Delving into the role of reward and punishment sensitivity in anorexia nervosa: Punishment responsivity as the only predictor of eating disorder symptom persistence in adolescents.

OBJECTIVE: This study differentiated between self-reported punishment responsivity (PR) and motivation to avoid punishment (MP) and examined their relationship with anorexia nervosa (AN) and its course in a combined cross-sectional and longitudinal approach. We explored whether inconsistent findings regarding reward sensitivity may be explained by previous research not differentiating between reward responsivity (RR) and motivation to approach reward (MR). METHOD: Participants were 69 adolescents with AN and 69 adolescents without AN matched on age, sex and educational level. Eating disorder (ED) symptom severity, PR, MP, RR, and MR were assessed at the start of treatment and 1 year later. RESULTS: Only PR was higher in patients with AN than in the comparison group. Both PR and MP decreased over the course of 1 year, however, only the reduction in PR was related to the reduction in ED symptoms. Lastly, only higher baseline PR was independently related to less improvement in ED symptoms over the course of 1 year. CONCLUSION: There was no support for the involvement of RS or its specific dimensions in AN. Most critical, the findings suggest that specifically the PR dimension of punishment sensitivity is related to the persistence of AN and could be an important target for treatment.

Behavioral problems in anxious youth: Cross-sectional and prospective associations with reinforcement sensitivity and parental rejection.

A subsample of children and young people (CYP) with anxiety disorders presents with comorbid behavioral problems. These CYP have greater impairment in daily life, profit less from current treatments, and have an increased risk for continued mental problems. We investigated two potential explanations for these comorbid behavioral problems. First, high punishment sensitivity (PS) may lead to a strong inclination to experience threat, which may not only elicit anxiety but also defensive behavioral problems. Second, behavioral problems may arise from high reward sensitivity (RS), when rewards are not obtained. Behavioral problems may subsequently elicit parental rejection, thereby fueling anxiety. We used a cross-sectional (age = 16.1, N = 61) and prospective (age = 22.2, N = 91) approach to test the relationship between PS/RS and comorbid behavioral problems. Participants were a subsample of highly anxious CYP from a large prospective cohort study. PS/RS were indexed by a spatial orientation task. We also investigated the prospective association between behavioral problems and anxiety at 6-year follow-up, and the proposed mediation by parental rejection. PS and RS showed no cross-sectional or prospective relationships with comorbid behavioral problems in highly anxious CYP. Yet, behavioral problems in adolescence showed a small prospective relationship with anxiety in young adulthood, but this was not mediated nor moderated by parental rejection. No evidence was found for PS/RS being involved in comorbid behavioral problems in anxious CYP. Findings point to comorbid behavioral problems as potential factor contributing to the further increase of anxiety.

The reward and punishment responsivity and motivation questionnaire (RPRM-Q): A stimulus-independent self-report measure of reward and punishment sensitivity that differentiates between responsivity and motivation.

Reward and punishment sensitivity seem important traits in understanding behavior in general and psychopathology in particular. Though the definitions used for reward and punishment sensitivity differentiate between responsivity and motivation, the measures thus far used to assess these constructs do not. Further, specificity of the type of reward (e.g., drugs) and punishment (e.g., spiders) in questionnaires might result in measurement bias especially when examining the relationship with psychopathology. Therefore, we developed a stimulus-independent multidimensional questionnaire of reward and punishment sensitivity that differentiates between responsivity and motivation. This study addresses the psychometric qualities of this newly developed reward and punishment responsivity and motivation questionnaire (RPRM-Q). On the basis of exploratory ordinal factor analysis (N = 273) that was used to examine the quality of the initial pool of 39 items, the number of items was reduced to 18. Confirmatory ordinal factor analysis on the remaining items in an independent sample (N = 328) supported a 18-item four-factor model, and showed acceptable to good internal reliability. The relationship between the subscales of the RPRM-Q and often used questionnaires was examined in the combined sample (N = 601), which showed some first support for the ability of the new questionnaire to differentiate between responsivity and motivation to approach/avoid. The findings indicate that the RPRM-Q might be a helpful instrument to further test the relevance of punishment and reward sensitivity in psychopathology.

Punishment sensitivity and the persistence of anorexia nervosa: High punishment sensitivity is related to a less favorable course of anorexia nervosa.

OBJECTIVE: Cross-sectional research provides robust evidence that individuals with anorexia nervosa (AN) report higher punishment sensitivity (PS) than individuals without an eating disorder (ED). High PS might interfere with treatment motivation and the ability to learn from experience. The current study took a longitudinal approach to test predictions that follow from the proposed relevance of PS as a factor in the persistence of AN symptoms. More specifically we tested (1) if higher PS at the start of treatment was related to less improvement in ED symptoms after one year, and (2) if a decrease in ED symptoms was associated with a concurrent decrease in PS. METHOD: Participants were 69 adolescents with a diagnosis of AN at the start of treatment of whom 62 participated again one year later. ED symptom severity and PS were assessed at both time points. RESULTS: Findings showed that (1) higher PS at the start of treatment was related to less improvement in ED symptoms, and (2) an improvement in ED symptoms was related to a decrease in PS. DISCUSSION: These findings are consistent with the proposed relevance of PS in the persistence of AN and suggest that it might be beneficial to address high PS in treatment. PUBLIC SIGNIFICANCE: Consistent with the view that punishment sensitivity (PS) is related to the persistence of anorexia nervosa, high PS at the start of treatment was related to less improvement in eating disorder symptoms in patients with anorexia nervosa. Furthermore, an improvement in eating disorder symptoms was associated with a concurrent decrease in PS, suggesting that PS can be subject to change and may be a relevant target for treatment.

Satisfaction with normative life domains and the course of anorexia nervosa.

OBJECTIVE: Satisfaction with normative life domains has been proposed as an important factor in the persistence of anorexia nervosa (AN). Initial evidence from a cross-sectional study indicated that individuals with AN reported lower satisfaction with normative life domains than individuals without an eating disorder. As an important next step in understanding causal relations, the present study used a longitudinal design to examine whether an improvement in AN symptoms is paralleled by an increase in satisfaction with normative life domains from baseline to follow-up and whether relatively low satisfaction with normative life domains at baseline is related to less improvement in AN symptoms. METHODS: During baseline and at 1-year follow-up, adolescents with AN (N = 69) completed the Brief Multidimensional Students' Life Satisfaction Scale to measure satisfaction with normative life domains (e.g., friendships, school experience). Furthermore, eating disorder symptoms and BMI were measured. RESULTS: Improvement in eating disorder symptoms, but not in BMI, was paralleled by an increase in satisfaction with normative life domains. Relatively low satisfaction with normative life domains at baseline was not prospectively related to less improvement in eating disorder symptoms or BMI at follow-up. DISCUSSION: Our findings provide initial evidence that satisfaction with normative life domains is a malleable factor which fluctuates with symptom severity in AN. The results of this exploratory study point to the relevance of examining whether targeting satisfactory engagement with specific life domains optimizes treatment effectiveness. PUBLIC SIGNIFICANCE: We explored whether an improvement in anorexia nervosa symptoms from start of treatment to 1-year follow-up would be paralleled by an increase in satisfaction with normative life domains. Improvement in eating disorder symptoms (but not BMI) was indeed related to a concurrent increase in satisfaction with normative life domains. These preliminary results point to the promising possibility that targeting satisfactory engagement with specific life domains may potentially enhance treatment effectiveness.

Why Dieters Succeed or Fail: The Relationship Between Reward and Punishment Sensitivity and Restrained Eating and Dieting Success.

BACKGROUND: The current study set out to improve our understanding of the characteristics of individuals who are motivated to restrict their food intake yet who nevertheless fail to do so. We examined whether punishment sensitivity (PS) was related to restrained eating, and reward sensitivity (RS) to perceived dieting success. Additionally, it was examined whether executive control (EC) moderates the association between RS and perceived dieting success. METHODS: Female student participants (N = 290, aged 17-29, BMI between 18.5 and 38.0) completed questionnaires on restrained eating, perceived dieting success, RS and PS, and carried out a behavioral task to index EC. RESULTS: PS was indeed positively related to restrained eating. RS was positively related to perceived dieting success, yet, EC did not moderate this association. CONCLUSION: The current study adds to the evidence that PS is related to individuals' motivation to restrict their food intake. Furthermore, it shows support for the suggestion that RS may facilitate food restriction.

A Promising Candidate to Reliably Index Attentional Bias Toward Alcohol Cues-An Adapted Odd-One-Out Visual Search Task.

Attentional bias (AB) has been suggested to contribute to the persistence of substance use behavior. However, the empirical evidence for its proposed role in addiction is inconsistent. This might be due to the inability of commonly used measures to differentiate between attentional engagement and attentional disengagement. Attesting to the importance of differentiating between both components of AB, a recent study using the odd-one-out task (OOOT) showed that substance use was differentially related to engagement and disengagement bias. However, the AB measures derived from the OOOT showed insufficient reliability to be used as a solid measure of individual differences. Therefore, the current study aimed to improve the reliability of the AB measures derived from the OOOT by using more distinct contrast stimuli, adding practice trials, increasing the number of trials, and by having participants perform the task in an alcohol-relevant context. We contrasted the original OOOT with the adapted OOOT (i.e., OOOT-adapt) and assessed AB in low- and high-drinking individuals. Participants were 245 undergraduate students who typically tend to drink either low or high amounts of alcohol. In one condition, AB was measured with the original OOOT in a typical laboratory context, whereas in the other condition, AB was measured with the OOOT-adapt in a bar (i.e., alcohol-relevant) context. The OOOT-adapt showed superior internal consistency, especially for the high-drinking group. Further, specifically the OOOT-adapt differentiated between low- and high-drinking participants showing that high drinkers engaged faster with alcohol cues than did low drinkers. Thus, the OOOT-adapt was found to be a promising candidate to reliably index AB in the context of alcohol use. The OOOT-adapt further showed superior criterion validity as it could differentiate between low- and high-drinking individuals, thereby adding to the evidence that AB might be involved in substance use behavior.

Individual differences in avoiding feelings of disgust: Development and construct validity of the disgust avoidance questionnaire.

We developed and examined the construct validity of the Disgust Avoidance Questionnaire (DAQ) as a measure of people's inclination to prevent experiencing disgust (disgust prevention) and to escape from the experience of disgust (disgust escape). In a stepwise item-reduction (Study 1; N = 417) using Exploratory Factor Analysis (EFA) based on a 4-subscale distinction (behavioral prevention, cognitive prevention, behavioral escape, cognitive escape), we selected 17 items from a pool of potential items. In order to incorporate the conceptual overlap between dimensions of disgust avoidance, focus (prevention vs. escape), and strategy (behavioral avoidance vs. cognitive avoidance), we specified an adapted model. In this model, we allowed each item to load on one type of dimension and one type of strategy, resulting in four overlapping factors (prevention, escape, behavioral avoidance, cognitive avoidance). Evaluation of this overlapping 4-factor model (Study 2; N = 513) using Exploratory Structural Equation Modeling (ESEM) and Confirmatory Factor Analysis (CFA) showed promising model fit indices, factor loadings, factor correlations, and reliability estimates for three of the four factors (prevention, behavioral avoidance, cognitive avoidance). Those three subscales also showed good convergent validity. In contrast, the results related to the escape factor may call the suitability of self-report to assess disgust escape into question. In light of the exploratory nature of the project, future examinations of the DAQ's validity and applicability to more diverse samples are essential. A critical next step for future research would be to examine the DAQ's criterion validity and the distinctive roles of the DAQ subscales in (clinical) psychological constructs and processes.

Low satisfaction with normative life domains in adolescents with anorexia nervosa.

OBJECTIVE: Low satisfaction with normative life domains might be an important factor in the persistence of anorexia nervosa (AN). Initial evidence in non-clinical samples showed that lower satisfaction with normative life domains was related to more intense eating disorder symptoms. As a critical next step, the current study examined satisfaction with normative life domains in a clinical sample. Specifically, the present study tested whether adolescents with AN reported lower satisfaction with normative life domains than adolescents without an eating disorder. METHOD: Adolescents with AN (n = 69) and adolescents without an eating disorder matched on age, gender and educational level (n = 69) completed the Brief Multidimensional Students' Life Satisfaction Scale to assess satisfaction with five life domains (family, friendships, school, self and living location) and life in general. RESULTS: Adolescents with AN reported significantly lower satisfaction with normative life domains than the comparison group. Subsequent analyses showed that this overall group difference was primarily driven by adolescents with AN reporting lower satisfaction with the self, school experience and life in general. CONCLUSIONS: Findings supported the hypothesis that adolescents with AN show relatively low satisfaction with meaningful, non-AN-related life domains. This points to the potential relevance of enhancing satisfaction with specific life domains to optimize treatment effectiveness.

Visual attention to food cues and the course of anorexia nervosa.

Previously, adolescents with anorexia nervosa (AN) showed reduced attentional engagement with food cues compared to adolescents without eating disorder (Jonker, Glashouwer, Hoekzema, Ostafin, & De Jong, 2019). This study tested whether (i) improvement in eating disorder symptoms and BMI are related to an increase in attentional engagement with food, and whether (ii) relatively low attentional engagement is related to persistent AN symptomatology, in the same sample of adolescents with AN (N = 69) from the study of Jonker et al. (2019). Eating disorder symptoms, BMI, and attention for food cues were measured during baseline and at one year follow-up. Adolescents with AN showed a substantial improvement in symptoms and BMI. However, their low attentional engagement with food cues remained unchanged. Change in attentional engagement with food was not related to change in symptoms, nor was low baseline attentional engagement with food predictive of symptom persistence. These findings indicate that improvement in AN symptoms does not seem to require an increase in attentional engagement with food.

Influence of hunger on attentional engagement with and disengagement from pictorial food cues in women with a healthy weight.

Because of inconsistencies in the field of attentional bias to food cues in eating behavior, this study aimed to re-examine the assumption that hungry healthy weight individuals have an attentional bias to food cues, but satiated healthy weight individuals do not. Since attentional engagement and attentional disengagement have been proposed to play a distinct role in behavior, we used a performance measure that is specifically designed to differentiate between these two attentional processes. Participants were healthy weight women who normally eat breakfast. In the satiated condition (n = 54), participants were instructed to have breakfast just before coming to the lab. In the fasted condition (n = 50), participants fasted on average 14 h before coming into the lab. Satiated women showed no stronger attentional engagement or attentional disengagement bias to food cues than to neutral cues. Fasted women did show stronger attentional engagement to food cues than to neutral cues that were shown briefly (100 ms). They showed no bias in attentional engagement to food cues that were shown longer (500 ms) or in attentional disengagement from food cues. These findings are in line with the assumption that healthy weight individuals show an attentional bias to food cues when food stimuli are motivationally salient. Furthermore, the findings point to the importance of differentiating between attentional engagement and attentional disengagement.

Heightened self-reported punishment sensitivity, but no differential attention to cues signaling punishment or reward in anorexia nervosa.

This study examined whether adolescents with anorexia nervosa (AN) are more sensitive to punishment and less sensitive to reward than a non-eating disorder comparison group. Both self-report and performance measures were used to index reward and punishment sensitivity. Participants were adolescents with AN (n = 69) and an individually matched comparison group with healthy weight (n = 69). They completed the Behavioral Inhibition Scale/Behavioral Activation Scale and the Sensitivity to Punishment and Sensitivity to Reward Questionnaire to index self-reported reward and punishment sensitivity, and performed the Spatial Orientation Task to index attention to cues signaling reward and punishment. There was extremely strong evidence (BF10 > 100), that adolescents with AN reported higher sensitivity to punishment than adolescents without an eating disorder. However, adolescents with AN did not differ from the comparison group on self-reported reward sensitivity, and attention to cues signaling reward or punishment. Adolescents with AN clearly show heightened punishment sensitivity, yet this was not paralleled by a heightened proneness to detect signals of punishment. An important next step would be to examine whether punishment sensitivity is a reliable risk factor for the development or maintenance of AN.

Attentional bias for alcohol cues in visual search-Increased engagement, difficulty to disengage or both?

Cognitive models emphasise the importance of attentional bias in addiction. However, many attentional bias tasks have been criticised for questionable psychometric properties and inability to differentiate between engagement and disengagement processes. This study therefore examined the suitability of two alternative tasks for assessing attentional bias within the context of alcohol use. Participants were undergraduate students (N = 169) who completed the Visual Search Task and Odd-One-Out Task, the latter of which is designed to differentiate between engagement and disengagement processes of attention, at baseline and one week later. Participants also completed baseline measures of alcohol consumption, craving, and alcohol use problems. Internal consistency was adequate for the Visual Search Task index, and weak for the Odd-One-Out Task indices. Test-retest reliability was weak for both tasks. The Visual Search Task index and the disengagement (but not the engagement) index of the Odd-One-Out Task showed a positive association with alcohol consumption. This study was restricted to a non-clinical student sample. The relatively high error rate of the Odd-One-Out Task might have reduced its sensitivity as an index of attentional bias. Both tasks showed some merit as attentional bias measures, and results suggested that attentional disengagement might be particularly related to alcohol use. However, the reliability of the current measures was inadequate. One potential explanation for the low reliability is that non-clinical samples may have weak and unstable attentional biases to alcohol. Future efforts should be made to improve the psychometric qualities of both tasks and to administer them in a clinical sample.

No Differential Reward Responsivity and Drive, Punishment Sensitivity or Attention for Cues Signaling Reward or Punishment in Adolescents With Obesity.

Although it has been proposed that obese and healthy weight individuals might differ in their reward and punishment sensitivity, the literature shows diverse and inconsistent findings. The current study was set out to examine the role of reward and punishment sensitivity in adolescent obesity by differentiating between reward responsivity and reward drive, and by complementing self-report measures with performance-based measures indexing attention for cues signaling reward and punishment as well as effort to approach reward and avoid punishment. Participants were adolescents aged 12-23, with obesity (n = 51, adjusted BMI [(actual BMI/Percentile 50 of BMI for age and gender) × 100) between 143 and 313%], and with a healthy weight (n = 51, adjusted BMI between 75 and 129%). Individuals with obesity did not significantly differ from adolescents with a healthy weight in reward responsivity, reward drive or attention to cues signaling reward. Further, no differences in self-reported punishment sensitivity or attention for cues signaling punishment were found between obese and healthy weight adolescents. The current study thus does not corroborate the theories that general reward and punishment sensitivity play a role in obesity.

A new approach to facilitating attentional disengagement from food cues in unsuccessful dieters: The bouncing image training task.

This study tested the capacity of a modified Bouncing Image Training Task (BITT) to enhance unsuccessful dieters' attentional disengagement from food cues. Unsuccessful dieters were assigned to a training group performing daily BITT sessions for one week (n = 57) or a waitlist control group (n = 56). Change in attention was assessed using a visual search task and an odd-one-out task. Impact of the BITT on food craving and food intake were also assessed. Participants in the training group, compared to waitlist controls, showed reduced attention to food cues from pre-to post-training. Moreover, the reduction in AB to food cues exhibited by those who completed the BITT reflected the relative facilitation of attentional disengagement from food cues, rather than a reduction in attention engagement with food cues. The groups did not differ on food craving or intake post-training. It is concluded that the BITT is a promising procedure for directly manipulating individuals' attentional disengagement from food cues, though its capacity to enhance dieting success has not yet been established.

Reduced automatic approach tendencies towards task-relevant and task-irrelevant food pictures in Anorexia Nervosa.

BACKGROUND AND OBJECTIVES: Anorexia Nervosa (AN) patients are characterized by an excessive restriction of their food-intake. Prior research using an Affective Simon Task (AST) with food as a task-irrelevant feature, provided evidence for the view that AN patients' ability to refrain from food is facilitated by reduced automatic approach tendencies towards food. However, because food was task-irrelevant (i.e., participants had to base their reaction on the perspective of the picture and not on its content), the findings may in fact reflect a relatively strong ability to ignore the content of the food stimuli rather than weakened approach towards food per se. Therefore, this study also included a Stimulus Response Compatibility (SRC) task with food as task-relevant feature that could not be ignored, because the required response depended on the [food vs non-food] content of the pictures. METHODS: AN spectrum patients (n = 63), and a comparison group of adolescents without eating pathology (n = 57) completed both a SRC task with food as task-relevant feature, and an Affective Simon Task AST with food as task-irrelevant feature. RESULTS: AN patients showed reduced approach tendencies for high caloric food. Only the SRC uniquely predicted the presence of AN. LIMITATIONS: Comparison between tasks was hampered because the SRC only included high caloric food stimuli, whereas the AST included high and low caloric food stimuli. CONCLUSION: Patients with AN are characterized by weakened automatic approach of high caloric food. This might 'help' restrict their food-intake even in a condition of starvation.

Attentional engagement with and disengagement from food cues in Anorexia Nervosa.

This study examined differences in food-related Attentional Bias (AB) between patients with Anorexia Nervosa (AN) and adolescents without an eating disorder. AB was assessed with an Attentional Response to Distal versus Proximal Emotional Information (ARDPEI) task that was specifically designed to differentiate between attentional engagement with and attentional disengagement from food. We tested if patients with AN would show less attentional engagement and less difficulty to disengage their attention from food cues than individuals without an eating disorder. Both might contribute to patients' ability to refrain from eating even in a state of starvation. Participants were adolescents with AN (n = 69) and a comparison group with healthy weight, matched on age and educational level (n = 69). No differences were found in attentional disengagement. However, patients with AN did show less attentional engagement when food cues were shown briefly (100 ms). Given that the adolescents without an eating disorder showed a significant engagement bias to food cues, the results suggest that patients with AN lack the bias involved in healthy eating behavior. Future studies should further examine the direction of the relationship between decreased attentional engagement with food cues and anorexia nervosa.

Reinforcement sensitivity and restrained eating: the moderating role of executive control.

PURPOSE: As the prevalence of overweight and obesity are still increasing, it is important to help individuals who encounter difficulty with losing weight. The current study was set out to further investigate characteristics of individuals who are highly motivated to restrict their food intake to lose weight, but fail to do so (i.e., restrained eaters). The motivation to lose weight might stem from high punishment sensitivity, whereas the failure to succeed in restricting food intake might be the result of high reward sensitivity. Thus, it was examined whether restrained eaters are characterized by both high reward sensitivity and high punishment sensitivity. Additionally, this is the first study to examine executive control as a potential moderator of this relationship. METHODS: Female undergraduates (N = 60) performed a behavioral measure of executive control, and completed the Restraint Scale to index level of restrained eating as well as two questionnaires on reinforcement sensitivity; the Behavioral Inhibition Scale/Behavioral Activation Scale, and the Sensitivity to Punishment and Sensitivity to Reward Questionnaire. RESULTS: There was a positive relationship between restrained eating and punishment sensitivity as indexed by both questionnaires. Reward sensitivity as measured by both indices was not directly related to restrained eating. Executive control moderated the relation between reward responsivity (but not reward-drive) and restrained eating; specifically in women with relatively weak executive control there was a positive relationship between reward responsivity and restrained eating behavior. CONCLUSION: In women with low executive control, restrained eating is associated with both heightened sensitivity to punishment and heightened responsivity to reward.

Attentional Bias for Reward and Punishment in Overweight and Obesity: The TRAILS Study.

More than 80% of obese adolescents will become obese adults, and it is therefore important to enhance insight into characteristics that underlie the development and maintenance of overweight and obesity at a young age. The current study is the first to focus on attentional biases towards rewarding and punishing cues as potentially important factors. Participants were young adolescents (N = 607) who were followed from the age of 13 until the age of 19, and completed a motivational game indexing the attentional bias to general cues of reward and punishment. Additionally, self-reported reward and punishment sensitivity was measured. This study showed that attentional biases to cues that signal reward or punishment and self-reported reward and punishment sensitivity were not related to body mass index or the change in body mass index over six years in adolescents. Thus, attentional bias to cues of reward and cues of punishment, and self-reported reward and punishment sensitivity, do not seem to be crucial factors in the development and maintenance of overweight and obesity in adolescents. Exploratory analyses of the current study suggest that the amount of effort to gain reward and to avoid punishment may play a role in the development and maintenance of overweight and obesity. However, since the effort measure was a construct based on face validity and has not been properly validated, more studies are necessary before firm conclusions can be drawn.