Publications by authors named "Cara Bohon"

52 Publications

Factors that predict persistence versus non-persistence of eating disorder Symptoms: A prospective study of high-risk young women.

Behav Res Ther 2021 Jul 14;144:103932. Epub 2021 Jul 14.

Oregon Research Institute, 1776 Millrace Drive, Eugene, OR, 97403, USA. Electronic address:

Investigate baseline factors that prospectively predict persistence versus non-persistence of behavioral and cognitive eating disorder symptoms because knowledge of maintenance factors, which is limited, could inform the design of more effective eating disorder treatments. Data from 4 prevention trials that targeted young women with body image concerns (N = 1952; M age 19.7, SD 5.7) and collected interview-assessed data on behavioral and cognitive symptoms over 1-year follow-up were combined to address this aim. Greater binge eating severity predicted binge eating persistence. Greater dieting, binge eating frequency and severity, weight/shape overvaluation, and feeling fat predicted compensatory behavior persistence. Lower BMI predicted low BMI persistence. Greater thin-ideal internalization, body dissatisfaction, dieting, negative affect, binge eating frequency, binge eating severity, compensatory behaviors, weight/shape overvaluation, fear of fatness or weight gain, and feeling fat predicted weight/shape overvaluation persistence. Greater thin-ideal internalization, dieting, compensatory behaviors, weight/shape overvaluation, fear of fatness or weight gain, and feeling fat predicted persistence of fear of fatness or weight gain. Results provide support for intervention targets of several extant eating disorder treatments and identified novel maintenance factors not commonly targeted in treatments (e.g., negative affect). Results also imply that certain features of eating disorders predict symptom persistence.
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http://dx.doi.org/10.1016/j.brat.2021.103932DOI Listing
July 2021

Virtually delivered family-based eating disorder treatment using an enhanced multidisciplinary care team: A case study.

Clin Case Rep 2021 Jun 6;9(6):e04173. Epub 2021 May 6.

Equip Health San Diego CA USA.

Both patients experienced meaningful clinical improvements with this virtual approach and the augmented treatment team in regards to weight gain, acceptability, and clinical assessment scores. These findings offer preliminary support for this model.
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http://dx.doi.org/10.1002/ccr3.4173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8222740PMC
June 2021

Maintenance of Training Effects of Two Models for Implementing Evidence-Based Psychological Treatment.

Psychiatr Serv 2021 Jun 30:appips202000702. Epub 2021 Jun 30.

Department of Psychiatry (Fitzsimmons-Craft, Laing, Welch, Wilfley), Washington University School of Medicine, and the George Warren Brown School of Social Work (Proctor), Washington University, St. Louis; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California (Bohon, Jo, Mondal, Agras); Graduate School of Applied and Professional Psychology, Rutgers, State University of New Jersey, Piscataway (Wilson); Silver School of Social Work, New York University, New York City (Raghavan).

Objective: The authors compared maintenance of training outcomes for two approaches to training college therapists in interpersonal psychotherapy (IPT): train the trainer versus expert training.

Methods: A cluster-randomized trial was conducted in 24 college counseling centers. Therapists were recruited from enrolled centers, and the therapists enrolled students with depression and eating disorder symptoms. The therapists (N=184) provided data during baseline, posttraining (during the 12 months of expert consultation offered to the expert training group), and maintenance (approximately 7 months after the expert consultation ended). Outcomes were therapist fidelity (i.e., adherence and competence) and IPT knowledge.

Results: Both groups showed within-group improvement from baseline to the maintenance period for adherence, competence, and IPT knowledge; however, the train-the-trainer group had greater improvement over time in adherence and competence.

Conclusions: Given that the effects of the train-the-trainer approach were better maintained, and this model's potential to train more therapists over time, the train-the-trainer approach may help increase dissemination of evidence-based treatments such as IPT.
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http://dx.doi.org/10.1176/appi.ps.202000702DOI Listing
June 2021

The insulo-opercular cortex encodes food-specific content under controlled and naturalistic conditions.

Nat Commun 2021 06 14;12(1):3609. Epub 2021 Jun 14.

Department of Neurosurgery, Stanford University, Stanford, CA, USA.

The insulo-opercular network functions critically not only in encoding taste, but also in guiding behavior based on anticipated food availability. However, there remains no direct measurement of insulo-opercular activity when humans anticipate taste. Here, we collect direct, intracranial recordings during a food task that elicits anticipatory and consummatory taste responses, and during ad libitum consumption of meals. While cue-specific high-frequency broadband (70-170 Hz) activity predominant in the left posterior insula is selective for taste-neutral cues, sparse cue-specific regions in the anterior insula are selective for palatable cues. Latency analysis reveals this insular activity is preceded by non-discriminatory activity in the frontal operculum. During ad libitum meal consumption, time-locked high-frequency broadband activity at the time of food intake discriminates food types and is associated with cue-specific activity during the task. These findings reveal spatiotemporally-specific activity in the human insulo-opercular cortex that underlies anticipatory evaluation of food across both controlled and naturalistic settings.
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http://dx.doi.org/10.1038/s41467-021-23885-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203663PMC
June 2021

Subcortical brain volume and cortical thickness in adolescent girls and women with binge eating.

Int J Eat Disord 2021 Jun 1. Epub 2021 Jun 1.

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA.

Objective: Alterations in brain structure have been implicated in the onset and acute phases of several forms of psychopathology. However, there is a dearth of research investigating brain structure in persons with binge eating, contributing to poor understanding of mechanisms associated with binge eating.

Method: Adolescent girls and women (aged 14-35 years) with binge eating (n = 56) and group age-matched girls and women without binge eating (n = 26) completed structural magnetic resonance imaging (MRI) scans and interview-based and self-report assessments of eating disorder and general psychopathology. MRI data were processed using FreeSurfer. Analysis of covariance tested mean differences in subcortical volume and cortical thickness of a priori selected regions of interest between binge-eating and non-binge-eating groups, controlling for age, body mass index, purging frequency, depression, and medication use. Exploratory partial correlations tested associations between brain structure and eating disorder symptoms within participants with binge eating.

Results: We did not observe differences in regional subcortical volume and cortical thickness between girls and women with and without binge eating. Within participants with binge eating, severity of attitudinal eating disorder symptoms was inversely associated with caudal middle frontal gyrus, right precentral gyrus, right postcentral gyrus, superior parietal, left inferior parietal thickness, and left accumbens volume; however, these associations would not survive multiple-comparison corrections.

Discussion: Correlations between attitudinal eating disorder symptoms and frontoparietal thinning may represent a state marker of binge eating. Future research could investigate whether frontoparietal thinning worsens with illness duration or persists beyond binge eating cessation.
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http://dx.doi.org/10.1002/eat.23563DOI Listing
June 2021

Cognitive Behavioral Therapy for the Eating Disorders.

Annu Rev Clin Psychol 2021 05;17:417-438

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California 94305, USA; email:

Research findings strongly suggest that cognitive behavioral therapy for the eating disorders (CBT-ED) is more effective than other treatments for bulimia nervosa (BN) and for binge eating disorder (BED), although interpersonal psychotherapy appears to be equally effective for BED. Evidence for the effectiveness of CBT-ED for the persistent (adult) form of anorexia nervosa (AN) is insufficient at present and is essentially absent for AN in adolescents except for some evidence from uncontrolled trials. This article begins with an overview of the early studies in the development of CBT-ED that showed a similar effectiveness of other symptom-focused psychotherapies-a finding that was neglected at the time. Later developments are then considered, including comparisons of CBT-ED with other psychotherapies, efforts to develop Internet-based training and treatment, and electronic applications for treatment. Finally, implications of the findings for future short- and long-term research and for clinical practice are considered.
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http://dx.doi.org/10.1146/annurev-clinpsy-081219-110907DOI Listing
May 2021

Understanding outcomes in family-based treatment for adolescent anorexia nervosa: a network approach.

Psychol Med 2021 05 6:1-12. Epub 2021 May 6.

Stanford University School of Medicine, Division, Stanford, CA, USA.

Background: Family-based treatment (FBT) is the first-line treatment for adolescent anorexia nervosa (AN). Yet, remission is not achieved for about half of adolescents with AN receiving FBT. Understanding patient- and parent-level factors that predict FBT response may inform treatment development and improve outcomes.

Methods: Network analysis was used to identify the most central symptoms of AN in adolescents who completed the Eating Disorder Examination (EDE) prior to FBT (N = 409). Bridge pathways between adolescent AN and parental self-efficacy in facilitating their child's recovery from AN were identified in a subset of participants (n = 184). Central and bridge symptoms were tested as predictors of early response (⩾2.4 kg weight gain by the fourth session of FBT) and end-of-treatment weight restoration [⩾95% expected body weight (EBW)] and full remission (⩾95% EBW and EDE score within 1 standard deviation of norms).

Results: The most central symptoms of adolescent AN included desiring weight loss, dietary restraint, and feeling fat. These symptoms predicted early response, but not end-of-treatment outcomes. Bridge symptoms were parental beliefs about their responsibility to renourish their child, adolescent discomfort eating in front of others, and adolescent dietary restraint. Bridge symptoms predicted end-of-treatment weight restoration, but not early response nor full remission.

Conclusions: Findings highlight the prognostic utility of core symptoms of adolescent AN. Parent beliefs about their responsibility to renourish their child may maintain associations between parental self-efficacy and AN psychopathology. These findings could inform strategies to adapt FBT and improve outcomes.
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http://dx.doi.org/10.1017/S0033291721001604DOI Listing
May 2021

Test-retest reliability of functional MRI food receipt, anticipated receipt, and picture tasks.

Am J Clin Nutr 2021 Apr 13. Epub 2021 Apr 13.

Department of Psychiatry, Stanford University, Stanford, CA, USA.

Background: Functional MRI (fMRI) tasks are increasingly being used to advance knowledge of the etiology and maintenance of obesity and eating disorders. Thus, understanding the test-retest reliability of BOLD signal contrasts from these tasks is important.

Objectives: To evaluate test-retest reliability of responses in reward-related brain regions to food receipt paradigms (palatable tastes, anticipated palatable tastes), food picture paradigms (high-calorie food pictures), a monetary reward paradigm (winning money and anticipating winning money), and a thin female model picture paradigm (thin female model pictures).

Method: We conducted secondary univariate contrast-based analyses in data drawn from 4 repeated-measures fMRI studies. Participants (Study 1: N = 60, mean [M] age = 15.2 ± 1.1 y; Study 2: N = 109, M age = 15.1 ± 0.9 y; Study 3: N = 39, M age = 21.2 ± 3.7 y; Study 4: N = 62, M age = 29.7 ± 6.2 y) completed the same tasks over 3-wk to 3-y test-retest intervals. Studies 3 and 4 included participants with eating disorders and obesity, respectively.

Results: Test-retest reliability of the food receipt and food picture paradigms was poor, with average ICC values ranging from 0.07 to 0.20. The monetary reward paradigm and the thin female model picture paradigm also showed poor test-retest reliability: average ICC values 0.21 and 0.12, respectively. Although several regions demonstrated moderate to good test-retest reliability, these results did not replicate across studies using similar paradigms. In Studies 3 and 4, but not Study 1, test-retest reliability in visual processing regions was moderate to good when contrasting single conditions with a low-level baseline.

Conclusions: Results underscore the importance of examining the temporal reliability of fMRI tasks and call for the development and use of well-validated standardized fMRI tasks in eating- and obesity-related studies that can provide more reliable measures of neural activation. The trials were registered at clinicaltrials.gov as NCT02084836, NCT01949636, NCT03261050, and NCT03375853.
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http://dx.doi.org/10.1093/ajcn/nqab096DOI Listing
April 2021

Anticipatory human subthalamic area beta-band power responses to dissociable tastes correlate with weight gain.

Neurobiol Dis 2021 Jul 26;154:105348. Epub 2021 Mar 26.

Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, 94305, USA. Electronic address:

The availability of enticing sweet, fatty tastes is prevalent in the modern diet and contribute to overeating and obesity. In animal models, the subthalamic area plays a role in mediating appetitive and consummatory feeding behaviors, however, its role in human feeding is unknown. We used intraoperative, subthalamic field potential recordings while participants (n = 5) engaged in a task designed to provoke responses of taste anticipation and receipt. Decreased subthalamic beta-band (15-30 Hz) power responses were observed for both sweet-fat and neutral tastes. Anticipatory responses to taste-neutral cues started with an immediate decrease in beta-band power from baseline followed by an early beta-band rebound above baseline. On the contrary, anticipatory responses to sweet-fat were characterized by a greater and sustained decrease in beta-band power. These activity patterns were topographically specific to the subthalamic nucleus and substantia nigra. Further, a neural network trained on this beta-band power signal accurately predicted (AUC ≥ 74%) single trials corresponding to either taste. Finally, the magnitude of the beta-band rebound for a neutral taste was associated with increased body mass index after starting deep brain stimulation therapy. We provide preliminary evidence of discriminatory taste encoding within the subthalamic area associated with control mechanisms that mediate appetitive and consummatory behaviors.
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http://dx.doi.org/10.1016/j.nbd.2021.105348DOI Listing
July 2021

Quadratic relations of BMI with depression and brain volume in children: Analysis of data from the ABCD study.

J Psychiatr Res 2021 04 15;136:421-427. Epub 2021 Feb 15.

Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, USA.

Background: Weight-related health conditions and depression peak during adolescence and show relations with brain structure. Understanding how these conditions relate to each other prior to adolescence may guide research on the co-development of unhealthy weight conditions (both underweight and overweight) and depression, with a potential brain-based link. This study examines the cross-sectional relations between body mass index (BMI), depressive symptoms, and brain volume (total and regional) to determine whether BMI has a linear or quadratic relation with depressive symptoms and brain volume and how depressive symptoms and brain volume are related.

Methods: Cross-sectional study using structural magnetic resonance imaging, height and weight to calculate BMI z-scores, and Child Behavior Checklist withdrawn depression scores. Data were from the Adolescent Brain Cognitive Development Study, collected at 21 sites across the United States from 11,875 9- and 10-year-old children recruited as a national sample. Mixed models were used to examine the linear and quadratic effects of BMI z-score on both brain volume (total and regional) and withdrawn depression scores, as well as the relations between brain volume and depression scores. Intracranial volume, age, sex, race, site, and family were included in the models as covariates.

Results: Overall, BMI z-scores showed a quadratic relation with brain volumes and depressive symptoms. When including intracranial volume as a covariate, regional volumes investigated did not follow the same global pattern of effects except for right hippocampus and left lateral orbitofrontal cortex. Total brain volume was negatively related to depressive symptoms.

Conclusions: Links between depressive symptoms and low or high weight could improve our understanding of brain structural differences in depression. These findings also emphasize the importance of including the full spectrum of BMI from underweight to overweight and testing for nonlinear effects in models.
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http://dx.doi.org/10.1016/j.jpsychires.2021.02.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8225589PMC
April 2021

Descriptive analysis of binge eating in adult and adolescent females.

Eat Weight Disord 2021 May 22;26(4):1149-1158. Epub 2020 Sep 22.

Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA, 94305-5719, USA.

Purpose: Provide qualitative descriptions of context and characteristics of binge eating in adults and adolescents to explore consistency in precipitating factors.

Method: Open-ended, qualitative interviews were administered to an adult sample (n = 24) and an adolescent sample (n = 20) to collect details about the context in which two binge episodes occurred.

Results: Factors and context of the binge episodes were similar between adults and adolescents. In contrast, the two binge episodes described by each individual were not consistent. Binge episodes were not strongly affect-driven or food cue-driven.

Conclusions: Binge eating appears similar between adults and adolescents, which may have treatment implications. Similar treatment approaches may be used with both age groups and would benefit from covering a broad range of binge triggers rather than attempting to match individuals into an approach focused on particular triggers.

Level Of Evidence: Level III, case-control analytic study.
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http://dx.doi.org/10.1007/s40519-020-01013-3DOI Listing
May 2021

Brain-Responsive Neurostimulation for Loss of Control Eating: Early Feasibility Study.

Neurosurgery 2020 Jul 27. Epub 2020 Jul 27.

Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.

Background: Loss of control (LOC) is a pervasive feature of binge eating, which contributes significantly to the growing epidemic of obesity; approximately 80 million US adults are obese. Brain-responsive neurostimulation guided by the delta band was previously found to block binge-eating behavior in mice. Following novel preclinical work and a human case study demonstrating an association between the delta band and reward anticipation, the US Food and Drug Administration approved an Investigational Device Exemption for a first-in-human study.

Objective: To assess feasibility, safety, and nonfutility of brain-responsive neurostimulation for LOC eating in treatment-refractory obesity.

Methods: This is a single-site, early feasibility study with a randomized, single-blinded, staggered-onset design. Six subjects will undergo bilateral brain-responsive neurostimulation of the nucleus accumbens for LOC eating using the RNS® System (NeuroPace Inc). Eligible participants must have treatment-refractory obesity with body mass index ≥ 45 kg/m2. Electrophysiological signals of LOC will be characterized using real-time recording capabilities coupled with synchronized video monitoring. Effects on other eating disorder pathology, mood, neuropsychological profile, metabolic syndrome, and nutrition will also be assessed.

Expected Outcomes: Safety/feasibility of brain-responsive neurostimulation of the nucleus accumbens will be examined. The primary success criterion is a decrease of ≥1 LOC eating episode/week based on a 28-d average in ≥50% of subjects after 6 mo of responsive neurostimulation.

Discussion: This study is the first to use brain-responsive neurostimulation for obesity; this approach represents a paradigm shift for intractable mental health disorders.
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http://dx.doi.org/10.1093/neuros/nyaa300DOI Listing
July 2020

Family-based treatment via videoconference: Clinical recommendations for treatment providers during COVID-19 and beyond.

Int J Eat Disord 2020 07 13;53(7):1142-1154. Epub 2020 Jun 13.

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA.

The necessity to employ distance-based methods to deliver on-going eating disorder care due to the novel coronavirus (COVID-19) pandemic represents a dramatic and urgent shift in treatment delivery. Yet, TeleHealth treatments for eating disorders in youth have not been adequately researched or rigorously tested. Based on clinical experience within our clinic and research programs, we aim to highlight the common challenges clinicians may encounter in providing family-based treatment (FBT) via TeleHealth for children and adolescents with anorexia nervosa and bulimia nervosa. We also discuss possible solutions and offer practical considerations for providers delivering FBT in this format. Additional research in TeleHealth treatment for eating disorders in youth may lead to improved access, efficiency, and effectiveness of FBT delivered via videoconferencing.
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http://dx.doi.org/10.1002/eat.23326DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323318PMC
July 2020

Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy.

J Med Internet Res 2020 04 23;22(4):e16386. Epub 2020 Apr 23.

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States.

Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.
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http://dx.doi.org/10.2196/16386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206518PMC
April 2020

Investigating Early Response to Treatment in a Multi-Site Study for Adolescent Bulimia Nervosa.

Front Psychiatry 2020 28;11:92. Epub 2020 Feb 28.

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States.

Background: This secondary data analysis seeks to replicate and extend findings that early response to treatment in adolescent bulimia nervosa (BN) predicts outcome, resulting in earlier identification of patients who might need a different treatment approach.

Methods: Participants were 71 adolescents ( ± : 15.69 ± 1.55 years; 93% female; 75% non-Hispanic) with a Diagnostic and Statistical Manual of Mental Disorders, 4 Edition (DSM-IV) diagnosis of BN or partial BN enrolled in a two-site treatment study. Participants were randomized to cognitive behavioral therapy for adolescents (CBT-A), family-based treatment for BN (FBT-BN), or supportive psychotherapy (SPT). The Eating Disorder Examination was administered at baseline, end-of-treatment (EOT), 6-month, and 12-month follow-up. Binge eating and purge symptoms were self-reported at each session. Outcome was defined as abstinence of binge eating and compensatory behaviors (self-induced vomiting, laxative use, diet pills, diuretics, compensatory exercise, fasting) in the 28 days prior to assessment. Receiver operating characteristic (ROC) analyses were utilized to assess the viability of predicting treatment outcomes based on reduction of symptoms within the first 10 sessions of treatment.

Results: ROC analyses suggest that reduction in purging at session 2 (AUC =.799, < .001) and binge eating at session 4 (AUC =.750, < .01) were independently related to abstinence of symptoms at EOT, regardless of treatment type. Symptom reduction later in treatment predicted outcome at follow-up, as change in binge eating at session 8 and purging at session 9 were the strongest predictors of abstinence at 6-month follow-up (AUCs =.726-.763, s < .01). Change in binge eating, but not purging behaviors, was significantly related to abstinence at 12-month follow-up (AUC =.766, < .01). Only slight differences emerged based on treatment group, such that reductions in symptoms most predictive of abstinence at EOT occurred one session sooner in FBT-BN than SPT.

Conclusion: Reductions in binge eating and purge symptoms early in adolescent BN treatment suggest better outcome, regardless of treatment modality. Additional research with larger samples is needed to better understand which treatments, if any, contribute to earlier change in BN symptoms and/or likelihood of improved patient response.
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http://dx.doi.org/10.3389/fpsyt.2020.00092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058584PMC
February 2020

Confirming the Efficacy of an Adaptive Component to Family-Based Treatment for Adolescent Anorexia Nervosa: Study Protocol for a Randomized Controlled Trial.

Front Psychiatry 2020 12;11:41. Epub 2020 Feb 12.

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States.

Family-based treatment (FBT) has the largest evidence base for treating adolescents with anorexia nervosa (AN); 35-50% of cases remit at the end-of-treatment and remain remitted 3-4 years after treatment. Studies of FBT demonstrate that weight restoration by session 4 (of 2.4 kgs) predicts remission at end of treatment in 85-90% of cases. One way to improve outcomes is to tailor treatments to patients depending on successful weight restoration at session 4. Pilot data found that by adding three sessions of Intensive Parental Coaching (IPC) after session 4 improved outcomes in early non-responders. Further, data suggest that the mechanism underlying FBT is early improvements in parental self-efficacy related to re-feeding their child. This manuscript describes a study protocol to examine whether adding IPC to FBT improves outcomes in early non-responders and confirm whether change in parental self-efficacy is the mechanism by which FBT works. This two-site randomized controlled trial (RCT) will randomize 60 adolescents with a DSM-5 diagnosis of AN (30 per site) who are between the ages of 12-18 years old and do not gain 2.4 kgs by session 4 of FBT. Randomized participants will either continue standard FBT or receive the three sessions of IPC and then continue FBT as usual. Both arms include up to 18 sessions over the course of 9 months. Blinded assessments will be conducted at baseline, 3-month within-treatment, end of treatment, and at 6 and 12-month follow-up. Parental-self efficacy will be assessed using the Parent versus Anorexia Scale at all major assessment time points and at each of the first eight sessions of treatment. The primary outcome is achievement of weight remission (> 94% expected mean percent body mass index (BMI) adjusted for age, height, and gender).

Clinical Trial Registration: http://www.ClinicalTrials.gov, identifier NCT03097874.
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http://dx.doi.org/10.3389/fpsyt.2020.00041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028765PMC
February 2020

A Protocol for Integrating Neuroscience Into Studies of Family-Based Treatment for Anorexia Nervosa: An Approach to Research and Potential Benefits for Clinical Care.

Front Psychiatry 2019 18;10:919. Epub 2019 Dec 18.

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States.

Anorexia nervosa (AN) is a life-threatening disorder with peak onset during adolescence. Prior research supports the effectiveness of family-based treatment (FBT) for AN in adolescents, but studies do not regularly include neuroimaging to investigate the effects of FBT on the brain. This is important because we know that malnutrition has a detrimental impact on brain volume, cortical thickness, and function, which often recover with weight restoration. Additionally, early weight gain in FBT has emerged as a robust predictor of treatment outcome, yet it is unclear whether it is associated with neural change. Understanding neural change during treatment, particularly in the early weeks, has the potential to improve outcome by enhancing motivation for rapid behavior change, while also highlighting mechanisms by which early treatment response leads to improved outcome. This manuscript describes a study protocol and discusses both challenges and implications for this type of integrative research.
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http://dx.doi.org/10.3389/fpsyt.2019.00919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930315PMC
December 2019

Superior response inhibition to high-calorie foods in adolescents with anorexia nervosa.

Behav Res Ther 2020 01 22;124:103441. Epub 2019 Jul 22.

Department of Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, USA.

Anorexia nervosa (AN) is a severe eating disorder that is characterized by significant weight loss as a result of self-starvation. Little is known about the mechanisms that allow these patients to endure self-starvation for long periods of time. It has been suggested that the neurocognitive mechanism responsible for stopping inappropriate actions (i.e., response inhibition) may contribute to this process. However, empirical evidence to support this notion is lacking. The goal of the current study was to assess if exposure to high-calorie food stimuli may trigger response inhibition to a greater extent in adolescents with AN compared to healthy adolescents. Thirty adolescents with restrictive type AN (AN-R) and 30 healthy adolescents completed a food-stop signal task wherein their ability to inhibit prepotent responses was assessed following exposure to high- and low-calorie food images. The results revealed superior ability of adolescents with AN-R to inhibit actions following exposure to high-calorie food images compared with controls. No such difference was found between the groups following exposure to low-calorie foods. The results indicate that high-calorie foods automatically trigger stronger activation of response inhibition in adolescents with AN compared to healthy adolescents. Such activation is likely a unique feature of AN that potentially contributes to patients' ability to severely restrict eating.
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http://dx.doi.org/10.1016/j.brat.2019.103441DOI Listing
January 2020

Training Models for Implementing Evidence-Based Psychological Treatment: A Cluster-Randomized Trial in College Counseling Centers.

JAMA Psychiatry 2020 02;77(2):139-147

Graduate School of Applied and Professional Psychology, Rutgers, The State University of New Jersey, Piscataway.

Importance: Progress has been made in establishing evidence-based treatments for psychiatric disorders, but these are not often delivered in routine settings. A scalable solution for training clinicians in evidence-based treatments is needed.

Objective: To compare 2 methods of training college (university) counseling center therapists to treat psychiatric disorders using interpersonal psychotherapy. The hypothesis was that the train-the-trainer condition would demonstrate superior implementation outcomes vs the expert condition. Moderating factors were also explored.

Design, Setting, And Participants: This cluster-randomized trial was conducted from October 2012 to December 2017 in 24 college counseling centers across the United States. Therapist participants were recruited from enrolled centers, and student patients with symptoms of depression and eating disorders were recruited by therapists. Data were analyzed from 184 enrolled therapists.

Interventions: Counseling centers were randomized to the expert condition, which involved a workshop and 12 months of follow-up consultation, or the train-the-trainer condition, in which a staff member from the counseling center was coached to train other staff members.

Main Outcomes And Measures: The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, as assessed via audio recordings of therapy sessions. Therapist knowledge of interpersonal psychotherapy was a secondary outcome.

Result: A total of 184 therapists (mean [SD] age, 41.9 [10.6] years; 140 female [76.1%]; 142 white [77.2%]) were included. Both the train-the-trainer-condition and expert-condition groups showed significant within-group improvement for adherence to interpersonal psychotherapy (change: 0.233 [95% CI, 0.192-0.274] and 0.190 [0.145-0.235], respectively; both P < .001), with large effect sizes (1.64 [95% CI, 1.35-1.93] and 1.34 [95% CI, 1.02-1.66], respectively) and no significant difference between conditions. Both groups also showed significant within-group improvement in interpersonal therapy competence (change: 0.179 [95% CI, 0.132-0.226] and 0.106 [0.059-0.153], respectively; both P < .001), with a large effect size for the train-the-trainer condition (1.16 [95% CI, 0.85-1.46]; P < .001) and a significant difference between groups favoring the train-the-trainer condition (effect size, 0.47 [95% CI, 0.05-0.89]; P = .03). Knowledge of interpersonal psychotherapy improved significantly within both groups (effect sizes: train-the-trainer, 0.64 [95% CI, 0.28-0.99]; P = .005; expert, 0.69 [95% CI, 0.38-1.01]; P < .001), with no significant difference between groups. The significant moderating factors were job satisfaction for adherence (b, 0.120 [95% CI, 0.001-0.24]; P = .048) and competence (b, 0.133 [95% CI, 0.001-0.27]; P = .048), and frequency of clinical supervision for competence (b, 0.05 [95% CI, 0.004-0.09]; P = .03).

Conclusions And Relevance: Results demonstrate that the train-the-trainer model produced training outcomes comparable with the expert model for adherence and was superior on competence. Given its potential capability to train more therapists over time, it has the potential to facilitate widespread dissemination of evidence-based treatments.

Trial Registration: ClinicalTrials.gov Identifier: NCT02079142.
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http://dx.doi.org/10.1001/jamapsychiatry.2019.3483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865264PMC
February 2020

Bariatric Surgery in Children and Adolescents with Cognitive Impairment and/or Developmental Delay: Current Knowledge and Clinical Recommendations.

Obes Surg 2019 12;29(12):4114-4126

Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA, 94305, USA.

Bariatric surgery is an effective treatment for children and adolescents with severe obesity. However, outcomes in youth with cognitive impairments and/or developmental delays are understudied. This paper reviewed the literature on bariatric surgery within this population. Fourteen studies published from 1975 to 2019 were identified. The majority (93%) of studies included patients with genetic disorders. Most studies reported no peri-operative complications (69%) and improved health outcomes (79%), with variable weight-loss results (29.2-86.2% excess weight loss). No significant differences were reported for youth with and without cognitive impairment and/or developmental delay in two studies. Limited available data suggest bariatric surgery may promote weight loss and improve health comorbidities for youth, irrespective of cognitive or developmental functioning. Clinical recommendations for working with patients and families are included.
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http://dx.doi.org/10.1007/s11695-019-04219-2DOI Listing
December 2019

Binge Eating Disorder in Children and Adolescents.

Authors:
Cara Bohon

Child Adolesc Psychiatr Clin N Am 2019 10 2;28(4):549-555. Epub 2019 Jul 2.

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5719, USA. Electronic address:

Binge eating disorder onset often occurs during adolescence, yet the diagnosis and treatment of the disorder in this age group has been inadequately studied. Criteria and challenges in making the diagnosis in children and adolescents are reviewed, as well as prevalence rates, current treatment options, and complications.
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http://dx.doi.org/10.1016/j.chc.2019.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6709690PMC
October 2019

Performance and brain activity during the Wisconsin Card Sorting Test in adolescents with obsessive-compulsive disorder and adolescents with weight-restored anorexia nervosa.

Eur Child Adolesc Psychiatry 2020 Feb 21;29(2):217-226. Epub 2019 May 21.

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA, 94305-5719, USA.

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) both show a peak age of onset during adolescence and share a number of phenotypic features, such as rigid rule-bound behavior and perseverative thinking. There is evidence of difficulties with set shifting or task switching in adults with each disorder, but evidence in adolescents is limited. Furthermore, no studies have previously directly compared AN and OCD on this cognitive process or examined comparative neural correlates. This study provides exploratory analyses to address this gap by measuring brain activity with functional magnetic resonance imaging (fMRI) during a computerized version of the Wisconsin Card Sorting Test (WCST) in female adolescents with weight-restored AN (WR-AN) (n = 14), OCD (n = 11), and healthy controls (n = 24). Results revealed greater perseverative errors in the OCD group than healthy controls and WR-AN, but no difference between WR-AN and healthy controls. Greater activity in the right front pole, inferior frontal gyrus, and middle frontal gyrus during the task (compared to a control matching task) was associated with more perseverative errors in the OCD group, but not healthy controls. The correlation between perseverative errors and brain response to the task in the WR-AN group was not different from either comparison group. These findings propose a hypothesis that behavioral similarities between OCD and AN, as well as difficulties with set shifting in adults with AN, are driven by obsessive-compulsive features present in AN rather than a shared underlying neurocognitive signature. This notion should be tested in larger samples in future studies.
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http://dx.doi.org/10.1007/s00787-019-01350-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868308PMC
February 2020

Set-shifting in adolescents with weight-restored anorexia nervosa and their unaffected family members.

J Psychiatr Res 2019 05 28;112:71-76. Epub 2019 Feb 28.

Department of Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, Stanford, CA. 401 Quarry Rd, Stanford, CA, 94305, USA.

Set-shifting difficulties have been suggested to underlie rigid and inflexible thinking in patients with anorexia nervosa (AN). Studies reported set-shifting deficiencies in adults with AN and also in their unaffected family members, suggesting that set-shifting deficits are heritable in AN. Surprisingly, studies failed to show set-shifting difficulties in adolescents with AN. If set-shifting difficulties are heritable, it is not clear why they are absent in adolescents with AN. The current study aimed to elucidate this discrepancy by assessing several components of set-shifting in adolescents with weight-restored AN (WR-AN) and their unaffected parents and siblings. Twenty-one families that include an adolescent who was diagnosed with AN prior to weight restoration (N = 19), an unaffected parent (N = 18), and an unaffected sibling (N = 20) were recruited. Additionally, 28 healthy control families were recruited and included an age-matched adolescent (N = 27), a parent (N = 26), and a sibling (N = 17). Visual-motor set-shifting, verbal set-shifting, and set-shifting clean of inhibition were assessed using the Delis-Kaplan Executive Function System. The results revealed intact set-shifting in parents and siblings of adolescents with WR-AN. Surprisingly, the results revealed superior visual-motor and verbal set-shifting in adolescents with WR-AN compared to age-matched controls. However, when controlling for inhibition abilities, poorer set-shifting was revealed in adolescents with WR-AN. The results suggest that superior inhibition abilities in adolescents with WR-AN may compensate for their set-shifting deficiencies. The study emphasizes the importance of controlling for inhibition abilities when assessing neurocognitive functioning in adolescents with AN. Furthermore, the study does not support the notion that set-shifting deficits are heritable in adolescent AN.
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http://dx.doi.org/10.1016/j.jpsychires.2019.02.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6543829PMC
May 2019

Change in brain volume and cortical thickness after behavioral and surgical weight loss intervention.

Neuroimage Clin 2019 10;21:101640. Epub 2018 Dec 10.

Department of Psychiatry, Icahn School of Medicine at Mount Sinai, Touro College and University System, New York, NY, USA; Department of Psychology, Touro College and University System, New York, NY, USA.

Obesity is associated with reduced cortical thickness and brain volume, which may be related to poor nutrition. Given that brain atrophy in anorexia nervosa recovers with nutritional improvements and weight gain, it is worth examining how brain structure changes at the other end of the weight spectrum with weight loss. Thus, this study aimed to examine change in cortical thickness and brain volume in 47 patients with severe obesity who participated in no treatment, behavioral weight loss, or bariatric surgery. T1-weighted MRI scans were conducted pre-treatment and approximately four months later. Measures of cortical thickness, gray matter volume, and white matter volume were compared between time points. Despite overall reduction in BMI, there was no significant change in cortical thickness. There was a significant increase in left hemisphere gray matter and white matter volumes across the sample. At baseline and follow-up, there was no relationship between cortical thickness or brain volumes and BMI. This study is the first to examine changes in cortical thickness and brain volume with weight loss in adults with obesity and the findings show partial support for the hypotheses that weight loss results in increased cortical gray and white matter.
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http://dx.doi.org/10.1016/j.nicl.2018.101640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411903PMC
December 2019

Aberrant Dynamic Connectivity for Fear Processing in Anorexia Nervosa and Body Dysmorphic Disorder.

Front Psychiatry 2018 26;9:273. Epub 2018 Jun 26.

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States.

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) share distorted perceptions of appearance with extreme negative emotion, yet the neural phenotypes of emotion processing remain underexplored in them, and they have never been directly compared. We sought to determine if shared and disorder-specific fronto-limbic connectivity patterns characterize these disorders. FMRI data was obtained from three unmedicated groups: BDD ( = 32), weight-restored AN ( = 25), and healthy controls (HC; = 37), while they viewed fearful faces and rated their own degree of fearfulness in response. We performed dynamic effective connectivity modeling with medial prefrontal cortex (mPFC), rostral anterior cingulate cortex (rACC), and amygdala as regions-of-interest (ROI), and assessed associations between connectivity and clinical variables. HCs exhibited significant within-group bidirectional mPFC-amygdala connectivity, which increased across the blocks, whereas BDD participants exhibited only significant mPFC-to-amygdala connectivity ( < 0.05, family-wise error corrected). In contrast, participants with AN lacked significant prefrontal-amygdala connectivity in either direction. AN showed significantly weaker mPFC-to-amygdala connectivity compared to HCs ( = 0.0015) and BDD ( = 0.0050). The mPFC-to-amygdala connectivity was associated with greater subjective fear ratings ( = 0.11, = 0.0016), eating disorder symptoms ( = 0.33, = 0.0029), and anxiety ( = 0.29, = 0.0055) intensity scores. Our findings, which suggest a complex nosological relationship, have implications for understanding emotion regulation circuitry in these related psychiatric disorders, and may have relevance for current and novel therapeutic approaches.
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http://dx.doi.org/10.3389/fpsyt.2018.00273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028703PMC
June 2018

Changes in Cerebral Cortical Thickness Related to Weight Loss Following Bariatric Surgery.

Obes Surg 2018 08;28(8):2578-2582

School of Medicine, Section of Bariatric and Minimally Invasive Surgery, Stanford University, 900 Blake Wilbur Drive, Room W0048, Stanford, CA, 94305, USA.

Cerebral cortical thickness is associated with memory and intelligence test scores and serves as a measure for changes in cortical gray matter. Previous studies suggest reduced cortical thickness in patients with obesity. This study aimed to investigate changes in cortical thickness following bariatric surgery. Magnetic resonance imaging (MRI) data of five patients were analyzed preoperatively and 6 months postoperatively to assess changes in global measures of cortical thickness. No patients were lost to follow-up. This study provides preliminary evidence of brain change following surgery, suggests increases in cerebral cortical thickness in patients with greater excess weight loss, and indicates the need for further investigation using larger samples and correlation with neurocognitive measures, such as memory recall.
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http://dx.doi.org/10.1007/s11695-018-3317-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6400222PMC
August 2018

Comorbid depressive symptoms and self-esteem improve after either cognitive-behavioural therapy or family-based treatment for adolescent bulimia nervosa.

Eur Eat Disord Rev 2018 05 15;26(3):253-258. Epub 2018 Feb 15.

Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, CA, USA.

This study examined the effect of family-based treatment for bulimia nervosa (FBT-BN) and cognitive behavioral therapy for adolescents (CBT-A) on depressive symptoms and self-esteem in adolescents with BN. Data were collected from 110 adolescents, ages 12-18, who met Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, text revision criteria for BN or partial BN. Participants were randomly assigned to FBT-BN or CBT-A and completed measures of depressive symptoms and self-esteem before and after treatment and at 6- and 12-month follow-up assessments. Depressive symptoms and self-esteem significantly improved in both treatments, and neither treatment appeared superior on these clinical outcomes. Parents often worry whether FBT-BN addresses comorbid depressive symptoms and low self-esteem. Our findings address this concern, as they demonstrate that FBT-BN does not differ from CBT-A in improving depressive symptoms and self-esteem, and both treatments result in symptom improvement. These findings can help clinicians guide families to choose a treatment that addresses BN and depressive symptoms and low self-esteem.
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http://dx.doi.org/10.1002/erv.2582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6010314PMC
May 2018

Differences in Emotion Regulation Difficulties Across Types of Eating Disorders During Adolescence.

J Abnorm Child Psychol 2018 08;46(6):1351-1358

Department of Psychiatry and Behavioral Sciences, Child and Adolescent Psychiatry, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA, 94305, USA.

Emotion regulation appears to play a key role in eating disorders. However, prior attempts to associate specific emotion regulation abilities with specific types of eating disorders resulted in inconsistent findings. Moreover, far less is known about emotion regulation in eating disorders during adolescence, a critical period of emotional development. The current study addresses this gap, comparing emotion regulation characteristics between adolescents with restrictive types of eating disorders and those with binge eating or purging types of eating disorders. Ninety-eight adolescents with eating disorders (49 with restrictive and 49 with binge eating/purging eating disorders) completed a set of questionnaires including the Difficulties in Emotion Regulation Scale (DERS). The results revealed that binge eating/purging types of eating disorders were associated with greater difficulties in a variety of emotion regulation dimensions including impulse control, goal-directed behavior and access to effective emotion regulation strategies. Awareness and clarity of emotions were also worse in the binge eating/purging types of eating disorders, but this difference did not remain when comorbid psychopathology measures were controlled for. Moreover, the emotion regulation profile of adolescents with anorexia nervosa-binging/purging type was more similar to that of adolescents with bulimia nervosa than to that of adolescents with anorexia nervosa-restrictive type. While both restrictive and binge eating/purging eating disorders have been associated with emotion regulation difficulties, the current study shows that the presence of binge eating or purging episodes is linked with greater severity of emotion regulation deficits among adolescents with eating disorders.
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http://dx.doi.org/10.1007/s10802-017-0365-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6014925PMC
August 2018

An interoceptive model of bulimia nervosa: A neurobiological systematic review.

J Psychiatr Res 2017 11 19;94:36-46. Epub 2017 Jun 19.

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States.

The objective of our study was to examine the neurobiological support for an interoceptive sensory processing model of bulimia nervosa (BN). To do so, we conducted a systematic review of interoceptive sensory processing in BN, using the PRISMA guidelines. We searched PsychInfo, Pubmed, and Web of Knowledge databases to identify biological and behavioral studies that examine interoceptive detection in BN. After screening 390 articles for inclusion and conducting a quality assessment of articles that met inclusion criteria, we reviewed 41 articles. We found that global interoceptive sensory processing deficits may be present in BN. Specifically there is evidence of abnormal brain function, structure and connectivity in the interoceptive neural network, in addition to gastric and pain processing disturbances. These results suggest that there may be a neurobiological basis for global interoceptive sensory processing deficits in BN that remain after recovery. Data from taste and heart beat detection studies were inconclusive; some studies suggest interoceptive disturbances in these sensory domains. Discrepancies in findings appear to be due to methodological differences. In conclusion, interoceptive sensory processing deficits may directly contribute to and explain a variety of symptoms present in those with BN. Further examination of interoceptive sensory processing deficits could inform the development of treatments for those with BN.
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http://dx.doi.org/10.1016/j.jpsychires.2017.06.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026544PMC
November 2017

Brain response to taste in overweight children: A pilot feasibility study.

Authors:
Cara Bohon

PLoS One 2017 24;12(2):e0172604. Epub 2017 Feb 24.

Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, United States of America.

Understanding the neural response to food and food cues during early stages of weight gain in childhood may help us determine the drive processes involved in unhealthy eating behavior and risk for obesity. Healthy weight and overweight children ages 6-8 (N = 18; 10 with BMI between 5th and 85th %ile and 8 with BMI >85th %ile) underwent fMRI scans while anticipating and receiving tastes of chocolate milkshake. Parents completed a Children's Eating Behaviour Questionnaire. Results reveal greater response to milkshake taste receipt in overweight children in the right insula, operculum, precentral gyrus, and angular gyrus, and bilateral precuneus and posterior cingulate. No group differences were found for brain response to a visual food cue. Exploratory analyses revealed interactions between self-report measures of eating behavior and weight status on brain response to taste. This pilot study provides preliminary evidence of feasibility of studying young children's taste processing and suggests a possible developmental shift in brain response to taste.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0172604PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5325294PMC
August 2017