Examining anxious temperament in anorexia nervosa: Behavioural inhibition and intolerance of uncertainty and their contribution to trait anxiety in adolescents with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious and complex psychiatric disorder yet treatment results are suboptimal. Insight into the etiology of this illness is much needed. Research highlights the implication of anxiety-related traits in the development and maintenance of AN. This study investigates firstly, behavioural inhibition and intolerance for uncertainty (IU) in adolescents with and without AN, and secondly relations between these traits. METHODS: In a cross-sectional study, 165 adolescent girls (AN = 94, HC = 71) completed questionnaires measuring behavioural inhibition, IU and trait anxiety. ANOVAs tested differences between AN and HC groups, and mediation models with IU as a mediator between behavioural inhibition and trait anxiety were run. RESULTS: AN adolescents reported significantly higher levels of behavioural inhibition, IU and trait anxiety compared to their peers. In both AN and HC, a direct and a total effect of behavioural inhibition on trait anxiety was found. However, only in the AN group IU partially mediated the relation between behavioural inhibition and trait anxiety. LIMITATIONS: Data is cross-sectional and longitudinal studies are required. A mean illness duration of nearly 2 years may mean early effects of malnourishment and habituation and future studies should include patients with shorter illness duration. CONCLUSIONS: Results highlight that behavioural inhibition and IU may contribute to anxiety in AN whilst their peers may have developed better executive and social-emotional skills to manage uncertainty. Adolescents with AN may benefit from interventions targeting behavioural inhibition and IU.

Intolerable feelings of uncertainty within the body: Associations between interoceptive awareness, intolerance of uncertainty, and body dissatisfaction.

BACKGROUND: Adolescence is a period marked by important physical and social changes, which often leads to an increase of body dissatisfaction. Recent studies have shown an association between interoception and body dissatisfaction in female adolescents. One variable that may contribute to the association between interoceptive awareness and body dissatisfaction is intolerance of uncertainty (IU). This study aims to investigate multiple facets of interoceptive awareness, IU, and their relations with body dissatisfaction in adolescent girls. METHODS: In a cross-sectional study, a convenience sample of 307 adolescent girls (mean age = 17.73; SD = 1.02) was recruited in the Netherlands in 2022. Three questionnaires were completed measuring interoceptive awareness, IU, and body dissatisfaction. A moderation analyses using a multiple hierarchical regression was used to investigate associations between variables. RESULTS: Correlation analyses indicated that several facets of lower interoceptive awareness (Not distracting, Not worrying and Trusting) were related to higher levels of body dissatisfaction. IU only marginally moderated the relationship between several domains of interoceptive awareness (Notice, Attention regulation and Emotional awareness) and body dissatisfaction. DISCUSSION: Findings suggest that experiencing bodily signals as ambiguous and uncertain may result in more complex body image issues. Within certain domains of interoceptive awareness, IU may affect the process of appraising bodily signals. Furthermore, adolescent girls who do not feel safe in their body and who find it difficult to distract their thoughts when experiencing pain or discomfort in their body may be particularly at risk for developing more complex body image disturbances and may benefit from interventions improving both interoceptive awareness and IU. Moreover, future research should focus on interoceptive awareness and IU as potential underlying mechanisms for body image issues.

Understanding relations between intolerance of uncertainty and body checking and body avoiding in anorexia nervosa.

BACKGROUND: A key feature of anorexia nervosa is body image disturbances and is often expressed by dysfunctional body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of AN, yet empirical evidence is scarce. One variable that may contribute to the need for engaging in these behaviours is intolerance of uncertainty. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127). METHODS: Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. One-way ANOVAS were used to test group differences. Moderation analyses were used to investigate associations between variables. RESULTS: Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill followed by AN-rec and, lastly, the control group, confirming group differences. Intolerance of uncertainty was associated with body checking in the AN-rec group and the control group but not in the AN-ill group. The association between intolerance of uncertainty and body avoiding was reported in the AN-rec group and only marginally in the control group. CONCLUSION: Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill, however still elevated in AN-rec, confirming the presence of body image disturbances, even after recovery. The unique associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may eventually have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty. Women with anorexia nervosa often experience disturbances in their body image and are expressed in body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of anorexia nervosa. Intolerance of uncertainty is defined as the incapacity to tolerate uncertainty and may contribute to the need for engaging in these behaviours. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127). Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill and still elevated in AN-rec, even after recovery. The associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty.

Persistence, Reward Dependence, and Sensitivity to Reward Are Associated With Unexpected Salience Response in Girls but Not in Adult Women: Implications for Psychiatric Vulnerabilities.

BACKGROUND: Adolescence is a critical period for the development of not only personality but also psychopathology. These processes may be specific to sex, and brain reward circuits may have a role. Here, we studied how reward processing and temperament associations differ across adolescent and adult females. METHODS: A total of 29 adolescent girls and 41 adult women completed temperament assessments and performed a classical taste conditioning paradigm during brain imaging. Data were analyzed for the dopamine-related prediction error response. In addition, unexpected stimulus receipt or omission and expected receipt response were also analyzed. Heat maps identified cortical-subcortical brain response associations. RESULTS: Adolescents showed stronger prediction error and unexpected receipt and omission responses (partial η2 = 0.063 to 0.166; p = .001 to .043) in insula, orbitofrontal cortex (OFC), and striatum than adults. Expected stimulus receipt response was similar between groups. In adolescents versus adults, persistence was more strongly positively related to prediction error (OFC, insula, striatum; Fisher's z = 1.704 to 3.008; p = .001 to .044) and unexpected stimulus receipt (OFC, insula; Fisher's z = 1.843 to 2.051; p = .014 to .033) and negatively with omission (OFC, insula, striatum; Fisher's z = -1.905 to -3.069; p = .001 to .028). Reward sensitivity and reward dependence correlated more positively with unexpected stimulus receipt and more negatively with stimulus omission response in adolescents. Adolescents showed significant correlations between the striatum and FC for unexpected stimulus receipt and omission that correlated with persistence but were absent in adults. CONCLUSIONS: Associations between temperamental traits and brain reward response may provide neurotypical markers that contribute to developing adaptive or maladaptive behavior patterns when transitioning from adolescence to adulthood.

How deep is your thought? The relations between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa.

BACKGROUND: Inherent to anorexia nervosa are repetitive thoughts about weight and shape. Growing research suggests the relevance of intolerance of uncertainty and worry in maintaining these types of repetitive thoughts. The relation between these cognitive processes and weight and shape concerns in adolescent girls with anorexia nervosa is understudied. This study investigated associations between prospective (desire for predictability) and inhibitory (uncertainty paralysis) intolerance of uncertainty, and weight and shape concerns and the mediating role of worry in these associations. METHODS: In a cross-sectional study, 93 adolescent girls with anorexia nervosa completed questionnaires measuring the variables of interest. A mediation model with worry as a mediator between inhibitory and prospective intolerance of uncertainty and weight and shape concerns was tested. RESULTS: A total and direct effect of inhibitory intolerance of uncertainty on weight and shape concerns was found. Worry did not mediate this relation. CONCLUSIONS: These results confirm the importance of inhibitory intolerance of uncertainty in adolescent girls with anorexia nervosa, more specifically to weight and shape concerns. This group may benefit from intervention strategies targeting intolerance of uncertainty. General worry seems less relevant to weight and shape concerns in adolescent girls with anorexia nervosa. Adolescent girls with anorexia nervosa often experience repetitive thoughts about weight and shape. Growing research suggests the relevance of intolerance of uncertainty and worry in maintaining these types of repetitive thoughts. Intolerance of uncertainty is defined as the incapacity to tolerate uncertainty and is often divided into two components; prospective intolerance of uncertainty (desire for predictability) and inhibitory intolerance of uncertainty (uncertainty paralysis). The relation between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa is understudied. This study aims to investigate study relations between prospective and inhibitory intolerance of uncertainty, worry, and weight and shape concerns. A total of 93 adolescent girls with anorexia nervosa completed three questionnaires, measuring prospective and inhibitory intolerance of uncertainty worry, and weight and shape concerns, respectively. The results of this study confirmed the importance of inhibitory intolerance of uncertainty in adolescent girls with anorexia nervosa, more specifically to weight and shape concerns. This group may benefit from intervention strategies targeting intolerance of uncertainty. General worry seems less relevant to weight and shape concerns in adolescent girls.

Understanding implicit and explicit learning in adolescents with and without anorexia nervosa.

BACKGROUND: Cognitive disturbances such as impairments in learning are thought to play a role in adult Anorexia Nervosa (AN). It is remains unclear to what extent these disturbances result from starvation of the brain, or relate to an abnormal premorbid cognitive profile. This study investigates learning processes in adolescents with AN, hypothesizing that implicit learning is intact, as found previously in explicit learning tasks. Secondly, we hypothesized that anxiety and depression symptoms, inherent to AN, are associated to learning processes in AN. METHODS: In total 46 adolescents diagnosed with AN and 44 control participants were administered an implicit category learning task in which they were asked to categorize simple perceptual stimuli (Gabor patches) based on a linear integration (i.e., an implicit task) of orientation and spatial frequency of the stimulus. A subgroup of adolescents (n = 38) also completed a task assessing explicit learning. RESULTS: Model-based analyses indicated that adolescents with AN performed significantly more accurately compared to their healthy peers regardless of whether they used the optimal strategy or not. Depression and anxiety did not relate to learning performance in the AN group. CONCLUSIONS: Overall, our findings of augmented implicit and explicit learning in adolescents with AN corroborate recent studies that suggested higher stimulus-response learning during prediction error paradigms. Learning disturbances in adult AN may then be at least partly due to long-term malnourishment, highlighting the importance of early recognition and refeeding in treatments for AN.

We know that some adults with anorexia nervosa (AN) experience difficulties in learning processes. It is remains unclear to what extent these difficulties result from long-term starvation of the brain. This study looked at learning processes in adolescents with AN who have a relatively short duration of illness. We also investigated whether anxiety and depression affected learning. Forty-six adolescents diagnosed with AN and 44 control participants completed tasks that assessed learning and questionnaires assessing depression and anxiety. We found that adolescents with AN performed more accurately compared to their healthy peers. However, depression and anxiety did not relate to learning performance. Overall, our findings suggest that individuals with AN, relative to their healthy peers, may be quicker in forming automatic responses and behaviors to cues. Learning disturbances in adult AN may then be at least partly due to long-term malnourishment, which highlights the importance of early recognition of AN and refeeding in treatments for AN.

Relationships between educational achievement, intelligence, and perfectionism in adolescents with eating disorders.

OBJECTIVE: High performance at school is associated with the risk of eating disorders (EDs), and perfectionism is proposed as an explanatory factor for this association. This study aims to evaluate (a) potential discrepancies between the measured IQ of adolescents with EDs and the IQ that is expected given their educational track, and (b) to what extent perfectionism was associated with educational achievement independent from IQ. METHOD: WISC-III Verbal IQ, Performance IQ, and Full Scale IQ of 386 adolescent ED patients were compared with population norms for their educational track, using one-sample t tests. The association between self-oriented perfectionism (Eating Disorder Inventory-2) and educational achievement, adjusted for IQ, was determined with sequential ordinal regression analyses. RESULTS: Over 50% of the patients received pre-university education, the most complex educational track. For patients receiving education in the second most complex track, IQ-scores were lower than normative data for that track. For patients receiving pre-university education, the verbal IQ was lower than the norm for that track. Self-oriented perfectionism was associated with educational achievement independent from intelligence. DISCUSSION: This study suggests that high educational achievement is common in adolescents with EDs. Particularly for patients who receive education in the most complex tracks the demands at school may be higher than they can handle, based on their IQ. Self-oriented perfectionism contributed to educational achievement independent from IQ. Our results indicate that treatment for EDs should include awareness for the possibility of a too high target level of patients at school and perfectionism.

Understanding Relations Between Intolerance of Uncertainty, Social Anxiety, and Body Dissatisfaction in Women.

Body dissatisfaction (BD) is highly prevalent among young females and is associated with negative mental health outcomes. Social anxiety (SA) has been identified as an important determinant of BD; however, potential factors underlying SA-related BD remain unstudied. Research indicates that intolerance of uncertainty (IU), the tendency to respond negatively to uncertainty, may be critical for developing and maintaining SA. The current study investigated whether IU is associated with SA and whether SA, in turn, is related to BD. In a cross-sectional study, 139 women completed an online survey measuring IU, SA, and BD. Correlation analyses showed that IU, SA, and BD were strongly positively associated. A mediation analysis revealed that higher levels of IU were indirectly related to more BD through higher levels of SA. A direct effect of IU on BD was also found. These findings suggest that individuals with SA-related BD may benefit from interventions targeting IU.

Cognitive Remediation Therapy Does Not Enhance Treatment Effect in Obsessive-Compulsive Disorder and Anorexia Nervosa: A Randomized Controlled Trial.

BACKGROUND: Guideline-recommended therapies are moderately successful in the treatment of obsessive-compulsive disorder (OCD) and anorexia nervosa (AN), leaving room for improvement. Cognitive inflexibility, a common trait in both disorders, is likely to prevent patients from engaging in treatment and from fully benefiting from existing therapies. Cognitive remediation therapy (CRT) is a practical augmentation intervention aimed at ameliorating this impairing cognitive style prior to disorder-specific therapy. OBJECTIVE: To compare the effectiveness of CRT and a control treatment that was not aimed at enhancing flexibility, named specialized attention therapy (SAT), as add-ons to treatment as usual (TAU). METHODS: In a randomized controlled multicenter clinical trial, 71 adult patients with OCD and 61 with AN were randomized to ten twice-weekly sessions with either CRT or SAT, followed by TAU. Patients were evaluated at baseline, post-CRT/SAT, and after 6 and 12 months, with outcomes being quantified using the Yale-Brown Obsessive Compulsive Scale for OCD and the Eating Disorder Examination Questionnaire for AN. RESULTS: Across study groups, most importantly CRT+TAU was not superior to control treatment (SAT)+TAU in reducing OCD and AN pathology. Contrary to expectations, SAT+TAU may have been more effective than CRT+TAU in patients being treated for OCD. CONCLUSIONS: CRT did not enhance the effect of TAU for OCD and AN more than SAT. Unexpectedly, SAT, the control condition, may have had an augmentation effect on TAU in OCD patients. Although this latter finding may have been due to chance, the effect of SAT delivered as a pretreatment add-on intervention for adults with OCD and AN merits future efforts at replication.

Negative Body Attitudes and Sexual Dissatisfaction in Men: The Mediating Role of Body Self-Consciousness During Physical Intimacy.

Previous research indicated that negative attitudes about the body and appearance are common among men and demonstrated that negative body attitudes are associated with negative sexual experiences. The present study investigated the association between body attitudes and sexual dissatisfaction and the mediating role of body self-consciousness during physical intimacy. In a cross-sectional design, 201 Dutch men completed an online survey regarding body attitudes toward muscularity, body fat, height, and genitals, body self-consciousness during physical intimacy, and sexual dissatisfaction. Hypotheses were tested using correlation analyses and a mediation analysis with body attitudes as predictors, body self-consciousness as mediator, and sexual dissatisfaction as outcome. Correlation analyses showed that negative body attitudes and body self-consciousness during physical intimacy were significantly related to sexual dissatisfaction. The mediation analysis revealed that negative attitudes toward muscularity, body fat, and genitals had indirect effects on sexual dissatisfaction through body self-consciousness during physical intimacy. Negative attitudes toward genitals additionally had a direct effect on sexual dissatisfaction. These findings indicate that body image interventions focused on male body attitudes may be beneficial in improving men's body image, which may ultimately increase sexual satisfaction.

Predicting intolerance of uncertainty in individuals with eating disorder symptoms.

BACKGROUND: Intolerance of Uncertainty (IU) is recognized for its contribution to various psychopathologies, in particular anxiety and depression. Studies highlight the relevance of IU for Eating Disorders (EDs) however, potential factors contributing to IU in EDs remain unstudied. METHODS: Three hundred and forty-nine women with ED symptoms and 214 individuals without ED symptoms were recruited and compared on levels of IU, insecure (anxious and avoidant) attachment styles, extraversion and openness. Secondly, the contribution of these factors to IU were tested. RESULTS: Compared to the non-ED group, the ED group scored higher on IU, insecure attachment, and lower on extraversion and openness. Regression analyses confirmed that higher insecure attachment, and lower extraversion predicted higher IU scores in the ED group, and that insecure attachment predicted higher IU scores in the non-ED group. CONCLUSIONS: Results confirm the relevance of IU to ED, and demonstrate that personality traits and insecure attachment styles contribute to IU in ED. Findings add to the growing literature on IU in ED and suggest that people with EDs may benefit from clinical interventions targeting IU.

Mental capacity to consent to treatment and the association with outcome: a longitudinal study in patients with anorexia nervosa.

BACKGROUND: Relevance of diminished mental capacity in anorexia nervosa (AN) to course of disorder is unknown. AIMS: To examine prognostic relevance of diminished mental capacity in AN. METHOD: A longitudinal study was conducted in 70 adult female patients with severe AN. At baseline, mental capacity was assessed by psychiatrists, and clinical and neuropsychological data (decision-making) were collected. After 1 and 2 years, clinical and neuropsychological assessments were repeated, and remission and admission rates were calculated. RESULTS: People with AN with diminished mental capacity had a less favourable outcome with regard to remission and were admitted more frequently. Their appreciation of illness remained hampered. Decision-making did not improve, in contrast to people with full mental capacity. CONCLUSIONS: People with AN with diminished mental capacity seem to do less well in treatment and display decision-making deficiencies that do not ameliorate with weight improvement. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Intellectual functioning of adolescent and adult patients with eating disorders.

OBJECTIVE: Intelligence is a known vulnerability marker in various psychiatric disorders. In eating disorders (ED) intelligence has not been studied thoroughly. Small-scale studies indicate that intelligence levels might be above general population norms, but larger scale studies are lacking. The aim of this study was to determine intellectual functioning in ED patients and associations with severity of the disorder. METHODS: Wechsler's Full scale IQ (FSIQ), Verbal IQ (VIQ) and Performance IQ (PIQ) of 703 adolescent and adult ED patients were compared with population norms. Exploratory analyzes were performed on associations between IQ and both somatic severity (BMI and duration of the disorder) and psychological/behavioral severity (Eating Disorder Inventory [EDI-II] ratings) of the ED. RESULTS: Mean IQ's were significantly higher than population means and effect-sizes were small-to-medium (d = .28, .16 and .23 for VIQ, PIQ, and FSIQ). No linear associations between IQ and BMI were found, but the most severely underweight adult anorexia nervosa (AN) patients (BMI ≤ 15) had higher VIQ (107.7) than the other adult AN patients (VIQ 102.1). In adult AN patients PIQ was associated with psychological/behavioral severity of the ED. DISCUSSION: Our findings suggest that, in contrast with other severe mental disorders where low intelligence is a risk factor, higher than average intelligence might increase the vulnerability to develop an ED. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:481-489).