Kelsey E. Hagan

Characterizing severe and enduring anorexia nervosa: An empirical approach

Targeted approaches for the treatment of severe and enduring anorexia nervosa (SE-AN) have been recommended, but there is no consensus definition of SE-AN to inform research and clinical practice. This study aimed to take initial steps toward developing an empirically based definition of SE-AN by characterizing associations among putative indicators of severity and chronicity in eating disorders. Patients with AN (N = 355) completed interviews and questionnaires at treatment admission and discharge; height and weight were assessed to calculate body mass index (BMI). Structural equation mixture modeling was used to test whether associations among potential indicators of SE-AN (illness duration, treatment history, BMI, binge eating, purging, quality-of-life) formed distinct subgroups, a single group with one or more dimensions, or a combination of subgroups and dimensions. A three-factor (dimensional), two-profile (categorical) mixture model provided the best fit to the data. Factor 1 included eating disorder behaviors; Factor 2 comprised quality-of-life domains; Factor 3 was characterized by illness duration, number of hospitalizations, and admission BMI. Profiles differed on eating disorder behaviors and quality-of-life, but not on indicators of chronicity or BMI. Factor scores, but not profile membership, predicted outcome at discharge from treatment. Data suggest that patients with AN can be classified on the basis of eating disorder behaviors and quality-of-life, but there was no evidence for a chronic subgroup of AN. Rather, indices of chronicity varied dimensionally within each class. Given that current definitions of SE-AN rely on illness duration, these findings have implications for research and clinical practice.

Is Dietary Restraint a Unitary or Multi-Faceted Construct?

Given that approximately two-thirds of adults are overweight or obese, there is substantial interest in dieting (dietary restraint) to promote weight loss. However, research on the associations between dietary restraint and binge eating is inconsistent. One possible explanation for contradictory findings is that measures of dietary restraint assess heterogeneous constructs. Nonclinical samples of university student (n = 433; 62.6% female) and community-recruited (n = 407; 47.4% female) adults completed self-report measures of dietary restraint. Exploratory structural equation modeling and exploratory and confirmatory factor analyses were used to identify latent dietary restraint factor(s). Structural equation modeling and multiple regression were used to test associations among latent dietary restraint factor(s), body mass index (BMI), eating-disorder risk, binge eating, and psychopathological and personality variables. Three latent dietary restraint factors emerged: (a) Calorie Counting; (b) Preoccupation With Dieting; and (c) Weight-Focused Restraint. The model demonstrated a good fit to the data. Eating-disorder risk was significantly and positively associated with all restraint factors, whereas higher levels of BMI and binge eating were significantly associated with greater Preoccupation with Dieting and Weight-Focused Restraint only. Our findings indicated that dietary restraint is a heterogeneous construct and that measures of restraint assess different aspects of dieting. Our results have important implications for eating and weight disorders treatment, and suggest that weight-loss interventions that do not simultaneously increase negative attitudes toward one’s body may be useful for treating weight disorders, without promoting disordered eating.

Voluntary emotion regulation in anorexia nervosa: A preliminary emotion-modulated startle investigation

Emotion regulation difficulties are implicated in the development and maintenance of anorexia nervosa (AN). However, research has been limited by an almost exclusive reliance on self-report. This study is the first to use the emotion-modulated startle paradigm (EMSP) to investigate emotional reactivity and voluntary emotion regulation in individuals with AN. Twenty women with AN viewed negative, positive, neutral, and food images and were asked to enhance, suppress, or maintain their emotional responses mid-way through picture presentation. Startle eyeblink magnitudes in response to startle probes administered prior, and subsequent, to regulation instructions indexed emotional reactivity and regulation, respectively. On emotional reactivity trials, startle magnitudes were greater for negative, positive, and food images, compared to neutral images. Participants had difficulty suppressing startle responses to negative and food images, as indicated by non-significant suppress-maintain comparisons. In contrast, startle responses to enhance and suppress cues during presentation of pleasant images were comparable and significantly lower than maintain cues. Findings converge with self-report data to suggest that patients with AN have difficulties with voluntary emotion regulation. The EMSP may be a promising trans-diagnostic method for examining emotion regulation difficulties that underlie risk for eating disorders and other psychiatric conditions.

Concurrent and prognostic utility of subtyping anorexia nervosa along dietary and negative affect dimensions.

Bulimia nervosa can be reliably classified into subtypes based on dimensions of dietary restraint and negative affect. Community and clinical studies have shown that dietary-negative affect subtypes have greater test–retest reliability and concurrent and predictive validity compared to subtypes based on the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although dietary-negative affect subtypes have shown utility for characterizing eating disorders that involve binge eating, this framework may have broader implications for understanding restrictive eating disorders. Objective: The purpose of this study was to test the concurrent and predictive validity of dietary-negative affect subtypes among patients with anorexia nervosa (AN; N = 194). Method: Latent profile analysis was used to identify subtypes of AN based on dimensions of dietary restraint and negative affect. Chi-square and multivariate analysis of variance were used to characterize baseline differences between identified subtypes. Structural equation modeling was used to test whether dietary-negative affect subtypes would outperform DSM categories in predicting clinically relevant outcomes. Results: Results supported a 2-profile model that replicated dietary-negative affect subtypes: Latent Profile 1 (n = 68) had clinically elevated scores on restraint only; Latent Profile 2 (n = 126) had elevated scores on both restraint and negative affect. Validation analyses showed that membership in the dietary-negative affect profile was associated with greater lifetime psychiatric comorbidity and psychosocial impairment compared to the dietary class. Dietary-negative affect subtypes only outperformed DSM categories in predicting quality-of-life impairment at 1-year follow-up. Conclusions: Findings highlight the clinical utility of subtyping AN based on dietary restraint and negative affect for informing future treatment-matching or personalized medicine strategies.

A new approach to eating-disorder classification: Using empirical methods to delineate diagnostic dimensions and inform care

OBJECTIVE Despite changes to the diagnostic criteria for eating disorders (EDs) in the DSM-5, the current diagnostic system for EDs has limited ability to inform treatment planning and predict outcomes. Our objective was to test the clinical utility of a novel dimensional approach to understanding the structure of ED psychopathology. METHOD Participants (N = 243; 82.2% women) were community-recruited adults with a DSM-5 ED assessed at baseline, 6-month, and 1-year follow-up. Hierarchical factor analysis was used to identify a joint hierarchical-dimensional structure of eating, mood, and anxiety symptoms. Exploratory structural equation modeling was used to test the ability of the dimensional model to predict outcomes. RESULTS At the top of the hierarchy, we identified a broad Internalizing factor that reflected diffuse symptoms of eating, mood, and anxiety disorders. Internalizing branched into three subfactors: distress, fear-avoidance (fears of certain stimuli and behaviors to neutralize fears, including ED behaviors designed to reduce fear of weight gain), and body dissatisfaction, which was nested within distress. The lowest level of the hierarchy was characterized by 15 factors. The hierarchical model predicted 60.1% of the variance in outcomes at 6-month follow-up, whereas all DSM eating, mood, and anxiety disorders combined predicted 35.8% of the variance in outcomes. DISCUSSION A dimensional approach to understanding and diagnosing EDs improved the ability to prospectively predict clinical course above-and-beyond the traditional categorical (DSM-based) approach. Our findings have implications for endeavors to improve the prediction of ED prognosis and course, and to develop more effective trans-diagnostic treatments.

The Athletes’ relationships with training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders

Abstract Objective Several studies indicate that eating‐disorder (ED) psychopathology is elevated in athletes compared to non‐athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non‐athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical‐activity patterns. Most ED assessments were developed and normed in non‐athlete samples and, therefore, do not capture the nuances of athletes’ training experiences. The purpose of the current study was to develop and validate a clinically useful, self‐report measure of unhealthy training behaviors and beliefs in athletes, the Athletes’ Relationships with Training Scale (ART). Method The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment. Results Factor analyses indicated the ART had a four‐factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge. Discussion The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.

Data for: The Association of Folate and Depression: A Meta-Analysis

Files used for full data (APRILEXCEL1), for full data without outliers (April Excel No Outliers 1), and for subgroup analyses. Includes R script (MetaBH).