Rhonda M. Merwin

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.

Preliminary Findings on the Effects of Self-Referring and Evaluative Stimuli on Stimulus Equivalence Class Formation.

Thirty-two subjects completed 2 stimulus equivalence tasks using a matching-to-sample paradigm. One task involved direct reinforcement of conditional discriminations designed to produce derived relations between self-referring stimuli (e.g., me, myself, I) and positive evaluation words (e.g., whole, desirable, perfect). The other task was designed to produce derived relations between self-referring stimuli and negative evaluation wordls (e.g., unworthy, flawed, inadequate). Performance on each task was recorded via response latency and percent correct. Prior to completion of the equivalence tasks, subjects completed 2 self-report measures: the Outcome Ouestionnaire-45 (OQ-45) and the Rosenberg Self-Esteem Scale (RSE). Subjects were divided into groups based on their OQ-45 score (high or low distress) and RSE score (high or low self-esteem). Significant differences in percent correct were found between both the OQ-45 groups and the RSE groups. Subjects who reported high distress and a negative sense of self made significantly more errors on the tests for equivalence for the task that required matching self-referential stimuli with positive evaluation words.

Emotion regulation difficulties in anorexia nervosa: Relationship to self-perceived sensory sensitivity.

Changes in sensation (e.g., prickly skin) are crucial constituents of emotional experience, and the intensity of perceived changes has been linked to emotional intensity and dysregulation. The current study examined the relationship between sensory sensitivity and emotion regulation among adults with anorexia nervosa (AN), a disorder characterised by disturbance in the experience of the body. Twenty-one individuals with AN, 20 individuals with AN who were weight–restored, and 23 typical controls completed self-report measures of sensory sensitivity and emotion regulation. AN participants reported heightened sensory sensitivity and greater difficulty regulating emotions relative to controls. Self-perceived sensory sensitivity was associated with greater emotion dysregulation. Weight-restored AN participants reported greater ability to regulate emotions than their currently underweight counterparts, despite heightened sensitivity. Findings suggest that hypersensitivity may be a persisting feature in AN, and that weight restoration may involve improved ability to cope with sensation.

Hostility and Fasting Glucose in African American Women

Objective: To examine whether the relationship of hostility (HOST) to fasting glucose indices is moderated by sex and race. HOST has been associated with abnormalities in glucose metabolism. Prior studies suggested that this association may be more prevalent in women and in African American (AA) individuals. Methods: A total of 565 healthy AA and white (W) men and women (mean age = 33 ± 6 years) were assessed. HOST was measured by the 27-item version of the Cook Medley HOST Scale. The moderating effects of sex and race were evaluated for the associations of HOST to fasting glucose, insulin, and insulin sensitivity (HOMA-IR). Results: Analysis showed a moderating effect of sex and race on the association of HOST to fasting glucose (p = .03), but not for insulin (p = .12). Analysis of HOMA-IR revealed a trend (p = .06) for the interaction. Stratified analyses by race and sex revealed a positive association between HOST and fasting glucose only in AA women, which remained significant after controlling for age and body mass index. Conclusion: A relationship between HOST and fasting glucose was evident in AA women only, a group that has twice the risk of developing Type 2 diabetes compared with W women. Further studies are needed to elucidate the mechanisms by which HOST may affect glucose metabolism in AA women. AA = African American; BMI = body mass index; CVD = cardiovascular disease; HOMA-IR = homeostasis model assessment of insulin resistance; HOST = hostility; T2DM = Type 2 diabetes mellitus; W = white.

Perception of affect in biological motion cues in anorexia nervosa

OBJECTIVE Nonverbal motion cues (a clenched fist) convey essential information about the intentions of the actor. Individuals with anorexia nervosa (AN) have demonstrated impairment in deciphering intention from facial affective cues, but it is unknown whether such deficits extend to deciphering affect from body motion cues. METHOD We examined the capacities of adults with AN (n = 21) or those weight restored for ≥12 months (WR; n = 20) to perceive affect in biological motion cues relative to healthy controls (HC; n = 23). RESULTS Overall, individuals with AN evidenced greater deficit in discriminating affect from biological motion cues than WR or HC. Follow-up analyses showed that individuals with AN differed especially across two of the five conditions--deviating most from normative data when discriminating sadness and more consistently discriminating anger relative to WR or HC. DISCUSSION Implications of these findings are discussed in relation to some puzzling interpersonal features of AN.

An open trial of Acceptance-based Separated Family Treatment (ASFT) for adolescents with anorexia nervosa

Family based-treatments have the most empirical support in the treatment of adolescent anorexia nervosa; yet, a significant percentage of adolescents and their families do not respond to manualized family based treatment (FBT). The aim of this open trial was to conduct a preliminary evaluation of an innovative family-based approach to the treatment of anorexia: Acceptance-based Separated Family Treatment (ASFT). Treatment was grounded in Acceptance and Commitment Therapy (ACT), delivered in a separated format, and included an ACT-informed skills program. Adolescents (ages 12-18) with anorexia or sub-threshold anorexia and their families received 20 treatment sessions over 24 weeks. Outcome indices included eating disorder symptomatology reported by the parent and adolescent, percentage of expected body weight achieved, and changes in psychological acceptance/avoidance. Half of the adolescents (48.0%) met criteria for full remission at the end of treatment, 29.8% met criteria for partial remission, and 21.3% did not improve. Overall, adolescents had a significant reduction in eating disorder symptoms and reached expected body weight. Treatment resulted in changes in psychological acceptance in the expected direction for both parents and adolescents. This open trial provides preliminary evidence for the feasibility, acceptability, and efficacy of ASFT for adolescents with anorexia. Directions for future research are discussed.

Disinhibited eating and weight-related insulin mismanagement among individuals with type 1 diabetes☆

OBJECTIVE Withholding insulin for weight control is a dangerous practice among individuals with type 1 diabetes; yet little is known about the factors associated with this behavior. Studies of nondiabetic individuals with weight concerns suggest that eating in a disinhibited manner (e.g., binge eating) predicts the use of maladaptive compensatory strategies (e.g., self-induced vomiting). The purpose of this study was to test whether individuals with type 1 diabetes are less restrained in their eating when they think their blood glucose (BG) is low and whether this contributes to insulin omission for weight control purposes and subsequently higher hemoglobin A1c (HbA1c). METHODS Two-hundred and seventy-six individuals with type 1 diabetes completed an online survey of eating behaviors, insulin dosing and most recent HbA1c. We used structural equation modeling to test the hypothesis that disinhibited eating when blood sugar is thought to be low predicts weight-related insulin mismanagement, and this, in turn, predicts higher HbA1c. RESULTS The majority of participants endorsed some degree of disinhibition when they think their blood glucose is low (e.g., eating foods they do not typically allow) and corresponding negative affect (e.g., guilt/shame). The frequency of disinhibited eating was positively associated with weight-related insulin mismanagement. Controlling for age, sex, education, and insulin pump use, the model explained 31.3% of the variance in weight-related insulin mismanagement and 16.8% of the variance in HbA1c. CONCLUSION Addressing antecedents to disinhibited eating that are unique to type 1 diabetes (e.g., perceived BG level) and associated guilt or shame may reduce weight-related insulin omission.

Children's Reasons for Living, Self-esteem, and Violence

Attitudes toward violence and reasons for living in young adolescents with high, moderate, and low self-esteem were examined. The authors devised an Attitudes Toward Violence questionnaire; the Rosenbergs Self-esteem Scale (RSE) and the Brief Reasons for Living in Adolescents (BRFL-A) was used to assess adaptive characteristics. The independent variables were gender and self-esteem. The dependent variables were total Reasons for Living score and Attitudes Toward Violence score. Participants included 138 boys and 95 girls, ages 11 to 15 years (M = 13.3) from a city middle school. The results showed that for the dependent variable attitudes toward violence, main effects were found for both gender and self-esteem. For the dependent variable reasons for living, a main effect was found for self-esteem but not for gender. An inverse relationship was found between violence and reasons for living. Being male and low self-esteem emerged as predictors of more accepting attitudes toward violence. Low self-esteem was significantly related to fewer reasons for living.

Hostility and Minimal Model of Glucose Kinetics in African American Women

Objective: To explore the underlying physiology of hostility (HOST) and to test the hypothesis that HOST has a greater impact on fasting glucose in African American (AA) women than it does on AA men or white men or women, using an intravenous glucose tolerance test (IVGTT) and the minimal model of glucose kinetics. Methods: A total of 115 healthy subjects selected for high or low scores on the 27 item Cook Medley HOST Scale underwent an IVGTT. Fasting nonesterified fatty acids (NEFA) levels were measured before the IVGTT. Catecholamine levels were measured 10 minutes into the IVGTT. Results: Moderation by group (AA women versus others) of HOST was found for glucose effectiveness (Sg, p = .02), acute insulin response (AIRg, p = .02), and disposition index (DI, p = .02). AA women showed a negative association between HOST and both Sg (&bgr; = −0.45, p = .04) and DI (&bgr; = −0.49, p = .02), controlling for age and body mass index. HOST was also associated with changes in epinephrine (&bgr; = 0.39, p = .05) and fasting NEFA (&bgr; = 0.44, p = .02) in the AA women. Controlling for fasting NEFA reduced the effect of HOST on both Sg and DI. Conclusions: This study shows that HOST is related to decreased DI, a measure of pancreatic compensation for increased insulin resistance as well as decreased Sg, a measure of noninsulin-mediated glucose transport compared in AA women. These effects are partly mediated by the relationship of HOST to fasting NEFA. AA = African American; BMI = body mass index; CVD = cardiovascular disease; DI = disposition index; EPI = epinephrine; HOST = hostility; IVGTT = intravenous glucose tolerance test; IPAQ = international physical activity questionnaire; NEFA = nonesterified fatty acids; NOREPI = norepinephrine; OGTT = oral glucose tolerance test; Sg= glucose effectiveness; Si = insulin sensitivity; SNS = sympathetic nervous system; T2DM = Type 2 diabetes mellitus; W = white.