An empirical taxonomy of reward response patterns in a transdiagnostic eating disorder sample.

Reward response patterns may contribute to risk and maintenance of eating disorders (EDs), and there may be clinically meaningful heterogeneity in behavioral responses to different actual and anticipated rewards across ED diagnoses. We used an empirical approach to classify individuals with EDs based on self-reported tendencies for responding to reward-related stimuli. Latent profile analysis was conducted in a transdiagnostic ED sample (N = 104) using Temperament and Character Inventory (Cloninger et al., 1993) subscales to categorize participants on reward responses of behavioral activation towards immediate, hedonic rewards (Novelty Seeking subscale), persistence towards long-term rewards (Persistence subscale), and maintenance by social rewards (Reward Dependence subscale) rewards. Two profiles were identified: (1) Behavioral Activation group (elevated Novelty Seeking; n = 62); and (b) Behavioral Persistence group (elevated Persistence; n = 42). Generalized linear models comparing profiles showed that frequency of these reward response profiles did not differ in probable AN, BN, or OSFED groups; however, individuals with probable BED more often demonstrated the Behavioral Activation profile (p = .041). These profiles exhibited comparable ED severity, but different presentations. Across probable ED diagnoses, the Behavioral Activation group reported greater binge eating (p = .006, d = 0.32) and had higher BMIs (p = .001, d = 0.57); the Behavioral Persistence group endorsed greater driven exercise (p = .042, d = 0.33). Categorization by activation to novel, immediate rewards versus persistence towards long-term rewards was associated with different symptoms across diagnoses, potentially supporting the role of specific reward response profiles in ED phenomenology.

Neurobiological and Psychological Maintenance Mechanisms Associated with Anticipatory Reward in Bulimia Nervosa.

The purpose of this investigation is to identify the anticipatory reward mechanisms that maintain binge eating and purging in bulimia nervosa. Emerging data indicate the importance of reward and anticipatory processes as maintenance mechanisms of bulimia nervosa that can be targeted in treatment. The proposed research will identify neurobiological and psychological anticipatory mechanisms of binge eating and purging using functional magnetic resonance imaging (fMRI), and ecological momentary assessment (EMA) in the natural environment. In this investigation, 60 adults (30 with bulimia nervosa and 30 matched comparison participants) will undergo negative and positive mood inductions followed by an fMRI food selection task (and a comparison shopping task) to examine neurobiological and affective responses to food and non-food reward anticipation. Participants with bulimia nervosa will complete two weeks of EMA examining real-time affect changes in relation to the anticipation of binge eating and purging. These methods will facilitate rigorous assessment of the links between neurobiological (fMRI) and naturalistic (EMA) data in anticipatory reward processes. Findings from this investigation will inform the conceptualization and treatment of bulimia nervosa by identifying the role of reward anticipation in symptom maintenance, providing a crucial framework for targeting these anticipatory processes in existing and novel interventions.

Resting State Hypoconnectivity of Reward Networks in Binge Eating Disorder.

The clinical presentation of binge eating disorder (BED) and data emerging from task-based functional neuroimaging research suggests that this disorder may be associated with alterations in reward processing. However, there is a dearth of research investigating the functional organization of brain networks that mediate reward in BED. To address this gap, 27 adults with BED and 21 weight-matched healthy controls (WMC) completed a multimodel assessment consisting of a resting functional magnetic resonance imaging scan, behavioral tasks measuring reward-based decision-making (i.e., delay discounting and reversal learning), and self-report assessing clinical symptoms. A seed-based approach was employed to examine the resting state functional connectivity (rsFC) of the striatum (nucleus accumbens [NAcc] and ventral and dorsal caudate), a collection of regions implicated in reward processing. Compared with WMC, the BED group exhibited lower rsFC of striatal seeds, with frontal regions mediating executive functioning (e.g., superior frontal gyrus [SFG]) and posterior, parietal, and temporal regions implicated in emotional processing. Lower NAcc-SFG rsFC was associated with more difficulties with reversal learning and binge eating frequency in the BED group. Results suggest that hypoconnectivity of striatal networks that integrate self-regulation and reward processing may promote the clinical phenomenology of BED. Interventions for BED may benefit from targeting these circuit-based disturbances.

Longitudinal associations between emotion regulation skills, negative affect, and eating disorder symptoms in a clinical sample of individuals with binge eating.

OBJECTIVE: Although deficits in emotion regulation have been implicated in the maintenance of binge eating, few prospective studies have examined longitudinal associations between emotion regulation and eating disorder symptoms, which are needed to test these theoretical models. METHOD: Using a naturalistic design, the current study utilized longitudinal multilevel analyses to examine whether improvements in emotion regulation during treatment are associated with decreased binge eating frequency and eating disorder cognitions in a heterogeneous sample of adults with binge eating (N = 97). Analyses also accounted for between- and within-person differences in negative affect to inform specific targets for intervention. RESULTS: Significant within-person associations between emotion regulation, negative affect, and eating disorder severity support hypotheses that emotion dysregulation and negative affect co-occur with eating disorder psychopathology. Only between-person differences in negative affect demonstrated associations with binge eating frequency over time. DISCUSSION: Data suggest that momentary interventions targeting negative affect and emotion regulation skills may decrease eating disorder cognitions, but not binge eating frequency, among adults with binge eating.

Relationships between eating disorder-specific and transdiagnostic risk factors for binge eating: An integrative moderated mediation model of emotion regulation, anticipatory reward, and expectancy.

Although relationships between negative affect, emotion dysregulation, and binge eating have been well-established, the mechanisms and individual risk factors that account for this relationship have yet to be elucidated. In addition to emotion dysregulation, altered reward functioning and negative affect eating expectancies (i.e., the expectancy that eating will relieve negative affect) are factors that have been previously linked to binge eating, though theoretical frameworks have not provided an integrated conceptualization of relationships between these domains. Therefore, the present study examined an integrative moderated mediation model among a sample of 101 adults with self-reported eating disorder (ED) symptoms who completed a battery of online questionnaires. Results supported the hypothesized model, which demonstrated that eating expectancies mediated the relationship between emotion dysregulation and binge eating frequency, and there was a positive association between emotion dysregulation and eating expectancies among individuals high in anticipatory reward. These findings provide preliminary support for an integrated approach to understanding transdiagnostic and ED-specific risk factors that potentiate binge eating.

A test of a state-based, self-control theory of binge eating in adults with obesity.

It has been theorized that state the levels of self-control depletion (as caused by negative affect and restraint) may lead to binge eating (BE) when individuals also endorse momentary expectancies that eating will make them feel better (EE). Given commonalities in precipitants of BE across populations, the current study tested this theory in a sample of adults with obesity using ecological momentary assessment (EMA). Fifty obese adults completed the EMA protocol during which they provided pre-eating episode ratings of negative affect, restraint, and EE, and post-eating episode ratings of BE. Generalized estimating equations (GEE) identified a 3-way interaction between within-person pre-eating episode variables: higher self-control depletion (e.g., higher restraint and higher negative affect) was predictive of BE episodes only when individuals also endorsed higher EE. To our knowledge, this is the first empirical test of this theory, highlighting the impact of momentary self-control depletion and EE on BE in obese adults.

Executive functioning in a racially diverse sample of children who are overweight and at risk for eating disorders.

Difficulties with executive functioning may underlie both overweight and loss of control (LOC) eating behavior across the age spectrum, but there is a relative paucity of research in children with both conditions. This study aimed to characterize general executive functioning among children with overweight and LOC eating as compared to their overweight and normal-weight peers. Participants were 75 racially diverse children (58.7% female; 81.3% African-American), aged 9-12y (M age = 10.5 ± 1.1), of whom 26 were overweight/obese and endorsed LOC eating (OW-LOC), 34 were overweight controls (OW-CON), and 15 were normal-weight controls (NW-CON). All children completed interview-based measures of eating pathology, and behavioral measures of executive functioning. Parents reported on behavioral facets of children's executive functioning. Groups were compared across parent-report measures and behavioral tasks using analyses of covariance (ANCOVAs) and multivariate analyses of covariance (MANCOVAs) which adjusted for general intellectual functioning. Significant group differences were revealed on a behavioral measure of planning, the Tower of London task [F (5,65) = 3.52; p = 0.007], and a behavioral measure of working memory, the List Sorting task [F (2,71) = 6.45; p = 0.003]. Post-hoc tests revealed that OW-LOC and OW-CON performed worse than NW-CON on the Tower of London, with relative decrements in accuracy rather than performance time. Further, OW-LOC performed worse than both OW-CON and NW-CON on the List Sorting task. Overweight with or without concomitant LOC eating in children may characterize a unique pattern of executive dysfunction. Interventions for eating- and weight-related problems in youth should address underlying deficits in planning and working memory.

Associations of borderline personality disorder traits with stressful events and emotional reactivity in women with bulimia nervosa.

Borderline personality disorder (BPD) traits are common among those with bulimia nervosa (BN). However, how these traits impact the state experience of precipitants of BN behavior, such as stressful events and emotional reactivity, has not been determined. Thus, the purpose of this naturalistic study was to examine this trait-state association in BN. Women with DSM-IV BN (N = 133) completed a baseline measure of personality pathology traits, and subsequently recorded their affective state and the frequency and perception of 3 types of stressful events (interpersonal, work/environment, and daily hassles) several times per day for 2 weeks using ecological momentary assessment (EMA). Pearson correlations assessed the associations between BPD traits (affective lability, identity problems, insecure attachment, and cognitive dysregulation) and (a) frequency of stressful events and (b) perception of stressful events. Generalized linear models (GLM) were used to evaluate the relationship between BPD traits and changes in negative affect following stressful events. Results revealed that while all traits were significantly associated with perceived stressfulness, certain BPD traits were significantly associated with the frequency of stressful events. Individuals with higher trait insecure attachment experienced larger increases in negative affect following interpersonal stressful events. These findings suggest that interventions focused on addressing stressful events and enhancing adaptive emotional responses to interpersonal events may be particularly useful for a subset of individuals with BN with BPD-related personality characteristics, including insecure attachment, affective lability, and identity problems. (PsycINFO Database Record

Stability and change in patterns of eating disorder symptoms from adolescence to young adulthood.

Using a community adolescent sample, we aimed to (a) empirically derive eating disorder (ED) symptom groups, (b) examine the longitudinal stability of those groups over 10 years, and (c) identify risk factors associated with ED group stability and transition through young adulthood. Young people (N = 2,287) from the Project EAT cohort participated at baseline (1998-1999) and at 10-year follow-up (2008-2009). Participants completed anthropometric measures at baseline and self-report surveys on disordered eating symptoms and risk factors at both time points. Latent transition modeling was used to test the first two aims and multinomial logistic regression was used for the third aim. Three groups emerged and were labeled as: (a) asymptomatic, (b) dieting, (c) disordered eating (e.g., binge eating, compensatory behaviors). Stability of group membership over 10 years was highest for those in the asymptomatic group, while those in the dieting group showed equal likelihood of transitioning to any group. There was a 75% chance that those in the disordered eating group would continue to belong to a symptomatic group 10 years later. We found that these transitions could be predicted by baseline risk factors. For example, adolescents with one standard deviation higher depressive symptoms than their peers had 53% higher odds (OR = 1.53, 95% CI 1.09-2.16) of transitioning from the asymptomatic group to the disordered eating group. Transition among ED groups is relatively common during adolescence and early adulthood. By targeting risk factors such as self-esteem and familial factors in early adolescence, prevention efforts may be improved.

Contextual factors associated with eating in the absence of hunger among adults with obesity.

Eating in the absence of hunger (EAH) is under-explored in adults with obesity. In this study, 50 adults with obesity recorded eating episodes and theoretically-relevant environmental, perceptual, and emotional correlates in the natural environment for 2weeks via ecological momentary assessment (EMA). Generalized linear models and mixed models were used to characterize correlates and consequences of EAH vs. non-EAH episodes/tendencies (within-subjects and between-subjects effects, respectively), time of day, and time of day×EAH interactions. Approximately 21% of EMA-recorded eating episodes involved EAH, and 70% of participants reported at least 1 EAH episode. At the within-person level, participants' EAH episodes were associated with greater self-labeled overeating than their non-EAH episodes. At the between-person level, participants who tended to engage in more EAH reported less self-labeled overeating than those who engaged in less EAH. Across EAH and non-EAH episodes, eating in the evening was associated with overeating, expecting eating to be more rewarding, greater alcoholic beverage consumption, eating alone, eating because others are eating, and eating while watching television. Significant EAH×time of day interactions were also observed but the pattern of findings was not consistent. Findings suggest that EAH may be a relevant target for reducing food intake in individuals with obesity given its high prevalence and association with perceptions of overeating, although results should be extended using objective measures of food intake. Associations between evening eating episodes and perceptual and environmental factors should be further explored.

Empirically derived personality subtyping for predicting clinical symptoms and treatment response in bulimia nervosa.

OBJECTIVE: Evidence suggests that eating disorder subtypes reflecting under-controlled, over-controlled, and low psychopathology personality traits constitute reliable phenotypes that differentiate treatment response. This study is the first to use statistical analyses to identify these subtypes within treatment-seeking individuals with bulimia nervosa (BN) and to use these statistically derived clusters to predict clinical outcomes. METHODS: Using variables from the Dimensional Assessment of Personality Pathology-Basic Questionnaire, K-means cluster analyses identified under-controlled, over-controlled, and low psychopathology subtypes within BN patients (n = 80) enrolled in a treatment trial. Generalized linear models examined the impact of personality subtypes on Eating Disorder Examination global score, binge eating frequency, and purging frequency cross-sectionally at baseline and longitudinally at end of treatment (EOT) and follow-up. In the longitudinal models, secondary analyses were conducted to examine personality subtype as a potential moderator of response to Cognitive Behavioral Therapy-Enhanced (CBT-E) or Integrative Cognitive-Affective Therapy for BN (ICAT-BN). RESULTS: There were no baseline clinical differences between groups. In the longitudinal models, personality subtype predicted binge eating (p = 0.03) and purging (p = 0.01) frequency at EOT and binge eating frequency at follow-up (p = 0.045). The over-controlled group demonstrated the best outcomes on these variables. In secondary analyses, there was a treatment by subtype interaction for purging at follow-up (p = 0.04), which indicated a superiority of CBT-E over ICAT-BN for reducing purging among the over-controlled group. DISCUSSION: Empirically derived personality subtyping appears to be a valid classification system with potential to guide eating disorder treatment decisions. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:506-514).

Examining the role of self-discrepancy and self-directed style in bulimia nervosa.

Two of the primary components within Integrative Cognitive Affective Therapy (ICAT) are self-discrepancy and self-directed style. Self-discrepancy includes both actual:ideal (discrepancy between oneself and who one wishes they were) and actual:ought (discrepancy between oneself and who one believes they ought to be). Self-directed style in ICAT refers to a variety of behaviors emitted by a person toward the self including self-blaming and self-affirming. This study explored main effects and interactions between self-discrepancy and self-directed style in relation to global eating disorder (ED) psychopathology, depressive symptoms, and anxiety. Eighty treatment-seeking adults from the Midwest with BN or subthreshold BN completed interviews and self-report measures. Self-affirm and self-blame were associated with ED psychopathology, depressive symptoms, and anxiety. Actual:ideal discrepancy was related to anxiety and actual:ought discrepancy was related to anxiety and depressive symptoms. Interactions were found between self-affirm and actual:ought discrepancy as well as self-blame and actual:ought discrepancy for depressive symptoms. High actual:ought was related to increased depressive symptoms regardless of levels of self-affirm or self-blame. Effect sizes for models were medium-to-large with anxiety models demonstrating the largest effects. This study provides further evidence supporting the ICAT model and treatment, which targets self-discrepancies, self-directed styles, and related emotional states.

Personality psychopathology differentiates risky behaviors among women with bulimia nervosa.

OBJECTIVE: Individuals with bulimia nervosa (BN) frequently endorse risky behaviors such as self-harm and substance use. However, no studies of BN to date have examined factors associated with engaging in individual or co-occurring risky behaviors. Given that individuals with BN often have personality psychopathology, which has been linked to symptoms and course of illness, this study sought to examine how personality may differentiate engagement in risky behaviors among BN individuals. METHOD: A sample of 133 women with BN completed self-report measures of personality psychopathology at baseline, and then reported on bulimic and risky behaviors (e.g., substance misuse, self-harm) over 2 weeks using ecological momentary assessment. A series of hierarchical multiple regression analyses were conducted to examine the unique associations between state-level predictor variables (each risky behavior, e.g., substance misuse, and combination of risky behaviors, e.g., substance misuse plus self-harm) and trait-level personality constructs. RESULTS: Substance misuse behavior, above and beyond all other risky behaviors, was significantly associated with higher scores on trait dissocial behavior (P = 0.004). DISCUSSION: Substance misuse in BN has a unique association with dissocial behavior, a personality trait characterized by hostility, impulsivity, and entitlement. These results suggest that targeting personality variables may help facilitate more effective treatment of risky behaviors, including substance use in BN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:681-688).

Investigating the reinforcing value of binge anticipation.

Binge eating is a hallmark feature of several types of eating disorders, including bulimia nervosa, anorexia nervosa (binge/purge type), and binge-eating disorder, and is associated with numerous harmful consequences. For decades, researchers have sought to understand what maintains and reinforces this behavior in the face of such profound negative consequences. In this context, researchers have focused on the binge-eating behavior itself, and given little consideration to what may be a crucial part of the process: anticipating or planning binge-eating episodes. In this article, we discuss binge anticipation, its potential reinforcing value, and methodologies which would allow researchers to investigate this potentially critical process in individuals who binge eat. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:539-541).

Factors Predicting an Escalation of Restrictive Eating During Adolescence.

PURPOSE: To examine longitudinal risk factors and short-term risk correlates for the development of extreme forms of restrictive eating among adolescent dieters. METHODS: Data from Project Eating and Activity in Teens and Young Adults, a population-based study of 2,516 students aged 12-18 years, were collected in 1998-1999 (Time 1) and 5 years later (Time 2). Within this sample, 243 adolescents who reported dieting but not engaging in disordered forms of restrictive eating (e.g., fasting, skipping meals) at Time 1 were followed to determine the self-reported psychological, familial, and social variables predicting initiation of disordered restrictive eating at Time 2. To investigate short-term risk correlates of initiating disordered restrictive eating, the same risk factors were also compared cross-sectionally at Time 2 between the dieters who had and had not initiated disordered restrictive eating. Poisson regression models with robust standard errors were fit for each predictor adjusted for covariates. RESULTS: Depressive symptoms and low self-esteem were significantly associated with the initiation of disordered restrictive eating in both longitudinal and cross-sectional analyses. Poor family communication/caring and maternal dieting significantly predicted long-term risk for escalating restrictive eating severity; whereas, individual body image issues (i.e., weight concerns, body dissatisfaction) and social concerns (i.e., weight-related teasing, peer dieting) were significant short-term correlates of initiating disordered restrictive eating. CONCLUSIONS: Depressive symptoms and low self-esteem may be especially important targets for risk identification and prevention for disordered restrictive eating. Intervening on family influences may decrease long-term risk, whereas intervening on body image and responses to social influences may decrease short-term risk for disordered restrictive eating.

Bulimic symptom onset in young girls: A longitudinal trajectory analysis.

To investigate whether there are different patterns of development for binge eating and purging behavior among preadolescent and early adolescent girls, we conducted trajectory analyses of those behaviors in 938 girls across 8 waves of data from the spring of 5th grade (the last year of elementary school) through the spring of 9th grade (the first year of high school). Analyses revealed 4 separate developmental trajectories for binge eating behavior (labeled none, increasing, decreasing, and high steady) and 3 separate developmental trajectories for purging behavior (labeled none, dabble, and increasing). Fifth grade scores on risk factors that were both transdiagnostic (negative affect and negative urgency) and eating disorder specific (expectancies for reinforcement from eating and from thinness) differentiated among the trajectory groups, in some cases before the groups differed in the target behaviors. These findings are the first, to our knowledge, to examine developmental trajectories for bulimic symptom onset in youth as young as elementary school. Clinical implications are discussed.

A risk and maintenance model for bulimia nervosa: From impulsive action to compulsive behavior.

This article offers a new model for bulimia nervosa (BN) that explains both the initial impulsive nature of binge eating and purging, as well as the compulsive quality of the fully developed disorder. The model is based on a review of advances in research on BN and advances in relevant basic psychological science. It integrates transdiagnostic personality risk, eating-disorder-specific risk, reinforcement theory, cognitive neuroscience, and theory drawn from the drug addiction literature. We identify both a state-based and a trait-based risk pathway, and we then propose possible state-by-trait interaction risk processes. The state-based pathway emphasizes depletion of self-control. The trait-based pathway emphasizes transactions between the trait of negative urgency (the tendency to act rashly when distressed) and high-risk psychosocial learning. We then describe a process by which initially impulsive BN behaviors become compulsive over time, and we consider the clinical implications of our model. (PsycINFO Database Record

A longitudinal test of impulsivity and depression pathways to early binge eating onset.

OBJECTIVE: The very early engagement in bulimic behaviors, such as binge eating, may be influenced by factors that dispose individuals to impulsive action as well as by factors that dispose individuals to depressive symptomatology. Using a longitudinal design, we conducted the first test of the simultaneous operation of both risk factors as children transition from elementary to middle school. METHOD: In a sample of 1,906 children, we assessed risk for impulsive action (negative urgency, which is the tendency to act rashly when distressed, and eating expectancies, which are learned anticipations that eating will alleviate negative mood) and risk for depression (negative affect and depressive symptomatology) and binge eating behavior at three time points using a longitudinal design: the end of fifth grade (last year of elementary school: T0), the beginning of sixth grade (first year of middle school: T1), and the end of sixth grade (T2). RESULTS: Both the impulsive action and depression pathways predicted very early engagement in binge eating: each accounted for variance beyond the other. Mediation tests found that T1 eating expectancies mediated the predictive influence of T0 negative urgency on T2 binge eating (z = 2.45, p < .01) and that T1 depressive symptoms mediated the influence of T0 negative affect on T2 binge eating (z = 2.04, p < .05). DISCUSSION: In children, elevated levels of both negative urgency and negative affect predict early binge eating. This finding has important clinical implications because there are different interventions for the two different risk processes.

Two pathways toward impulsive action: an integrative risk model for bulimic behavior in youth.

BACKGROUND: This study provides an integrative review of existing risk factors and models for bulimia nervosa (BN) in young girls. We offer a new model for BN that describes two pathways of risk that may lead to the initial impulsive act of binge eating and purging in children and adolescents. SCOPE: We conducted a selective literature review, focusing on existing and new risk processes for BN in this select population. FINDINGS: We identify two ways in which girls increase their risk to begin engaging in the impulsive behavior of binge eating and purging. The first is state-based: the experience of negative mood, in girls attempting to restrain eating, leads to the depletion of self-control and thus increased risk for loss of control eating. The second is personality-based: elevations on the trait of negative urgency, or the tendency to act rashly when distressed, increase risk, particularly in conjunction with high-risk psychosocial learning. We then briefly discuss how these behaviors are reinforced, putting girls at further risk for developing BN. CONCLUSIONS: We highlight several areas in which further inquiry is necessary, and we discuss the clinical implications of the new risk model we described.

Validation of an existing measure of eating disorder risk for use with early adolescents.

This study tested a brief eating disorder risk measure, originally developed for use with college students, in young adolescents. The measure is called the COEDS (College Eating Disorders Screen) and is constructed of items written in everyday language used by youth to discuss weight issues, rather than in the language of symptom assessment. A sample of 246 early adolescents (mean age, 13) completed questionnaire measures of puberty, eating disorder behavior, and eating disorder risk two times in a 12-month span. We found that: (a) the COEDS was internally consistent; (b) COEDS scores were stable across one year; and (c) COEDS scores predicted restricting and compensatory behavior one year later, above and beyond prediction from sex, race, prior restricting and compensatory behavior, and prior BMI. The COEDS appears to be a reliable and valid measure for risk assessment in youth; it may prove useful for researchers and clinicians interested in screening for risk and as a means to test whether prevention efforts have reduced risk.