Investigating the Theory of Clinical Perfectionism in a Transdiagnostic Eating Disorder Sample Using Network Analysis.

Eating disorders are deadly psychiatric illnesses, with treatments working for less than half of individuals who seek treatment. The transdiagnostic theory of eating disorders proposes that eating disorders share similar maintaining symptoms, such as what this theory calls clinical perfectionism (i.e., high levels of concern over mistakes and personal standards). However, it has been difficult to examine the interrelationship of specific aspects of perfectionism, beyond assessing moderation effects, which have generally not found support for the theory of clinical perfectionism in eating disorders. Thus, we used network analysis to test the theory of perfectionism by testing the interrelationships between maladaptive perfectionism facets (concern over mistakes, personal standards, parental criticism, parental expectations, and personal standards) and eating disorder symptoms in 397 individuals diagnosed with an eating disorder. Concern over mistakes was a central symptom and demonstrated the strongest interrelationships with eating disorder symptoms compared to the other aspects of perfectionism, connecting to eating concerns and cognitive restraint. Objective binge eating had a strong negative connection to personal standards. We identified specific central symptoms and illness pathways of perfectionism, which partially supports the theory of clinical perfectionism. Results, if replicated, may suggest that concern over mistakes might be best reconceptualized as part of eating disorder pathology and be targeted to improve treatment outcomes for eating disorders.

A pilot randomized controlled trial of transdiagnostic network-informed personalized treatment for eating disorders versus enhanced cognitive behavioral therapy.

OBJECTIVE: Eating disorders (EDs) are serious mental illnesses with high mortality and relapse rates and carry significant societal and personal costs. Nevertheless, there are few evidence-based treatments available. One aspect that makes treatment difficult is the high heterogeneity in symptom presentation. This heterogeneity makes it challenging for clinicians to identify pertinent treatment targets. Personalized treatment based on idiographic models may be well-suited to address this heterogeneity, and, in turn, presumably improve treatment outcomes. METHODS: In the current randomized controlled trial, participants will be randomly assigned to either 20 sessions of enhanced cognitive behavioral therapy (CBT-E) or transdiagnostic network-informed personalized treatment for EDs (T-NIPT-ED). Assessment of ED symptoms, clinical impairment, and quality of life will occur at pre-, mid-, posttreatment, and 1-month follow-up. RESULTS: We will examine the acceptability and feasibility of T-NIPT-ED compared to CBT-E. We also will test the initial clinical efficacy of T-NIPT-ED versus CBT-E on clinical outcomes (i.e., ED symptoms and quality of life). Finally, we will test if the network-identified precision targets are the mechanisms of change. DISCUSSION: Ultimately, this research may inform the development and dissemination of evidence-based personalized treatments for EDs and serve as an exemplar for personalized treatment development across the broader field of psychiatry. PUBLIC SIGNIFICANCE: Current evidence-based treatments for eating disorders result in low rates of recovery, especially for adults with AN. Our study aims to test the feasibility, acceptability, and clinical efficacy of a data-driven, individualized approach to ED treatment, network-informed personalized treatment, compared to the current evidence-based treatment for EDs, Enhanced CBT. Findings have the potential to improve treatment outcomes for EDs by identifying and targeting core symptoms maintaining EDs.

Baseline symptomatology and treatment outcomes of young adults in a virtual versus in-person partial hospitalization and intensive outpatient program for eating disorders.

OBJECTIVE: The COVID-19 pandemic resulted in a shift from traditional, in-person treatment to virtual treatment for eating disorders (EDs), with little knowledge about the relative efficacy of virtual formats. METHOD: In the current study, we examined baseline symptomatology and treatment outcomes of young adults in our virtual partial hospitalization and intensive outpatient program (PHP/IOP) for EDs, implemented shortly after the onset of the COVID-19 pandemic. We investigated outcomes on body mass index, ED symptoms, anxiety, ED-related clinical impairment, and emotion regulation. RESULTS: We found significant differences in ED symptomatology, ED-related clinical impairment, and difficulties with emotion regulation at admission between participants in the virtual and in-person versions of our PHP/IOP. Despite these differences, the results demonstrated that the degree of change from admission to discharge on these measures was comparable for both conditions. DISCUSSION: These findings suggest that PHPs and IOPs are relatively effective in a virtual format. Providing effective virtual options across various levels of care will improve access to specialized treatment for EDs. PUBLIC SIGNIFICANCE: (i) Participants in the virtual program reported less severe symptomatology at baseline, (ii) Participants in the virtual and in-person programs experienced similar improvements, (iii) Virtual programs may be an effective option for young adults with eating disorders.

The interaction between affective lability and eating expectancies predicts binge eating.

Both affective lability and eating expectancies have been found to predict binge eating. There is the additional possibility that the joint effect of affective lability and eating expectancies incurs further risk: perhaps expectancies for affective relief from eating operate more strongly in those experiencing frequent, rapid shifts in emotion. In the current study, we tested whether such a joint effect predicts binge eating prospectively in college students. We assessed affective lability, eating expectancies, and binge eating in 358 college students at two time points during the first year of college (e.g., December and April). The interaction of affective lability and eating expectancies in December predicted binge eating 4 months later in April. The influence of eating expectancies on binge eating was stronger at higher levels of affective lability. Findings offer support to the hypothesis that risk factors may transact to further elevate risk for eating disorder behaviors.Clinical implicationsThe interaction of affective lability and eating expectancies predicts binge eatingRisk factors may interact to further increase binge eatingIdentification of co-occurring risk factors may have vital treatment implications.

Pinpointing core and pathway symptoms among sleep disturbance, anxiety, worry, and eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa.

BACKGROUND: Sleep, anxiety, and worry are strongly related to psychiatric illness and in particular to eating disorder (ED) symptoms. However, it is unclear how these specific sleep and anxiety symptoms are interrelated with anorexia nervosa (AN) pathology. METHODS: We utilized network analysis to test our theoretically-based conceptual model, by identifying core features and illness (i.e., bridge) pathways among sleep disturbance, anxiety, worry, and ED symptoms in 267 participants with a diagnosis of AN or atypical AN. RESULTS: The following core symptoms were identified: shape judgement, restriction, and feeling tired. The strongest bridge symptoms included worry, feeling tired, loss of energy, and physical anxiety. Worry was connected positively to fasting, fear of gaining weight or becoming fat, loss of energy, and feeling tired, and negatively to changes in sleeping patterns. Feeling tired was connected to restriction, fasting, binge eating, and worry. Loss of energy was connected to loss of control over eating and worry. Physical anxiety was negatively connected to restriction. CONCLUSIONS: We identified specific core symptoms and illness pathways supporting our theoretical conceptual model of how ED symptoms, anxiety, worry, and sleep disturbances inter-relate in AN and atypical AN. In particular we found that symptoms associated with sleep and anxiety were central and had strong connections with AN symptoms. In addition to targeting AN symptoms, these data suggest that targeting sleep disturbance, anxiety, and worry could improve treatment for AN.

Latent profile analysis of impulsivity and perfectionism dimensions and associations with psychiatric symptoms.

BACKGROUND: Impulsivity and perfectionism are transdiagnostic personality factors that have been studied extensively and shown to relate to externalizing and internalizing pathology respectively. Typically, these personality factors are antithesized, with impulsivity characterized by lack of control and perfectionism characterized by rigid overcontrol. METHODS: The current study (N = 1,353 undergraduate students) used latent profile analysis to identify subgroups based on impulsivity and perfectionism dimensions and tested the relations of these subgroups with the symptomatology of ten prevalent types of psychopathology (depression, worry, social anxiety, attention-deficit hyperactivity disorder inattentive subtype, attention-deficit hyperactivity disorder impulsive-hyperactive subtype, alcohol use, obsessive-compulsive disorder, posttraumatic stress disorder, restrictive eating pathology, and binge eating pathology). RESULTS: The latent profile analysis identified four meaningful subgroups: high perfectionism, high impulsivity, combined impulsivity and perfectionism, and low impulsivity and perfectionism. The combined group was the most prevalent, comprising almost half of the sample. Further, the perfectionism group had the highest scores for obsessive-compulsive disorder, worry, and restrictive eating pathology, the impulsivity group had the highest scores for alcohol use disorder, and the combined group had the highest or second-highest scores across all types of psychopathology. LIMITATIONS: Limitations include the undergraduate sample, self-report, cross-sectional study design, and high bivariate residuals. CONCLUSIONS: These findings suggest impulsivity and perfectionism can co-occur. Further, the co-occurrence of these personality traits may heighten risk for psychopathology and help explain comorbidity across internalizing and externalizing disorders. Future research should continue to investigate the presentation, prevalence, and treatment for individuals high in both perfectionism and impulsivity.

Transactions between early binge eating and personality predict transdiagnostic risk.

Psychiatric comorbidities are prevalent in youth eating disorders. In a sample of 1,906 youth from the United States (49.2% female), followed from elementary school into high school, we found support for a model to help explain this comorbidity. Endorsement of binge eating in fifth grade (elementary school) predicted increases in negative urgency, negative affect, and lack of planning in seventh grade (middle school). In turn, seventh grade negative urgency predicted increases in 10th grade (high school) externalizing dysfunction (binge eating, alcohol use problems, and smoking) and internalizing dysfunction (depressive symptoms). Seventh grade negative affect predicted increases in 10th grade binge eating and depressive symptoms. Seventh grade lack of planning predicted increases only in 10th grade externalizing behaviours. Early engagement in binge eating may elevate risk for multiple forms of dysfunction, at least in part due to its prediction of high-risk personality change in middle school.

Transactions among thinness expectancies, depression, and binge eating in the prediction of adolescent weight control behaviors.

OBJECTIVE: Binge eating, the transdiagnostic risk associated with depression, and the eating disorder-specific risk associated with expectancies for reinforcement from thinness have been identified as risk factors for the development of weight control behaviors. The purpose of this study was to examine if these risk factors transact to further predict risk in youth. METHOD: Binge eating, depressive symptoms, thinness expectancies, and weight control behaviors were assessed in 1,758 adolescents three times during the transitional period between middle school and high school. We tested six different possible transactional processes. RESULTS: Mediation tests demonstrated that both 8th grade binge eating and 8th grade depressive symptoms predicted 10th grade weight control behaviors through their predictive influence on thinness expectancies in 9th grade. However, our results were not consistent with a mediational process in which 8th grade thinness expectancies predicted 9th grade depression to further predict 10th grade weight control behaviors. No interactions among binge eating, depressive symptoms, or thinness expectancies predicted weight control. Results did not differ between girls and boys. DISCUSSION: Thinness expectancies appear to mediate the predictive influence of binge eating and depressive symptoms on risk for engaging in weight control behaviors. These results add to theoretical understanding of risk and suggests potential intervention pathways for clinicians.

The Occurrence and Covariation of Binge Eating and Compensatory Behaviors Across Early to Mid-Adolescence.

The purpose of this study was to examine the occurrence and covariation of four eating disorder behaviors across the elementary, middle, and high school years. In a sample of 1,906 youth measured over 5 years at nine time points, from the past year of elementary school through the second year of high school, binge eating, purging (self-induced vomiting), compensatory exercise, and fasting behavior were assessed by self-report. Over the 5-year period, rates of binge eating and purging increased but rates of compensatory exercise and fasting decreased. Girls and boys did not differ in their rates of engagement in any of the behaviors. Within time, the behaviors covaried modestly. Health-care professionals are advised to assess each behavior individually, rather than base interventions on the presence or absence of a diagnosable eating disorder. Gender should not be a basis for assessing for the presence of any of these behaviors.