Publications by authors named "Kelsey E Hagan"

23 Publications

  • Page 1 of 1

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

Int J Eat Disord 2021 08 1;54(8):1527-1536. 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
August 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

Reconsidering delay discounting in bulimia nervosa.

Eat Behav 2021 04 29;41:101506. Epub 2021 Mar 29.

Department of Psychology, University of Kansas, 1415 Jayhawk Boulevard, Fraser Hall Room 426, Lawrence, KS 66045, USA.

Delay discounting measures one's preference for smaller-sooner versus larger-later reward and is a facet of impulsivity. Studying delay discounting in bulimia nervosa (BN) may enhance clinical understanding of BN, as BN is characterized by engagement in behaviors that provide immediate reward (i.e., binge eating, purging) at the expense of future well-being. Prior research suggests that individuals with BN prefer smaller amounts of money available sooner compared to psychiatrically healthy (HC) persons. Here, we aimed to replicate and extend previous work by studying delay discounting of both monetary and food reward in women with BN relative to HC women. We also compared delay discounting of monetary and food reward, and examined associations among delay discounting, trait impulsivity, and eating disorder symptom expression in women with BN. Participants were 20 women with sub- or full-threshold DSM-5 BN and 20 HC women who completed a diagnostic interview, paper-and-pencil measures of delay discounting of monetary and food commodities, and a measure of trait impulsivity. Contrary to previous work, we found that women with BN showed decreased delay discounting of monetary and food reward relative to HC women. Within-group analyses demonstrated that women with BN showed elevated delay discounting of food reward relative to monetary reward. Within women with BN, elevated delay discounting of food, but not money, was associated with elevated negative and positive urgency, two facets of trait impulsivity that relate to acting rashly when experiencing strong emotion. Results suggest that delay discounting may be more variable in BN than previously assumed.
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http://dx.doi.org/10.1016/j.eatbeh.2021.101506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428544PMC
April 2021

Reward learning in unmedicated women with bulimia nervosa: A pilot investigation.

J Psychiatr Res 2021 04 3;136:63-70. Epub 2021 Feb 3.

Department of Psychology, University of Kansas, Lawrence, KS, USA.

Bulimia nervosa (BN) is characterized by recurrent engagement in eating disorder behaviors despite negative consequences, potentially reflecting aberrant stimulus-response or reward-learning processes. Indeed, frontostriatal circuitry involved in reward learning is altered in persons with BN and preliminary research suggests reward learning is impaired in persons with BN. Additional research on reward learning in BN and its association with eating disorder symptom expression is warranted to further the field's understanding of potential pathophysiological mechanisms of BN. To this end, the probabilistic reward learning task (PRLT) was administered to unmedicated women with BN (n = 15) and demographically matched psychiatrically healthy women (n = 18). Contrary to our hypotheses, results demonstrated that women with BN showed greater reward learning during the PRLT relative to healthy comparison women when covarying for symptoms of depression, social anxiety, and mania. Exploratory analyses showed that binge-eating frequency was inversely associated with reward learning in women with BN; however, results should be interpreted with caution due to the small sample size. Together, results suggest that women with BN do not have deficits in implicit reward learning. Given the preliminary nature of this investigation, larger-scale studies are needed to further examine reward learning in current BN and could compare reward learning using general (e.g., monetary) and disorder-specific (e.g., food) reinforcers. Further work is needed to confirm the inverse association between reward learning and binge eating.
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http://dx.doi.org/10.1016/j.jpsychires.2021.01.046DOI Listing
April 2021

State of the Art: The Therapeutic Approaches to Bulimia Nervosa.

Clin Ther 2021 01 23;43(1):40-49. Epub 2020 Dec 23.

Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA.

Purpose: Bulimia nervosa (BN) is an eating disorder characterized by binge eating, inappropriate compensatory behaviors, and body image concerns in persons at or above a healthy weight. BN is a serious disorder with medical sequelae and marked psychosocial impairment. To reduce and eliminate symptoms of BN, psychological and pharmacologic treatments for BN have been developed. We review the current state-of-the-art treatments for BN.

Methods: We conducted a narrative review of the BN treatment literature to synthesize the current evidence base, provide recommendations, and propose future directions for BN treatment research.

Findings: Currently, the first-line, state-of-the-art treatment for adults with BN is cognitive-behavioral therapy (CBT). Interpersonal therapy is a second-line evidence-based treatment for adults with BN, and dialectical behavior therapy and integrative cognitive-affective therapy are also promising. For BN in adolescents, family-based treatment for BN or CBT are evidence-based approaches. Pharmacotherapy is best considered adjunctive to psychotherapy in adults with BN but may be helpful, depending on the type of psychotherapy and whether psychotherapy is ineffective or unavailable. Fluoxetine 60 mg/d is the medication of choice for adults with BN. Little is known with respect to pharmacologic treatment of BN in adolescents, although fluoxetine 60 mg/d holds promise.

Implications: Despite decades of treatment-development research in BN, there is room for improvement because nearly 60% of those with BN do not achieve remission with specialty treatment and strikingly few randomized controlled trials for BN in adolescents exist. Moreover, the field should address issues related to treatment dissemination, access, and cost.
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http://dx.doi.org/10.1016/j.clinthera.2020.10.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902447PMC
January 2021

Functional neuroimaging biomarkers of resilience in major depressive disorder.

Curr Opin Psychiatry 2021 01;34(1):22-28

Department of Psychology, Stanford University, Stanford, California, USA.

Purpose Of Review: In this review we provide an overview of definitions and determinants of resilience in the context of neuroimaging research in major depressive disorder (MDD). We summarize emerging literature on functional neuroimaging biomarkers of resilience in MDD and discuss their clinical relevance and implications for future research.

Recent Findings: Resilience in MDD is characterized by dissociable profiles of activation and functional connectivity within brain networks involved in cognitive control, emotion regulation, and reward processing. Increased activation of frontal cortical brain regions implicated in cognitive appraisal and emotion regulation is a common characteristic of resilient individuals at high risk for MDD and of individuals with MDD with a favorable illness course. Furthermore, significant associations between fronto-striato-limbic functional connectivity and both positively interpreted stressful life events in resilient high-risk individuals and a favorable response to first-line treatments in depressed individuals suggest that neuro-compensatory changes and experience-dependent plasticity underlie resilience in MDD.

Summary: Emerging research has identified functional neuroimaging biomarkers of resilience in MDD. A continued focus on identifying neurobiological underpinnings of resilience, in the context of dynamic environmental and developmental influences, will advance our understanding of resilience and improve approaches to prevention and treatment of MDD.
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http://dx.doi.org/10.1097/YCO.0000000000000662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769009PMC
January 2021

Neural Correlates of Positive Emotion Processing That Distinguish Healthy Youths at Familial Risk for Bipolar Versus Major Depressive Disorder.

J Am Acad Child Adolesc Psychiatry 2021 07 29;60(7):887-901. Epub 2020 Jul 29.

Stanford University School of Medicine, California. Electronic address:

Objective: Familial risk for bipolar disorder (BD) or major depressive disorder (MDD) may lead to differential emotion processing signatures, resulting in unique neural vulnerability.

Method: Healthy offspring of a parent with BD (n = 29, "BD-risk") or MDD (n = 44, "MDD-risk") and healthy control youths without any personal or family psychopathology (n = 28, "HC") aged 8 to 17 years (13.64 ± 2.59 years) completed an implicit emotion-perception functional magnetic resonance imaging task. Whole-brain voxelwise and psychophysiological interaction analyses examined neural differences in activation and connectivity during emotion processing. Regression modeling tested for neural associations with behavioral strengths and difficulties and conversion to psychopathology at follow-up (3.71 ± 1.91 years).

Results: BD-risk youth showed significantly reduced bilateral putamen activation, and decreased connectivity between the left putamen and the left ventral anterior cingulate cortex (vACC) and the right posterior cingulate cortex (PCC) during positive-valence emotion processing compared to MDD-risk and HC (Z >2.3; p <.001). Decreased left putamen-right PCC connectivity correlated with subsequent peer problems in BD-risk (β = -2.90; p <.05) and MDD-risk (β = -3.64; p < .05) groups. Decreased left (β = -0.09; p < .05) and right putamen activation (β = -0.07; p = .04) were associated with conversion to a mood or anxiety disorder in BD-risk youths. Decreased left putamen-right PCC connectivity was associated with a higher risk of conversion in BD-risk (HR = 8.28 , p < .01) and MDD-risk (HR = 2.31, p = .02) groups.

Conclusion: Reduced putamen activation and connectivity during positive emotion processing appear to distinguish BD-risk youths from MDD-risk and HC youths, and may represent a marker of vulnerability.
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http://dx.doi.org/10.1016/j.jaac.2020.07.890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855111PMC
July 2021

Development and initial validation of the Eating Pathology Symptoms Inventory-Clinician-Rated Version (EPSI-CRV).

Psychol Assess 2020 Oct 27;32(10):943-955. Epub 2020 Jul 27.

Department of Psychiatry and Behavioral Neuroscience, University of Chicago.

Proper assessment and diagnosis of eating disorders (EDs) are critical to determine to whom prevention and treatment efforts should be targeted, the extent to which treatment is working, and when an individual has recovered. Although existing ED diagnostic interviews have numerous strengths, they also have certain limitations, including poor internal consistency, low discriminant validity, and poor factor-structure replicability. The purpose of the current study was to address problems of past ED diagnostic interviews through the creation of a new clinician-rated interview-the Eating Pathology Symptoms Inventory-Clinician-Rated Version (EPSI-CRV). The EPSI-CRV was designed to measure dimensional constructs assessed in the self-report version of the EPSI and generate current Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnoses. Participants were community-recruited adults with a DSM-5 ED (N = 257). Participants completed self-report and interview-based measures of eating, mood, and anxiety disorders and self-report measures of psychiatric impairment. The EPSI-CRV demonstrated evidence for interrater reliability, convergent and discriminant validity, and a good-fitting factor structure. EPSI-CRV dimensions showed concurrent validity for distinguishing among ED diagnoses. Baseline EPSI-CRV dimensions significantly predicted psychiatric impairment at baseline but not at 1-year follow-up. Although some scales had lower internal consistency than ideal, internal consistency values were similar to those of other established diagnostic measures. The EPSI-CRV appears to represent a promising new interview that can be used across a variety of clinical and research settings. Interested readers can access the EPSI-CRV and relevant training materials here: https://kuscholarworks.ku.edu/handle/1808/29616. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pas0000820DOI Listing
October 2020

A preliminary systematic review and meta-analysis of randomized-controlled trials of cognitive remediation therapy for anorexia nervosa.

Eat Behav 2020 04 3;37:101391. Epub 2020 May 3.

Department of Psychology, University of Kansas, Lawrence, KS 66049, United States of America.

Cognitive remediation therapy (CRT) for anorexia nervosa (AN) was developed as an adjuvant treatment to target set-shifting and central coherence inefficiencies important in AN and to ultimately improve clinical outcomes of those with AN. The primary aim of this preliminary systematic review and meta-analysis was to determine the effect of CRT for AN relative to control treatments in randomized-controlled trials (RCTs) on neuropsychological inefficiencies at end-of-treatment. Secondary aims were to assess the effect of CRT for AN on dropout, eating-disorder-related, and other psychological outcomes at end-of-treatment. Systematic review and meta-analytic procedures were conducted in accordance with PRISMA Guidelines. RCTs evaluating CRT for AN compared to a control treatment were identified via ProQuest, PsycINFO, PubMed, and SCOPUS. Seven RCTs and one quasi-RCT of CRT for AN were included. RCT quality ratings ranged from fair (n = 3) to good (n = 4). Random-effects meta-analysis was conducted using Hedge's g. Study heterogeneity was assessed using I and publication bias was assessed with Begg's adjusted-rank correlation and the trim-and-fill method. CRT was not associated with improvement in central coherence compared to control treatments at end-of-treatment (g = 0.25, 95% CI = -0.35, 0.85, k = 3). Set-shifting outcomes were mixed due to heterogeneity of set-shifting measures across studies. CRT may prevent dropout; yet, more studies are needed to draw conclusions. CRT did not confer advantage over control treatments for eating-disorder-related and other psychological outcomes at end-of-treatment. Future RCTs of CRT for AN should use precise measures to assess constructs (particularly for set shifting), increase sample size, and implement longitudinal follow-up. (Word Count: 247 words).
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http://dx.doi.org/10.1016/j.eatbeh.2020.101391DOI Listing
April 2020

A systematic review and meta-analysis of attentional bias toward food in individuals with overweight and obesity.

Appetite 2020 08 13;151:104710. Epub 2020 Apr 13.

Department of Psychology, University of Kansas, Lawrence, KS, USA.

Attentional bias to food stimuli may contribute to the etiology and/or maintenance of overweight and obesity. We conducted a literature review and meta-analysis per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify the effect size associated with attentional bias to palatable food in persons with overweight/obesity across the age spectrum. Included studies measured attentional bias to food stimuli using two reaction-time tasks (dot-probe, emotional Stroop), eye-tracking methodology, and/or event-related potentials. Meta-analysis showed that persons with overweight/obesity did not differ from persons with a healthy weight on any of the following: automatic and maintained attention to food stimuli measured by the dot-probe task (Hedge's g = -0.355, 95% CI = -0.383, 0.486; and Hedge's g = 0.006, 95% CI = -0.187, 0.199); attentional bias to food stimuli measured by the emotional Stroop task (Hedge's g = 0.184, 95% CI = -0.283, 0.651); and attentional bias to food images on gaze-direction and gaze-duration bias eye-tracking metrics (Hedge's g = 0.317, 95% CI = -0.096, 0.729; and Hedge's g = 0.056, 95% CI = -0.296, 0.407). Systematic review of preliminary event-related potentials research suggested automatic, but not maintained, attention to food images in persons with overweight/obesity. Limitations of past attentional bias research in overweight/obesity, such as poor reliability of measures and lack of consideration of moderators, such as binge eating and degree of overweight/obesity, preclude the ability to draw firm conclusions. We recommend implementation of empirically based methods for improving psychometric properties of attentional bias measures and examination of potential moderators so that the field can understand whether attentional bias to food is truly greater in overweight/obesity.
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http://dx.doi.org/10.1016/j.appet.2020.104710DOI Listing
August 2020

Longitudinal trajectories of behavior change in a national sample of patients seeking eating-disorder treatment.

Int J Eat Disord 2020 06 10;53(6):917-925. Epub 2020 Apr 10.

Recovery Record Inc., Palo Alto, CA, USA.

Objective: Rapid response to treatment, indicated by substantial decreases in eating-disorder (ED) symptoms within the first 4-6 weeks of treatment, is the most reliable predictor of treatment outcomes for EDs. However, there is limited research evaluating short-term longitudinal trajectories of ED symptoms during treatment. Thus, it is difficult to know which aspects of ED psychopathology are slow or fast to change. The purpose of this study was to elucidate three-month trajectories of ED psychopathology during treatment and test whether ED diagnosis influenced the direction and rate of change.

Method: Participants were Recovery Record users seeking treatment for an ED (N = 4,568; 86.8% female). Participants completed the Eating Pathology Symptoms Inventory once per month for 3 months.

Results: Latent growth curve models indicated that ED diagnosis influenced the rate of ED behavior change. Anorexia nervosa was associated with faster reductions in cognitive restraint, excessive exercise, restricting, yet slower reductions in body dissatisfaction, and binge eating. Bulimia nervosa was associated with faster reductions in binge eating, cognitive restraint, excessive exercise, and purging. Binge-eating disorder was associated with faster reductions in body dissatisfaction and binge eating, yet slower reductions in restricting.

Conclusions: Our results have implications for future research by providing initial information about the direction and rate of ED change over the course of treatment. If clinicians and researchers know which ED symptoms are slow to change, on average, across diagnostic groups, treatment protocols could be adjusted to target slow changing symptoms more quickly, and therefore improve ED treatment outcomes.
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http://dx.doi.org/10.1002/eat.23272DOI Listing
June 2020

Is all nonhomeostatic eating the same? Examining the latent structure of nonhomeostatic eating processes in women and men.

Psychol Assess 2019 Oct 20;31(10):1220-1233. Epub 2019 Jun 20.

Department of Psychology.

Nonhomeostatic eating is a complex (presumably) multidimensional construct associated with negative health outcomes. However, little research has examined the latent structure of nonhomeostatic eating processes, interrelationships among nonhomeostatic eating constructs, and differential associations between nonhomeostatic eating constructs and external correlates. This study adopted a construct validation approach to investigate these research questions in a large sample of undergraduate women and men (N = 998; 54.6% female). Exploratory and confirmatory factor analyses were conducted on items from 8 measures representing numerous nonhomeostatic eating process constructs (e.g., binge eating, loss of control [LOC] over eating, "food addiction"). The 7-factor retained solution included the following: (1) emotional eating, (2) external eating, (3) LOC over eating, (4) overeating, (5) distress over nonhomeostatic eating, (6) hedonic hunger, and (7) food addiction. LOC over eating was the nonhomeostatic eating factor most strongly related to other factors (M rs = .71 and .65 in women and men, respectively). Factor score multiple regressions conducted separately by sex indicated that distress over nonhomeostatic eating was related to body mass index, depressive symptoms, and eating-related clinical impairment in both women and men. In women, food addiction demonstrated unique associations with depressive symptoms, emotion dysregulation, and clinical impairment, whereas overeating uniquely predicted these outcomes in men. This is the first comprehensive analysis of the latent structure of nonhomeostatic eating processes and associations with external correlates, and results suggest that LOC over eating, distress over nonhomeostatic eating, food addiction (in women), and overeating (in men) exhibited the strongest relations with psychosocial impairment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/pas0000749DOI Listing
October 2019

The Athletes' Relationships with Training scale (ART): A self-report measure of unhealthy training behaviors associated with eating disorders.

Int J Eat Disord 2018 09 12;51(9):1080-1089. Epub 2018 Oct 12.

Pennington Biomedical Research Center, Baton Rouge, Louisiana.

Objective: Several studies indicate that eating-disorder (ED) psychopathology is elevated in athletes compared to non-athletes. The assessment of excessive exercise among athletes is a challenge because, compared to non-athletes, athletes are required to train at higher intensities and for longer periods of time. However, individuals participating in competitive sports are still susceptible to unhealthy physical-activity patterns. Most ED assessments were developed and normed in non-athlete samples and, therefore, do not capture the nuances of athletes' training experiences. The purpose of the current study was to develop and validate a clinically useful, self-report measure of unhealthy training behaviors and beliefs in athletes, the Athletes' Relationships with Training Scale (ART).

Method: The initial item pool was administered to N = 267 women collegiate athletes who were participating in an ED prevention program study and N = 65 women athletes who were in ED treatment.

Results: Factor analyses indicated the ART had a four-factor structure. Factorial and construct validity of the ART were demonstrated. ART scores significantly predicted health care utilization and differed between athletes with an ED versus athletes without an ED. For athletes in ED treatment, ART scores significantly decreased from treatment admission to discharge.

Discussion: The ART showed evidence of strong psychometric properties and clinical utility. The ART could be helpful for clinicians and athletic trainers to help gauge whether athletes are engaging in unhealthy training practices that may warrant clinical attention and for tracking clinical outcomes in athletes with EDs who are receiving treatment.
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http://dx.doi.org/10.1002/eat.22960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6519369PMC
September 2018

A new approach to eating-disorder classification: Using empirical methods to delineate diagnostic dimensions and inform care.

Int J Eat Disord 2018 07 21;51(7):710-721. Epub 2018 Aug 21.

Department of Psychology, University of Minnesota, Minneapolis, Minnesota.

Objective: Despite changes to the diagnostic criteria for eating disorders (EDs) in the DSM-5, the current diagnostic system for EDs has limited ability to inform treatment planning and predict outcomes. Our objective was to test the clinical utility of a novel dimensional approach to understanding the structure of ED psychopathology.

Method: Participants (N = 243; 82.2% women) were community-recruited adults with a DSM-5 ED assessed at baseline, 6-month, and 1-year follow-up. Hierarchical factor analysis was used to identify a joint hierarchical-dimensional structure of eating, mood, and anxiety symptoms. Exploratory structural equation modeling was used to test the ability of the dimensional model to predict outcomes.

Results: At the top of the hierarchy, we identified a broad Internalizing factor that reflected diffuse symptoms of eating, mood, and anxiety disorders. Internalizing branched into three subfactors: distress, fear-avoidance (fears of certain stimuli and behaviors to neutralize fears, including ED behaviors designed to reduce fear of weight gain), and body dissatisfaction, which was nested within distress. The lowest level of the hierarchy was characterized by 15 factors. The hierarchical model predicted 60.1% of the variance in outcomes at 6-month follow-up, whereas all DSM eating, mood, and anxiety disorders combined predicted 35.8% of the variance in outcomes.

Discussion: A dimensional approach to understanding and diagnosing EDs improved the ability to prospectively predict clinical course above-and-beyond the traditional categorical (DSM-based) approach. Our findings have implications for endeavors to improve the prediction of ED prognosis and course, and to develop more effective trans-diagnostic treatments.
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http://dx.doi.org/10.1002/eat.22891DOI Listing
July 2018

New Horizons in Measurement: a Review of Novel and Innovative Approaches to Eating-Disorder Assessment.

Curr Psychiatry Rep 2017 Sep 11;19(10):76. Epub 2017 Sep 11.

Department of Psychology, University of Kansas, Fraser Hall, 1415 Jayhawk Boulevard, Lawrence, KS, 66045, USA.

Purpose Of Review: Eating disorders are serious mental-health concerns that will affect over 30 million individuals in the USA at some point in their lives. Eating disorders occur across the lifespan, in a variety of ethnicities and races, in both men and women, and across the socioeconomic spectrum. Given the prevalence and severity of eating disorders, it is important that clinicians and researchers have access to appropriate assessment tools to aid in the early identification and treatment referral, differential diagnosis, treatment planning, and progress monitoring, and to ensure valid research findings. In this review, we describe novel and innovative assessment tools that were developed within the past 5 years for utilization in research and/or clinical practice with individuals with eating disorders.

Recent Findings: We identified six multidimensional assessments for eating disorders, all of which can be administered online (with some also offering paper-and-pencil versions). Strengths of the measures included good internal consistency, test-retest reliability, and convergent validity. However, in part, due to problematic scale construction methods, certain scales had poor discriminant validity and most were developed and validated in mostly female samples. There are promising new eating disorder measures from which to choose; however, many measures continue to be limited by poor discriminant validity and need additional validation prior to incorporation into routine research and clinical practice.
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http://dx.doi.org/10.1007/s11920-017-0826-2DOI Listing
September 2017

The association of folate and depression: A meta-analysis.

J Psychiatr Res 2017 12 22;95:9-18. Epub 2017 Jul 22.

The University of Kansas, USA.

Background: Previous research suggested that folate levels play an important role in the etiology and course of depression. However, the literature has been inconsistent with regard to differences in folate level between individuals with and without depression. The present meta-analysis synthesized the results of previous studies to examine whether individuals with depression had lower levels of folate than individuals without depression.

Methods: Meta-analytic procedures were conducted in accordance with PRISMA guidelines. Studies evaluating folate levels in individuals with and without depression via red blood cell folate, serum folate, or dietary intake of folate methods were identified via PsycINFO and PubMed. Random-effects meta-analysis was conducted using Hedge's g, and moderation analysis was used for both folate measurement method and population type. Study heterogeneity was assessed with I and publication bias was qualitatively assessed via funnel plot and quantitatively assessed with the trim-and-fill method and Begg's adjusted rank test.

Results: We found a significant, small effect size, such that individuals with depression had lower folate levels than those without depression, Hedge's g = -0.24 (95% CI = -0.31, -0.16), p < 0.001. Study heterogeneity was high (I = 84.88%), and neither folate measurement method nor population accounted for study heterogeneity.

Conclusions: Individuals with depression have lower serum levels of folate and dietary folate intake than individuals without depression. Given that previous literature suggested folate supplementation improved the efficacy of traditional antidepressant medications, future research on folate supplementation in depression is warranted and clinicians may wish to consider folate supplementation for patients with depression.
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http://dx.doi.org/10.1016/j.jpsychires.2017.07.019DOI Listing
December 2017

Understanding eating disorders within internalizing psychopathology: A novel transdiagnostic, hierarchical-dimensional model.

Compr Psychiatry 2017 11 28;79:40-52. Epub 2017 Jun 28.

Children's Mercy Kansas City, United States.

Background: Several problems with the classification and diagnosis of eating disorders (EDs) have been identified, including proliferation of 'other specified' diagnoses, within-disorder heterogeneity, and frequent diagnostic migration over time. Beyond problems within EDs, past research suggested that EDs fit better in a spectrum of internalizing psychopathology (characterized by mood and anxiety disorders) than in a separate diagnostic class.

Purpose: To develop a transdiagnostic, hierarchical-dimensional model relevant to ED psychopathology that: 1) reduces diagnostic heterogeneity, 2) includes important dimensions of internalizing psychopathology that are often excluded from ED diagnostic models, and 3) predicts clinical impairment.

Procedures: Goldberg's (2006) method and exploratory structural equation modeling were used to identify a hierarchical model of internalizing in community-recruited adults with EDs (N=207).

Findings: The lowest level of the hierarchy was characterized by 15 factors that defined specific aspects of eating, mood, and anxiety disorders. At the two-factor level, Internalizing bifurcated into Distress (low well-being, body dissatisfaction, suicidality, dysphoria, ill temper, traumatic intrusions) and Fear-Avoidance (claustrophobia, social avoidance, panic symptoms, dietary restricting, excessive exercise, and compulsions). Results showed that the lowest level of the hierarchy predicted 67.7% of the variance in clinical impairment. In contrast, DSM eating, mood, and anxiety disorders combined predicted 10.6% of the variance in impairment secondary to an ED.

Conclusions: The current classification model represents an improvement over traditional nosologies for predicting clinically relevant outcomes for EDs.
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http://dx.doi.org/10.1016/j.comppsych.2017.06.009DOI Listing
November 2017

Do emotion regulation difficulties when upset influence the association between dietary restraint and weight gain among college students?

Appetite 2017 07 22;114:101-109. Epub 2017 Mar 22.

Department of Psychology, University of Kansas, Lawrence, KS, USA.

Obesity is a significant public health concern that affects more than one-fifth of adolescents aged 12-19 in the United States. Theoretical models suggest that prolonged dietary restraint leads to binge-eating behaviors, which in turn increases individuals' risk for weight gain or obesity. Results from the literature indicate a potential role for negative urgency (the tendency to act rashly when distressed) as a mediating variable that explains the link between dietary restraint and binge-eating episodes. The current study tested short-term, prospective longitudinal associations among dietary restraint, binge eating, negative urgency, and weight gain among college students - a population at increased risk for the development of overweight and obesity. We hypothesized that dietary restraint and weight gain would be mediated by negative urgency and binge eating, but only among participants with overweight and obesity. College students (N = 227) completed the Eating Pathology Symptoms Inventory, UPPS-P Impulsivity Scale, and self-reported weight and height to calculate body mass index. Results showed that the association between dietary restraint and weight gain was mediated by negative urgency and binge eating, but only among participants with overweight and obesity. Our findings indicated that negative urgency might represent a mechanism that explains why dietary restraint leads to future binge-eating episodes and weight gain among college students with overweight and obesity. Results suggest that future treatment and prevention programs for overweight and obesity may benefit from incorporating strategies to improve emotion regulation as a way to reduce binge eating and to prevent additional weight gain among 'at-risk' populations.
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http://dx.doi.org/10.1016/j.appet.2017.03.029DOI Listing
July 2017

Concurrent and prognostic utility of subtyping anorexia nervosa along dietary and negative affect dimensions.

J Consult Clin Psychol 2017 Mar;85(3):228-237

Department of Psychiatry, University of Pittsburgh.

Bulimia nervosa can be reliably classified into subtypes based on dimensions of dietary restraint and negative affect. Community and clinical studies have shown that dietary-negative affect subtypes have greater test-retest reliability and concurrent and predictive validity compared to subtypes based on the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although dietary-negative affect subtypes have shown utility for characterizing eating disorders that involve binge eating, this framework may have broader implications for understanding restrictive eating disorders.

Objective: The purpose of this study was to test the concurrent and predictive validity of dietary-negative affect subtypes among patients with anorexia nervosa (AN; N = 194).

Method: Latent profile analysis was used to identify subtypes of AN based on dimensions of dietary restraint and negative affect. Chi-square and multivariate analysis of variance were used to characterize baseline differences between identified subtypes. Structural equation modeling was used to test whether dietary-negative affect subtypes would outperform DSM categories in predicting clinically relevant outcomes.

Results: Results supported a 2-profile model that replicated dietary-negative affect subtypes: Latent Profile 1 (n = 68) had clinically elevated scores on restraint only; Latent Profile 2 (n = 126) had elevated scores on both restraint and negative affect. Validation analyses showed that membership in the dietary-negative affect profile was associated with greater lifetime psychiatric comorbidity and psychosocial impairment compared to the dietary class. Dietary-negative affect subtypes only outperformed DSM categories in predicting quality-of-life impairment at 1-year follow-up.

Conclusions: Findings highlight the clinical utility of subtyping AN based on dietary restraint and negative affect for informing future treatment-matching or personalized medicine strategies. (PsycINFO Database Record
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http://dx.doi.org/10.1037/ccp0000164DOI Listing
March 2017

Incremental validity of weight suppression in predicting clinical impairment in bulimic syndromes.

Int J Eat Disord 2017 06 17;50(6):672-678. Epub 2017 Jan 17.

Department of Psychology, University of Kansas, 1415 Jayhawk Blvd., Lawrence, KS, 66045.

Research has shown that weight suppression (WS; the difference between a person's highest and current body weight in pounds) is a robust predictor of weight gain and eating-disorder (ED) symptoms among individuals with bulimic syndromes. Given the important prognostic role that WS plays in ED course and outcome, we hypothesized that WS would represent a clinically useful indicator of impairment for bulimic syndromes. We further posited that WS would demonstrate incremental validity above-and-beyond other proposed indicators in explaining clinical impairment in bulimic syndromes. Participants were community-recruited adults (N = 101; 80.2% female) with full-threshold (n = 51) or subthreshold (n = 50) bulimia nervosa. Other indicators of impairment included body mass index, frequency of inappropriate compensatory behaviors, lifetime history of any internalizing disorder, and multiple purging. Clinical impairment was assessed with the clinical impairment assessment (CIA). Hierarchical linear regression tested whether WS added to the explanation of CIA score variance above-and-beyond other indicators of bulimic-syndrome impairment. WS was significantly associated with clinical impairment (p = .011), but did not demonstrate incremental validity over other independent variables in predicting CIA scores. WS explained an additional 1.7% of the variance in CIA scores above-and-beyond other variables and the independent effect of WS on CIA scores represented a medium-sized effect (Cohen's d = 0.521). Results suggested that WS may be an indicator of ED-related clinical impairment. Inquiring about WS could be an informative component of routine bulimic-syndrome assessment, given that WS explains some of the variance in clinical impairment in bulimic syndromes.
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http://dx.doi.org/10.1002/eat.22673DOI Listing
June 2017

Is dietary restraint a unitary or multi-faceted construct?

Psychol Assess 2017 Oct 19;29(10):1249-1260. Epub 2016 Dec 19.

Department of Psychology, University of Kansas.

Given that approximately two-thirds of adults are overweight or obese, there is substantial interest in dieting (dietary restraint) to promote weight loss. However, research on the associations between dietary restraint and binge eating is inconsistent. One possible explanation for contradictory findings is that measures of dietary restraint assess heterogeneous constructs. Nonclinical samples of university student (n = 433; 62.6% female) and community-recruited (n = 407; 47.4% female) adults completed self-report measures of dietary restraint. Exploratory structural equation modeling and exploratory and confirmatory factor analyses were used to identify latent dietary restraint factor(s). Structural equation modeling and multiple regression were used to test associations among latent dietary restraint factor(s), body mass index (BMI), eating-disorder risk, binge eating, and psychopathological and personality variables. Three latent dietary restraint factors emerged: (a) Calorie Counting; (b) Preoccupation With Dieting; and (c) Weight-Focused Restraint. The model demonstrated a good fit to the data. Eating-disorder risk was significantly and positively associated with all restraint factors, whereas higher levels of BMI and binge eating were significantly associated with greater Preoccupation with Dieting and Weight-Focused Restraint only. Our findings indicated that dietary restraint is a heterogeneous construct and that measures of restraint assess different aspects of dieting. Our results have important implications for eating and weight disorders treatment, and suggest that weight-loss interventions that do not simultaneously increase negative attitudes toward one's body may be useful for treating weight disorders, without promoting disordered eating. (PsycINFO Database Record
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http://dx.doi.org/10.1037/pas0000429DOI Listing
October 2017

Characterizing severe and enduring anorexia nervosa: An empirical approach.

Int J Eat Disord 2017 Apr 19;50(4):389-397. Epub 2016 Dec 19.

Department of Psychology, University of Kansas, Lawrence, Kansas.

Targeted approaches for the treatment of severe and enduring anorexia nervosa (SE-AN) have been recommended, but there is no consensus definition of SE-AN to inform research and clinical practice. This study aimed to take initial steps toward developing an empirically based definition of SE-AN by characterizing associations among putative indicators of severity and chronicity in eating disorders. Patients with AN (N = 355) completed interviews and questionnaires at treatment admission and discharge; height and weight were assessed to calculate body mass index (BMI). Structural equation mixture modeling was used to test whether associations among potential indicators of SE-AN (illness duration, treatment history, BMI, binge eating, purging, quality-of-life) formed distinct subgroups, a single group with one or more dimensions, or a combination of subgroups and dimensions. A three-factor (dimensional), two-profile (categorical) mixture model provided the best fit to the data. Factor 1 included eating disorder behaviors; Factor 2 comprised quality-of-life domains; Factor 3 was characterized by illness duration, number of hospitalizations, and admission BMI. Profiles differed on eating disorder behaviors and quality-of-life, but not on indicators of chronicity or BMI. Factor scores, but not profile membership, predicted outcome at discharge from treatment. Data suggest that patients with AN can be classified on the basis of eating disorder behaviors and quality-of-life, but there was no evidence for a chronic subgroup of AN. Rather, indices of chronicity varied dimensionally within each class. Given that current definitions of SE-AN rely on illness duration, these findings have implications for research and clinical practice.
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http://dx.doi.org/10.1002/eat.22651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5386793PMC
April 2017

Voluntary emotion regulation in anorexia nervosa: A preliminary emotion-modulated startle investigation.

J Psychiatr Res 2016 Jun 23;77:1-7. Epub 2016 Feb 23.

Department of Psychology, University of North Carolina-Greensboro, Greensboro, NC, USA.

Emotion regulation difficulties are implicated in the development and maintenance of anorexia nervosa (AN). However, research has been limited by an almost exclusive reliance on self-report. This study is the first to use the emotion-modulated startle paradigm (EMSP) to investigate emotional reactivity and voluntary emotion regulation in individuals with AN. Twenty women with AN viewed negative, positive, neutral, and food images and were asked to enhance, suppress, or maintain their emotional responses mid-way through picture presentation. Startle eyeblink magnitudes in response to startle probes administered prior, and subsequent, to regulation instructions indexed emotional reactivity and regulation, respectively. On emotional reactivity trials, startle magnitudes were greater for negative, positive, and food images, compared to neutral images. Participants had difficulty suppressing startle responses to negative and food images, as indicated by non-significant suppress-maintain comparisons. In contrast, startle responses to enhance and suppress cues during presentation of pleasant images were comparable and significantly lower than maintain cues. Findings converge with self-report data to suggest that patients with AN have difficulties with voluntary emotion regulation. The EMSP may be a promising trans-diagnostic method for examining emotion regulation difficulties that underlie risk for eating disorders and other psychiatric conditions.
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http://dx.doi.org/10.1016/j.jpsychires.2016.02.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4826846PMC
June 2016
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