Vandana Aspen

A review of attention biases in women with eating disorders

There is robust evidence that women with eating disorders (EDs) display an attention bias (AB) for disorder-salient stimuli. Emerging data suggest that the presence of these biases may be due, in part, to neurological deficits, such as poor set shifting and weak central coherence. While some have argued that these biases function to predispose and/or act to maintain disordered eating behaviours, evidence supporting this view has rarely been examined. This report summarises and integrates the existing literature on AB in EDs and other related psychiatric disorders to better understand its potential role in the development and maintenance of an ED. The domains reviewed include experimental data using the dot-probe and modified Stroop task and neurobiological findings on AB in women with EDs as well as the role of AB in current theoretical models. We conclude by proposing an integrated model on the role of AB in EDs and discuss treatment approaches aimed at modifying these biases.

What constitutes clinically significant binge eating? Association between binge features and clinical validators in college‐age women

OBJECTIVE To investigate the association between binge features and clinical validators. METHOD The Eating Disorder Examination assessed binge features in a sample of 549 college-age women: loss of control (LOC) presence, binge frequency, binge size, indicators of impaired control, and LOC severity. Clinical validators were self-reported clinical impairment and current psychiatric comorbidity, as determined via a semistructured interview. RESULTS Compared with women without LOC, those with LOC had significantly greater odds of reporting clinical impairment and comorbidity (ps < 0.001). Among women with LOC (n = 252), the indicators of impaired control and LOC severity, but not binge size or frequency, were associated with greater odds of reporting clinical impairment and/or comorbidity (ps < 0.05). DICUSSION: Findings confirm that the presence of LOC may be the hallmark feature of binge eating. Further, dimensional ratings about the LOC experience--and possibly the indicators of impaired control--may improve reliable identification of clinically significant binge eating.

An examination of the Clinical Impairment Assessment among women at high risk for eating disorder onset

Identifying measures that reliably and validly assess clinical impairment has important implications for eating disorder (ED) diagnosis and treatment. The current study examined the psychometric properties of the Clinical Impairment Assessment (CIA) in women at high risk for ED onset. Participants were 543 women (20.6 ± 2.0 years) who were classified into one of three ED categories: clinical ED, high risk for ED onset, and low risk control. Among high risk women, the CIA demonstrated high internal consistency (α = 0.93) and good convergent validity with disordered eating attitudes (rs = 0.27-0.68, ps < 0.001). Examination of the CIAs discriminant validity revealed that CIA global scores were highest among women with a clinical ED (17.7 ± 10.7) followed by high risk women (10.6 ± 8.5) and low risk controls (3.0 ± 3.3), respectively (p < 0.001). High risk women reporting behavioral indices of ED psychopathology (objective and/or subjective binge episodes, purging behaviors, driven exercise, and ED treatment history) had higher CIA global scores than those without such indices (ps < 0.05), suggesting good criterion validity. These data establish the first norms for the CIA in a United States sample. The CIA is psychometrically sound among high risk women, and heightened levels of impairment among these individuals as compared to low risk women verify the relevance of early intervention efforts.

Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial.

OBJECTIVE Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated. METHOD 206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II. RESULTS ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4). CONCLUSIONS An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research.

Central Coherence in Adolescents with Bulimia Nervosa Spectrum Eating Disorders

BACKGROUND Weak central coherence-a tendency to process details at the expense of the gestalt-has been observed among adults with bulimia nervosa (BN) and is a potential candidate endophenotype for eating disorders (EDs). However, as BN behaviors typically onset during adolescence it is important to assess central coherence in this younger age group to determine whether the findings in adults are likely a result of BN or present earlier in the evolution of the disorder. This study examines whether the detail-oriented and fragmented cognitive inefficiency observed among adults with BN is observable among adolescents with shorter illness duration, relative to healthy controls. METHOD The Rey-Osterrieth Complex Figure Test (RCFT) was administered to a total of 47 adolescents with DSM5 BN, 42 with purging disorder (PD), and 25 healthy controls (HC). Performance on this measure was compared across the three groups. RESULTS Those with BN and PD demonstrated significantly worse accuracy scores compared to controls in the copy and delayed recall condition with a moderate effect size. These findings were exacerbated when symptoms of BN increased. DISCUSSION Poorer accuracy scores reflect a fragmented and piecemeal strategy that interferes with visual-spatial integration in BN spectrum disorders. This cognitive inefficiency likely contributes to broad difficulties in executive functioning in this population especially in the context of worsening bulimic symptoms. The findings of this study support the hypothesis that poor global integration may constitute a cognitive endophenotype for BN.

An exploration of salivation patterns in normal weight and obese children

We examined whether childrens changes in salivary habituation to food vary based on weight status and/or allocating attention to a task. Children (31 non-overweight and 26 obese, ages 9-12 year) were presented with nine trials of a food stimulus and either listened to an audiobook (attention-demanding) or white noise (no-attention control). The salivary pattern differed significantly by weight status but not by condition or a condition by weight status interaction. This is the first study of salivary habituation in obese children; findings dovetail with an emerging set of evidence that obese individuals display distinctive biological responses to food.

Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa

OBJECTIVE This study provides data on the psychometric properties of a newly developed measure of treatment fidelity in Family-Based Treatment (FBT) for adolescent anorexia nervosa (AN). The Family Therapy Fidelity and Adherence Check (FBT-FACT) was created to evaluate therapist adherence and competency on the core interventions in FBT. METHOD Participants were 45 adolescents and their families sampled from three randomized clinical trials evaluating treatment for AN. Trained fidelity raters evaluated 19 therapists across 90 early session recordings using the FBT-FACT. They also rated an additional 15 session 1 recordings of an alternate form of family therapy-Systemic Family Therapy for the purpose of evaluating discriminant validity of the FBT-FACT. The process of development and the psychometric properties of the FBT-FACT are presented. RESULTS Overall fidelity ratings for each session demonstrated moderate to strong inter-rater agreement. Internal consistency of the measure was strong for sessions 1 and 2 and poor for session 3. Principal components analysis suggests sessions 1 and 2 are distinct interventions. DISCUSSION The FBT-FACT demonstrates good reliability and validity as a measure of treatment fidelity in the early phase of FBT.

Family-based treatment without a family: case report of an adolescent with anorexia nervosa.

Anorexia nervosa (AN) is a debilitating disease with the highest death rates of any psychiatric illness [1]. Given the seriousness of this condition, interventions for this population are in high demand. Thus far, adult behavioral treatments available have been largely ineffective [2] and clinical trials are plagued with high drop-out and low remission rates, especially for those with longer duration of illness [3]. In contrast, family-based therapy for anorexia nervosa (FBT-AN; [4]), has shown promising results with adolescents [5–10] and is currently recommended as the front-line treatment [11]. Studies show that FBT-AN is effective for 80–90 % of adolescents [12], and is superior to both individual [8, 9] and supportive psychotherapy [10]. In addition, recent data suggest that enhanced Cognitive Behavioral Therapy (CBT-E; [13]) may be another possible and economic alternative for older adolescents with AN. A full manual for FBT-AN has been published elsewhere [4]. Briefly, FBT-AN is divided into 3 phases and is typically completed within a 6–12 month period. In FBTAN, therapy is conducted with the entire family and at its core is focused around (1) mobilizing the family to fight AN (2) teaching the parents how to re-feed their starving offspring and (3) transitioning independence over eating back to adolescent once he/she is able to. Central elements of phase 1 include educating the family about the dangers of severe malnutrition and enlisting the parents to help the child begin eating again. The primary goal is to keep the family focused on the eating disorder and in particular, weight gain. The family is taught to view AN as a disease that is attacking their child. Siblings are aligned with the patient and a parental alliance is formed around re-feeding. Parents are coached in how to take control over their child’s eating and sessions are used to problem solve any issues around eating and activity—any issues that interfere with weight gain. An in-session family meal is used to provide the therapist with objective information about the family dynamics around food and to provide in vivo coaching on how to have their child eat more than he/she is prepared to. Phase 1 continues until the adolescent is able to eat on his/her own and has made steady gains in weight (approximately 90 % IBW). The primary goal of phase 2 is transitioning parental authority back to the adolescent. This goal is achieved slowly and cautiously, dependent on the patient’s weight and level of familial anxiety. Once the adolescent is eating independently and weight is in a healthy range, the final phase of treatment initiates (Phase 3). In Phase 3, the focus shifts away from weight restoration and moves more towards the impact that AN has had on typical adolescent development. These sessions are tailored to address the particular issues surrounding the adolescent and his/her family. In the description of FBT-AN above, the role of the family is unambiguously clear—particularly the function/ responsibility of the parent(s). The focus of this report is on the applicability of FBT-AN in a setting in which no parent is available.