Timo Brockmeyer

Difficulties in emotion regulation across the spectrum of eating disorders

Theoretical models consider difficulties in emotion regulation (ER) as central trans-diagnostic phenomena across the spectrum of eating disorders (ED). However, there is a lack of studies directly comparing ED subtypes regarding ER problems. Furthermore, patients with anorexia nervosa-restricting type (AN-R) and patients with AN-binge/purge type (AN-BP) have usually been merged into one overall AN group in previous research on ER. In order to overcome these limitations of previous studies, the present study investigated specific ER difficulties in 120 patients with different ED subtypes, including AN-R, AN-BP, bulimia nervosa (BN), and binge-eating disorder (BED). As compared to 60 healthy normal-weight controls (NWC) and 29 healthy over-weight controls (OWC), all ED subtypes reported greater difficulties in ER. ED subtypes did not differ regarding most domains of ER except BED showing less severe ER difficulties in some domains. In addition, AN-BP but not BN reported greater impulse control difficulties than AN-R and BED. The findings underscore the relevance of ER difficulties in ED and support the trans-diagnostic view of ER difficulties being present across the whole spectrum of ED. In addition, the present results suggest that certain domains of ER may be linked more closely to certain ED subtypes than to others.

Starvation and emotion regulation in anorexia nervosa

Self-starvation, with concomitant weight loss, may serve as a dysfunctional behavior to attenuate negative affective states in anorexia nervosa (AN). A total of 91 participants composed of patients with acute AN, women recovered from AN, clinical controls with either depression or anxiety disorder, and healthy controls were tested on a measure of emotion regulation. Patients with acute AN as well as recovered patients with AN and clinical controls showed increased emotion regulation difficulties as compared with healthy controls. In patients with acute AN, a specific association between body weight and emotion regulation was found: the lower the body mass index in patients with acute AN, the lesser were their difficulties in emotion regulation. This association could only be found in the subsample of patients with acute AN but not in the control groups. Moreover, there were no confounding effects of depression or duration of illness. The findings are consistent with the hypothesis that self-starvation with accompanying low body weight serves as a dysfunctional behavior to regulate aversive emotions in AN.

Training cognitive flexibility in patients with anorexia nervosa: A pilot randomized controlled trial of cognitive remediation therapy

OBJECTIVE Inefficient cognitive flexibility is considered a neurocognitive trait marker involved in the development and maintenance of anorexia nervosa (AN). Cognitive Remediation Therapy (CRT) is a specific treatment targeting this cognitive style. The aim of this study was to investigate the feasibility and efficacy (by estimating the effect size) of specifically tailored CRT for AN, compared to non-specific cognitive training. METHOD A prospective, randomized controlled, superiority pilot trial was conducted. Forty women with AN receiving treatment as usual (TAU) were randomized to receive either CRT or non-specific neurocognitive therapy (NNT) as an add-on. Both conditions comprised 30 sessions of computer-assisted (21 sessions) and face-to-face (9 sessions) training over a 3-week period. CRT focused specifically on cognitive flexibility. NNT was comprised of tasks designed to improve attention and memory. The primary outcome was performance on a neuropsychological post-treatment assessment of cognitive set-shifting. RESULTS Data available from 25 treatment completers were analyzed. Participants in the CRT condition outperformed participants in the NNT condition in cognitive set-shifting at the end of the treatment (p = 0.027; between-groups effect size d = 0.62). Participants in both conditions showed high treatment acceptance. DISCUSSION This study confirms the feasibility of CRT for AN, and provides a first estimate of the effect size that can be achieved using CRT for AN. Furthermore, the present findings corroborate that neurocognitive training for AN should be tailored to the specific cognitive inefficiencies of this patient group.

Specific emotion regulation impairments in major depression and anorexia nervosa

Emotion regulation (ER) difficulties have been considered to play an important role in the development and maintenance of various mental disorders such as depression and anorexia nervosa. However, previous research has failed to provide detailed insight into the disorder-specificity of ER difficulties. Therefore, the present study investigated specific ER difficulties in female samples of patients with major depression, patients with anorexia nervosa, and healthy controls (total sample: N=140). As compared to healthy controls, both clinical groups reported greater ER difficulties concerning both the experience and the differentiation as well as the attenuation and the modulation of emotions. Patients in both clinical groups reported comparably elevated ER difficulties regarding the experience and differentiation of emotions. However, depressed patients reported stronger ER difficulties regarding the attenuation and modulation of emotions as compared to patients with anorexia nervosa. These findings support the notion of ER difficulties as transdiagnostic phenomena, and suggest that depression may be characterized by broader and greater ER difficulties than anorexia nervosa.

Reward-related decision making in eating and weight disorders: A systematic review and meta-analysis of the evidence from neuropsychological studies.

Eating disorders (EDs) and overweight/obesity (OW/OB) are serious public health concerns that share common neuropsychological features and patterns of disturbed eating. Reward-related decision making as a basic neurocognitive function may trans-diagnostically underlie both pathological overeating and restricted eating. The present meta-analysis synthesizes the evidence from N=82 neuropsychological studies for altered reward-related decision making in all ED subtypes, OW and OB. The overall effect sizes for the differences between currently-ill ED patients and OW/OB people and controls were Hedges g=-0.49 [CI: -0.63; -0.35], and Hedges g=-0.39 [CI: -0.53; -0.25], respectively. Decision making was found to be altered to similar degrees in all ED subtypes and OB. Effect sizes, however, diverged for the different measures of decision making. Adolescents appear to be less affected than adults. When foods were used as rewarding stimuli, decision making was found to be intact in OB. The findings support that altered general reward-related decision making is a salient neuropsychological factor across eating and weight disorders in adulthood.

Approach Bias Modification in Food Craving—A Proof-of-Concept Study

The aim of the present proof-of-concept study was to test a novel cognitive bias modification (CBM) programme in an analogue sample of people with subclinical bulimic eating disorder (ED) psychopathology. Thirty participants with high levels of trait food craving were trained to make avoidance movements in response to visual food stimuli in an implicit learning paradigm. The intervention comprised ten 15-minute sessions over a 5-week course. At baseline, participants showed approach and attentional biases towards high-caloric palatable food that were both significantly reduced and turned into avoidance biases after the training. Participants also reported pronounced reductions in both trait and cue-elicited food craving and in ED symptoms as well. The overall evaluation of the training by the participants was positive. The specific CBM programme tested in this pilot trial promises to be an effective and feasible way to alter automatic action tendencies towards food in people suffering from bulimic ED psychopathology.

Approach bias and cue reactivity towards food in people with high versus low levels of food craving

OBJECTIVE Even though people suffering from high levels of food craving are aware of the negative consequences of binge eating, they cannot resist. Automatic action tendencies (i.e. approach bias) towards food cues that operate outside conscious control may contribute to this dysfunctional behavior. The present study aimed to examine whether people with high levels of food craving show a stronger approach bias for food than those with low levels of food craving and whether this bias is associated with cue-elicited food craving. METHOD Forty-one individuals reporting either extremely high or extremely low levels of trait food craving were recruited via an online screening and compared regarding approach bias towards visual food cues by means of an implicit stimulus-response paradigm (i.e. the Food Approach-Avoidance Task). State levels of food craving were assessed before and after cue exposure to indicate food cue reactivity. RESULTS As expected, high food cravers showed stronger automatic approach tendencies towards food than low food cravers. Also in line with the hypotheses, approach bias for food was positively correlated with the magnitude of change in state levels of food craving from pre-to post-cue exposure in the total sample. DISCUSSION The findings suggest that an approach bias in early stages of information processing contributes to the inability to resist food intake and may be of relevance for understanding and treating dysfunctional eating behavior.

Impaired cross-talk between mesolimbic food reward processing and metabolic signaling predicts body mass index

The anticipation of the pleasure derived from food intake drives the motivation to eat, and hence facilitate overconsumption of food, which ultimately results in obesity. Brain imaging studies provide evidence that mesolimbic brain regions underlie both general as well as food-related anticipatory reward processing. In light of this knowledge, the present study examined the neural responsiveness of the ventral striatum (VS) in participants with a broad BMI spectrum. The study differentiated between general (i.e., monetary) and food-related anticipatory reward processing. We recruited a sample of volunteers with greatly varying body weights, ranging from a low BMI (below 20 kg/m2) over a normal (20–25 kg/m2) and overweight (25–30 kg/m2) BMI, to class I (30–35 kg/m2) and class II (35–40 kg/m2) obesity. A total of 24 participants underwent functional magnetic resonance imaging while performing both a food and monetary incentive delay task, which allows to measure neural activation during the anticipation of rewards. After the presentation of a cue indicating the amount of food or money to be won, participants had to react correctly in order to earn “snack points” or “money coins,” which could then be exchanged for real food or money, respectively, at the end of the experiment. During the anticipation of both types of rewards, participants displayed activity in the VS, a region that plays a pivotal role in the anticipation of rewards. Additionally, we observed that specifically anticipatory food reward processing predicted the individual BMI (current and maximum lifetime). This relation was found to be mediated by impaired hormonal satiety signaling, i.e., increased leptin levels and insulin resistance. These findings suggest that heightened food reward motivation contributes to obesity through impaired metabolic signaling.

Mood Regulation and Cognitive Reactivity in Depression Vulnerability

There is substantial evidence supporting the hypothesis that cognitive reactivity is an important variable in the etiology of depression. However, there is a lack of studies examining possible mechanisms that underlie cognitive reactivity. The present study tested whether two specific mood regulation processes differentially appear in vulnerable and non-vulnerable individuals, and whether they can account for differences in cognitive reactivity. In a cross-sectional experimental design, 20 formerly-depressed individuals (FD) were compared with 20 never-depressed individuals (ND). In an autobiographical memory task both groups differed concerning the use of positively and negatively toned emotion words: FD retrieved fewer positive emotion words than ND in the second phase of this task. Furthermore, FD with a high cognitive reactivity retrieved more negatively toned emotion words. In the ND group there was a different pattern: Subjects with a high cognitive reactivity retrieved less positively toned emotion words. Two different cognitive processes seem to account for cognitive reactivity in individuals who are at high versus low risk for depression.

Differentiating early-onset chronic depression from episodic depression in terms of cognitive-behavioral and emotional avoidance.

BACKGROUND Although chronic depression is associated with lower global functioning and poorer treatment response than episodic depression, little is known about the differences between these two forms of depression in terms of psychological factors. Thus, the present study aimed at differentiating chronic and episodic depression regarding cognitive-behavioral and emotional avoidance that have been proposed as important risk factors for depression and promising targets for the treatment of depression. METHODS Thirty patients with early onset chronic depression were compared with 30 patients with episodic depression and 30 healthy, never-depressed controls in terms of self-reported cognitive-behavioral (social and non-social) and emotional avoidance. RESULTS Chronically depressed patients reported more avoidance than healthy controls in each of the measures. Moreover, they reported more cognitive-nonsocial and behavioral-nonsocial as well as behavioral-social and emotional avoidance (in the form of restricted emotional expression to others) than patients with episodic depression. This kind of emotional avoidance also separated best between chronically and episodically depressed patients. Furthermore, general emotion avoidance and behavioral-social avoidance were positively correlated with levels of depression in chronically depressed patients. LIMITATIONS The results are based on self-report data and should thus be interpreted with caution. Additionally, the cross-sectional design limits any causal conclusions. CONCLUSIONS The findings underscore the relevance of cognitive-behavioral and emotional avoidance in differentiating chronic from episodic depression and healthy controls and advocate a stronger focus on maladaptive avoidance processes in the treatment of chronic depression.