Publications by authors named "Valentina Cardi"

73 Publications

A multifaceted study of interpersonal functioning and cognitive biases towards social stimuli in adolescents with eating disorders and healthy controls.

J Affect Disord 2021 Jul 19;295:397-404. Epub 2021 Jul 19.

Department of General Psychology, University of Padova, Italy.

Background: Cognitive biases towards social stimuli have been identified as one of the putative modifiable mechanisms to remediate interpersonal difficulties in adolescents with mental disorders. However, evidence for these biases in adolescents with eating disorders is scarce.

Methods: This study assessed interpersonal sensitivity, cognitive biases towards social stimuli, and quantity and quality of social group memberships in adolescents with eating disorders (n = 80), compared to healthy controls (n = 78), and examined whether a negative interpretation bias would mediate the relationship between interpersonal sensitivity, eating disorder symptoms and positive group memberships.

Results: Adolescents with eating disorders displayed greater interpersonal awareness, negative interpretation biases of ambiguous social information and poorer quality relationships with their social groups compared to healthy controls. In a simple mediation model, interpersonal awareness predicted eating disorder symptoms, and this effect was partially mediated by a negative interpretation bias.

Conclusions: Psychological interventions which aim to reduce a negative interpretation bias might help to reduce the severity of eating disorder symptoms in adolescents with eating disorders.
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http://dx.doi.org/10.1016/j.jad.2021.07.013DOI Listing
July 2021

A pilot randomized control trial of online exposure for eating disorders and mechanisms of change delivered after discharge from intensive eating disorder care: A registered report.

Int J Eat Disord 2021 Sep 4. Epub 2021 Sep 4.

Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky, USA.

More than 50% of individuals with an eating disorder (ED) will readmit to treatment within 6 months of treatment discharge and often due to persistent cognitive ED pathology. Interventions addressing unremitted cognitive ED pathology following discharge from intensive treatment are crucial to prevent readmission. Imaginal exposure therapy facilitates the approach of feared stimuli not accessible in everyday life (e.g., rapidly gaining weight). In the current pilot randomized control trial (RCT), participants will be randomly assigned to a five-session online imaginal exposure condition (n = 65) or a control online writing and thinking intervention (n = 65) within a month of discharge from intensive treatment. Exposure participants write about and imagine an ED fear and control participants will write about their ED generally. We will examine the feasibility and acceptability of the treatment conditions and whether imaginal exposure is more effective in preventing readmission than the control condition. We will test the efficacy of the imaginal exposure treatment in reducing ED symptoms and fears of food and weight gain, and whether fear learning is a mechanism of change related to ED pathology. Ultimately, this research will lead to the development of an easily deployable readmission prevention treatment based on fear conditioning targets.
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http://dx.doi.org/10.1002/eat.23603DOI Listing
September 2021

Fear conditioning in women with anorexia nervosa and healthy controls: A preliminary study.

J Abnorm Psychol 2021 Jul;130(5):490-497

Institute of Psychiatry, Psychology and Neuroscience.

Anorexia nervosa is characterized by anxiety-driven behaviors, such as food avoidance and distressing persistent thoughts about weight gain and body image. The present study used a classical fear conditioning procedure to test the processes of fear acquisition and generalization, extinction, and renewal in patients with anorexia nervosa and healthy controls. An app-based fear conditioning procedure was administered remotely to 64 patients and 60 healthy controls, over two sessions. A human female scream served as the unconditioned stimulus (US) and two neutral shapes were used as either the paired conditioned stimulus (danger cue; CS+) or the unpaired conditioned stimulus (safe cue; CS-). Patients with anorexia nervosa reported greater threat expectancy in response to the danger cue during the extinction and renewal phases and overall higher levels of negative affect throughout the task, compared with controls. Future research is warranted to replicate these findings and highlight the role that anxiety plays in explaining fear conditioning responses in patients with anorexia nervosa. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/abn0000549DOI Listing
July 2021

Dimensionality and psychometric properties of an Italian translation of the Intuitive Eating Scale-2 (IES-2): An assessment using a bifactor exploratory structural equation modelling framework.

Appetite 2021 11 2;166:105588. Epub 2021 Jul 2.

Department of General Psychology, University of Padova, Padova, Italy. Electronic address:

The construct of intuitive eating is most often measured using the 23-item Intuitive Eating Scale-2 (IES-2), but previous studies have typically relied solely on confirmatory factor analysis (CFA) to understand IES-2 dimensionality. In contrast, a bifactor exploratory structural equation modelling (B-ESEM) framework offers a more realistic account of IES-2 multidimensionality. Here, we assessed the psychometric properties of a novel Italian translation using a combination of exploratory factor analysis and B-ESEM. A total of 950 adults completed the IES-2 alongside measures of positive body image, disordered eating, and psychological well-being. Results indicated that a 4-factor B-ESEM model had adequate fit to the data and that fit was improved when the correlated uniqueness of seven negatively worded IES-2 items was accounted for. This model of IES-2 scores showed adequate internal consistency and good test-retest reliability up to three weeks. Evidence of construct validity was good in terms of a global IES-2 factor, and broadly supported in terms of its specific-factors. These results highlight the utility of a B-ESEM framework for understanding the dimensionality of IES-2 scores and may help scholars better understand the extent to which the IES-2 adequately operationalises the construct of intuitive eating.
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http://dx.doi.org/10.1016/j.appet.2021.105588DOI Listing
November 2021

Attitudes Surrounding Music of Patients With Anorexia Nervosa: A Survey-Based Mixed-Methods Analysis.

Front Psychiatry 2021 2;12:639202. Epub 2021 Jun 2.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.

Anorexia nervosa (AN) is one of the main eating disorders. It has the highest mortality of all psychiatric disorders, and the success rates of current therapies are not fully satisfactory. Thus, there is a need for novel interventions. We investigated the attitudes surrounding music of 41 patients with clinically-diagnosed AN as well as their thoughts on the potential therapeutic uses of music using a questionnaire of 50 questions. Free text responses were qualitatively analyzed for reoccurring themes with NVivo 12 software. Yes/no questions and questions of best fit were analyzed using the IBM SPSS Statistics version 25. The most prevalent theme was the positive effect of music. Most patients reported that listening to music evokes varying emotions in them (83%) which may be of positive or negative nature. Similarly, patients associated certain music with particular positive, but also with particular negative memories. A majority of patients stated that music helps to distract them (85%), helps with loneliness (59%) and helps them feel more connected to others (58%). This data indicates that people with AN make nonclinical use of music which seems to elicit positive as well as negative emotions and memories. Patients felt music is beneficial with regard to important aspects of AN, such as emotional problems, loneliness, and relationship difficulties. Most of them would also like to attend music therapy.
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http://dx.doi.org/10.3389/fpsyt.2021.639202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206484PMC
June 2021

An examination of social group memberships in patients with eating disorders, carers, and healthy controls.

Eur Eat Disord Rev 2021 Sep 3;29(5):733-743. Epub 2021 Jun 3.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

This study compared the quantity and quality of social group memberships in patients with anorexia nervosa (n = 30), carers of patients with anorexia nervosa, unrelated to those patients (n = 30), and two cohorts of healthy controls (n = 60) age-matched to these focal groups. A secondary aim was to examine the associations between the quality of group relationships and severity of eating disorder and depression symptoms in patients; and depression symptoms in carers. Participants completed the online Social Identity Mapping Tool, which was used to measure the quantity and quality of social group memberships (e.g., number of social groups, number of groups rated 'highly positive'). Participants also completed self-report measures of clinical symptoms. Compared to controls, patients reported fewer social groups when eating disorder-related groups were included, and significantly fewer social groups, and community groups in particular, when eating disorder-related groups were excluded. Number of positive groups was negatively associated with severity of eating disorder and depression symptoms in patients when eating disorder-related groups were excluded. Carers reported fewer groups overall, fewer family groups, and fewer positive and supportive groups compared to healthy controls. There was a weak association between the number of positive groups and the severity of depression symptoms in carers. Positive group memberships might play a protective role towards developing more severe eating disorder and depression symptoms.
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http://dx.doi.org/10.1002/erv.2840DOI Listing
September 2021

Socio-cognitive processing in people with eating disorders: Computerized tests of mentalizing, empathy and imitation skills.

Int J Eat Disord 2021 08 31;54(8):1509-1518. Epub 2021 May 31.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy.

Objective: Eating disorders are psychiatric illnesses characterized by extreme eating behaviors, such as sustained food restriction or loss of control over eating. Symptoms are thought to be maintained by a variety of mechanisms, one of which may be the socio-cognitive impairments associated with eating disorders. While some previous work has addressed socio-cognitive impairments in eating disorders, this work has relied mostly on self-report data.

Method: Here we employed computerized tests of (a) mentalizing (ability to infer the mental states of others); (b) empathy (the degree to which the emotional states of others can be identified and the degree to which the states of others impact one's own emotional state); and (c) imitation (the degree to which observation of another's actions prompts the performance of those actions); in a group of 78 women with an eating disorder and a matched control group of 66 healthy women.

Results: People with eating disorders showed both hyper- and hypo-mentalizing and reduced accuracy of emotional and cognitive mental state inference. They displayed less imitation of observed actions, but no differences in empathy compared to healthy controls. Although anxiety and depressive symptoms had significant effects on mentalizing, most of the observed inter-group differences persisted.

Discussion: Women with eating disorders have difficulties mentalizing and imitating observed actions despite intact non-social automatic imitation, compared to healthy controls. These findings provide an indication that intervention modules to strengthen specific areas of social cognition might be helpful to improve patients' social skills.
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http://dx.doi.org/10.1002/eat.23556DOI Listing
August 2021

The relationship between working alliance with peer mentors and eating psychopathology in a digital 6-week guided self-help intervention for anorexia nervosa.

Int J Eat Disord 2021 08 27;54(8):1519-1526. Epub 2021 May 27.

Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy.

Objective: The quality of working alliance (WA) is associated with treatment outcomes across several types of psychiatric disorders and psychological interventions. This study examined the role of WA with peer mentors (people with lived experience of illness) and student mentors (graduated psychology students) in a 6-week, digital, guided self-help (GSH) intervention for anorexia nervosa.

Method: Ninety-nine patients rated weekly, for 6 weeks: (a) eating psychopathology using the short version of the Eating Disorder Examination Questionnaire (EDE-QS) and (b) WA with a student mentor (n = 14) or a peer mentor (n = 10). WA was assessed by asking patients the extent to which they felt comfortable working with their mentor and the extent to which they agreed with them on the goals for support. WA with mentors and the association with eating psychopathology change were measured on a session-by-session basis. The analysis involved a random intercepts cross-lagged panel model.

Results: WA with peer mentors was slightly higher than WA with students (ES = 0.3). Peer mentors' WA in the previous session was significantly associated with eating psychopathology ratings in the next session. No significant relationship was found between the previous session's EDE-QS scores and peer mentor alliance in the following session. In the student mentor group, there were no session-by-session associations between WA and eating psychopathology. However, greater WA with the student mentor across sessions was associated with less eating psychopathology.

Discussion: These findings suggest that clinical outcomes are in part associated with the characteristics of the mentor delivering guidance in an online GSH for eating disorders.
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http://dx.doi.org/10.1002/eat.23559DOI Listing
August 2021

Lower pattern recognition memory scores in anorexia nervosa.

J Eat Disord 2021 Apr 17;9(1):49. Epub 2021 Apr 17.

Section of Eating Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 103 Denmark Hill, London, SE5 8AF, UK.

Background: There is extensive evidence for volumetric reductions in the hippocampus in patients with anorexia nervosa (AN), however the impact on function is unclear. Pattern separation and recognition are hippocampus-dependent forms of learning thought to underlie stimulus discrimination.

Methods: The present study used the Mnemonic Similarity Task to investigate pattern separation and recognition for the first time in patients with AN (N = 46) and healthy controls (N = 56). An Analysis of Covariance examined between-group differences, controlling for age, antidepressant use and method of task delivery (remote vs. in person).

Results: When controlling for covariates, pattern recognition memory scores were lower in the AN group with a medium effect size (d = 0.51). In contrast, there was a small effect whereby patients with AN had a greater pattern separation score than controls (d = 0.34), albeit this difference was not significant at the p = 0.05 threshold (p = 0.133). Furthermore, pattern separation and recognition memory abilities were not related to age, body mass index, eating disorder psychopathology or trait anxiety levels.

Conclusions: This preliminary study provides initial evidence for an imbalance in pattern separation and recognition abilities in AN, a hippocampus-dependent cognitive ability. Further studies should endeavour to investigate pattern separation and recognition performance further in AN, as well as investigate other hippocampus-dependent functions.
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http://dx.doi.org/10.1186/s40337-021-00406-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052530PMC
April 2021

Characterising binge eating over the course of a feasibility trial among individuals with binge eating disorder and bulimia nervosa.

Appetite 2021 09 2;164:105248. Epub 2021 Apr 2.

Centre for Cognitive Neuroscience, Department of Psychology, Paris-Lodron University of Salzburg, Salzburg, Austria.

Binge eating disorder and bulimia nervosa are eating disorders that are characterized by recurrent binge eating episodes. The highly contextualized nature of binge eating makes naturalistic research a particularly suitable means of understanding the context within which binge eating occurs. The present study aimed to characterise binge eating days with regards to the frequency and probability of negative affect, food craving, meal skipping, and dietary restriction. In addition, it aimed to examine whether a combined intervention that targets the experience of 'loss of control' over eating can decrease these potential maintenance factors that often precede binge eating episodes. Seventy-eight participants with bulimia nervosa (N = 40) or binge eating disorder (n = 38), who were randomly allocated to a food-specific or general intervention combining inhibitory control training and implementation intentions, completed mood and food diaries over four weeks. Results suggest that negative affect and food craving were elevated on binge eating days, but that dietary restraint and meal skipping did not characterise binge eating days. Moreover, meal skipping, binge eating, restriction, and compensation decreased throughout the intervention period, while negative affect and food craving did not. This suggests that some interventions may successfully reduce binge eating frequency without necessarily decreasing negative affect or food craving, thus pointing to the different routes to targeting binge eating and providing implications for future interventions.
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http://dx.doi.org/10.1016/j.appet.2021.105248DOI Listing
September 2021

Outcomes for adults with anorexia nervosa who do not respond early to outpatient treatment.

Int J Eat Disord 2021 07 24;54(7):1278-1282. Epub 2021 Mar 24.

Department of Psychological Medicine, Kings College London, London, UK.

Objective: To better understand those patients with anorexia nervosa who do not show early response to treatment and are likely to have poorer outcome.

Method: From an existing data set of 187 patients with anorexia nervosa across 22 eating disorder outpatient services in the United Kingdom, participants who had started treatment and had at least one body mass index (BMI) observation in the first 6 weeks of treatment were eligible for these secondary analyses (N = 65), a latent class analysis of BMI change over the first 6 weeks of treatment. Fifty-six patients showed no early change in BMI. We used logistic regression to examine predictors of good outcome in the 40 participants who had 12-month follow-up data. Predictors included global EDE-Q, negative affect (Depression, Anxiety, and Stress Scales) and functional impairment (Work and Social Adjustment Scale).

Results: Good outcome was achieved by 23% of patients and remission by 15%. Good outcome was predicted by less functional impairment at baseline.

Discussion: Further work that can identify sub-groups of patients with anorexia nervosa who do not achieve good outcome after treatment will inform the development of targeted engagement approaches.
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http://dx.doi.org/10.1002/eat.23508DOI Listing
July 2021

A systematic review of interventions to support transitions from intensive treatment for adults with anorexia nervosa and/or their carers.

Eur Eat Disord Rev 2021 May 9;29(3):355-370. Epub 2021 Mar 9.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aim: In the short term, intensive treatment focusing on restoring weight for anorexia nervosa can remediate many symptoms. However, there is a high level of relapse after discharge. This paper examines interventions developed to bridge the transition from intensive to less intensive forms of treatment for adult anorexia nervosa.

Method: We undertook a systematic review of the literature on interventions aimed at providing transition support. The Template for Intervention Description and Replication was used to describe components of the transition interventions. Patient's drop-out rates, weight, eating disorder psychopathology and mood data were extracted at end of treatment and follow-up to describe preliminary efficacy.

Results: Fourteen studies were selected: nine used psychological interventions delivered through face-to-face talking therapy or guided self-help, three examined the use of fluoxetine and two assessed stepped-care approaches. Transition support was delivered to patients in 11 studies, to patients and carers in two studies, and carers alone in another study.

Conclusions: There was a great heterogeneity in the content and structure of the transition interventions evaluated. Overall, drop-out rates were lower for psychological support than pharmacological interventions or stepped-care approaches. Changes in eating disorder outcomes and mood were small to moderate throughout for studies that included a comparison group.
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http://dx.doi.org/10.1002/erv.2824DOI Listing
May 2021

A Critical Review of Studies Assessing Interpretation Bias Towards Social Stimuli in People With Eating Disorders and the Development and Pilot Testing of Novel Stimuli for a Cognitive Bias Modification Training.

Front Psychol 2020 29;11:538527. Epub 2020 Sep 29.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.

People with eating disorders display a negative interpretation bias towards ambiguous social stimuli. This bias may be particularly relevant to young people with the illness due to the developmental salience of social acceptance and rejection. The overall aim of this study was to systematically develop and validate stimuli for a cognitive bias modification training to reduce a social rejection-related negative interpretation bias in young people with eating disorders. A mixed-methods design was used to achieve this aim. A review of the literature was conducted using EMBASE, MEDLINE, PsycINFO, Web of Science, and PubMed. Six studies were included in the review. Focus groups were held with patients with eating disorders, carers and healthcare professionals. Content analysis was used to identify key themes from the qualitative data. Based on these themes, a total of 339 scenarios were generated by the researchers. Salient themes identified from the focus group data included virtual rejection/exclusion, rejection associated with an aspect of the eating disorder, rejection triggered by ambiguous/benign comments or behaviors of others and rejection perceived when confiding in others. Patients rated these scenarios in terms of their age-relevance and emotional salience and 301 scenarios were included in the final stimulus set. These materials may be used by researchers conducting future experimental research into the potential benefits of interpretation bias training for young people with eating disorders.
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http://dx.doi.org/10.3389/fpsyg.2020.538527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556207PMC
September 2020

Network intervention analysis to assess the trajectory of change and treatment effects associated with the use of online guided self-help for anorexia nervosa.

Early Interv Psychiatry 2021 Oct 15;15(5):1210-1216. Epub 2020 Oct 15.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aim: The aim of this study was to use the innovative technique of Network Intervention Analysis (NIA) to examine the trajectory of symptom change associated with the use of a digital guided self-help intervention (RecoveryMANTRA) to augment treatment as usual in adult anorexia nervosa.

Methods: Self-reported eating disorder symptoms and mood (stress, anxiety and depression), work and social adjustment, motivation and treatment (Treatment as usual + RecoveryMANTRAand Treatment as usual) were included as nodes in the network and examined using NIA. Networks were computed at baseline (n = 88, 99), at end of treatment (6 weeks, n = 71, 75) and at 6- (n = 58, 63) and 12-month (n = 52, 63) follow-up.

Results: RecoveryMANTRA was associated with a direct effect on anxiety, shape concern and restraint at the end of the intervention. This effect was not maintained at follow-up. There were no direct effects of RecoveryMANTRA on motivation, stress and depression.

Conclusions: These findings indicate that RecoveryMANTRA exerts a direct effect on eating disorder symptoms and anxiety. NIA is a promising method to evaluate trajectories of clinical change and direct and indirect effects of a therapeutic intervention compared to a control condition.
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http://dx.doi.org/10.1111/eip.13064DOI Listing
October 2021

Treatment for eating disorders in a post-COVID world: The case of TRIANGLE.

Eur Eat Disord Rev 2020 11 26;28(6):796-798. Epub 2020 Jul 26.

Institute of Psychiatry, Psychology and Neuroscience, Psychological Medicine, Section of Eating Disorders, King's College London, London, UK.

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http://dx.doi.org/10.1002/erv.2761DOI Listing
November 2020

Targeting binge eating in bulimia nervosa and binge eating disorder using inhibitory control training and implementation intentions: a feasibility trial.

Psychol Med 2020 Jul 27:1-10. Epub 2020 Jul 27.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: This trial examined the feasibility, acceptability, and effect sizes of clinical outcomes of an intervention that combines inhibitory control training (ICT) and implementation intentions (if-then planning) to target binge eating and eating disorder psychopathology.

Methods: Seventy-eight adult participants with bulimia nervosa or binge eating disorder were randomly allocated to receive food-specific, or general, ICT and if-then planning for 4 weeks.

Results: Recruitment and retention rates at 4 weeks (97.5% and 79.5%, respectively) met the pre-set cut-offs. The pre-set adherence to the intervention was met for the ICT sessions (84.6%), but not for if-then planning (53.4%). Binge eating frequency and eating disorder psychopathology decreased in both intervention groups at post-intervention (4 weeks) and follow-up (8 weeks), with moderate to large effect sizes. There was a tendency for greater reductions in binge eating frequency and eating disorders psychopathology (i.e. larger effect sizes) in the food-specific intervention group. Across both groups, ICT and if-then planning were associated with small-to-moderate reductions in high energy-dense food valuation (post-intervention), food approach (post-intervention and follow-up), anxiety (follow-up), and depression (follow-up). Participants indicated that both interventions were acceptable.

Conclusions: The study findings reveal that combined ICT and if-then planning is associated with reductions in binge eating frequency and eating disorder psychopathology and that the feasibility of ICT is promising, while improvements to if-then planning condition may be needed.
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http://dx.doi.org/10.1017/S0033291720002494DOI Listing
July 2020

Exposure to food in anorexia nervosa and brain correlates of food-related anxiety: findings from a pilot study.

J Affect Disord 2020 09 25;274:1068-1075. Epub 2020 May 25.

Dept. of Psychological Medicine, Section of Eating Disorders, King's College London's Institute of Psychiatry, Psychology and Neuroscience, UK; fDepartment of General Psychology, University of Padova, Italy. Electronic address:

Background: Although the primary target of treatment for anorexia nervosa (AN) is weight gain, established psychological interventions focus on maintaining factors of AN, and do not specifically address eating behaviours. We have previously reported results of a case series investigating in-vivo food exposure in AN, demonstrating the feasibility and acceptability of this treatment together with evidence of significant clinical change (Cardi, Leppanen, Mataix-Cols, Campbell, & Treasure, 2019). The current study examined the neural circuitry of food-related anxiety.

Methods: We examined neural reactivity (fMRI) to food images pre- and post-food exposure therapy (n=16), and compared it to a group of healthy control participants (HC n=21) who were scanned on two occasions.

Results: Prior to treatment, the AN group (compared to HC) showed less reactivity in the anterior cingulate cortex (ACC). Following exposure treatment, patients (compared to HC), show increased activity in the dorsolateral prefrontal cortex, decreased activity in the superior parietal lobe and no differences in the ACC. The level of activation of the insula (pre-treatment) predicted the degree of post-treatment reduction in self-reported food anxiety in AN. Changes in food-related anxiety were also associated with changes in neural activation in a cluster located in the middle temporal gyrus/lateral parietal cortex.

Limitations: The primary limitations of this work are the small sample size and lack of patient comparison group.

Conclusions: Exposure to food in AN may be associated with changes in neural circuitries implicated in emotion regulation and attentional processes. However, these findings need replication in larger and controlled studies.
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http://dx.doi.org/10.1016/j.jad.2020.05.077DOI Listing
September 2020

Exploring the ways in which COVID-19 and lockdown has affected the lives of adult patients with anorexia nervosa and their carers.

Eur Eat Disord Rev 2020 11 9;28(6):826-835. Epub 2020 Jul 9.

Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, Section of Eating Disorders, King's College London, London, UK.

Objective: This qualitative study explores the ways in which the coronavirus disease 2019 (COVID-19) pandemic and associated lockdown measures have affected the lives of adult patients with anorexia nervosa (AN) and their carers.

Method: Semi-structured interviews were conducted with patients with AN (n = 21) and carers (n = 28) from the start of UK Government imposed lockdown. Data related directly to the impact of lockdown and COVID-19 were analysed using thematic analysis.

Results: Four broad themes were identified for patients and carers separately. Patients experienced: 1. reduced access to eating disorder (ED) services; 2. disruption to routine and activities in the community; 3. heightened psychological distress and ED symptoms; 4. increased attempts at self-management in recovery. Carer themes included: 1. concern over provision of professional support for patients; 2. increased practical demands placed on carers in lockdown; 3. managing new challenges around patient wellbeing; 4. new opportunities.

Conclusions: Reduced access to ED services, loss of routine and heightened anxieties and ED symptoms resulting from COVID-19 and lockdown measures presented challenges for patients and carers. Increased remote support by ED services enabled the continuation of treatment and self-management resources and strategies promoted self-efficacy in both groups.
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http://dx.doi.org/10.1002/erv.2762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362064PMC
November 2020

Exploring Changes in Event-Related Potentials After a Feasibility Trial of Inhibitory Training for Bulimia Nervosa and Binge Eating Disorder.

Front Psychol 2020 27;11:1056. Epub 2020 May 27.

Department of Psychology, Centre for Cognitive Neuroscience, Paris-Lodron-University of Salzburg, Salzburg, Austria.

In a feasibility trial comparing two forms of combined inhibitory control training and goal planning (i.e., food-specific and general) among patients with bulimia nervosa (BN) and binge eating disorder (BED), we found evidence of symptomatic benefit, with stronger effects among participants receiving a food-specific intervention. The aim of the present study was to examine changes in behavioral outcomes and event-related potentials (ERPs; N2 and P3 amplitudes) from baseline to post-intervention that might suggest the mechanisms underpinning these effects. Fifty-five participants completed go/no-go tasks during two electroencephalography (EEG) sessions, at baseline and post-intervention. The go/no-go task included "go" cues to low energy-dense foods and non-foods, and "no-go" cues to high energy-dense foods and non-foods. Datasets with poor signal quality and/or outliers were excluded, leaving 48 participants ( = 24 BN; = 24 BED) in the analyses. Participants allocated to the food-specific, compared to the general intervention group, showed significantly greater reductions in reaction time to low energy-dense foods, compared to non-foods, by post-intervention. Commission errors significantly increased from baseline to post-intervention, regardless of stimulus type (food vs. non-food) and intervention group (food-specific vs. general). There were no significant changes in omission errors. P3 amplitudes to "no-go" cues marginally, but non-significantly, decreased by post-intervention, but there was no significant interaction with stimulus type (high energy-dense food vs. non-food) or intervention group (food-specific vs. general). There were no significant changes in N2 amplitudes to "no-go" cues, N2 amplitudes to "go" cues, or P3 amplitudes to "go" cues from baseline to post-intervention. Training effects were only marginally captured by these event-related potentials. We discuss limitations to the task paradigm, including its two-choice nature, ease of completion, and validity, and give recommendations for future research exploring ERPs using inhibitory control paradigms.
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http://dx.doi.org/10.3389/fpsyg.2020.01056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269126PMC
May 2020

The Feasibility of Using Guided Self-Help in Anorexia Nervosa: An Analysis of Drop-Out From the Study Protocol and Intervention Adherence.

Front Psychol 2020 16;11:707. Epub 2020 Apr 16.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.

The implementation of online technologies to promote wellbeing is increasingly becoming a worldwide priority. This study includes secondary analyses of data and examined drop-out rates in an online guided self-help intervention for patients with anorexia nervosa. Specifically, rates of drop-out at end of treatment (i.e., 6 weeks assessment), as well as intervention adherence (minimum of four of six online guided sessions) and differences between completers and drop-outs were examined. Motivation to change and associated patient variables were assessed as predictors of drop-out using structural equation modeling. Ninety-nine patients were randomized to the intervention arm of the trial. Data were available for 82 individuals, 67 of whom completed the 6 weeks assessment and attended a minimum of four online sessions. No significant differences were found between completers and drop-outs at baseline. At the end of the first week of participation, drop-outs from the 6 weeks assessment or the intervention reported less satisfaction with their work with the mentor delivering online guidance. Greater confidence in own ability to change and higher controlled motivation (willingness to change due to pressure from others) predicted lower drop-out rates from the 6 weeks assessment. Stronger alliance with the therapist at the treatment center and lower psychological distress were associated with greater autonomous motivation (self-directed motivation) and importance and ability to change. Data demonstrate that a novel online guided self-help intervention for patients with anorexia nervosa is feasible. Early satisfaction with the program and external pressure to change have a protective role against drop-out rates. www.ClinicalTrials.gov, identifier NCT02336841.
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http://dx.doi.org/10.3389/fpsyg.2020.00707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178255PMC
April 2020

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness.

J Clin Med 2020 Feb 27;9(3). Epub 2020 Feb 27.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, SE5 8AF London, UK.

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.
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http://dx.doi.org/10.3390/jcm9030630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141127PMC
February 2020

A multicenter audit of outpatient care for adult anorexia nervosa: Symptom trajectory, service use, and evidence in support of "early stage" versus "severe and enduring" classification.

Int J Eat Disord 2020 08 17;53(8):1337-1348. Epub 2020 Feb 17.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: We explored the utility of "staging" anorexia nervosa (AN) by duration of illness and psychological wellbeing. We also investigated 12-month symptom trajectories and service usage in a large cohort of patients with AN assessed for outpatient treatment.

Method: We conducted secondary analyses on data from a multisite clinical trial of adults with AN (n = 187) recruited from 22 NHS England specialist eating disorder (ED) services into a digital treatment augmentation study. Clinical outcomes and service use were measured at postintervention (six weeks), 6 and 12 months. We grouped patients into two categories: "early stage" (illness duration <3 years; n = 60) and "severe and enduring" stage (SE-AN; n = 41) indicated by distress (Depression Anxiety and Stress Scales, DASS ≥60) and illness duration (≥7 years).

Results: At 12 months, patients reported large improvements in body mass index, small to moderate improvements in ED symptoms, mood, and work/social adjustment, and 23.6% met criteria for recovery. However, patients classified as SE-AN reported higher rates of accessing intensive services, higher ED symptomatology, and poorer work/social adjustment at baseline, and lower rates of improvement in work/social adjustment at 12 months compared to "early stage" respondents.

Discussion: Although present findings suggest overall symptomatic improvements, exploratory results highlight marked differences in course and service use between people at different stages of AN, suggesting a need to consider staging for clinical decision-making. Further research differentiating between clinical subtypes of AN and adoption of a more personalized approach may ensure that services and care pathways better fit patient needs.
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http://dx.doi.org/10.1002/eat.23246DOI Listing
August 2020

A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa.

Psychol Med 2020 11 16;50(15):2610-2621. Epub 2019 Oct 16.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa.

Methods: Participants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months.

Results: Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks.

Conclusions: Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.
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http://dx.doi.org/10.1017/S0033291719002824DOI Listing
November 2020

Basal ganglia volume and shape in anorexia nervosa.

Appetite 2020 01 2;144:104480. Epub 2019 Oct 2.

Kings' College London, Institute of Psychiatry, Psychology, and Neuroscience, Psychological Medicine, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom; Illia State University, Department of Psychology, Tbilisi, Georgia.

Background: Reward-centred models have proposed that anomalies in the basal ganglia circuitry that underlies reward learning and habit formation perpetuate anorexia nervosa (AN). The present study aimed to investigate the volume and shape of key basal ganglia regions, including the bilateral caudate, putamen, nucleus accumbens (NAcc), and globus pallidus in AN.

Methods: The present study combined data from two existing studies resulting in a sample size of 46 women with AN and 56 age-matched healthy comparison (HC) women. Group differences in volume and shape of the regions of interest were examined. Within the AN group, the impact of eating disorder characteristics on volume and shape of the basal ganglia regions were also explored.

Results: The shape analyses revealed inward deformations in the left caudate, right NAcc, and bilateral ventral and internus globus pallidus, and outward deformations in the right middle and posterior globus pallidus in the AN group.

Conclusions: The present findings appear to fit with the theoretical models suggesting that there are alterations in the basal ganglia regions associated with habit formation and reward processing in AN. Further investigation of structural and functional connectivity of these regions in AN as well as their role in recovery would be of interest.
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http://dx.doi.org/10.1016/j.appet.2019.104480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6891247PMC
January 2020

Interpersonal difficulties in obesity: A systematic review and meta-analysis to inform a rejection sensitivity-based model.

Neurosci Biobehav Rev 2019 12 1;107:846-861. Epub 2019 Oct 1.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. Electronic address:

Obesity is associated with difficulties due to stigma and loneliness. These impact negatively on individuals' quality of life and behaviour change efforts. Increased sensitivity to others' negative feedback might play a role in the maintenance of these difficulties and could be addressed in psychological interventions. We conducted a systematic review of interpersonal difficulties in individuals with obesity, across the lifespan. We investigated early interpersonal adversity (i.e. frequency of teasing/bullying), perceived interpersonal stress and quality of social life, based on a rejection sensitivity model. The databases PubMed, Web of Knowledge and AGRIS, Embase, Medline and PsychINFO were searched for published peer-reviewed journal articles (1980-June 2018). Thirty-two studies met inclusion criteria. Results from the meta-analyses (n = 16 studies) indicated that overweight/obese individuals reported more frequent experiences of teasing/bullying, greater interpersonal stress and poorer quality of social life than healthy weight individuals. Findings in the systematic review aligned to this evidence. Psychological interventions targeting increased sensitivity to negative interpersonal feedback could improve interpersonal functioning and, in turn, eating behaviours in individuals with obesity.
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http://dx.doi.org/10.1016/j.neubiorev.2019.09.039DOI Listing
December 2019

Neural responses to food stimuli among individuals with eating and weight disorders: a systematic review of event-related potentials.

Int Rev Psychiatry 2019 06 27;31(4):318-331. Epub 2019 Jun 27.

f Social, Genetic, and Developmental Psychiatry Centre (SGDP) , King's College London , London , UK.

A systematic review was conducted to investigate event-related potentials (ERPs) in response to food and non-food stimuli among individuals with eating and weight disorders. Limiting the search to studies that have analysed ERPs relating to motivated attention and inhibitory control, 19 research papers were extracted from a systematic search in PubMed, Ovid, and Web of Science (2000-2018). An enhanced attentional bias towards food over non-food images (as indexed by P3(00) and LPP amplitudes) was evident for all populations. Individuals with binge eating disorder showed an enhanced attentional response to food cues compared to healthy controls. Inhibitory control-related ERP components (N2(00) and P3a) increased during food-specific no-go trials, but did not differentiate overweight from 'healthy' weight groups. The N2 amplitude to food pictures were positively correlated with caloric intake and food craving among individuals with obesity and binge eating disorder, respectively, while P3(00) was sensitive to hunger levels among overweight and obese females. The heterogeneity of stimuli/paradigms adopted, component timescales extracted, ERPs analysed, and data presented has challenged this review's ability to produce a robust synthesis of results. Some recommendations for future research are discussed.
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http://dx.doi.org/10.1080/09540261.2019.1622515DOI Listing
June 2019

Cortical morphometry in anorexia nervosa: An out-of-sample replication study.

Eur Eat Disord Rev 2019 09 6;27(5):507-520. Epub 2019 Jun 6.

Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, King's College London, London, UK.

Background: Acute anorexia nervosa (AN) is frequently accompanied by reduced global cortical volume. Investigations of local cortical alterations in AN have revealed widespread reduction in cortical thickness, gyrification, and curvature. The aim of the present study was to combine data from two previous studies to replicate previous findings.

Methodology: Magnetic resonance imaging (MRI) images from 46 adult women with AN and 54 age-matched healthy comparison (HC) women were analysed using FreeSurfer. Group differences in cortical volume and local cortical measures, including gyrification, curvature, thickness, and area, were examined controlling for dataset and age.

Results: The AN group had reduced global cortical volume relative to the HC group. The AN group also had reduction in local cortical gyrification, small localised clusters of reduced cortical thickness, in the occipital and parietal cortices, and surface area in the frontal and temporal cortices. The AN group also had increased cortical thickness in the ACC relative to the HC participants.

Conclusions: The present findings replicate and validate previous findings of reduced global cortical volume and local gyrification in acute AN. The findings highlight the need for further investigation of local cortical folding, thickness, and surface area in AN to gain further insight into the biological underpinnings of AN.
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http://dx.doi.org/10.1002/erv.2686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698193PMC
September 2019

A systematic review of the 'eating disorder voice' experience.

Int Rev Psychiatry 2019 06 29;31(4):347-366. Epub 2019 Apr 29.

a Section of Eating Disorders, Institute of Psychiatry, Psychology and Neuroscience , King's College London , London , UK.

The 'eating disorder voice' experience has been reported by both clinicians and by patients with eating disorders (ED) as an important feature of eating psychopathology, however this has only become an area of research in the last decade. The main aim of this paper was to systematically review and synthesize the available literature on this topic. Systematic searches of seven electronic databases were performed up to June 2018. Thirteen peer-reviewed articles were identified. Findings suggested that the existence of an 'ED voice' is often recognized by patients with eating disorders and that this voice has a powerful, negative and omnipotent nature. Feelings of entrapment and defeat are commonly experienced in response to it and patients appear ambivalent towards it. The negative characteristics and responses to the voice are associated with eating disorder symptoms. Addressing the eating disorder voice using relational and interpersonal approaches has the potential to improve clinical and treatment outcomes for patients with eating disorders.
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http://dx.doi.org/10.1080/09540261.2019.1593112DOI Listing
June 2019

Task-sharing interventions for patients with anorexia nervosa or their carers: a systematic evaluation of the literature and meta-analysis of outcomes.

Int Rev Psychiatry 2019 06 5;31(4):367-381. Epub 2019 Apr 5.

a Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience , King's College London , London , UK.

The eating disorder clinical and scientific community advocates for the use of a shared approach to healthcare that actively involves patients and carers. A systematic review of the literature on guided self-help or self-help in anorexia nervosa (targeting either the individual affected by the illness or their carers) and meta-analyses of studies using randomised controlled designs for the evaluation of the outcomes: (1) drop-out from end-of-treatment assessment, (2) body mass index (BMI), (3) anxiety, (4) depression and (5) quality of life, were undertaken. Guided self-help was directed to patients in 15 studies and to carers in seven studies. The interventions were based on a variety of theoretical models, used different formats (books and digital materials), and were delivered by individuals with a range of experiences and expertise (e.g. individuals with lived experience of the illness, graduate students, or clinically trained professionals). Guided self-help was associated with significantly lower drop-out from the completion of end-of-treatment assessments compared to a control condition. There was an improvement in carers' wellbeing from skill-sharing interventions. Guided self-help may facilitate patients' treatment engagement and also improve carers' wellbeing.
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http://dx.doi.org/10.1080/09540261.2019.1588711DOI Listing
June 2019
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