Nancy Zucker

Anorexia Nervosa and Autism Spectrum Disorders: Guided Investigation of Social Cognitive Endophenotypes.

Death by suicide occurs in a disproportionate percentage of individuals with anorexia nervosa (AN), with a standardized mortality ratio indicating a 57-fold greater risk of death from suicide relative to an age-matched cohort. Longitudinal studies indicate impaired social functioning increases risk for fatal outcomes, while social impairment persists following recovery. Study of social cognition in AN may elucidate impaired processes that may influence therapeutic efficacy. Symptoms of autism spectrum disorders (ASD) are overrepresented in those who evidence a chronic course. Relative to that in AN, social information processing in ASD is well characterized and may inform systematic study in AN. This article (a) reviews impaired interpersonal processes in AN, (b) compares the phenotype of AN with that of ASD, (c) highlights deficits of social cognitive disturbance in ASD relative to AN, and (d) proposes a new framework to understand the interaction of individuals with AN with their social context.

Body image assessment for obesity (BIA-O): development of a new procedure

OBJECTIVE: A new measure of body image, named the body image assessment for obesity (BIA-O) was developed and tested for reliability and validity in a sample of 1209 adult men and women. Separate BIA-O procedures were developed for men and women. Current, ideal and reasonable body image estimates of Caucasian and African-American men and women were compared.METHOD: Figural stimuli of males and females were developed for body sizes ranging from very thin to very obese in 18 increments. Participants selected figures that represented estimates of current, ideal and reasonable (a body size that could be maintained over time) body size. Some participants (n=641) also completed two measures of body dissatisfaction in a test of the validity of the BIA-O as a measure of body dissatisfaction. A sample of 77 participants was administered the BIA-O on two occasions to test the test–retest reliability of the BIA-O.RESULTS: The reliability of the BIA-O was supported by test–retest reliability coefficients which ranged from 0.65 to 0.93. Concurrent validity of the discrepancy between current and ideal and current and reasonable body size estimates was supported by positive correlations with two measures of body dissatisfaction. The BIA-O body size estimates of Caucasians and African-Americans, controlled for age and BMI, were compared. As BMI increased, Caucasian men and women were found to select larger current body size estimates in comparison to African-Americans.DISCUSSION: The reliability and validity of the BIA-O were supported. Greater body size dissatisfaction in obese Caucasians, relative to African-Americans of the same size, may be a function of biased estimates of current body size.

Duration of illness predicts outcome for bulimia nervosa: a long-term follow-up study.

OBJECTIVE The purpose of this study was to investigate long-term outcome and prognosis in a bulimic and subthreshold bulimic sample. METHOD In a follow-up study, 44 patients diagnosed with bulimia nervosa and subthreshold bulimia nervosa were contacted after an average follow-up period of 9 years. RESULTS Results revealed that 72.7% (n = 32) of the participants were recovered at the time of follow-up. An investigation of prognostic variables showed that good outcome was associated with a shorter duration of illness, which was defined as the time between onset of symptoms and first treatment intervention. If participants were initially treated within the first few years of the illness, the probability of recovery was above 80%. However, if they were initially treated 15 years or more after the onset of the illness, the probability of recovery fell below 20%. DISCUSSION This finding suggests that early identification of bulimia nervosa may be a very important factor in preventing a chronic eating disorder.

Classification of Eating Disturbance in Children and Adolescents: Proposed Changes for the DSM-V

Childhood and adolescence are critical periods of neural development and physical growth. The malnutrition and related medical complications resulting from eating disorders such as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified may have more severe and potentially more protracted consequences during youth than during other age periods. The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.

Changes in depressive symptoms and glycemic control in diabetes mellitus.

Objective: To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes. Methods: Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels. Results: Mean and standard deviation baseline BDI and HbA1c levels were 17.9 ± 5.8 and 7.6 ± 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group. Conclusion: Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes. CBT = cognitive behavioral therapy; BDI = Beck Depression Inventory; BMI = body mass index; HAM-D = Hamilton depression scale.

Two Novel Treatments to Reduce Overeating in Overweight Children: A Randomized Controlled Trial

OBJECTIVE Our purpose in this study was to examine 2 treatments targeted at reducing eating in the absence of hunger in overweight and obese children. METHOD Thirty-six overweight and obese 8- to 12-year-old children (58% female; mean age = 10.3 years, SD = 1.3), with high scores on eating in the absence of hunger, and their parents were randomly assigned to an 8-week childrens appetite awareness training or cue exposure treatment-food. Children completed an eating in the absence of hunger (EAH) paradigm, an Eating Disorder Examination interview for children, and three 24-hr dietary recalls, and their height and weight were measured. Parents completed the EAH Questionnaire and the Binge Eating Scale, and their height and weight were measured. Assessments were conducted at baseline, posttreatment, and 6 and 12 months posttreatment. RESULTS Results showed that both treatments resulted in significant decreases in binge eating in children over time. Additionally, children in the food cue exposure treatment showed significant decreases in EAH posttreatment and 6 months posttreatment, but children in the appetite awareness training showed no change in EAH. Neither treatment produced significant effects on caloric intake in children or on any of the parent outcomes. CONCLUSIONS This study demonstrates that training in food cue responsitivity and appetite awareness has the potential to be efficacious for reducing EAH and binge eating in children. Because these data are preliminary, further treatment development and randomized controlled studies are needed.

Psychological Inflexibility and Symptom Expression in Anorexia Nervosa

The purpose of this article is to outline a model of anorexia nervosa (AN) as a disorder of psychological inflexibility, motivated by an insatiable desire for prediction and control with related intolerance for uncertainty. We describe preliminary data that provide initial support for this conceptualization and point to the ways in which mindfulness and acceptance-based strategies might be particularly useful for treating AN. This article is not intended to be an exhaustive literature review, rather a conceptual framework to guide future research and treatment development.

Interoceptive awareness in eating disorders: Distinguishing lack of clarity from non-acceptance of internal experience

Poor interoceptive awareness is often cited as a key feature of eating disorders, yet the precise nature of the deficits and their relationship to eating pathology remains unclear. Interoceptive awareness includes both acceptance of affective experience and clarity regarding emotional responses. The aim of the current study was to parse these components and examine the association between these deficits and two representative eating disorder symptoms: dietary restraint and binge eating. Participants were 50 eating disorder patients who completed a medical examination, clinical interview and symptom self-report measures. Results of regression analyses controlling for BMI and illness duration indicated that non-acceptance, not lack of clarity, was significantly associated with dietary restraint. Neither predicted binge eating. Findings suggest that negative reactions to emotional responses may contribute to the development or maintenance of dietary restraint. Results highlight the need to investigate the experience of emotional arousal in individuals with eating disorders using experimental methods that deconstruct the components of interoceptive awareness, and the potential utility of treatments that increase comfort with affective experience for individuals with more restrictive patterns.

Development and implementation of the body logic program for adolescents: A two-stage prevention program for eating disorders

It has been hypothesized that targeting adolescents who are at risk for developing eating disorders may result in more effective prevention efforts. The Body Logic Program is a two-stage prevention program, which included a school-based intervention component for all students within the school setting, as well as a more intensive intervention for students identified as at risk for developing eating disorders. The efficacy of the program was tested using a controlled treatment outcome design. Participants were 157 female and 130 male sixth and seventh graders from two private schools (School 1: n = 122; School 2: n = 165). The school-based intervention led to decreases in scores for students in School 1 on the Fear of Fatness scale of the Multiaxial Assessment of Eating Disorder Symptoms (MAEDS) for all female participants, as well as female participants identified as at risk, and the Avoidance of Forbidden Foods scale of the MAEDS (all females), which were maintained at 10.5-week follow-up. Efforts to attract the students identified as at risk for eating disorders (n = 55) and their parents for participation in the intensive family-based intervention proved unsuccessful. No significant effects for the intervention were noted for male participants, but baseline scores for boys were quite low, which limits the conclusions that can be drawn.

Altered social reward and attention in anorexia nervosa

Dysfunctional social reward and social attention are present in a variety of neuropsychiatric disorders including autism, schizophrenia, and social anxiety. Here we show that similar social reward and attention dysfunction are present in anorexia nervosa (AN), a disorder defined by avoidance of food and extreme weight loss. We measured the implicit reward value of social stimuli for female participants with (n = 11) and without (n = 11) AN using an econometric choice task and also tracked gaze patterns during free viewing of images of female faces and bodies. As predicted, the reward value of viewing bodies varied inversely with observed body weight for women with anorexia but not control women, in contrast with their explicit ratings of attractiveness. Surprisingly, women with AN, unlike control women, did not find female faces rewarding and avoided looking at both the face and eyes – independent of observed body weight. These findings suggest comorbid dysfunction in the neural circuits mediating gustatory and social reward in anorexia nervosa.