consistent with probable ED diagnoses. Expected influence and predictability (proportion of each node's variance explained by other nodes in the network) were calculated for each node. RESULTS: Shape overvaluation, desiring weight loss, fear of losing control over eating, feeling guilty for missing weight training, and using supplements had the greatest expected influence and predictability. Network structures did not significantly differ between participants with versus without core ED symptoms. DISCUSSION: The centricity of body dissatisfaction items in the networks supports some components of cognitive behavioral theories of EDs. However, the findings also suggest the importance of muscularity- and leanness-oriented concerns, which have been traditionally neglected from leading ED theories that tend to focus on thinness pursuits as a main driver of body dissatisfaction.

Which Comes First? An Examination of Associations and Shared Risk Factors for Eating Disorders and Suicidality.

PURPOSE OF REVIEW: This narrative review evaluates recent literature on the associations between eating disorders and suicidality and discusses potential shared mechanisms that may account for these relationships. Additionally, the review highlights shortcomings with the literature to date and suggests avenues for future research. RECENT FINDINGS: Individuals with anorexia nervosa, bulimia nervosa, and binge eating disorder experience elevated rates of suicidality compared to the general population. Suicide risk is higher when eating disorders occur with other psychological conditions. Additionally, genetic factors, emotion dysregulation, trauma, stressful life events, and lack of body regard may have roles in the development of both eating disorders and suicidality. Much of the risk for suicidality in eating disorders appears to be driven by comorbid psychopathology and genetic factors. However, the lack of longitudinal research makes it difficult to draw conclusions about the directionality or temporality of these relations; thus, novel methods are needed.

Implicit attitudes toward eating stimuli differentiate eating disorder and non-eating disorder groups and predict eating disorder behaviors.

OBJECTIVE: The current study tested whether people with and without eating disorders (EDs) varied in their implicit attitudes toward ED-relevant stimuli. Additionally, the study tested whether implicit evaluations of ED-relevant stimuli predicted ED symptoms and behaviors over a 4-week interval. METHOD: Participants were people without EDs (N = 85) and people seeking treatment for EDs (N = 92). All participants completed self-report questionnaires and a version of the affect misattribution procedure (AMP) at baseline. The AMP indexed implicit evaluations of average body stimuli, eating stimuli, and ED-symptom stimuli. Participants with EDs completed weekly follow-up measures of ED symptoms and behaviors for 4 weeks. RESULTS: Contrary to predictions, the anorexia nervosa (AN) group did not differ from the no ED group on implicit attitudes toward ED-symptom stimuli, and the bulimia nervosa (BN) group had less positive implicit attitudes toward ED-symptom stimuli relative to the no ED group. In line with predictions, people with AN and BN had more negative implicit attitudes toward average body and eating stimuli relative to the no ED group. In addition, among the ED group more negative implicit attitudes toward eating stimuli predicted ED symptoms and behaviors 4 weeks later, over and above baseline ED symptoms and behaviors. DISCUSSION: Taken together, implicit evaluations of eating stimuli differentiated people with AN and BN from people without EDs and longitudinally predicted ED symptoms and behaviors. Interventions that increase implicit liking of eating-related stimuli may reduce ED behaviors.