Mental health apps within the healthcare system: associations with stigma and mental health literacy.

BACKGROUND: Mental health apps (MHA) as a new form of self-help have gained popularity over the last years. Tentative evidence has suggested that MHA might also present a first step into the help-seeking process, because their anonymity circumvents stigma. Using MHA might also increase mental health literacy and reduce stigma through psychoeducation, which could encourage formal help-seeking. To date, it remains unclear how MHA usage relates to stigma, mental health literacy, and utilization of professional help within the public healthcare system. METHODS: We conducted a cross-sectional survey with N = 1,263 individuals from the general population (mean age 32.56 ± 11.51, 58.2% female) and employed structural equation modeling to investigate associations between stigma (against individuals with psychological disorders and against help-seeking), mental health literacy, MHA usage, and service utilization within the public healthcare system for mental health problems. RESULTS: MHA usage is high within the general population (40.5% of participants). Results indicate that higher stigma against help-seeking is associated with and increased likelihood of MHA usage, which in turn is positively associated with increased likelihood of service utilization. Symptoms of psychological disorder were associated with higher likelihood of service utilization, but not MHA usage. CONCLUSIONS: It can be concluded that MHA appeal especially to individuals with higher stigma against help-seeking and therefore might provide an opportunity to reach underserviced individuals. At the current time, MHA usage appears to take place mostly in a preventative manner or as a supplement to treatment. Better integration into the public healthcare system might help to exploit both preventative and interventional benefits of MHA.

Subclinical patterns of disordered eating behaviors in the daily life of adolescents and young adults from the general population.

BACKGROUND: Disordered eating behaviors (DEBs), a risk factor for the development of eating disorders (EDs), are prevalent in young people and different DEBs frequently co-occur. Previous studies on DEB-patterns have largely used traditional retrospective questionnaires to assess DEBs. In addition, most previous studies did not specifically exclude individuals with clinical EDs, which limits current knowledge concerning purely subclinical patterns of DEBs. In the present study, we aimed to explore phenotypes and group sizes of subclinical patterns of DEBs reported in everyday life via smartphone-based ecological momentary assessment (EMA) in adolescents and young adults from the general population without lifetime EDs. In secondary analyses, we further aimed to investigate whether DEB-patterns would be associated with additional previously identified risk factors for ED-development. METHODS: EMA was conducted in a community sample of 14-21-year-olds from Dresden, Germany, over four days for up to eight times a day and covered engagement in four DEBs: skipping eating, restrained eating, eating large amounts of food, and loss-of-control eating. Data were analyzed from N = 966 individuals without lifetime EDs with an EMA compliance rate of at least 50% (81.9% of the total sample; average compliance: 84.6%). Latent profile analyses were performed to identify subclinical patterns of DEBs, stratified by sex. Associations between symptomatic profiles and ED-risk factors were tested via regression analyses. RESULTS: Based on theoretical deliberations, statistical indices, interpretability, and parsimony, a three-profile solution, namely no DEBs, high-mixed DEBs, and low-mixed DEBs, was selected for both sexes. Both symptomatic profiles in both sexes were associated with more unfavorable manifestations in additional ED risk factors compared to the no DEBs profile, with the highest number of associations being observed in the female high-mixed profile. CONCLUSIONS: The present findings suggest that problematic manifestations of DEBs in young people may occur even in the absence of an ED diagnosis and that they are associated with additional risk factors for EDs, warranting increased efforts in targeted prevention, early identification and intervention in order to counteract symptom progression.

Tension and disordered eating behaviors in the daily lives of adolescents and young adults from the general population: Associations and moderating role of trait emotion regulation.

Experiences of tension and difficulties in emotion regulation have been linked to eating pathology in clinical samples and are targeted in respective treatment approaches. The present study aimed to investigate the impact of tension on engagement in disordered eating behaviors (DEBs) and potential moderating effects of trait emotion regulation in young people from the general population. A subsample of 971 adolescents and young adults from an epidemiological cohort study reported on levels of tension and four different DEBs (skipping eating, restrained eating, eating large amounts of food, loss-of-control-eating) via ecological momentary assessment (EMA), as well as on trait emotion regulation via questionnaire. In multilevel models, momentary tension did not predict levels of subsequent DEBs. However, higher average levels of tension across the EMA period predicted higher levels of all DEBs. No interactions with emotion regulation emerged. Individuals experiencing overall higher levels of tension appear to be more prone to engaging in DEBs.

Temporal associations between experiential avoidance and disordered eating behaviors in adolescents and young adults: findings from an epidemiological cohort study with ecological momentary assessment.

PURPOSE: Previous studies linking experiential avoidance (EA) and eating pathology have largely relied on single measurements based on traditional retrospective questionnaires. Taking advantage of available repeated assessments of EA and disordered eating behaviors (DEBs) in the everyday lives of young people from an epidemiological cohort, we aimed to investigate ecologically valid temporal associations between these constructs. METHODS: A random population sample of N = 1180 14-21-year-olds from Dresden, Germany, participated at baseline (2015/2016). As part of smartphone-based ecological momentary assessment (EMA), participants reported on engagement in EA and four DEBs (skipping eating, eating large amounts of food, loss-of-control eating, and restrained eating) up to eight times per day for four days. Multilevel modeling of concurrent and time-lagged associations between EA and DEBs, was conducted among those with at least 50% EMA-compliance (n = 1069). RESULTS: EA was associated with higher concurrent levels of all four types of concurrent DEBs. In addition, EA significantly predicted subsequent levels of restrained eating. Only loss-of-control eating significantly predicted subsequent EA, and this effect depended on the timespan between consecutive assessments. When this timespan was short, higher Loss-of-control eating predicted lower subsequent EA, while it predicted higher subsequent EA when the timespan was longer. CONCLUSION: The present findings suggest that EA is temporally closely linked to greater engagement in DEBs, supporting theoretical assumptions that DEBs may serve an attempted avoidance function in the context of unpleasant inner experiences. Future studies may benefit from examining samples with more pronounced eating pathology. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Increased Habit Frequency in the Daily Lives of Patients with Acute Anorexia Nervosa.

Strict eating routines and frequent rigid behavior patterns are commonly observed in patients with anorexia nervosa (AN). A recent theory proposes that while these behaviors may have been reinforced initially, they later become habitual. To date, however, research has been overly focused on eating-disorder (ED)-related habits. Over the course of seven days, we applied an ecological momentary assessment (EMA) to investigate the habit frequency and strength of ED-specific (food intake) and ED-unspecific (hygiene) habits in the daily lives of a sample of n = 57 AN and n = 57 healthy controls (HC). The results of the hierarchical models revealed that habits were significantly more likely in patients compared with HC for both categories, independently. Furthermore, a lower body mass index (BMI) was associated with increased habit frequency in AN. Our study strengthens the habit theory of AN by showing the relevance of habits beyond ED-specific behavioral domains. This also supports the development of innovative therapeutic interventions targeting habitual behavior in EDs.

Real-life self-control conflicts in anorexia nervosa: An ecological momentary assessment investigation.

BACKGROUND: Individuals with anorexia nervosa (AN) are often thought to show heightened self-control and increased ability to inhibit desires. In addition to inhibitory self-control, antecedent-focused strategies (e.g., cognitive reconstrual-the re-evaluation of tempting situations) might contribute to disorder maintenance and enable disorder-typical, maladaptive behaviors. METHODS: Over a period of 14 days, 40 acutely underweight young female patients with anorexia nervosa (AN) and 40 healthy control (HC) participants reported their affect and behavior in self-control situations via ecological momentary assessment during inpatient treatment (AN) and everyday life (HC). Data were analyzed via hierarchical analyses (linear and logistic modeling). RESULTS: Conflict strength had a significantly lower impact on self-control success in AN compared to HC. While AN and HC did not generally differ in the number or strength of self-control conflicts or in the percentage of self-control success, AN reported self-controlled behavior to be less dependent on conflict strength. CONCLUSIONS: While patients with AN were not generally more successful at self-control, they appeared to resolve self-control conflicts more effectively. These findings suggest that the magnitude of self-control conflicts has comparatively little impact on individuals with AN, possibly due to the use of antecedent-focused strategies. If confirmed, cognitive-behavioral therapy might focus on and help patients to exploit these alternative self-control strategies in the battle against their illness.

Intact neural and behavioral correlates of emotion processing and regulation in weight-recovered anorexia nervosa: a combined fMRI and EMA study.

Altered emotion processing and regulation mechanisms play a key role in eating disorders. We recently reported increased fMRI responses in brain regions involved in emotion processing (amygdala, dorsolateral prefrontal cortex) in acutely underweight anorexia nervosa (AN) patients while passively viewing negatively valenced images. We also showed that patients' ability to downregulate activity elicited by positively valenced pictures in a brain region involved in reward processing (ventral striatum) was predictive of worse outcomes (increased rumination and negative affect). The current study tries to answer the question of whether these alterations are only state effects associated with undernutrition or whether they constitute a trait characteristic of the disorder that persists after recovery. Forty-one individuals that were weight-recovered from AN (recAN) and 41 age-matched healthy controls (HC) completed an established emotion regulation paradigm using negatively and positively valenced visual stimuli. We assessed behavioral (arousal) and fMRI measures (activity in the amygdala, ventral striatum, and dorsolateral prefrontal cortex) during emotion processing and regulation. Additionally, measures of disorder-relevant rumination and affect were collected several times daily for 2 weeks after scanning via ecological momentary assessment. In contrast to our previous findings in acute AN patients, recAN showed no significant alterations either on a behavioral or neural level. Further, there were no associations between fMRI responses and post-scan momentary measures of rumination and affect. Together, these results suggest that neural responses to emotionally valenced stimuli as well as relationships with everyday rumination and affect likely reflect state-related alterations in AN that improve following successful weight-recovery.

The costs of over-control in anorexia nervosa: evidence from fMRI and ecological momentary assessment.

A growing body of evidence suggests that a high level of self-control may, despite its positive effects, influence cognitive processing in an unfavorable manner. However, the affective costs of self-control have only rarely been investigated. Anorexia nervosa (AN) is an eating disorder that is often characterized by excessive self-control. Here, we used fMRI to explore whether over-control in AN may have negative affective consequences. 36 predominantly adolescent female AN patients and 36 age-matched healthy controls (HC) viewed negative and neutral pictures during two separate fMRI sessions before and after 10 min of rest. We tested whether abnormally elevated neural activity during the initial presentation in a brain region broadly implicated in top-down control, the dorsolateral prefrontal cortex (dlPFC), could predict subsequent activation in limbic areas relevant to bottom-up affective processing. Using ecological momentary assessment (EMA), we also tested for associations between the aforementioned neuroimaging markers and negative affective states in the two weeks following the experiment. fMRI data revealed that higher initial activation of the dlPFC in AN predicted increased amygdala reactivity during the second fMRI session, which in turn was related to increased self-reported tension during two weeks following the scan. These data suggest that over-control in AN patients may come at a cost including negative affective states on a short (minutes) as well as a longer time scale (days). This mechanism may significantly contribute to the persistence of AN.

Automatic and Controlled Processing: Implications for Eating Behavior.

It is a widely held view that humans have control over their food choices and consumption. However, research also suggests that eating behavior is often triggered by contextual cues and guided by automaticities and habits. Interestingly, the dichotomy between automatic and controlled processing has recently been challenged, suggesting that they may be intertwined. In a large female sample (n = 567), we investigated the hypothesis that task-based and self-reported measures of automatic and controlled processing would interact and impact self-reported eating behavior. Results analyzed via structural equation modeling suggest that automatic, but not controlled processing, during a modified flanker task, including a context-specific proportion congruent (CSPC) manipulation, was inversely associated with self-reported self-control. The influence of self-control on unhealthy eating behavior (i.e., uncontrolled and emotional eating, heightened consumption of fat and sugar) was only indirect via habitual behavior, which itself had a strong direct impact. Unhealthy eating was further associated with real-life outcomes (e.g., body mass index (BMI)). Our findings suggest that eating behavior may indeed be guided primarily by automaticities and habits, whereas self-control might facilitate this association. Having self-control over eating might therefore be most effective by avoiding contextual cues eliciting undesired automatic behavior and establishing habits that serve long-term goals.

A naturalistic investigation of cognitive-affective dysfunction in anorexia nervosa: The role of inefficiency.

OBJECTIVE: Research has shown that rumination and negative affect are elevated in patients with anorexia nervosa (AN), but the underlying origins remain unclear. Drawing from the theoretical framework of the Goal Progress Theory of rumination, we propose that heightened feelings of "inefficiency" (i.e., low self-efficacy) in AN might play an important role in these dysfunctional cognitive-affective processes. METHOD: Thirty-two weight-recovered participants with a history of AN and 32 healthy control participants filled out questionnaires regarding rumination and affect six times a day over a period of 2 weeks via ecological momentary assessment in real-life. RESULTS: Analyses via hierarchical as well as conceptual process modeling suggest that while inefficiency is generally associated with more rumination and negative affect, additional amplifying mechanisms between these variables exist specifically in recovered participants with a history of AN. DISCUSSION: Inefficiency as a core aspect of AN appears to trigger dysfunctional cognitive-affective processes which may contribute to vulnerability for AN.

Rumination in anorexia nervosa: Cognitive-affective and neuroendocrinological aspects.

Rumination about body weight/figure as well as food is common in patients with Anorexia Nervosa (AN) and may be a maintenance factor of the disorder. While rumination can generally be considered as a cognitive-affective process, food-related rumination may be driven primarily by a physiological response to undernutrition. In the current longitudinal study, we integrate ecological momentary assessment of rumination and affect and, as a biological marker of undernutrition, plasma leptin levels collected from 33 AN patients. At the very acute stage and again after short-term weight-restoration patients answered short questionnaires six times per day over two weeks. Analyses via hierarchical linear modelling confirmed that rumination is closely linked to affect in AN before and after weight-restoration. Rumination about food decreased during weight-restoration and was correlated with leptin levels. In contrast, rumination about body weight/figure was not linked to leptin, persisted after weight gain, and showed stronger connections with affect. This suggests that rumination about body weight/figure seems to be a cognitive-affective aspect of the disorder, but food-related rumination may need to be considered from a physiological perspective. It is possible that food-related ruminative thoughts reflect a physiological symptom induced by undernutrition, similar to well-described leptin-associated changes in physical activity.