Experimental Therapeutics: Opportunities and Challenges Stemming From the National Institute of Mental Health Workshop on Novel Target Discovery and Psychosocial Intervention Development.

There has been slow progress in the development of interventions that prevent and/or reduce mental-health morbidity and mortality. The National Institute of Mental Health (NIMH) launched an experimental-therapeutics initiative with the goal of accelerating the development of effective interventions. The emphasis is on interventions designed to engage a target mechanism. A target mechanism is a process (e.g., behavioral, neurobiological) proposed to underlie change in a defined clinical endpoint and through change in which an intervention exerts its effect. This article is based on discussions from an NIMH workshop conducted in February 2020 and subsequent conversations among researchers using this approach. We discuss the components of an experimental-therapeutics approach such as clinical-outcome selection, target definition and measurement, intervention design and selection, and implementation of a team-science strategy. We emphasize the important contributions of different constituencies (e.g., patients, caregivers, providers) in deriving hypotheses about novel target mechanisms. We highlight strategies for target-mechanism identification using published and hypothetical examples. We consider the decision-making dilemmas that arise with different patterns of results in purported mechanisms and clinical outcomes. We end with considerations of the practical challenges of this approach and the implications for future directions of this initiative.

Experiences of mimicry in eating disorders.

BACKGROUND: People unknowingly mimic the behaviors of others, a process that results in feelings of affiliation. However, some individuals with eating disorders describe feeling "triggered" when mimicked. This study explores the effects of implicit non-verbal mimicry on individuals with a history of an eating disorder (ED-His) compared to healthy controls (HCs). METHOD: Women (N = 118, nED-His = 31; Mage = 21 years) participated in a laboratory task with a confederate trained to either discreetly mimic (Mimicry condition) or not mimic (No-Mimicry condition) the mannerisms of the participant. Participants rated the likability of the confederate and the smoothness of the interaction. RESULTS: Participants in the No-Mimicry condition rated the confederate as significantly more likable than in the Mimicry condition, and ED-His rated the confederate as more likable than HCs. ED-His in the Mimicry condition rated the interaction as less smooth than HCs, whereas this pattern was not found in the No-Mimicry condition. Among ED-His, longer disorder duration (≥ 3.87 years) was associated with less liking of a confederate who mimicked and more liking of a confederate who did not mimic. CONCLUSIONS: We discuss the implications of these findings for interpersonal therapeutic processes and group treatment settings for eating disorders. Our study on subtle, nonverbal mimicry revealed differences in social behavior for women with a history of an eating disorder compared to healthy women. For participants with an eating disorder history, a longer duration of illness was associated with a worse pattern of affiliation, reflected in lower liking of a mimicker. Further research on how diverging processes of affiliation may function to perpetuate the chronicity of eating disorders and implications for treatment is needed.

Shuffle the Decks: Children Are Sensitive to Incidental Nonrandom Structure in a Sequential-Choice Task.

As children age, they can learn increasingly complex features of environmental structure-a key prerequisite for adaptive decision-making. Yet when we tested children (N = 304, 4-13 years old) in the Children's Gambling Task, an age-appropriate variant of the Iowa Gambling Task, we found that age was negatively associated with performance. However, this paradoxical effect of age was found only in children who exhibited a maladaptive deplete-replenish bias, a tendency to shift choices after positive outcomes and repeat choices after negative outcomes. We found that this bias results from sensitivity to incidental nonrandom structure in the canonical, deterministic forms of these tasks-and that it would actually lead to optimal outcomes if the tasks were not deterministic. Our results illustrate that changes in decision-making across early childhood reflect, in part, increasing sensitivity to environmental structure.

Rigidity and Sensory Sensitivity: Independent Contributions to Selective Eating in Children, Adolescents, and Young Adults.

Objective: Selective or "picky" eating (SE) refers to rejection of a wide range of familiar and unfamiliar foods based on aversions to their sensory properties. When severe, SE can cause symptoms of avoidant/restrictive food intake disorder (ARFID), including weight loss, nutritional deficiencies, and/or psychosocial impairment. SE is highly prevalent in autism spectrum disorder (ASD) compared to both typical development and other developmental disorders. A possible explanation for the high prevalence of SE in ASD is the effect of core ASD symptoms, repetitive/restrictive behaviors (e.g., rigidity), and sensory sensitivity on feeding behaviors. These traits are found not only in ASD but also in other clinical groups and the general population, albeit often at subclinical levels. Identifying mechanisms of SE across various populations is critical to inform intervention approaches.Methods: In 263 unselected children ages 5-17, 534 unselected college students ages 18-22, 179 children with anxiety/obsessive spectrum disorders ages 5-17, and 185 children with ASD ages 4-17, we explored the unique contributions of sensory (i.e., oral texture and olfactory) sensitivities and rigidity as predictors of self/parent-reported SE.Results: In each sample, rigidity and oral texture sensitivity, controlling for olfactory sensitivity, age, and gender, emerged as significant, independent predictors of SE.Conclusions: This is the first study to highlight the importance of cognitive/behavioral rigidity to SE, and one of the first to illustrate the domain-specificity of the relationship between sensory sensitivity and SE.

Children's Beliefs about Pain: An Exploratory Analysis.

Functional abdominal pain (FAP) is one of the most common childhood medical complaints, associated with significant distress and impairment. Little is known about how children understand their pain. Do they attribute it to personal weakness? Do they perceive pain as having global impact, affecting a variety of activities? How do they cope with pain? We explored the pain beliefs of 5- to 9-year-old children with FAP using a novel Teddy Bear Interview task in which children answered questions about a Teddy bear's pain. Responses were analyzed quantitatively and qualitatively. Results indicate that the majority of young children with FAP are optimistic about pain outcomes. Children generated many types of coping strategies for Teddy's pain and adjusted their calibration of Teddy's pain tolerance dependent on the activity being performed. Early warning signs also emerged: a subset of children were pessimistic about Teddy's pain, and several children identified coping strategies that, while developmentally appropriate, could lead to excessive help seeking if not intervened upon (e.g., physician consultation and shot). The Teddy Bear Interview allows children to externalize their pain, making it a useful tool to access cognitive pain constructs in younger children. Thus, these findings highlight the importance of early intervention for childhood FAP.

The diagnosis of avoidant restrictive food intake disorder in the presence of gastrointestinal disorders: Opportunities to define shared mechanisms of symptom expression.

OBJECTIVE: Individuals with a gastrointestinal (GI) disorder often alter their diet to manage GI symptoms, adding complexity to understanding the diverse motivations contributing to food avoidance/restriction. When a GI disorder is present, the DSM-5 states that Avoidant/Restrictive Food Intake Disorder (ARFID) can be diagnosed only when eating disturbance exceeds that expected. There is limited guidance to make this determination. This study attempts to address this gap by characterizing the presentation of ARFID in adults with and without a self-reported GI disorder. METHOD: Participants were 2,610 adults ages 18-44 who self-identified as "picky eaters." Participants reported on motivations for food avoidance, affective experiences towards food, and perceived impairment. Responses were compared across four groups: GI issues and likely ARFID (L-ARFID/GI), L-ARFID-only, GI-only, and No-ARFID/No-GI. RESULTS: Groups with a GI disorder (L-ARFID/GI, GI-only) reported more fear of aversive consequences of eating than those without a GI disorder, while groups with L-ARFID (L-ARFID, L-ARFID/GI) evidenced significantly greater sensory aversion to food and indifference to food or eating, negative emotional reactions to food and overall disgust sensitivity, and eating related impairment. DISCUSSION: Consideration of the interplay of a GI disorder with ARFID can add precision to case conceptualization. Food avoidance may be attempts to manage fears of aversive consequences that are augmented by a history of GI symptoms, while sensory aversions and negative emotional reactions towards foods may be more elevated in ARFID. These findings emphasize the need to consider an ARFID diagnosis in patients with GI disorders to optimize care.

Longitudinal associations of trauma exposure with disordered eating: Lessons from the Great Smoky Mountains Study.

Disordered eating is prevalent among trauma survivors, yet little is known about mechanisms underlying this relation. We explored cross-sectional and longitudinal associations of trauma exposure and posttraumatic stress disorder symptoms (PTSD) with disordered eating among 1,420 community-based youth participating in the Great Smoky Mountain Study. Participants were interviewed about trauma exposure, PTSD symptoms, and disordered eating at regular intervals throughout childhood, adolescence, and early adulthood. Our findings confirmed associations of all forms of trauma exposure (violent, sexual, and other) with disordered eating symptoms in childhood and adulthood, although the pattern of results varied by disordered eating symptom and trauma exposure type. Only non-sexual, non-violent trauma exposure in childhood had significant associations with any disordered eating symptoms in adulthood. Within childhood, trauma exposures but not PTSD symptoms showed significant longitudinal associations with bulimia nervosa symptoms and sustained appetite changes and preoccupation with eating. In adulthood, PTSD symptoms but not trauma exposures showed significant longitudinal associations only with bulimia nervosa symptoms. The association of specific PTSD clusters on bulimia nervosa symptoms was significant for reexperiencing, whereas hyperarousal symptoms trended toward significance. The impact of trauma exposures on disordered eating may vary by developmental period.

Do interoceptive accuracy and interoceptive sensibility predict emotion regulation?

INTRODUCTION: Interoception refers to awareness, interpretation, and integration of sensations in the body. While interoceptive accuracy has long been regarded as a core component of emotional experience, less is known about the relationship of interoceptive accuracy and related facets of interoception to emotion regulation deficits. This study explores how interoceptive accuracy and interoceptive sensibility relate to emotion regulation in a non-clinical sample. METHODS: Undergraduate participants completed a heartbeat perception task and the Multidimensional Assessment of Interoceptive Awareness (Noticing and Body Listening sub-scales), and rated their confidence in performance on the heartbeat perception task. Participants also completed self-report measures of emotional awareness and regulation (Profile of Emotional Competence, intrapersonal emotion identification and emotion regulation sub-scales), and rated their use of different coping strategies (Brief COPE). RESULTS: Noticing predicted emotion identification, emotion regulation, and the use of adaptive but not maladaptive coping strategies. Heartbeat perception accuracy did not significantly contribute to the prediction of any outcome variables. DISCUSSION: Future work is needed to extend these findings to clinical populations. The results from this study support the use of interoceptive training interventions to promote emotional wellbeing.

Internal states and interoception along a spectrum of eating disorder symptomology.

OBJECTIVE: Recent studies on atypical interoceptive capabilities have focused on clinical populations, including anorexia nervosa[1,2]. The present exploratory study aims to characterize the influence of disordered eating symptomology on interoceptive capabilities in college students, a population for which dangerous dieting behaviors may emerge. METHOD: Ninety-nine participants were randomized to consume a blinded high calorie or low calorie midday shake. Participants reported frequency of eating disorder cognitions and behaviors; indicated changes in satiety, happiness, and energy pre- and post-consumption; and guessed the calories in their shake. Outcomes (perceived satiety, changes in mood, and caloric guess) were regressed on eating disorder symptoms scores, the high/low calorie shake condition, and the interaction between these predictors. RESULTS: Those randomized to receive the high calorie shake reported feeling fuller, but only when endorsing lower levels of eating concern. Those randomized to the high calorie shake reported greater post-meal happiness, but only at greater levels of eating concerns. Lastly, those with lower levels of eating restraint reported an expected positive association between level of fullness and calorie guess, but those with higher levels of eating restraint did not exhibit any relationship between perceived fullness and calorie guess. DISCUSSION: Results of this exploratory suggest that irregular eating habits (e.g., not eating a sufficient amount for lunch) may have direct consequences on interoceptive capabilities. Further, these capacities may be impacted by individual differences in eating concern and restraint. Preliminary findings suggest that impairment in deciphering visceral signals may be associated with the degree of eating disorder symptomology; such impairment may occur at lower levels of symptomatology than normative data would indicate.

Meal skipping and cognition along a spectrum of restrictive eating.

OBJECTIVE: Inadequate nutrition adversely impacts brain development and cognitive functioning (Pollitt et al., 1983). Studies examining the acute impact of eating regular meals on cognition have reported inconsistent findings, necessitating the exploration of individual differences in samples contributing to equivocal results. The present study examines the impact of skipping lunch on cognitive ability in college-aged students by including eating restraint as a moderator. METHODS: Participants were 99 college-aged students (M = 19.7 years, SD = 1.5) randomized to a blinded 'lunch' or 'lunch-omission' condition, and assessed on memory, attention, processing speed, set shifting, and eating disorder symptomology. RESULTS: Regressing long and short-term memory on the lunch manipulation, eating restraint scores, and their interaction revealed significant interactions: those who had lunch had superior memory performance, but only for those reporting lower levels of eating restraint. Regressing set shifting speed on the manipulation, those who had lunch had slower set shifting speed than those who skipped, but only for those reporting lower levels of eating restraint. CONCLUSIONS: Results suggest that skipping lunch may have immediate consequences on cognition, however, cognitive enhancing effects may be diminished in the presence of even low levels of eating restraint. Findings highlight the significance of purported subclinical levels of eating restraint and may inform health education strategies.

A multi-method assessment of interoception among sexual trauma survivors.

It is well established that many female sexual trauma survivors experience dissociation, particularly disconnection from the body, in the aftermath of sexual trauma. This study aims to address the open question of how sexual trauma is associated with awareness of inner body sensations (i.e., interoception). Given the important role that interoception has in emotion regulation, a process with which survivors often struggle, it is important to understand the associations between interoception and PTSD symptoms among survivors. Through multi-methods, we assessed associations between interoception, dissociation, and PTSD symptoms among 200 female sexual trauma survivors. We assessed two components of interoception: interoceptive accuracy (IAc: accurately perceiving internal body sensations; via heartbeat perception task) and interoceptive sensibility (IS: self-report perception of sensitivity to interoceptive sensations). We hypothesized that IAc and IS would be positively correlated with PTSD, with interactions between IAc/dissociation and IS/dissociation qualifying those main effects, weakening them for survivors with higher dissociation. Results showed an opposite pattern than was predicted: although IAc did explain significant PTSD variance, as IAc increased, PTSD decreased. Although IAc did explain significant variance in PTSD symptoms, interestingly, IS did not. Consistent with extant literature, dissociation predicted significant variance in PTSD. These correlational results suggest that the ability to more accurately perceive inner body sensations is related to lower PTSD symptoms. Findings provide a foundation for future research that can assess if interventions (such as yoga or exercise) that target increasing interoceptive accuracy lead to decreases in PTSD symptoms. We discuss further clinical implications, limitations and future directions.

On bells, saliva, and abdominal pain or discomfort: Early aversive visceral conditioning and vulnerability for anorexia nervosa.

Gastrointestinal (GI) symptoms are common in anorexia nervosa (AN), can predate illness onset, complicate renourishment, and persist after recovery. We explore how, through processes of aversive visceral conditioning, early GI pain and discomfort may increase vulnerability to AN in some individuals. Processes include enhanced preoccupation with the gut resulting from aversive visceral memories and disruptions in the typical acquisition of self-attunement when children learn to map and interpret interoceptive sensations and develop adaptive actions. We question whether a fear of weight gain, in some cases, may be an epiphenomenon of the recapitulation of actual or perceived GI symptoms that is especially relevant during puberty, especially in girls. This conceptualization has immediate clinical implications and offers ideas for future research. We propose that GI discomfort associated with renourishment may reignite prior aversive visceral experiences. We encourage development of a formulation that organizes the individual's current experience of the body with respect to these prior aversive experiences. Our conceptualization underscores the importance of assessment of GI experiences in individuals with AN; the examination of dietary strategies that minimize GI symptoms and enhance renourishment efficacy; and strategies that attempt to alter this aversive visceral conditioning by mapping sensations to meanings and adaptive actions.

The central role of disgust in disorders of food avoidance.

BACKGROUND: Individuals with extreme food avoidance such as Avoidant Restrictive Food Intake Disorder (ARFID) experience impairing physical and mental health consequences from nutrition of insufficient variety or/and quantity. Identifying mechanisms contributing to food avoidance is essential to develop effective interventions. Anxiety figures prominently in theoretical models of food avoidance; however, there is limited evidence that repeated exposures to foods increases approach behavior in ARFID. Studying disgust, and relationships between disgust and anxiety, may offer novel insights, as disgust is functionally associated with avoidance of contamination from pathogens (as may occur via ingestion) and is largely resistant to extinction. METHOD: This exploratory, cross-sectional study included data from 1,644 adults who completed an online questionnaire. Participant responses were used to measure ARFID classification, picky eating, sensory sensitivity, disgust, and anxiety. Structural equation modeling tested a measurement model of latent disgust and anxiety factors as measured by self-reported frequency of disgust and anxiety reactions. Mediational models were used to explore causal ordering. RESULTS: A latent disgust factor was more strongly related to severity of picky eating (B ≈ 0.4) and ARFID classification (B ≈ 0.6) than the latent anxiety factor (B ≈ 0.1). Disgust partially mediated the association between anxiety and picky eating and fully mediated the association between anxiety and ARFID. Models testing the reverse causal ordering demonstrated poorer fit. Findings suggest anxiety may be associated with food avoidance in part due to increased disgust. CONCLUSIONS: Disgust may play a prominent role in food avoidance. Findings may inform novel approaches to treatment.

Feeling and body investigators (FBI): ARFID division-An acceptance-based interoceptive exposure treatment for children with ARFID.

OBJECTIVE: Individuals with Avoidant Restrictive Food Intake Disorder (ARFID) experience impairing health consequences from insufficient nutritional variety and/or quantity. Early medical conditions and/or somatic symptoms such as abdominal pain may lead some with ARFID to experience somatic sensations as aversive. As such, food avoidance may be part of a broader behavioral repertoire aimed at suppressing bodily sensations. Avoiding these necessary and informative signals (e.g., growls of hunger) may subvert the emergence of healthy self-awareness and self-regulation. Teaching children with ARFID to engage adaptively with bodily sensations may help decrease aversiveness, increase self-awareness, and increase approach behaviors. METHOD: Drawing from interventions for panic disorder and irritable bowel syndrome, we developed an acceptance-based interoceptive exposure treatment for young children with ARFID, Feeling and Body Investigators (FBI)-ARFID Division. Using playful cartoons and developmentally sensitive exposures, we teach young children how to map interoceptive sensations onto meanings (e.g., emotions) and actions (e.g., if I feel nervous, I'll hold someone's hand). RESULTS: We present a case study of a 4-year old child with lifelong poor appetite/food indifference. DISCUSSION: Some individuals with ARFID may avoid food to avoid internal sensations. Developmentally appropriate interoceptive exposures may decrease ARFID symptoms while increasing more general self-regulation skills.

Neurobiology of social reward valuation in adults with a history of anorexia nervosa.

OBJECTIVE: Anorexia nervosa (AN) is a disorder characterized by atypical patterns of reward valuation (e.g. positive valuation of hunger). Atypical reward processing may extend into social domains. If so, such findings would be of prognostic significance as impaired social functioning predicts worse outcome. We explore neural circuits implicated in social reward processing in individuals with a history of AN who are weight-restored relative to controls and examine the effects of illness course on the experience of social value. METHOD: 20 weight-restored individuals with a history of AN (AN-WR) and 24 healthy control (HC) participants were assessed using fMRI tasks that tapped social reward: smiling faces and full human figures that varied in attractiveness and weight. RESULTS: AN-WR differed from HC in attractiveness ratings by weight (negatively correlated in AN-WR). While there were no significant differences when viewing smiling faces, viewing full figures resulted in decreased activation in regions implicated in reward valuation (the right caudate) for AN-WR and this region was negatively correlated with a sustained course of the disorder. Exploratory whole brain analyses revealed reduced activation in regions associated with social reward, self-referential processing, and cognitive reappraisal (e.g., medial prefrontal cortex, striatum, and nucleus accumbens) with sustained disorder course. DISCUSSION: The rewarding value of full body images decreases with a sustained disorder course. This may reflect an extension of atypical reward processing documented in AN-WR, perhaps as a function of starvation dampening visceral motivational signals; the deployment of cognitive strategies that lessen the experience of reward; and/or the nature of the stimuli themselves as provocative of eating disorder symptoms (e.g., thin bodies). These findings did not extend to smiling face stimuli. Advances in technology (e.g., virtual avatars, text messaging) may provide novel means to build relationships, including therapeutic relationships, to support improved social connections without threats to symptom provocation.

Time of Day When Type 1 Diabetes Patients With Eating Disorder Symptoms Most Commonly Restrict Insulin.

OBJECTIVE: Restricting insulin to lose weight is a significant problem in the clinical management of type 1 diabetes (T1D). Little is known about this behavior or how to effectively intervene. Identifying when insulin restriction occurs could allow clinicians to target typical high-risk times or formulate hypotheses regarding factors that influence this behavior. The current study investigated the frequency of insulin restriction by time of day. METHODS: Fifty-nine adults with T1D and eating disorder symptoms completed 72 hours of real-time reporting of eating and insulin dosing with continuous glucose monitoring. We used a generalized estimating equation model to test the global hypothesis that frequency of insulin restriction (defined as not taking enough insulin to cover food consumed) varied by time of day, and examined frequency of insulin restriction by hour. We also examined whether patterns of insulin restriction for 72 hours corresponded with patients' interview reports of insulin restriction for the past 28 days. RESULTS: Frequency of insulin restriction varied as a function of time (p = .016). Insulin restriction was the least likely in the morning hours (6:00-8:59 AM), averaging 6% of the meals/snacks consumed. Insulin restriction was more common in the late afternoon (3:00-5:59 PM), peaking at 29%. Insulin was restricted for 32% of the meals/snacks eaten overnight (excluding for hypoglycemia); however, overnight eating was rare. Insulin restriction was associated with higher 120-minute postprandial blood glucose (difference = 44.4 mg/dL, 95% confidence interval = 22.7-68.5, p < .001) and overall poorer metabolic control (r = 0.43-0.62, p's < .01). Patients reported restricting insulin for a greater percentage of meals and snacks for the past 28 days than during the 72 hour real-time assessment; however, the reports were correlated (Spearman's ρ = 0.46, p < .001) and accounted for similar variance in HbA1c (34% versus 35%, respectively). CONCLUSIONS: Findings suggest that insulin restriction may be less likely in the morning, and that late afternoon is a potentially important time for additional therapeutic support. Results also suggest that systematic clinical assessment and treatment of overnight eating might improve T1D management.

The Clinical Significance of Posterior Insular Volume in Adolescent Anorexia Nervosa.

OBJECTIVE: The diagnostic criterion disturbance in the experience of the body remains a poorly understood and persistent feature of anorexia nervosa (AN). Increased sophistication in understanding the structure of the insular cortex-a neural structure that receives and integrates visceral sensations with action and meaning-may elucidate the nature of this disturbance. We explored age, weight status, illness severity, and self-reported body dissatisfaction associations with insular cortex volume. METHODS: Structural magnetic resonance imaging data were collected from 21 adolescents with a history of AN and 20 age-, sex-, and body mass index-matched controls. Insular cortical volumes (bilateral anterior and posterior regions) were identified using manual tracing. RESULTS: Volumes of the right posterior insula demonstrated the following: (a) a significant age by clinical status interaction (ß = -0.018 [0.008]; t = 2.32, p = .02) and (b) larger volumes were associated with longer duration of illness (r = 0.48, p < .04). In contrast, smaller volumes of the right anterior insula were associated with longer duration of illness (r = -0.50, p < .03). The associations of insular volume with body dissatisfaction were of moderate effect size and also of opposite direction, but a statistical trend in right posterior (r = 0.40, p < .10 in right posterior; r = -0.49, p < .04 in right anterior). CONCLUSIONS: In this exploratory study, findings of atypical structure of the right posterior insular cortex point to the importance of future work investigating the role of visceral afferent signaling in understanding disturbance in body experience in AN.

Adolescent development of insula-dependent interoceptive regulation.

Adolescence is hypothesized to be a critical period for the maturation of self-regulatory capacities, including those that depend on interoceptive sensitivity, but the neural basis of interoceptive regulation in adolescence is unknown. We used functional magnetic resonance imaging and psychophysiology to study interoceptive regulation in healthy adolescent females. Participants regulated their gut activities in response to a virtual roller coaster by deep breathing aided by visually monitoring their online electrogastrogram (EGG) activity through a virtual thermometer (i.e. gut biofeedback), or without biofeedback. Analyses focused on the insula, given its putative role in interoception. The bilateral posterior insula showed increased activation in the no-biofeedback compared to biofeedback condition, suggesting that the participants relied more on interoceptive input when exteroceptive feedback was unavailable. The bilateral dorsal anterior insula showed activation linearly associated with age during both induction and regulation, and its activation during regulation correlated positively with change of EGG in the tachygastria frequency band from induction to regulation. Induction-related activation in the bilateral ventral anterior insula was nonlinearly associated with age and peaked at mid-adolescence. These results implicate different developmental trajectories of distinct sub-regions of the insula in interoceptive processes, with implications for competing neurobiological theories of female adolescent development.

Change in expressed emotion and treatment outcome in adolescent anorexia nervosa.

Expressed emotion (EE) has been associated with poor outcomes in anorexia nervosa (AN); however, whether changes in EE predict superior treatment outcomes is unknown. The current study examined whether decreases in EE during an open trial of a novel family-based treatment for AN predicted symptoms at end of treatment. Forty-seven adolescents (12-18 years of age) with AN or sub-threshold AN and their parents (mothers: n = 47, fathers: n = 39) participated in 6 months of family treatment. Measures of AN symptomatology (Eating Disorder Examination completed by adolescent and end of treatment recovery status) and parental EE (Family Questionnaire completed by parents which measures two facets of EE: critical communication [CC] and emotional over-involvement [EOI]) were collected at baseline and end of treatment. Parental EOI, but not CC, significantly decreased during the course of treatment. Change in mothers', but not fathers', EE accounted for additional variance in AN symptomatology at end of treatment above baseline EE and baseline AN symptom levels. Findings suggest a greater emphasis on parent support during treatment may improve outcomes.