Smartphone-based approach-avoidance bias modification training for anorexia nervosa - A randomized clinical trial.

Intoduction. Eating disorders, including anorexia nervosa, are common, severe, and often chronic mental disorders. The debate over the pathogenesis and supporting factors of anorexia nervosa continue because therapeutic interventions do not lead to satisfactory and long-lasting remission rates and persistent (resistant) forms of the disease are increasingly common. Several of English-language studies with a fundamental analysis that indicates a direct influence of psychoemotional state and/or existing psychopathological manifestations in parents on the development of eating disorders, including anorexia nervosa. Historically negative family dynamics are indicated as a key element in the development of anorexia nervosa, along with personality vulnerabilities. Emotional dysfunction within the family and interaction with individual personality traits contribute to the development and maintenance of anorexia nervosa. Concerning individual personality traits, studies have shown that anorexia nervosa in female adolescents is associated with difficulties in emotional regulation, which are associated with obsessive-compulsive / perfectionist and impulsive personality traits. However, the analysis of the array of Ukrainian-language scientific literature accumulated in recent years on this issue has not yet been made. Understanding the cause and effect of anorexia nervosa and treatment-resistant forms of the disease is a necessary prerequisite for further research and development of new effective approaches to therapy.Goal. Determining the current state of analysis of the problem of emotional regulation in patients with anorexia nervosa in Ukraine in comparison with world scientific developments. Describe a clinical case showing a violation of emotional regulation in a patient with anorexia nervosa.Materials. Qualitative and quantitative content analysis and concept analysis were conducted using meta-analyses and systematic reviews of scientific Ukrainian-language and English-language literature published for the period from January 2015 to December 2019.Results. Dysfunctional emotional processing and regulation play an important role in the development and maintenance of anorexia nervosa. Systematic reviews indicate that people with anorexia nervosa have difficulty with emotional awareness (including alexithymia and poor emotional clarity), along with high levels of disgust and shame. The limitations of modern theories of anorexia nervosa and the context of the phenomenological and interpersonal nature of the disorder led to the emergence of the theory of the organizing function of the mind I in anorexia nervosa. According to this theory, anorexia nervosa occurs against the background of vague emotional experience as a means of regulating emotions and restoring the sense of bodily I, which is determined by the judgments and appearance of others. Studies also show that patients with anorexia nervosa have particularly low rates of reflex function. Low reflexive functioning together with low consistency of opinion is a consequence of uncertainty in attachment and is manifested by increased anxiety of attachment or avoidance of attachment. The clinical significance of attachment dynamics for patients with anorexia nervosa is underscored by the association between greater attachment anxiety and the avoidance and symptoms of eating disorders.The above clinical case demonstrates a violation of emotional regulation in a patient with anorexia nervosa. The combination of psychotherapeutic methods (individual and family psychotherapy), which were aimed at correcting the I and adaptive changes in reflexive functioning, together with medical intervention, allowed to obtain positive results of treatment, as evidenced by the annual follow-up.Conclusions. At the heart of anorexia nervosa is marked dysfunctional emotional processing and regulation. Patients with anorexia nervosa have low rates of reflex function. The practical significance of the model of anorexia nervosa as a disorder, which is supported by difficulties with emotional experience, is proved by the application of their provisions in the psychotherapeutic process in real clinical practice. Developing interventions to improve emotional regulation skills in the treatment of patients with anorexia nervosa, in combination with family psychotherapy, can be an important component in improving treatment outcomes, reducing relapses, and developing resistant forms of the disease.

The objective of this study is to compare treatment trajectories in anorexia nervosa (AN) and atypical AN. Adolescents and adults with AN (n = 319) or atypical AN (n = 67) in a partial hospitalization program (PHP) completed diagnostic interviews and self-report questionnaires measuring eating disorder (ED), depression, and anxiety symptoms throughout treatment. Premorbid weight loss did not differ between diagnoses. Individuals with atypical AN had more comorbid diagnoses, but groups did not differ on specific diagnoses. ED psychopathology and comorbid symptoms of depression/anxiety did not differ at admission between groups nor did rate of change in ED psychopathology and comorbid symptoms of depression/anxiety from admission to 1-month. From admission to discharge, individuals with atypical AN had a faster reduction in ED psychopathology and comorbid symptoms of depression and anxiety (ps < 0.05; rs = 0.01-0.32); however, there were no group differences in ED psychopathology or depression symptoms at discharge (ps>.50; ds = .01-.30). Individuals with atypical AN had lower anxiety at discharge compared to individuals with AN (p = 0.05; d = .4). Length of stay did not differ between groups (p = 0.11; d = .21). Groups had similar ED treatment trajectories, suggesting more similarities than differences. PHP may also be effective for AAN. This study supports previous research that individuals with AN and atypical AN have more similarities than differences. Results from this study indicate that individuals with AN and atypical AN have similar treatment outcomes for both ED psychopathology and depressive symptoms; however, individuals with atypical AN have lower anxiety symptoms at discharge compared to individuals with AN. AN and atypical AN also have more symptom similarity at admission and throughout treatment, which challenges their current designation as distinct disorders.

Anorexia Nervosa is characterized by persistent restraint eating despite severe negative consequences and often a chronic course of the disease. Recent theoretical models suggest that abnormalities in reward processing and incentive salience of disorder-compatible stimuli as observed in addictive behaviours contribute to the development and maintenance of Anorexia Nervosa. The aim of the present study was to investigate the process of the acquisition of food-related conditioned responses and the influence of conditioned low-calorie and high-calorie food stimuli on instrumental responding for different foods. A Pavlovian-to-instrumental transfer paradigm and questionnaires on eating disorder psychopathology (EDE-Q, EDI-2) were administered to patients with Anorexia Nervosa (n=39) and healthy controls (n=41). Results indicated that patients with Anorexia Nervosa showed deficits of the acquisition of knowledge of the experimental contingencies. Nevertheless, in patients with Anorexia Nervosa and healthy controls instrumental responding for low- and high-calorie food rewards was affected by stimuli conditioned to these rewards; no group differences were observed. Importantly, in Anorexia Nervosa, instrumental responding for low-calorie food increased with increasing severity of eating disorder psychopathology suggesting weight-loss directed behaviour. Future studies are warranted to enhance our understanding of deficits of reward-associated learning and to replicate and extend findings with regard to the impact of conditioned stimuli on instrumental responding. At present, our findings suggest that cognitive treatment interventions might be warranted that challenge dysfunctional beliefs about weight loss.

Objective: Especially for adult patients with anorexia nervosa (AN), treatment response is generally low to moderate. The present study aimed to evaluate the efficacy of cognitive remediation therapy (CRT) as adjunctive treatment for AN regarding clinical and cognitive outcomes. Method: In this randomized controlled superiority trial, 167 adult and adolescent (≥17 years) patients with AN were randomly allocated (1:1) to 10 weekly sessions of group therapy of either CRT (n = 82) or art therapy (ART; n = 85) as an adjunct to inpatient treatment-as-usual (TAU). Outcomes were assessed at baseline, end-of-treatment (10 weeks), and 6-month follow-up. Change in body mass index (BMI), eating disorder psychopathology, and health-related quality of life (QoL) from baseline to 6-month follow-up served as primary outcomes. Improvements in motivation to change and several indices of set-shifting and central coherence between baseline and end-of-treatment and between baseline and 6-month follow-up served as secondary outcomes. Analysis was by intention to treat. Results: Treatment groups did not differ regarding change in BMI, eating disorder psychopathology, and health-related QoL from baseline to 6-month follow-up. Likewise, groups neither differed regarding improvements in these outcomes between baseline and end-of-treatment nor in motivation to change, set-shifting, and central coherence at any time, except for greater short-term improvements in one measure of set-shifting in the CRT group. Conclusions: CRT as an adjunct to inpatient TAU for AN was not efficacious in improving clinical and cognitive outcomes. The results do not support routine employment of CRT in inpatient treatment for AN. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Very brief exposure to masked images of spider stimuli can facilitate approach behaviour towards spiders in fearful subjects. We hypothesized that a similar effect might occur for fear of food in patients with anorexia nervosa (AN), possibly offering a new treatment approach, with advantages over other methods of food exposure. Patients with AN (n=60) were randomly assigned to one of three experimental conditions and received a single session of exposure to either masked and very briefly presented food images, clearly visible food images, or masked non-food images (i.e. household items). Effects of the three exposure conditions on fear of food and food avoidance were examined. Contrary to our expectations, very brief food cue exposure was not superior to the control conditions regarding fear of food and approach behaviour towards food immediately after the intervention and body mass index four weeks later. This finding suggests important differences between fear of food in AN and specific phobias such as fear of spiders. The absence of an effect reveals limitations of the very brief exposure method, which might be better suited for evolutionarily relevant threat stimuli.

This study examined whether adolescents with anorexia nervosa (AN) are more sensitive to punishment and less sensitive to reward than a non-eating disorder comparison group. Both self-report and performance measures were used to index reward and punishment sensitivity. Participants were adolescents with AN (n = 69) and an individually matched comparison group with healthy weight (n = 69). They completed the Behavioral Inhibition Scale/Behavioral Activation Scale and the Sensitivity to Punishment and Sensitivity to Reward Questionnaire to index self-reported reward and punishment sensitivity, and performed the Spatial Orientation Task to index attention to cues signaling reward and punishment. There was extremely strong evidence (BF10 > 100), that adolescents with AN reported higher sensitivity to punishment than adolescents without an eating disorder. However, adolescents with AN did not differ from the comparison group on self-reported reward sensitivity, and attention to cues signaling reward or punishment. Adolescents with AN clearly show heightened punishment sensitivity, yet this was not paralleled by a heightened proneness to detect signals of punishment. An important next step would be to examine whether punishment sensitivity is a reliable risk factor for the development or maintenance of AN.

Anorexia Nervosa

Attentional biases to body shape images in adolescents with anorexia nervosa: An exploratory eye-tracking study

This study examined the distinctiveness of specific constructs of body-image disturbance in patients with anorexia nervosa (AN) and bulimia nervosa (BN). We compared weight/shape dissatisfaction, weight/shape overvaluation, weight/shape preoccupation, and fear of weight gain in patients with AN and BN and examined how each specific body-image construct relates to clinical measures within and between AN and BN. A clinical sample of 490 treatment-seeking patients diagnosed with DSM-5 AN (N = 310) or BN (N = 180) by clinicians using structured interviews in Portugal completed the Eating Disorder Examination-Questionnaire to assess body image and eating-disorder (ED) psychopathology. Both within and between AN and BN, the four body-image constructs varied in their strengths of association among themselves, with ED psychopathology, and body mass index (BMI). Analyses revealed considerable variability in variance accounted for in clinical measures by body-image constructs. Body-image constructs predicted significant, albeit small, variance in BMI within BN (dissatisfaction, preoccupation significant) but not within AN. Body-image constructs predicted significant, albeit small, variance in the frequencies of binge eating and purging in AN (with preoccupation significant for both and fear for purging) but not within BN. Body-image constructs predicted significant variance in ED psychopathology (large amounts of variance for Eating Concern and Restraint) within both AN and BN (with overvaluation, preoccupation, and fear significant). Clinical manifestations of body-image disturbances are complex and show important differences across AN and BN. Understanding distinctions and differential salience of different body-image constructs across different EDs can inform refinement of specific case conceptualization.

To examine the impact of the DSM-5 on the diagnoses and severity indicators of eating disorders, we conducted a comparative study on the classification of eating disorders including subtypes of anorexia nervosa (AN) between the DSM-IV and DSM-5 criteria. In addition, we studied the association of the DSM-5 severity criteria and clinical variables. Participants were 304 outpatients, aged 16-45 years, with eating disorders, diagnosed using semi-structured clinical interviews and the eating disorder examination questionnaire (EDE-Q). The severity of AN, bulimia nervosa (BN), and binge-eating disorder (BED) was rated from mild to extreme using the DSM-5 severity criteria. The DSM-5 remarkably reduced the number of diagnoses in the residual category from 37.5% to 9.2% and effectively differentiated the diagnostic groups in eating disorder psychopathology. Unexpectedly, however, the scores of all the EDE-Q subscales significantly decreased as severity ratings increased in the DSM-5 AN. Furthermore, while the AN binge-eating/purging group reported significantly lower severity ratings than the AN restricting group, the former displayed more severe eating disorder psychopathology than the latter. In the BN and BED groups, the level of eating concern increased as severity ratings increased, but the severity groups did not differ on other eating pathology variables. The DSM-5 effectively reduced the reliance on residual categories and differentiated the diagnostic groups in eating disorder psychopathology. However, our findings show limited support for the DSM-5 severity specifiers for eating disorders. It is necessary to test additional clinical or functional variables for severity specifiers across eating disorders.

Eating Disorders: What Are the Risks?

Fear and anxiety are key maintaining factors for eating disorder (ED) pathology. Maladaptive fears lead to ED behaviors and avoidance, which provide temporary relief, but ultimately reinforce the fear and contribute to a cycle that maintains the ED. To date, fears of food and weight gain are the most explored fears underlying ED pathology. However, recently other important ED fears have been identified, including fears of social consequences and personal consequences. The current study (N=229 individuals with an ED) aimed to better characterize ED fears. Specifically, this study examined which ED fears were most endorsed across and within ED diagnoses, and if there were differences in ED fears by diagnosis and by weight status. Overall, fear of gaining weight was the most frequently endorsed fear, followed by fear of food, and fear of judgment. Individuals with anorexia nervosa (AN) most frequently endorsed fear of food, individuals with atypical AN and bulimia nervosa: fear of gaining weight, and those with other specified feeding and eating disorder: fear of judgment. Limited differences were found between diagnoses. When examining by weight category, participants with underweight most frequently endorsed fear of food, participants with normal weight: fear of gaining weight, and participants with overweight and obesity: fear of judgment. These findings suggest ED fears are heterogenous. Given such high heterogeneity, this work highlights the importance of assessing for specific ED fears at the beginning of treatment, which could be used to deliver personalized exposure treatment. Eating disorders (EDs) are serious mental illnesses with high rates of medical and psychiatric comorbidities. Fear plays an important role in the development and maintenance of EDs. The present study found fear of food, weight gain, and judgment are the most frequently endorsed fears for individuals with EDs and found few differences in fears based on ED diagnosis. These findings highlight the importance of assessing individuals' specific ED fears for treatment.

Difficulties in socio-emotional functioning are proposed to contribute to the development and maintenance of anorexia nervosa (AN). This study aimed to examine emotion recognition abilities in individuals in the acute and recovered stages of AN compared to healthy controls (HCs). A second aim was to examine whether attention to faces and comorbid psychopathology predicted emotion recognition abilities. The films expressions task was administered to 148 participants (46 AN, 51 recovered AN, 51 HC) to assess emotion recognition, during which attention to faces was recorded using eye-tracking. Comorbid psychopathology was assessed using self-report questionnaires and the Autism Diagnostic Observation Schedule–2nd edition (ADOS-2). No significant differences in emotion recognition abilities or attention to faces were found between groups. However, individuals with a lifetime history of AN who scored above the clinical cut-off on the ADOS-2 displayed poorer emotion recognition performance than those scoring below cut-off and HCs. ADOS-2 scores significantly predicted emotion recognition abilities while controlling for group membership and intelligence. Difficulties in emotion recognition appear to be associated with high autism spectrum disorder (ASD) traits, rather than a feature of AN. Whether individuals with AN and high ASD traits may require different treatment strategies or adaptations is a question for future research.

Objective: Altered cognitive functioning could have an important role in the development and maintenance of Anorexia Nervosa (AN). The majority of previous research has focused on flexibility and global-detail processing. The aim of this study was to explore planning abilities in women with AN. Method: Women with AN (n = 32) were compared to healthy controls (n = 42) using two different types of neuropsychological tasks for the assessment of planning abilities: Tower of London (ToL), a classic measure of planning abilities, and Zoo Map test, a more ecologically valid planning measure. Measures of AN psychopathology, anxiety, depression, and obsessive compulsivity were also collected. Results: The AN group did not differ from controls in the ToL (all p-values p > .05), although they performed significantly worse than controls in the main score of the Zoo Map (p = .02). A worse performance in the Zoo Map test More was associated with more eating disorders (rho = −.44, p = .018) and depressive (rho = −.42, p = .026) symptoms in the AN group. Conclusions: Our study suggests the presence of subtle planning difficulties in women with AN which might be better detected using tasks with increased ecological validity.

The factors contributing to the cause and maintenance of anorexia nervosa (AN) are poorly understood, though increasing interest surrounds the neurobiological underpinnings of the condition. The examination of saccadic eye movements has proven useful in our understanding of the neurobiology of some other psychiatric illnesses, as they utilize identifiable brain circuits. Square wave jerks (SWJs), which describe an involuntary saccade away and back to fixation, have been observed to occur at abnormally high rates in neurodegenerative disorders and some psychiatric illnesses, but have not been examined in AN. Therefore, the aim of this study was to investigate whether individuals with AN and healthy control (HC) individuals differ in SWJ rate during attempted fixation. Square wave jerk frequency was compared across 23 female participants with AN and 22 HC participants matched for age, sex, and premorbid intelligence. Anorexia nervosa participants were found to make SWJs at a significantly higher rate than HC participants. The rate of SWJs in AN was also found to negatively correlate with anxiety. Square wave jerk rate and anxiety were found to correctly classify groups, with an accuracy of 87% for AN participants and 95.5% for HCs. Given our current understanding of saccadic eye movements, the findings suggest a potential role of γ-aminobutyric acid (GABA) in the superior colliculus, frontal eye fields, or posterior parietal cortex in the psychopathology of AN.