Measuring cognitions during exercise: Associations between thoughts and eating disorder behaviors over a 3-week ecological momentary assessment study.

OBJECTIVE: Previous work has outlined cognitive beliefs about exercise in general, but very little is known about momentary cognitions while engaging in pathological exercise. The primary aim of this study was to explore thought content during exercise and to test whether these thoughts predicted later engagement in eating disorder behaviors. We also tested associations between thoughts and specific exercise activity. METHOD: We monitored 31 women with clinically significant eating psychopathology for 3 weeks via ecological momentary assessment as they reported on their exercise and eating disorder behaviors, and thoughts about shape, weight, or calories during exercise. Thoughts were self-reported upon cessation of each exercise session. RESULTS: Thinking about weight loss during exercise predicted later engagement in body-checking behaviors. Weight-bearing exercise was associated with a decreased likelihood of thinking about calories but an increased likelihood of thinking about shape during exercise. DISCUSSION: These findings show that shape and weight thoughts are present during exercise and that their influence on eating disorder behaviors may exist on a much briefer time scale (i.e., within a day) than previous studies show. Clinically, future studies may seek to test interventions aimed at changing or restructuring cognitions during exercise to help shape adaptive exercise behavior during and after treatment. PUBLIC SIGNIFICANCE: This is the first study measuring thoughts during pathological exercise in real-time among those with eating disorder psychopathology. The results show that thinking about weight loss during exercise might increase the likelihood of engaging in body-checking behaviors. Findings will inform the development of treatment approaches to help those in recovery from eating disorders re-engage with exercise.

Detecting pathological exercise in college men: An investigation using latent profile analysis.

OBJECTIVE: Pathological exercise is a dangerous behavior often observed in eating disorders. Data investigating associated characteristics of pathological exercise in men are lacking, despite college men and women being at equally elevated risk for developing eating disorders. PARTICIPANTS: Two hundred and twenty-four college men who exercise regularly completed a series of self-report questionnaires. METHODS: Latent profile analysis was used to identify empirically-derived homogenous subgroups of regular exercisers based on severity of other eating disorder attitudes and behaviors. Profiles were also compared on differences in exercise motivation and general psychopathology (i.e., depression, anxiety). RESULTS: Fit indices indicated a three-profile solution. Profiles described an eating psychopathology group, a low psychopathology group, and a high exercise frequency group without eating disorder features. CONCLUSIONS: Pathological exercise cannot be identified using exercise frequency alone. Other features like body dissatisfaction and exercise motivation style are relevant in identifying pathological exercise behavior in college men.

Risk management in dialectical behavior therapy: Treating life-threatening behaviors as problems to be solved.

Dialectical behavior therapy (DBT) is an empirically supported behavioral treatment for individuals with borderline personality disorder who frequently exhibit life-threatening behavior, such as suicide attempts, nonsuicidal self-injury urges and actions, and suicidal ideation. We provide an overview of the theoretical framework by which DBT conceptualizes these life-threatening behaviors and the principles by which safety planning measures are implemented and maintained throughout treatment. The importance of orienting clients to treatment and obtaining their commitment to decrease life-threatening behavior is reviewed. Relevant strategies associated with risk management and assessment, such as the diary card, chain analysis, solution analysis, phone coaching, and consultation team, are described. The overview concludes with a case example to illustrate the application of these techniques with a DBT client with a long-standing history of engaging in life-threatening behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Behavioral reinforcement of pathological exercise in anorexia nervosa.

Pathological exercise in anorexia nervosa (AN) is a harmful behavior associated with a chronic course and poor prognosis. To date, no comprehensive theoretical model exists to describe pathological exercise in the context of AN, and as such, few treatments are effective at promoting direct and sustained pathological exercise extinction. Using a framework put forth by Wise & Koob (2014), debating the relative importance of positive and negative reinforcement in substance use, we present three hypotheses of behavioral reinforcement of exercise, encompassing biological, psychological, and environmental influences. Specifically, we argue that exercise is positively reinforced through receipt of biological and behavioral rewards, negatively reinforced through avoidance of aversive emotions, and that these two systems work in tandem over time to engrain pathological exercise as a habit. We then present suggestions for testing each of these hypotheses as future directions for the field.

Cognitive rigidity and heightened attention to detail occur transdiagnostically in adolescents with eating disorders.

Cognitive inflexibility and attention to detail bias represent a promising target in eating disorder (ED) treatment. While prior research has found that adults with eating disorders exhibit significant cognitive inflexibility and heightened attention to detail, less is known about these cognitive impairments among adolescents, and across EDs transdiagnostically. To address this gap, adolescent females (N = 143) from a residential ED program with anorexia nervosa, bulimia nervosa, or other specified feeding or eating disorder completed the Detail and Flexibility Questionnaire (DFlex) and measures of ED and general psychopathology. Transdiagnostically, adolescents with EDs scored higher than an archival sample of healthy control adolescents on both cognitive rigidity (p < .001; Cohen's d = 1.92) and attention to detail (p < .001; Cohen's d = 1.16). These cognitive impairments were significantly associated with severity of eating pathology, and these relationships existed independent of age, duration of illness, or body mass index (BMI). Our findings suggest cognitive inflexibility and heightened attention to detail occur transdiagnostically in adolescents with eating disorders and are unlikely to be a scar of the disorder. Future prospective research is needed to determine whether these cognitive styles represent an endophenotype of eating disorders.

Adherence to low-calorie and low-sugar diets is uniquely associated with distinct facets of appearance/weight-related smoking motivations.

Smokers report weight and appetite control as motivators to smoking continuance. These concerns are particularly salient for smokers who use cigarettes to suppress appetite and manage weight. Dieting may influence weight, shape, and appetite-related smoking motivation; however, this has not yet been examined. This study tested associations between five diet types and smoking motivation to control weight, shape, and appetite among adult daily cigarette smokers (N = 550). A multivariate analysis was used to test the incremental association between diet types and Smoking-Related Weight and Eating Episodes Test (SWEET) subscales, adjusting for age, body mass index, sex, and cigarette dependence. Smokers who diet (n = 83, 15.1%) reported higher scores on all SWEET subscales compared to smokers not on a diet. Low-calorie dieting was associated with greater smoking motivation to cope with body dissatisfaction, and low-sugar dieting was associated with greater motivation for smoking to prevent withdrawal-related appetite increases. Treatment implications for smoking cessation are discussed.

Positive emotion and motivational dynamics in anorexia nervosa: A positive emotion amplification model (PE-AMP).

The role of positive emotion in anorexia nervosa (AN) has been underappreciated in both theory and treatment. Yet, people with AN demonstrate high motivation for and sustained effort toward weight loss, achieving success to an extreme beyond the capability of most people. Positive emotion dysregulation may facilitate and reinforce such efforts. The positive emotion amplification (PE-AMP) model of AN describes a dynamic interplay between biologically based enhanced reward responding and cognitive-behavioral factors that amplify positive emotion, resulting in positive feedback cycles that motivate and reinforce weight loss behavior during the AN onset phase. These experiences subvert the pursuit of happiness by providing artificial senses of autonomy, competency, and relatedness to others (self-determination theory; Ryan & Deci, 2000) that provide a stark contrast to an otherwise negative emotional environment, resulting in the emergence and persistence of AN psychopathology as a self-sustaining sense of purpose. Ultimately, negative emotion, PE dysregulation, and artificial self-determination threats continue to drive AN behavior during the AN maintenance phase, pushing patients toward a genuine self-determination breakdown that can lead to hospitalization, health crises, relational strife and diminished quality of life, or even manifest in suicidal behavior. Future research directions and novel methodological approaches inspired by the PE-AMP model are discussed, as are important treatment implications for addressing this highly treatment-resistant disorder. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Distress Intolerance in Relation to Reliance on Cigarettes for Weight, Shape, and Appetite Control.

BACKGROUND: Distress intolerance, one's inability to withstand distressing emotional or physical states, is a transdiagnostic vulnerability implicated in affect-based health behaviors, including cigarette smoking and poor weight control. The current study evaluated associations between distress intolerance and the reliance on cigarettes for management of weight, appetite, or body dissatisfaction, which may pose a burden for cessation and increase risk of weight-related health problems. METHOD: Daily smokers (n = 577) completed an online survey assessing distress tolerance and reliance on cigarettes for weight and shape control with the four subscales of the Smoking and Weight Eating Episodes Test (SWEET). Four hierarchical regression models were constructed to test the association between distress intolerance and SWEET scores, accounting for the effect of relevant covarying factors. RESULTS: After adjusting for model covariates, distress intolerance was significantly incrementally associated with greater tendency to rely on cigarettes to suppress appetite (adjR2 = .040), prevent overeating (adjR2 = .034), cope with body dissatisfaction (adjR2 = .046), and cope with nicotine withdrawal-related appetite increases (adjR2 = .030). CONCLUSION: Distress intolerance may play an etiological role in maladaptive use of cigarettes to control appetite, weight, and body dissatisfaction among daily smokers, particularly those with weight- or shape-related concerns. Interventions aimed at increasing perceived ability to withstand distress could potentially reduce reliance on cigarettes for the aforementioned purposes.

Behavioral inhibition moderates the association between overvaluation of shape and weight and noncompensatory purging in eating disorders.

OBJECTIVE: The cognitive-behavioral therapy (CBT) model of eating disorders suggests that compensatory purging behaviors (e.g., self-induced vomiting, inappropriate laxative use) are primarily driven by binge eating. However, many individuals endorse purging in the absence of binge eating (i.e., noncompensatory purging [NCP]). Research is needed to understand why some individuals purge in the absence of objective or subjective binge-eating episodes. METHOD: Given the importance of overvaluation of shape/weight in the CBT model, and the existing evidence linking temperamental characteristics like behavioral inhibition (i.e., the tendency to withdraw in response to threat cues) with purging in general, we tested whether behavioral inhibition moderated the relationship between overvaluation of shape/weight and NCP in a sample of individuals in a residential eating disorder treatment center (N = 143). RESULTS: Overvaluation was more strongly related to NCP in individuals with high (relative to low) levels of behavioral inhibition. Among individuals low in behavioral inhibition, overvaluation predicted engagement in NCP to a much weaker extent. DISCUSSION: For those high (relative to low) in behavioral inhibition, both emotional avoidance and overvaluation may be important targets in the treatment of NCP, particularly in the absence of binge eating.

The posited effect of positive affect in anorexia nervosa: Advocating for a forgotten piece of a puzzling disease.

Anorexia nervosa (AN) is a complex and life-threatening eating disorder. Current models of AN onset and maintenance have largely focused on the role of negative affect, while fewer models have described the role of positive affect (PA). Given that these theoretical models have informed current treatment approaches, and that treatment remains minimally effective for adults with AN, we advocate that targeting PA is one avenue for advancing maintenance models and by extension, treatment. We specifically propose that AN may arise and be chronically and pervasively maintained as a function of dysregulated PA in response to weight loss and weight loss behaviors (e.g., restriction, excessive exercise), to a degree that is not accounted for in existing models of AN. We present evidence from multiple domains, including biological, behavioral, and self-report, supporting the hypothesis that PA dysregulation in AN contributes to the maintenance of the disorder. We conclude with several specific avenues for treatment development research as well as a call for future work elucidating the biological correlates of PA.

Impact of expanded diagnostic criteria for avoidant/restrictive food intake disorder on clinical comparisons with anorexia nervosa.

OBJECTIVE: Avoidant/restrictive food intake disorder (ARFID) and anorexia nervosa (AN) are restrictive eating disorders. There is a proposal before the American Psychiatric Association to broaden the current DSM-5 criteria for ARFID, which currently require dietary intake that is inadequate to support energy or nutritional needs. We compared the clinical presentations of ARFID and AN in an outpatient sample to determine how a more inclusive definition of ARFID, heterogeneous for age and weight status, is distinct from AN. METHODS: As part of standard care, 138 individuals with AN or ARFID completed an online assessment battery and agreed to include their responses in research. RESULTS: Individuals with ARFID were younger, reported earlier age of onset, and had higher percent median BMI (%mBMI) than those with AN (all ps < .001). Individuals with ARFID scored lower on measures of eating pathology, depression, anxiety, and clinical impairment (all ps < .05), but did not differ from those with AN on restrictive eating (p = .52), and scored higher on food neophobia (p < .001). DISCUSSION: Allowing psychosocial impairment to be sufficient for an ARFID diagnosis resulted in a clinical picture of ARFID such that %mBMI was higher (and in the normal range) compared with AN. Differences in gender distribution, age, and age of onset remained consistent with previous research. Both groups reported similar levels of dietary restriction, although ARFID can be distinguished by relatively higher levels of food neophobia. Currently available measures of eating pathology may capture certain ARFID symptoms, but highlight the need for measures of impairment relative to ARFID.

Factorial integrity and validation of the Eating Pathology Symptoms Inventory (EPSI).

The Eating Pathology Symptoms Inventory (EPSI) is a 45-item self-report measure of eating pathology designed to be sensitive in assessing symptoms among diverse populations of individuals with disordered eating. The current study represents the first external validation of the EPSI as well as the first to examine the factor structure in an outpatient eating disorder clinic sample. We conducted an exploratory factor analysis in three separate samples: an outpatient clinic sample (n = 284), a college sample (n = 296), and a community sample (n = 341) and compared the observed factor structures to the original 8-factor solution proposed by Forbush et al. (2013). We also investigated whether the subscales correlated with the Eating Disorder Examination Questionnaire (EDE-Q) and a clinical impairment measure among the outpatient clinic sample. Results suggested between 7 and 8 factors for each of the three samples. Our findings largely replicated those of the original EPSI development study, excepting some deviations in the Muscle Building, Cognitive Restraint, and Excessive Exercise subscales. However, confirmatory factor analysis and exploratory structural equation modeling produced poor model fit, which may be related to the item heterogeneity within many of the subscales. Finally, eating disorder attitudes and behaviors assessed by the EPSI were significantly correlated with the EDE-Q and with clinical impairment. Overall, our results highlight both strengths and limitations of the EPSI. Findings provide preliminary support for the use of the EPSI among research with diverse populations, and present several avenues for future research for enhancing clinical utility.

Global/local processing style: Explaining the relationship between trait anxiety and binge eating.

OBJECTIVE: Anxiety is a risk factor for disordered eating, but the mechanisms by which anxiety promotes disordered eating are poorly understood. One possibility is local versus global cognitive processing style, defined as a relative tendency to attend to details at the expense of the "big picture." Anxiety may narrow attention, in turn, enhancing local and/or compromising global processing. We examined relationships between global/local processing style, anxiety, and disordered eating behaviors in a transdiagnostic outpatient clinical sample. We hypothesized that local (vs. global) processing bias would mediate the relationship between anxiety and disordered eating behaviors. METHOD: Ninety-three participants completed the eating disorder examination-questionnaire (EDE-Q), State-Trait Anxiety Inventory (STAI)-trait subscale, and the Navon task (a test of processing style in which large letters are composed of smaller letters both congruent and incongruent with the large letter). The sample was predominantly female (95%) with a mean age of 27.4 years (SD = 12.1 years). RESULTS: Binge eating, but not fasting, purging, or excessive exercise, was correlated with lower levels of global processing style. There was a significant indirect effect between anxiety and binge eating via reduced global level global/local processing. DISCUSSION: In individuals with disordered eating, being more generally anxious may encourage a detailed-oriented bias, preventing individuals from maintaining the bigger picture and making them more likely to engage in maladaptive behaviors (e.g., binge eating).

Won't stop or can't stop? Food restriction as a habitual behavior among individuals with anorexia nervosa or atypical anorexia nervosa.

Food restriction among individuals with anorexia nervosa (AN) is regarded as a goal-directed behavior. However, Walsh (2013) theorized that, although restriction is initially maintained by operant conditioning (with successful weight loss and external praise as salient rewards), it ultimately becomes a classically conditioned habit, persisting regardless of the presence of these once-salient rewards. Understanding food restriction as a well-ingrained habit may provide insight into treatment resistance. Further, it is not clear whether habitual food restriction is present among individuals with atypical AN (i.e. who engage in food restriction but are not low-weight). This study evaluated whether strength of habit predicted self-reported restriction above and beyond cognitive restraint. Seventy-eight individuals with AN or atypical AN completed the Eating Pathology Symptoms Inventory Restriction (EPSI-R) and Cognitive Restraint (EPSI-CR) subscales and the Self-Report Habit Index (SRHI) adapted for food restriction. We used a hierarchical multiple regression model to test whether habit strength predicted food restriction above and beyond cognitive restraint. After adding illness duration (step 1) and diagnosis (step 2) to the model, cognitive restraint (step 3) was not significant in explaining variation in restriction, whereas adding habit strength to the model (step 4) explained 27.9% of the variance in restriction (p<0.001). This is the first study to test a key component of Walsh's theory. Results provide support for food restriction maintenance through habit, rather than through effortful cognitive restraint. Because current models of AN characterize food restriction as purposeful, further research is needed to better understand habitual restriction in AN.