1. health and fitness
2. disorders

Oral Scientific Paper Session I
Friday, April 24, 2015
2:15 – 3:45 p.m.
BED & Obesity
Chairs: Marci Gluck PhD & Katharine Loeb PhD
Effects of Experiencing Versus Internalizing Weight Bias: An Experimental Study
Rebecca Pearl, MS, MPhil, Yale University, New Haven, Connecticut, USA; Rebecca Puhl , PhD, Rudd Center for Food
Policy and Obesity, Hartford, Connecticut, USA; John Dovidio, PhD, Yale University, New Haven, Connecticut, USA
This study aimed to determine and compare the causal effects of weight bias experiences (unfair treatment due to
overweight) versus internalization (negative self-evaluation due to overweight) on psychological well-being. Data were
collected online from 276 men and women with overweight and obesity living in the US: 84% White, Non-Hispanic, NonLatino; 50.4% female; Mage = 35 years; MBMI = 33.42 kg/m2. Participants were randomly assigned to one of two conditions
in which they were either primed to think about a time in which they were treated unfairly due to weight (“Experience”
condition) or a time in which they felt self-blame and worthlessness due to weight (“Internalization” condition).
Participants completed the Weight Bias Internalization Scale (WBIS), Positive and Negative Affect Schedule (PANAS),
Rosenberg Self-Esteem Scale (RSES), and items about their weight status and past experiences with weight bias. Analyses
of variance revealed that participants in the Internalization condition scored significantly higher on the WBIS than
participants in the Experience condition (p = .031). The Internalization condition also led to significantly higher reports of
negative affect (p = .014) and lower reports of positive affect (p = .028) on the PANAS. Finally, participants in the
Internalization condition scored lower on the RSES than participants in the Experience condition when controlling for
past experiences with weight bias (p = .037). These findings suggest that weight bias internalization may lead to worse
psychological well-being than weight bias experiences alone, and carry implications for targeting internalized weightbased stereotypes and beliefs among individuals with overweight and obesity in treatment settings.
Learning Objectives:
• Describe weight bias and the distinction between experiences and internalization.
• Understand the effects of weight bias experiences and internalization on psychological well-being among
individuals with overweight and obesity.
• Identify targets for intervention to buffer against negative effects of weight bias.
Prevention of Late Adolescent Obesity in the College Environment: An Optimal Default Paradigm
Katharine L. Loeb, PhD, Fairleigh Dickinson University, Teaneck, New Jersey, USA; Cynthia Radnitz, PhD, Fairleigh
Dickinson University, Teaneck, New Jersey, USA; Kathleen Keller, PhD, Penn State University, University Park,
Pennsylvania, USA; Marlene Schwartz, PhD, Yale University, New Haven, Connecticut, USA; Kerri Boutelle, PhD,
University of California, San Diego, La Jolla, California, USA; SueMarcus, PhD, Columbia University, New York, New
York, USA
This project applies behavioral economics to optimize late adolescents’ food choices in the college dining environment.
Specifically, this project tests an optimal defaults paradigm, capitalizing on the robust tendency of individuals to stay with
an existing, pre-selected, or easier choice (i.e., the default) rather than seeking out an available alternative. We examine
whether strategically manipulating the default option can be co-opted in the prevention of weight gain during the high risk
period of transition to college. The paradigm has yielded powerful effects in other areas of public policy (e.g., organ
donation), as well as in four proof-of-concept studies conducted previously by these investigators with federally- and
internally-funded grants. The current USDA/NIFA-funded study was a randomized pilot experiment comparing optimal
vs. suboptimal (standard) default vs. free array lunch selections for first-year college students. In both default conditions,
access to the alternative menu items was available but required a 15-minute wait. We hypothesized that the optimal
default meal will yield reduced caloric intake and increased fruit and vegetable consumption relative to the other
conditions. To date, approximately 30% of the expected sample of 135 college students has been recruited. Of those
students randomized to receive the nutritionally optimized default lunch array, 100% remained with these options despite
having access to the alternative menu choices; the same was true for the suboptimal default condition, where 100% of the
menu items selected were from the default array. The free array condition yielded a healthier item selection of 63%. Thus,
the mere positioning of choices, without restricting options, significantly affected which menu items the college students
selected. Planned analyses will compare conditions on caloric intake and produce servings, per primary hypotheses. This
is the first controlled study to test an obesity-related optimal default paradigm in first-year college students, a group at
high risk for weight gain. Results will inform policy regarding selection procedures in college dining programs and will be
discussed in the context of eating disorder prevention.
Learning Objectives:
•
•
•
Discuss the concept of optimal defaults in behavioral economics.
Apply optimal defaults as a theoretical framework to late adolescent obesity prevention.
Describe the results of a college-based experiment testing optimal defaults as a strategy to improve selection
procedures in the dining environment and increase the likelihood of choosing more health-promoting options.
An Examination of Neuropsychological Predictors of Response to Treatment for Binge Eating Disorder
Stephanie Manasse, BA, Drexel University, Philadelphia, Pennsylvania, USA; Adrienne Juarascio, PhD, Drexel
University, Philadelphia, Pennsylvania, USA; Leah Schumacher, BA, Drexel University, Philadelphia, Pennsylvania,
USA; Hallie Espel, BS, Drexel University, Philadelphia, Pennsylvania, USA; Evan Forman, PhD, Drexel University,
Philadelphia, Pennsylvania, USA
Identification of neuropsychological predictors of treatment outcome may provide direction for enhancing current
interventions; thus, the current study sought to examine neuropsychological predictors of treatment outcome for binge
eating disorder (BED). The Eating Disorders Examination (EDE) and a neuropsychological battery were administered to
women (18-60 years) with BED prior to entry in a 10-week acceptance-based group behavioral intervention. The battery
included the Tower Task (a measure of problem solving) the Color-Word Interference Task (a Stroop task which measures
self-regulatory control), a monetary delayed discounting task, and the Balloon Analogue Risk Task (BART; a measure of
risk-taking). Data collection for the current study is ongoing (n=12, projected n=20); thus, relations were examined using
effect sizes. After controlling for age, IQ, and objective binge episodes (OBEs) at baseline, move accuracy on the Tower
Task (ηp2 =.15), inhibition errors on the Color-Word Interference Task (ηp2 =.15), and average adjusted pumps on the
BART (ηp2=.10) strongly predicted OBEs at post-treatment, such that poorer performance on neuropsychological tasks
was associated with reduced improvements in binge eating. Additionally, less monetary discounting (ηp2=.35), more
efficient problem-solving (ηp2=.35), and better inhibitory control (ηp2=.31) were strongly associated with greater pre- to
post-treatment reductions in eating disorder pathology as measured by the EDE Global Score. Results indicate that
neuropsychological performance may be a viable predictor of treatment outcome. Specifically, poor self-regulatory
control, inefficient problem-solving, and increased risk-taking could lead to challenges with adherence to the behavioral
recommendations of treatment (e.g., self-monitoring, normalization of eating). With replication, future research should
focus on developing treatment components to target neuropsychological weaknesses.
Learning Objectives:
• Describe the relation of neuropsychological performance to treatment outcome for BED
• Identify specific tenants of executive function related to decreased treatment outcome
• Summarize potential treatment implications of executive function as a predictor of treatment outcome
The Interaction of Urgency and Mood on Eating Behavior in the Lab
Lauren Breithaupt, BA, George Mason University, Fairfax, Virginia, USA; Joseph Wonderlich, BA, George Mason
University, Fairfax, Virginia, USA; Catherine Byrne, BA, George Mason University, Fairfax, Virginia, USA; Sarah
Fischer, PhD, George Mason University, Fairfax, Virginia, USA
Urgency, the tendency to act impulsively while distressed, is positively associated with binge eating. Although this
relationship has been demonstrated in self-report studies, there is very little data on how urgency influences eating
behavior in the lab. Thus, this study aimed to test the hypothesis that urgency moderates the effect of negative affect on
impulsive food consumption in the lab. 118 participants were randomly assigned to a mood induction; positive, negative or
neutral, and deceived as to the true reason for the study. Participants completed self-report measures of disordered eating
and personality, a mood induction, and a computer task. They were then were left alone with a bowl of candy, and invited
to take some. Valence decreased after the negative mood induction (t = 4.22, p<.001) and increased after the positive
mood induction. Approximately 67% of the sample took between 1-16 pieces of candy. Hypotheses were tested using zero
inflated poisson regression, as the outcome variable was a count variable with a large number of zeros (pieces of candy
consumed). Predictors included sex, eating disorder symptoms, negative urgency, mood condition, and the interaction of
urgency with condition. In the poisson portion of the model, gender, condition, and the interaction were all significant
predictors of the number of pieces of candy consumed. However, the interaction was in the opposite direction than
expected. Individuals with high levels of urgency in the positive affect condition ate the most candy. Results suggest that
negative affect may not be as strong a predictor for binge eating as previously considered. Future research may want to
further explore the relationship between positive affect and urgency, as this could provide important implications in the
treatment of binge eating.
Learning Objectives:
• Following the training, participants will be able to thoroughly understand the concepts of urgency and impulsivity.
• Following the training, participants will be able to understand the influence of affect (positive and negative) on
impulsive food consumption.
•
Following the training, participants will have a greater understanding of whether or not reported levels of urgency
have an effect on the relation between affect and impulsive food consumption.
Changes Over Six Months in Food Palatability and Appetite in Roux-En-Y Gastric Bypass (RYGB),
Vertical Sleeve Gastrectomy (VSG) and Control (C) Participants
Kelly Allison, PhD, FAED, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Lucy Faulconbridge, PhD,
University of Pennsylvania, Philadelphia, Pennsylvania, USA; Louise Hesson, MS, University of Pennsylvania,
Philadelphia, Pennsylvania, USA; Alyssa Minnick, MS, University of Pennsylvania, Philadelphia, Pennsylvania, USA;
Scott Ritter, BA, University of Pennsylvania, Philadelphia, Pennsylvania, USA; David Sarwer, PhD, University of
Pennsylvania, Philadelphia, Pennsylvania, USA; Kosha Ruparel, MS, University of Pennsylvania, Philadelphia,
Pennsylvania, USA; Ryan Hopson, MS, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Allan Geliebter,
PhD, Columbia University, New York, New York, USA; Ruben Gur, PhD, University of Pennsylvania, Philadelphia,
Pennsylvania, USA; Thomas Wadden, PhD, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Changes in appetite after bariatric surgery likely play a role in weight loss. Controlled comparisons of these changes have
not been reported. This 6-month observational study compared changes in appetite and responses to food cues in women
seeking RYGB, VSG, or weight stability (ie, BMI-matched controls). Participants completed the Eating Inventory
(cognitive restraint, disinhibition, and hunger) at baseline and 6 months. They used visual analog scales (VAS) to rate
their liking (1=not at all, 11=very much) of high- and low-palatability foods presented visually during an fMRI task. Fiftynine women (RYGB=22, SG=18, C=19) with a mean (+SD) BMI of 44.0+4.3 kg/m2 and age of 36.9+8.8yr (59% black, 39%
white) participated. Mean weight changes at month 6 in RYGB, VSG and C were -27.7, -25.0, and 1.3 kg, respectively (both
ps <0.001 for C vs RYGB and VSG). Cognitive restraint increased more in RYGB (2.8+5.0) and VSG (3.6+1.4) than C (0.6+2.0; both ps < 0.03). Disinhibition decreased more in RYGB (-4.8+4.0) and VSG (-3.3+4.0) than C (0.5+3.6; both
ps<0.01), as did hunger, with changes in RYGB, VSG and C of -4.1+4.1, -3.9+3.6, and 1.1+3.3, respectively; both ps <
0.001. Changes in VAS ratings of low-palatability foods did not differ between groups (p=0.9). Liking of highly-palatable
foods declined more in RYGB (2.4+1.5) and VSG (1.9+1.7) than C (0.6+2.5; both ps < 0.05), with sweets declining
marginally more in RYGB than C (p =0.1). Greater reductions in BMI were significantly associated with greater increases
in restraint and greater decreases in disinhibition, hunger, and liking of highly palatable foods, including snack foods,
sweets, and high fat foods. In summary, RYGB and VSG, compared with no treatment among women with extreme
obesity, resulted in increased cognitive restraint and decreased disinhibition, hunger, and liking of highly palatable foods.
These changes were significantly associated with the clinically significant weight losses observed.
Learning Objectives:
• Understand how appetite changes with different forms of bariatric surgery as compared to no treatment.
• Understand how liking of highly palatable foods changes with bariatric surgery as compared to no treatment.
• Describe the relationship between weight change and changes in cognitive restraint, disinhibition, hunger, and
liking of highly palatable foods.
Using Dialectical Behaviour Therapy in the Treatment of Binge Eating Disorder: Is Dialectical Behaviour
Therapy as Effective as Cognitive Behaviour Therapy?
Mirjam Lammers, MSc, Amarum, specialist centre for eating disorders, Zutphen, Gelderland, Netherlands; Maartje
Vroling, PhD, MSc, Amarum, specialist centre for eating disorders & Radboud University Nijmegen, Zutphen,
Gelderland, Netherlands; Machteld Ouwens, PhD, MSc, GGZ Breburg, Tilburg, Noord-Brabant, Netherlands; Tatjana
van Strien, PhD, MSc, FAED, VU University Amsterdam & Radboud University Nijmegen, Amsterdam, Noord-Holland,
Netherlands
The purpose of the study is to test whether Dialectic Behaviour Therapy (DBT) is as effective as Cognitive Behaviour
Therapy (CBT) for treating binge eating disorder (BED). Dialectic Behaviour Therapy (DBT) was originally designed to
treat borderline personality disorder. Given the partial overlap in emotion regulation difficulties, DBT has also been
considered as a treatment for BED. Some evidence exists that DBT can indeed be considered an effective treatment for
BED. So far, DBT was found to be effective in an uncontrolled design and when compared to waitlist (Telch, Agras &
Linehan, 2000; 2001). In addition, DBT proved superior to an active control condition in attaining abstinence from
binges. However, at 12 months follow-up, this difference between treatments was no longer statistically significant (Safer,
Robinson & Jo, 2010). It was argued that the active control condition may have been effective in attaining treatment
effects as well (this effect is seen more often in studies comparing new treatments to active control conditions). DBT for
BED has never been directly compared to the current treatment of choice, CBT. Comparing DBT to CBT would prove the
ultimate test of effectiveness for DBT. We have set up a large study in which we compare DBT to our CBT treatment-asusual. Our study consists of two trials: a randomized controlled trial, and a quasi-experimental trial for those patients that
do not wish to be randomized. Although the trials are still ongoing, conclusions can already be drawn from our quasiexperimental trial (N = 100) We find that both CBT and DBT are effective in reducing BED pathology. On secondary
outcome measures (such as shape and weight concerns, or emotional eating), differences between the two treatments do
exist. In this presentation, we will present both the primary and secondary findings of our quasi-experimental trial, and
will take a brief look at the preliminary results of our RCT trial. We will discuss these results in terms of working
mechanisms of both treatments. Based on these findings, we will also look at the question what patients may benefit more
from what treatment.
Learning Objectives:
• After listening to the presentation, participants will know more about the effectiveness of DBT as a treatment for
BED.
• After listening to the presentation, participants can make informed decisions about what treatment (DBT or CBT)
to offer their BED patients.
• After listening to the presentation, participants know some more about the DBT treatment for BED.
Biology & Medical Complications
Chairs: Angela Guarda MD & Gabriella Heruc, BBSc, BSc(PsychHons), MNutrDiet
Examination of PYY Response in Purging Disorder, Bulimia Nervosa, and Healthy Controls: Novel Link
Between Physiology and Behavior
Pamela Keel, PhD, FAED, Florida State University, Tallahassee, Florida, USA; Britny Hildebrandt, MS, Michigan State
University, East Lansing, Michigan, USA; Alissa Haedt-Matt, PhD, Illinois Institute of Technology, Chicago, Illinois,
USA; Laurie McCormick, MD, University of Iowa, Iowa City, Iowa, USA; Jonathan Appelbaum, MD, Florida State
University, Tallahassee, Florida, USA; David Jimerson, MD, Beth Israel Deaconess Medical Center, Boston,
Massachusetts, USA
Lifetime prevalence estimates indicate that 1%-5% of women suffer from purging disorder (PD), a newly named syndrome
in the DSM-5 (APA, 2013), characterized by recurrent purging in the absence of binge-eating episodes. PD is associated
with impairment and suicidality (Stice et al., 2013), with more medically severe suicide attempts (Pisetsky et al., 2013) and
greater chronicity compared to anorexia nervosa, and higher mortality compared to bulimia nervosa (BN) (Koch et al.,
2013). These data underscore the clinical significance and distinctiveness of PD and the critical need to identify factors
that contribute to purging after normal or small amounts of food. The current study seeks a mechanism for our prior
finding of excessive post-prandial fullness in PD (Keel et al., 2007), focusing on the satiety gut peptide PYY. Normalweight women with PD (n=26), purging BN (n=28), and controls (n=28) provided subjective ratings and had blood drawn
before and after test meal consumption to measure responses to food intake. Women with PD demonstrated excessive PYY
responses compared to controls (p=.018) and women with BN (p=.003), and PYY responses predicted subjective fullness
(p<.001). Findings provide the first link between a physiological mechanism and purging, which may lead to novel
interventions for PD.
Learning Objectives:
• Describe the clinical presentation of purging disorder and distinguish this from other DSM-5 eating disorders.
• Describe the role of PYY in triggering feelings of satiety.
• Evaluate PYY response as a potential physiological mechanism to explain excessive fullness experienced by
individuals with purging disorder after normal or small amounts of food.
Attenuated Postprandial Blood Glucose Response and Delayed Gastric Emptying are Improved with
Refeeding in Anorexia Nervosa
Gabriella Heruc, RD, BSc, University of Adelaide, Adelaide, SA, Australia; Tanya Little, PhD, BSc, University of
Adelaide, Adelaide, SA, Australia; Michael Kohn, MBBS, The Children's Hospital at Westmead, Sydney, NSW, Australia;
Sloane Madden, MBBS, FAED, The Children's Hospital at Westmead, Sydney, NSW, Australia; Simon Clarke, MBBS,
Westmead Hospital, Sydney, NSW, Australia; Michael Horowitz, PhD, MBBS, University of Adelaide, Adelaide, SA,
Australia; Christine Feinle-Bisset, PhD, BSc, University of Adelaide, Adelaide, SA, Australia
The rate of gastric emptying (GE) is an important determinant of postprandial blood glucose (BG) concentrations, yet GE
is delayed in anorexia nervosa (AN). This study aimed to characterise GE and BG responses to a mixed-nutrient meal in
untreated AN on admission and following 1 and 2 weeks of refeeding, as well as to examine the relationship between GE
and BG responses. In 22 female adolescent AN inpatients and 17 age-matched healthy controls (HC), GE (13C-octanoate
breath test) of, and BG response to, an oral semi-solid test meal was evaluated over 120 min. Areas under the curve (0-120
min) were calculated, with data presented as mean±SE. Compared with HC, GE was markedly delayed in AN on
admission (AN: 192±21 vs. HC: 310±40%/hr, P<0.01), while faster (AN: 297±34, P=0.69) and no longer different from
HC after 2 weeks of refeeding. Although fasting BG concentrations did not differ between AN on admission and HC, they
did not rise postprandially in AN (AN: 635±14 vs HC: 803±29 mmol/L.min-1, P<0.01). Moreover, at 60 min
postprandially, BG concentration decreased below baseline in AN (P<0.01). After 2 weeks of refeeding, BG concentrations
increased postprandially in AN, yet the response remained significantly lower than in HC (AN: 713±18 mmol/L.min-1,
P<0.05). Furthermore, whilst there was a moderate correlation between GE and BG concentrations in HC (R2=0.643,
P<0.01), no correlation was found in AN. Overall, GE of, and BG response to, a mixed-nutrient meal were significantly
impaired in untreated AN relative to HC. The significant improvements in GE and BG seen after 2 weeks of refeeding
suggest that malnutrition significantly alters gastrointestinal responses to nutrients, with nutritional rehabilitation
potentially restoring gastrointestinal function and BG control. This study highlights the need for further research to
elucidate the mechanisms underlying altered postprandial BG responses in AN, and the importance of clinical monitoring
of BG during refeeding.
Learning Objectives:
• Predict the glycemic response to a meal in untreated anorexia nervosa.
• Recognize how postprandial blood glucose response and gastric emptying change with refeeding.
• Contrast the relationship between postprandial blood glucose response and gastric emptying in anorexia nervosa
with healthy controls.
The Gut-Brain Axis in Acute Anorexia Nervosa: Associations Between Intestinal Microbiota and
Psychopathology Measures
Susan Kleiman, BS, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Hunna Watson,
PhD, MPsych, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Emily Bulik-Sullivan,
Student, Kenyon College, Gambier, Ohio, USA; Ian Carroll, PhD, University of North Carolina at Chapel Hill, Chapel
Hill, North Carolina, USA; Eun Young Huh, MS, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina, USA; Lisa Tarantino, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA;
Cynthia Bulik, PhD, FAED, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
The intestinal microbiota modulates weight regulation and behavior, but its role in the emergence and maintenance of
anorexia nervosa (AN) remains unknown. Comorbid anxiety and depression are common in AN patients, and both have
been linked to intestinal dysbiosis. We hypothesized that specific taxa in the intestinal microbiota would be associated
with measures of psychopathology in AN patients. We characterized the composition and diversity of the intestinal
microbiota in AN patients upon admission to the UNC Center of Excellence for Eating Disorders for inpatient treatment
(n=16). The first stool sample after intake was collected. Within 48 hours of admission, participants completed the Beck
Depression Inventory, Beck Anxiety Inventory, and Eating Disorder Examination-Questionnaire. Genomic DNA was
isolated from stool samples, and bacterial composition was characterized by 454 pyrosequencing of the 16S rRNA gene.
Sequencing results were processed by the Quantitative Insights Into Microbial Ecology pipeline. Associations between
psychopathology measures and alpha and beta diversity and taxa abundance of bacterial groups were examined with the
tau-b correlation coefficient. Greater depression and anxiety were significantly associated with reduced abundance of
Lachnospira, Roseburia, and Ruminococcus species, which have been associated with IBS, IBD, and mouse models of
inflammation. Greater depression was also negatively associated with number of observed taxa and the Chao Diversity
index. Higher EDE-Q scores for Eating, Shape, and Weight Concerns were significantly associated with reduced
abundance of Anaerostipes and Faecalibacterium species. Results suggest that the acute phase of AN shares similarities
with the microbiotas of individuals with intestinal diseases that are marked by inflammation. Future directions include
mechanistic investigations of the gut-brain axis in animal models of AN and association of microbial measures with
recovery indices.
Learning Objectives:
• Describe the link between psychiatric disorders and intestinal dysbiosis.
• Understand the rationale and methodology for conducting microbiome research in eating disorder populations.
• Explain associations between composition/diversity of gut bacteria and psychopathology measures in patients
with anorexia nervosa.
Electrolyte Abnormalities in Adolescents with Anorexia Nervosa in the Ambulatory Setting
Jennifer Carlson, MD, Stanford University School of Medicine, Mountain View, California, USA; James Lock, MD, PhD,
FAED, Stanford University, Palo Alto, California, USA; Rebecka Peebles, MD, FAED, Children's Hospital of
Philadelphia, Philadelphia, Pennsylvania, USA; Debra Katzman, MD, FAED, Hospital for Sick Children, Toronto,
Ontario, Canada; W. Stewart Agras, MD, Stanford University, Palo Alto, California, USA
Serum electrolyte screening is common practice in the medical care of patients with anorexia nervosa (AN). However,
little data exists on the frequency of electrolyte abnormalities in an outpatient adolescent population with AN. This study
describes the frequency of electrolytes abnormalities and their association with hospital admission in an outpatient
population of adolescents with AN. Study design was comprised of a secondary data analysis collected for a multi-site
randomized clinical trial comparing therapy treatments for adolescents with AN. As part of the medical screening for
study participation, all adolescents had baseline and monthly electrolyte screening for the duration of the nine month
study. The results obtained from nine months of treatment were reviewed. A total of 584 tests were collected from 142
patients (129 female). Using potassium and phosphorus as the most clinically relevant electrolytes, levels were defined as
normal or abnormal based on the given laboratory range. Abnormal levels were further defined as being clinically
significant (e.g., an abnormal result which would prompt clinical intervention) or insignificant. Of all tests, 439 were
normal (75.2% of total tests). Of the 145 abnormal tests, only 9 samples were clinically significant (1.5% of total tests) and
4 of those were associated with a hospital admission (0.7% of total tests). Analyses of factors associated with those medical
admissions are pending. Our results indicate that electrolyte abnormalities for adolescents with AN in the outpatient
setting are relatively uncommon and rarely associated with a hospital admission. Given the financial and personal cost of
electrolyte monitoring and relatively low yield, further studies need to be done to determine the feasibility of routine
electrolyte screening in this population and to establish those outpatients who are most at risk for electrolyte
abnormalities.
Learning Objectives:
• Describe the frequency of electrolyte abnormalities in adolescent outpatients with anorexia nervosa.
• Discuss the association of abnormal electrolytes values with adverse outcomes in adolescent outpatients with
anorexia nervosa.
• Discuss the utility of electrolyte screening in adolescent outpatients with anorexia nervosa.
Predictors of Hypophosphatemia During Refeeding of Patients with Severe Anorexia Nervosa
Carrie Brown, MD, ACUTE Center for Eating Disorders at Denver Health, Denver, Colorado, USA; Allison Sabel, MD,
PhD, MPH, ACUTE Center for Eating Disorders at Denver Health, Denver, Colorado, USA; Jennifer Gaudiani, MD,
ACUTE Center for Eating Disorders at Denver Health, Denver, Colorado, USA; Philip Mehler, MD, FAED, ACUTE
Center for Eating Disorders at Denver Health, Denver, Colorado, USA
Hypophosphatemia of refeeding is one of the most dangerous complications seen during the treatment of patients with
anorexia nervosa. Although easily detectable and treatable, hypophosphatemia is still widely under-recognized as a
complication of refeeding. Furthermore, specific risk factors for hypophosphatemia are likely to also exist, specifically
within the anorexia nervosa population. We conducted a retrospective study of 136 patients admitted for medical
stabilization at the ACUTE Center for Eating Disorders between October 1, 2008 and December 31, 2013. Risk factors of
refeeding hypophosphatemia were determined from clinical parameters and laboratory values measured at the time of
admission. The prevalence of hypophosphatemia was 33.1% (45 of 136 patients). Hypoglycemia at the time of admission
was an excellent predictor of refeeding hypophosphatemia (p<0.001). Low body mass index, hypokalemia (p<0.01),
elevated AST, elevated hemoglobin, and low prealbumin (p<0.05) were also predictors. The development of refeeding
edema was more common among patients who developed refeeding hypophosphatemia (p=0.02). Binge-purge subtype
anorexia nervosa was also a significant risk factor for refeeding syndrome over restricting subtype anorexia nervosa
(p=0.03) Identification of findings which correlate with hypophosphatemia has the potential to help triage which patients
with anorexia nervosa are in need of inpatient treatment and close monitoring during refeeding. More data is needed in
order to create firm guidelines for identification and treatment of patients at risk for refeeding hypophosphatemia.
Learning Objectives:
• Recognize which laboratory abnormalities are useful for predicting refeeding hypophosphatemia.
• Identify which patients with anorexia nervosa are at highest risk for refeeding hypophosphatemia.
• Demonstrate awareness of the most dangerous medical complications of anorexia nervosa.
Intentional Insulin Omission for Weight Control among Individuals with Type I Diabetes
Rhonda Merwin, PhD, Duke University Medical Center, Durham, North Carolina, USA; Lisa Honeycutt, MA, Duke
University Medical Center, Durham, North Carolina, USA; Ashley Moskovich, PhD, Duke University Medical Center,
Durham, North Carolina, USA; Nancy Zucker, PhD, Duke University Medical Center, Durham, North Carolina, USA;
Natasha Dmitrieva, PhD, Duke University Medical Center, Durham, North Carolina, USA
Eating disorders (EDs) that co-occur with type 1 diabetes (T1D) are associated with early and severe diabetes-related
medical complications and premature death. Importantly, EDs in T1D not only include behaviors that typify EDs in the
general population (e.g., self-induced vomiting), but also the dangerous practice of withholding insulin for weight control.
There are no treatments that are effective for these patients. Although eating and weight attitudes change with treatment,
metabolic control does not improve, suggesting continued underdosing of insulin. One of the key barriers to effective
treatment has been a lack of systematic data on ED in T1D (which may be unique in some ways to other ED populations)
to inform treatment. Sixty-three T1D patients with ED symptoms and 20 T1D controls completed an assessment of
psychological and metabolic functioning, along with 3 days of momentary assessment of thoughts, feelings and behaviors.
Momentary data were collected at random prompts and during participant-initiated eating reports logged throughout the
day. Eating reports characterized the meal and included emotional experience and adequacy of insulin dosing. Clinical
participants evidenced higher and more variable blood glucose. They reported greater susceptibility to hunger which
corresponded to their frequency of binge eating and may be related to metabolic dysregulation. Similar to typical ED
populations, clinical T1D patients were higher on perfectionism and punishment sensitivity. These traits may make the
imprecision of T1D intolerable as well as contribute to greater distress regarding perceived failures in T1D management
and reliance on weight control as a measure of success. Heightened emotions such as guilt and disgust, but also feeling
upset about diabetes and not wanting to think about diabetes were momentary predictors of intentional insulin omission.
All p’s < .05. Findings have implications for the development of interventions for this patient population.
Learning Objectives:
• Describe the prevalence and impact of eating disorders in type 1 diabetes (T1D).
• Identify trait features associated with eating disorder symptom severity among T1D patients and how these
features might impact symptom development, maintenance or remission.
• Identify momentary antecedents to intentional insulin omission for weight control and implications for treatment.
Body Image
Chairs: Alissa Haedt-Matt, PhD & Thomas Hildebrandt, PsyD
“Will I Get Fat?” 22-Year Weight Trajectories of Individuals with Eating Disorders
Helen Murray, BA, Massachusetts General Hospital, Boston, Massachusetts, USA; Nassim Tabri, PhD, Massachusetts
General Hospital/Harvard Medical School, Boston, Massachusetts, USA; Jennifer Thomas, PhD, FAED, Massachusetts
General Hospital/Harvard Medical School, Boston, Massachusetts, USA; Debra Franko, PhD, FAED, Northeastern
University, Boston, Massachusetts, USA; Kamryn Eddy, PhD, FAED, Massachusetts General Hospital/Harvard Medical
School, Boston, Massachusetts, USA
Fat phobia or fear of uncontrollable weight gain is diagnostic of eating disorders and often challenges treatment
engagement. Prior research describes weight changes over time, but long-term weight outcomes, rates of change, and
predictors remain unknown. Our study examined 25-year longitudinal trajectories of body mass index (BMI) using latent
growth curve analysis (LGC) for women with anorexia nervosa (AN) or bulimia nervosa (BN). Women seeking treatment
for AN or BN self-reported height and weight annually over 10 years (N = 225) and again at 22 year follow-up (N = 176).
Using LGC, we examined (1) the shape and rate of intra-individual change in BMI over 10 years and (2) the relationship of
BMI change over 10-years with BMI 22 years later. Mean (SD) BMI at intake was 20.15 (3.87) kg/m2 (i.e., 36%
underweight, 53% normal weight, 8% overweight, and 3% obese). At 22-years, mean (SD) BMI across diagnosis was 21.84
(4.34) kg/m2 (i.e., 14% underweight, 69% normal weight, 13% overweight, and 4% obese). The best-fitting LGC model
captured overall intra-individual rates of BMI change in three time intervals, showing a moderate rate of increase in BMI
from intake to year 2 (d = .54, p < .01), modest rate of increase in BMI from years 2-5 (d = .30, p < .01), and a plateau from
years 5-10 (d = .03, z < 1). Moderate increases in BMI from intake to year 2 were associated with having an intake
diagnosis of AN-restricting type (β = .31, p < .01), or AN-binge eating/purging type (β = .29, p < .01), and a higher BMI at
22 years (β = .43, p < .01), with predicted values in the normal range (M = 22.22 kg/m2). Results emerged regardless of
participants’ recovery, pregnancy, or hospitalization status. Our findings demonstrate that for most individuals, the fear of
becoming “fat” is unfounded. BMI increases most rapidly during earlier stages of the eating disorder for those who require
weight restoration (i.e., AN) and plateaus over time, ultimately settling in the normal range. Learning Objectives:
• Describe the influence of fat phobia on patients’ perspectives of short-term and long-term consequences of
behavior change.
• Discuss longitudinal weight trajectories of individuals with eating disorders, from a 25-year standpoint.
• Discover how long-term data on weight changes can be used as a tool to facilitate treatment engagement with
eating disorder patients struggling with fat phobia or fear of weight gain.
Protective and Exacerbating Influences on Body Image Following Exposure to Thin-Ideal Media in
Adolescent Girls: The Role of Media Literacy and Appearance Comparison
Siân McLean, BSc, La Trobe University, Melbourne, Victoria, Australia; Susan Paxton, PhD, FAED, La Trobe
University, Melbourne, Victoria, Australia; Eleanor Wertheim, PhD, La Trobe University, Melbourne, Victoria,
Australia
It has been proposed that media literacy skills protect against the negative effect on body image of exposure to thin-ideal
media, while other processes, such as appearance comparison and the influence of peer appearance norms may exacerbate
the effect. However, little research exists that tests these propositions. Using an experimental design, this study aimed to
address this gap in the literature by a) examining the protective effects of media literacy, and b) comparing body
satisfaction outcomes following exposure to thin-ideal images in three conditions: 1) Control, 2) Appearance Comparison
(AC), and 3) Peer Appearance Norms (PN). Participants were 191 female grade 7 students (Mage= 13.0, SD = 0.4) who
completed baseline measures of media literacy, then viewed 10 idealized media images, before and after which state body
satisfaction was assessed. During media image exposure, participants responded to questions about the images which
focused on design features (control condition), comparison of oneself with the images (AC condition), or consideration of
peers’ appearance-based judgements of others (PN condition). As expected, there was a significant negative effect on body
satisfaction of image exposure and media literacy predicted change in body satisfaction. The AC group had significantly
lower post-exposure body satisfaction than both the control and PN groups, while the latter two groups were not
significantly different from one another. Furthermore, the extent to which participants reported comparing themselves
with the media images during exposure was positively related to change in body satisfaction. In contrast, peer norms
processing had no effect. This study is the first to demonstrate that pre-existing levels of media literacy protect against the
effects of media exposure on body image and extend the evidence that engaging in appearance comparison while viewing
images is a critical process in the manifestation of negative effects for body satisfaction.
Learning Objectives:
• Design an experimental study to examine effects of media exposure.
• Evaluate the influence of appearance comparison and peer appearance norms processing on the effect of media
exposure on body satisfaction.
• Recognise the implications for prevention.
Sociocultural Predictors of Increases in Body Dissatisfaction and Dietary Restriction at Eight and 14
Months in Early Adolescent Girls
Rachel Rodgers, PhD, Northeastern University, Boston, Massachusetts, USA; Siân McLean, MSc, La Trobe University,
Melbourne, Victoria, Australia; Candice Dunstan, PhD, La Trobe University, Melbourne, Victoria, Australia; Susan
Paxton, PhD, FAED, La Trobe University, Melbourne, Victoria, Australia
Although etiological sociocultural models predicting the development of body dissatisfaction and dietary restriction have
been proposed, few longitudinal tests of these models exist. In particular, studies that explore prospective relationships
between sociocultural pressures and body image and dietary restriction outcomes among early adolescent girls are
lacking. The aim of the present study was therefore to bridge this gap in the literature. A sample of 259 school girls with a
mean age of 12.76 years (SD = 0.44) completed self-report measures of sociocultural pressure, peer weight-related teasing,
fat talk, media-internalization, appearance comparison, body dissatisfaction, and dietary restriction at baseline, eight
months, and 14 months. As expected, sociocultural pressure, fat talk, media internalization, and appearance comparison
predicted increases in body dissatisfaction over time, although different patterns emerged at eight- and 14- months.
Similar findings appeared for increases in dietary restriction, with body dissatisfaction emerging as an additional
predictor. Our findings support the role of sociocultural variables in the development of body dissatisfaction and dietary
restraint in early female adolescents. This age group appear to constitute an important target for prevention programs
designed to decrease sociocultural risk factors, including appearance comparison. Sociocultural models provide a useful
framework for understanding the development of body image and dietary restraint, and should consider how relationships
between variables may vary over time.
Learning Objectives:
• To identify etiological pathways for eating disorders posited by sociocultural models.
• To describe the role of sociocultural risk factors in predicting body dissatisfaction and dietary restriction among
early adolescent girls.
• To discuss the time-varying nature of these relationships.
Media Exposure and Media Stress Contribute to Eating Pathology: Daily and Momentary Associations
Emily K White, MA, University of Nevada Las Vegas, Las Vegas, Nevada, USA; Cortney S Warren, PhD, University of
Nevada Las Vegas, Las Vegas, Nevada, USA; Li Cao, PhD, Neuropsychiatric Research Institute, Fargo, North Dakota,
USA; Ross D Crosby, PhD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Scott G Engel, PhD,
Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Stephen A Wonderlich, PhD, FAED, Neuropsychiatric
Research Institute, Fargo, North Dakota, USA; James E Mitchell, MD, FAED, Neuropsychiatric Research Institute,
Fargo, North Dakota, USA; Carol B Peterson, PhD, University of Minnesota, Minneapolis, Minnesota, USA; Scott J
Crow, PhD, University of Minnesota, Minneapolis, Minnesota, USA; Daniel Le Grange, PhD, FAED, University of
Chicago, Chicago, Illinois, USA
We examined whether exposure to media images and stress resulting from media exposure contributes to eating disorder
behaviors among women with anorexia nervosa (AN). 118 women with AN completed a two-week ecological momentary
assessment protocol during which they reported on media exposure, associated stress, and eating behaviors. Hierarchical
linear modeling was used to test for both daily and momentary-level associations of media exposure and stress with binge
eating, restrictive eating, purging, vomiting, exercise, laxative use, and restricted fluid intake. To examine daily-level
associations, we tested whether media stress predicted eating pathology on days with media exposure. To test for
momentary-level associations, we examined whether intensity of stress associated with media exposure prospectively
predicted eating pathology while controlling for eating pathology at the time of media exposure. On a daily level, media
exposure and stress increased the probability of a binge eating episode later that day. Results also supported momentary
associations for binge eating, purging, and vomiting. Higher media stress was associated with higher binge eating
frequency, higher purging frequency, and higher vomiting frequency (controlling for these behaviors at the time of media
exposure). Overall, these data suggest that media stress contributes to increased eating disorder behaviors in women with
AN. Specifically, those who see a media image and report this experience as stressful are more likely to engage in binge
eating, purging, or vomiting. Therapeutic strategies to reduce stress associated with viewing media images may have a
positive impact on reducing disordered eating behaviors.
Learning Objectives:
• Describe the basic methods of an ecological momentary assessment approach.
• Explain the association between media exposures, stress due to media exposure, and various forms of eating
pathology.
• Relate findings to the treatment of patients with AN (e.g., implement interventions to reduce stress associated
with viewing media images).
Body Dissatisfaction and Binge Eating,, Not Body Mass Index, Predict Poorer Quality Of Life
Kendrin Sonneville, ScD, RD, University of Michigan School of Public Health, Ann Arbor, Michigan, USA; Tracy K.
Richmond, MD, Boston Children's Hospital, Boston, Massachusetts, USA; Henry A. Feldman, PhD, Boston Children's
Hospital, Boston, Massachusetts, USA; Sarah D. de Ferranti, MD, Boston Children's Hospital, Boston, Massachusetts,
USA; Jennifer K.Cheng, MD, Boston Children's Hospital, Boston, Massachusetts, USA; Erinn T. Rhodes, MD, Boston
Children's Hospital, Boston, Massachusetts, USA; Nirav K. Desai, MD, Boston Children's Hospital, Boston,
Massachusetts, USA; Stavroula K. Osganian, MD, ScD, Boston Children's Hospital, Boston, Massachusetts, USA
The contribution of co-occurring disordered eating symptoms to the adverse consequences of obesity is often overlooked.
We sought to examine the independent association of body dissatisfaction and binge eating with quality of life (QOL), as
well as how these factors impact the association of body mass index (BMI) with QOL among overweight/obese youth. The
sample included 52 overweight/obese youth ages 13-26 (mean[SD]: 18.2[3.1] yr) enrolled in the POOL research registry at
Boston Children's Hospital. We used multiple linear regression adjusted for age, gender, race/ethnicity, and BMI to
examine the association between both body dissatisfaction and binge eating with the Pediatric Quality of Life Inventory
(PedsQL), including overall score and physical, emotional, social, school, and psychosocial functioning subscale scores.
Body dissatisfaction was computed by subtracting the participants’ desired body size from perceived body size using ageand gender-matched body silhouettes. Prevalent monthly binge eating was assessed using a single item that asked
participants to report the frequency of loss of control in eating. Higher BMI (p=0.03), greater body dissatisfaction
(p<0.01), and binge eating (p<0.01) were associated with lower QOL in unadjusted analyses. When BMI, body
dissatisfaction, and binge eating were modeled simultaneously, BMI was not associated with overall QOL or any of the
PedsQL subscales. Both body dissatisfaction (standardized coefficient: -0.39, p=0.02) and binge eating (standardized
coefficient: -0.46, p<0.01) but not BMI (standardized coefficient: 0.10, p=0.56), were associated with poorer school
functioning. Binge eating was also associated with lower physical (p=0.05), emotional (p=0.01), social (p=0.01), and
psychosocial (p<0.01) functioning and overall QOL (p<0.01) in mutually adjusted models. Co-occurring disordered eating
symptoms should be considered as an important independent explanation for the poorer quality of life seen among
overweight/obese youth.
Learning Objectives:
• Assess the association between BMI and quality of life among overweight and obese youth.
• Examine the association between body dissatisfaction and binge eating with quality of life, independent of BMI.
• Understand the association between body dissatisfaction and binge eating with Pediatric Quality of Life Inventory
subscales scores, independent of BMI.
Evaluating the Dove Self-Esteem Project Abridged Body Confidence Workshop for Secondary Schools:
Results from a School-based Cluster Randomised Controlled Trial
Melissa Atkinson, PhD, University of the West of England, Bristol, Avon, United Kingdom; Phillippa Diedrichs, PhD,
University of the West of England, Bristol, Avon, United Kingdom; Rebecca Steer, PhD, University of the West of
England, Bristol, Avon, United Kingdom; Kirsty Garbett, MSc, University of the West of England, Bristol, Avon, United
Kingdom; Emma Halliwell, PhD, University of the West of England, Bristol, Avon, United Kingdom; Nichola Rumsey,
PhD, University of the West of England, Bristol, Avon, United Kingdom
There is increasing demand from Governments and schools for brief workshops that can be delivered sustainably and
effectively by teachers in classroom settings to improve students’ body image. The aim of this study was to evaluate the
effectiveness and acceptability of a universal, evidence-informed 90-minute body image workshop for secondary school
adolescents aged 11-13 years (N=1707, 50.3% female). Six secondary schools in the UK were randomised to receive the
intervention teacher-led (TL; n=427) or researcher-led (RL: n=729), or lessons as usual (control; n=551). Standardised
self-report measures of body esteem and additional risk factors for body dissatisfaction and disordered eating were
completed at baseline, immediate post-intervention and approximately 8-weeks follow-up. Linear mixed model analyses,
controlling for baseline, demonstrated that girls participating in the intervention reported immediate improvements
relative to control in body esteem (TL: d = .24), as well as reductions in internalization (TL: d = .22), negative affect (TL: d
= .26; RL: d = .22), dietary restraint (TL: d = .24), disordered eating behaviours (RL: d = .27), and appearance-related
social impairment (TL: d = .31; RL: d = .44), with the effect for disordered eating behaviours maintained at follow-up. For
boys, the only difference superior to control was a reduction in appearance-related social impairment (TL: d = .41; RL: d =
.62), not maintained at follow-up. Overall, good acceptability was reported by students and teachers. The short-term
nature of these improvements suggests that a multi-session intervention is necessary for sustained impact. Nevertheless,
these findings demonstrate immediate benefits for young girls in participating in a brief body image workshop, and
indicate that secondary school teachers can effectively deliver the Dove Self Esteem Project Abridged Body Confidence
Workshop.
Learning Objectives:
• Assess the effectiveness of a classroom-based single-session body image intervention for young adolescents in
secondary schools.
• Describe gender differences with respect to classroom-based body image interventions in a universal sample.
• Identify the advantages and disadvantages of a single-session format for body image interventions.
Child & Adolescent Treatment: Caregivers & Families
Chairs: Susan Ringwood & Therese Waterhouse PhD, RD
Early Predictors of Outcome in Family-Based Treatment for Adolescent Anorexia Nervosa in Partial
Hospital Programs
Stuart Murray, PhD, DClinPsy, University of California, San Diego, San Diego, California, USA; Anne Cusack, PsyD,
University of California, San Diego, San Diego, California, USA; Scott Griffiths, PhD, University of Sydney, Sydney,
NSW, Australia; Tiffany Nakamura, MA, University of California, San Diego, San Diego, California, USA; Ana
Ramirez, PhD, University of California, San Diego, San Diego, California, USA; Tori Shen, BS, University of California,
San Diego, San Diego, California, USA; Roxanne Rockwell, PhD, University of California, San Diego, San Diego,
California, USA; Leslie Anderson, PhD, University of California, San Diego, San Diego, California, USA; Walter Kaye,
MD, University of California, San Diego, San Diego, California, USA
Increasing evidence suggests that weight-based indices of progress after 4 weeks of family-based treatment (FBT) for
adolescent anorexia nervosa (AN) may reliably predict overall outcome, which affords a valuable intersection at which
augmentative measures may be considered for those in whom treatment non-response is likely. However, little research
has examined the impact of early treatment mechanisms in FBT in more intensive levels of patient care. As such, we aimed
to investigate (i) the efficacy of FBT in partial hospital settings, and (ii) whether the trajectory of weight gain during the
early stage of FBT shares the same predictive value in more intensive levels of patient care. Preliminary analyses were
undertaken on a group of 28 female adolescents (mean age=14.75 years; SD=1.75 years) undergoing partial hospitalization
treatment for AN for a mean of 101 days (range=54-165 days). Results suggest that FBT is efficacious in partial hospital
settings, with both body weight, t(27) = 9.60, p < .001, and the psychological symptoms of AN (as indexed by the EDE-Q),
t(27) = -4.71, p . < .001, improving significantly throughout treatment. More specifically, greater weight gain in the first 4
weeks of FBT was significantly associated with greater weight gain at discharge, t(24) = 3.76, p = .001, but not with lower
EDE-Q scores at discharge, t(21) = -0.51, p = .617. In parallel, an early reduction in the psychological symptoms of AN (as
measured by the EDE-Q) at 4 weeks was significantly associated with lower psychological AN symptom severity at
discharge, t(21) = 3.43, p = .003, but was not associated with discharge body weight, t(21) = 0.41, p = .689. Further, early
weight gain was associated with shorter treatment duration, t(21) = -2.25, p = .036, whereas early psychological symptom
reduction was not associated with treatment duration, t(21) = -0.77, p = .452. Cumulatively, these preliminary findings
suggest possible alternate pathways for the reduction of cognitive and physiological symptom remission in adolescent AN,
whilst underscoring the importance of early symptom remission. These findings are novel in indexing the importance of
early treatment gains when adapting FBT to non-outpatient settings, offering important insights into the treatment
mechanisms in FBT across levels of care.
Learning Objectives:
• To disseminate data exploring the efficacy of FBT across intensive levels of patient care.
• To disseminate data demonstrating complex treatment mechanisms throughout FBT, and more specifically, in the
reduction of both cognitive and physiological AN symptoms.
• We aim to discuss the value of adapting FBT across intensive levels of patient care, outlining the practical
implications of the present findings.
Feasibility and Acceptability of an Adaptive Treatment Design of Family Therapy for Adolescent Anorexia
Nervosa
Katherine Arnow, BA, Stanford University, Stanford, California, USA; Sarah Forsberg, PsyD, Stanford University,
Stanford, California, USA; Erin Accurso, PhD, University of Chicago, Chicago, Illinois, USA; Stewart Agras, MD,
Stanford University, Palo Alto, California, USA; Daniel Le Grange, PhD, FAED, The University of Chicago, Chicago,
Illinois, USA; James Lock, MD, PhD, FAED, Stanford University, Stanford, California, USA
Mounting evidence gathered on family based treatment (FBT) for adolescent anorexia nervosa demonstrates rates of full
remission in about half of patients by the end of treatment. Recent data suggest that those who do not respond to FBT can
be identified as early as the fourth week of treatment by failure to meet early weight gain markers. Thus, once identified,
adaptations to the FBT model may be appropriate to intensify treatment and address possible unmet needs of this group.
The aim of this study was to test the feasibility of delivering a stepped-care model of treatment to participants who did not
respond to FBT within the first four weeks. A series of adaptations were made to standard FBT based on direct observation
of modifiable family behaviors that distinguished families who were categorized as early non-responders. The aim was to
randomize 45 adolescents with AN across two sites using designed uneven randomization (DUR) to ensure approximately
equal numbers in the standard and adaptive arms of FBT based on anticipated response rates. Standard FBT involved 15
sessions over 6 months, where Intensive Family Therapy (IFT) constituted 18 sessions over 6 months and included
additional interventions. Rate of recruitment for this study followed that of prior RCTs for AN, with the full cohort (45)
successfully recruited over one year. Of those randomized to the adaptive arm, 36% required adaptations. There were no
differences in retention by treatment arm and dropout rates were consistent with rates of other trials (22%). We describe
procedures related to recruitment, randomization and uptake, highlight challenges that arose in conducting this design
and suggest modifications for future studies. Given this is the first adaptive treatment design tested for adolescent AN,
findings have the potential to inform similar stepped-care approaches in a larger RCT.
Learning Objectives:
• Describe adaptations to standard family based treatment for adolescents with anorexia classified as early nonresponders
• Assess the feasibility and acceptability of a stepped-care treatment study design for adolescents with anorexia
nervosa in the family based treatment model
• Review suggestions for future RCTs employing an adaptive, stepped-care treatment design for adolescent anorexia
nervosa
Therapeutic Alliance in an FBT-Based Partial Hospitalization Program
Renee Hoste, PhD, University of Michigan, Ann Arbor, Michigan, USA; Rebekah Richmond, BA, University of Michigan,
Ann Arbor, Michigan, USA
In family-based treatment (FBT) for adolescents with anorexia nervosa (AN), parents are put in charge of the initial
process of weight restoration due to the ego-syntonic nature of the illness and the potentially serious medical and
psychological consequences associated with AN. Therapists and parents work closely together to restore the ill child to
health. Although the recovery process is often met with resistance from the eating disorder, studies have found that
patients can develop a strong alliance with the therapist. Less is known about parental therapeutic alliance in FBT. The
present study examined patient and parental alliance in a partial hospitalization program based on FBT principles.
Thirty-five patients and their parents completed the Working Alliance Inventory-Short Form two weeks into treatment
(W2) and at end of treatment (EOT) based on their alliance with the treatment team. At W2, mothers had significantly
higher therapeutic alliance scores than patients and fathers, who did not differ from each other. These differences were no
longer evident at EOT, as patients’ scores improved significantly from W2 to EOT but mothers’ and fathers’ scores did not.
Patients’ scores at W2 predicted global score on the Eating Disorders Examination-Questionnaire (EDE-Q) at end of
treatment, but mothers’ and fathers’ scores did not. Patients’ and parents’ WAI scores at W2 did not predict % expected
body weight at EOT. Studies on adolescent therapeutic alliance in FBT are limited, but results from the current study are
consistent with a previous study finding that adolescents’ engagement in therapy is associated with a decrease in
symptomatology as measured by the Eating Disorder Examination but was not related to weight remission. Current
findings are also consistent with a previous study finding that parental therapeutic alliance did not predict recovery at end
of treatment.
Learning Objectives:
• Describe therapeutic alliance in family-based treatment for anorexia nervosa
• Discuss the different roles of patient and parent therapeutic alliance in treatment
• Describe changes in therapeutic alliance over the course of treatment for patients and parents
'She’s Slipping Away, We Have to Catch her Quick!' A Qualitative Analysis of Parents’ Accounts of Caring
for a Child with an Eating Disorder.
Lesley O'Hara, PhD, MSc, BA, Saint John of God Hospitaller Services, Dublin, Leinster, Ireland;
Niamh McNamara, PhD, BA, University of Bedfordshire, Bedford, Bedfordshire, United Kingdom (Great Britain);
Walter Cullen, MD, University College Dublin, Dublin, Leinster, Ireland; Barbara Dooley, PhD, University College
Dublin, Dublin, Leinster, Ireland; Jacinta Hastings, MA, BA, Bodywhys, Dublin, Leinster, Ireland; Dasha Nicholls, MD,
FAED, Great Ormond Street Hospital, London, United Kingdom (Great Britain); Fiona McNicholas, MRCPsych, MD,
Saint John of God Hospitaller Services, Dublin, Leinster, Ireland
In 2006 a report of the Expert Group on Mental Health (MH) Policy in Ireland identified eating disorders (EDs) as a MH
category that urgently required community-based MH interventions, improved training for health professionals, and
comprehensive health promotion activities. This report also stated that service users and their families should be involved
at every level of service provision. Despite the integral role of parents in both gaining access to, and facilitating care, there
has been little acknowledgment of their role in the literature. With this in mind, we sought out the perspectives of parents
who care for a child with an eating disorder. Our aim was to gain an understanding of parents’ experience of seeking help,
caring for their child through treatment, and managing the disruption of ED to family life. In-depth qualitative interviews
were conducted with 8 parents of children with eating disorders. This presentation reports on our findings following a
grounded theory analysis of the interview data. Our findings depict the parental journey from the build-up to initial
diagnosis and through the treatment process. We highlight how parents progress from an initial phase of attempted
normalisation (in which they explain their child’s behaviours as typical of their age), to their assumed role of observer (in
which they quietly monitor their child) until an urgent call to action is initiated (by a deterioration in their child’s health or
their child’s call for help). It is at this point the treatment process and path to recovery may begin, and the parent must
adapt to their new role as carer for a child with an eating disorder.
Learning Objectives:
•
•
•
Describe the experience of parents who care for a child with an eating disorder.
Discuss the stages that inform a parent's decision to seek help for their child.
Identify how mental health services may provide greater support to parents of children with eating disorders.
Mindfulness-Based Group Parent Training for Adolescent Anorexia Nervosa: A Pilot Randomized
Controlled Trial
Nancy Zucker, PhD, Duke University, Duke University School of Medicine, Durham, North Carolina, USA; Ashley
Moskovich, PhD, Duke University, Durham, North Carolina, USA; Nandini Datta, BA, Duke University, Durham, North
Carolina, USA; Rhonda Merwin, PhD, Duke University School of Medicine, Durham, North Carolina, USA; Allison
Detloff, MS, Duke University, Durham, North Carolina, USA; Terrill Bravender, MD, University of Michigan, Ann
Arbor, Michigan, USA; Marsha Marcus, PhD, FAED, Western Psychiatric Institute, Pittsburgh, Pennsylvania, USA;
Cynthia Bulik, PhD, FAED, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; James Lock,
MD, FAED, Stanford University, Palo Alto, California, USA
Individuals with anorexia nervosa (AN) not only struggle with symptoms of their disorder, but also with trait features such
as perfectionism. The focus on outcomes characteristic of perfectionism can thwart enjoyment of ongoing experience and
compromise attainment of alternative sources of reinforcement beyond the illness. Mindfulness-based cognitive behavior
therapeutic approaches have been increasingly recommended in the treatment of AN: a treatment focus that helps
individuals to fully engage in the present moment with a stance of curiosity and openness. Heightened perfectionism has
also been documented in parents of those with AN, parent modeling of behavior has a potent and sustained influence on
child behavior, and parents are central to the treatment of AN. Helping both parents and adolescents manage eating
disorder symptoms while addressing perfectionism in the dyad may be an effective strategy. A mindfulness-based group
parent-training program (GPT) was compared to manualized family-based treatment delivered over a 6-month period.
Using non-inferiority analyses, the goal was to determine whether GPT did as well as this most empirically validated
intervention. In total, 37 adolescents with AN and their caregivers were randomized. Outcomes included body mass index
(BMI), scores on the Eating Disorder Examination (EDE), and scores on a measure of Perfectionistic Cognitions.
Participants randomized to GPT scored within the boundary of clinical equivalence for BMI and EDE scores [e.g., for EDE
restraint: pre-treatment/post-treatment mean (std deviation) for FBT (Pre: M=3.2 (1.0); Post: M=1.1(1.2); for GPT (Pre:
M=3.5(.9); Post: M=1.7(1.2)]. GPT also saw a greater mean change in perfectionistic cognitions in adolescents [FBT
change score: -4.4; GPT change score: -17.5]. Overall, GPT appears to be effective: addressing unique cognitive
components in AN while being highly acceptable and well-received by caregivers. Future directions for GPT will be
discussed.
Learning Objectives:
• Participants will be able to define negative and positive reinforcement and the relevance of these learning
principles for the design of interventions for anorexia nervosa.
• Participants will be able to define mindfulness and to summarize literature demonstrating an outcome focus in
anorexia nervosa.
• Participants will be able to summarize the components of a group parent training program for anorexia nervosa.
The Effect of Children’s Eating Disorder Symptoms on Parents’ Psychosocial Functioning
Rebekah Richmond, BA, University of Michigan, Ann Arbor, Michigan, USA; Renee Rienecke Hoste, PhD, University of
Michigan, Ann Arbor, Michigan, USA
This study investigated the degree to which parents experience psychosocial impairment due to their child’s eating
disorder. In addition, the relationship between parental impairment, parental expressed emotion and their child’s eating
disorder symptoms was assessed. Participants were parents and their children with anorexia nervosa or other specified
feeding or eating disorder who were enrolled in a partial hospitalization treatment program. Parents completed the
Family Questionnaire (FQ), which is a measure of expressed emotion, and the parental adaptation of the Clinical
Impairment Assessment (PCIA) at baseline and end of treatment (EOT), while patients completed the Eating Disorder
Examination Questionnaire (EDE-Q) and the CIA. Preliminary results from 72 parents of 44 patients, aged 12-24,
demonstrated that PCIA scores improved significantly from baseline to EOT for both mothers (p < .01) and fathers (p =
.01). Regression models found that mothers’ FQ subscales of critical comments and emotional overinvolvement explained
25.4% of the variance in their PCIA scores at baseline and 50% at EOT. Additionally, there was a significant difference in
PCIA scores (p < .01) at EOT between mothers with high emotional overinvolvement (M = 31.60, SD = 9.71) and those
with low emotional overinvolvement (M = 12.5, SD = 7.42). No relationship was found between the PCIA and EDE-Q
scores. Findings suggest that parents experience impairment related to their child’s eating disorder and that this
impairment improves with treatment. In addition, parental impairment is related to parents’ self-reported level of
expressed emotion, and not to the severity of their child’s eating disorder.
Learning Objectives:
• Describe parents' psychosocial impairment due to their child's eating disorder.
• Discuss the relationship between expressed emotion and parents' psychosocial impairment.
• Describe the role of treatment in the improvement of parents' psychosocial impairment.
Childhood and Adolescence
Chairs: Kamryn Eddy PhD & Stephanie Zerwas PhD
The Neuropsychological Profile of Children and Adolescents with Anorexia Nervosa
Katie Lang, MSc, BSc, Kings College London, Institute of Psychiatry, London, London, United Kingdom (Great Britain);
Jonathan Espie, DClinPsy, Child and Adolescent Eating Disorder Service, South London and Maudsley NHS Trust,
London, London, United Kingdom (Great Britain); Mima Simic, MD, Child and Adolescent Eating Disorder Service,
South London and Maudsley NHS Trust, London, London, United Kingdom (Great Britain); Janet Treasure, MD, FAED,
Kings College London, Institute of Psychiatry, London, London, United Kingdom (Great Britain); Kate Tchanturia, PhD,
DClinPsy, FAED, Kings College London, Institute of Psychiatry, London, London, United Kingdom (Great Britain)
There is consistent evidence of inefficient cognitive processing in adults with Anorexia Nervosa (AN), and this is
postulated to be a possible maintaining factor. Furthermore, it is hypothesized that such sub-optimal cognitive processing
could be an endophenotype for AN. However, the neuropsychological profile of children and adolescents with AN needs to
be clarified to confirm this. The present study therefore aimed to investigate the neuropsychological profile of children
and adolescents with AN, and contribute evidence to the endophenotype hypothesis. N=40 children and adolescents with
AN were compared to N=40 age and IQ matched healthy controls (HCs) on measures of set-shifting (Wisconsin Card
Sorting Task, WCST) and central coherence (Fragmented Pictures Task, FPT and Rey-Osterrieth Complex Figures Task,
ROCFT). Children and adolescents with AN displayed significantly more perseverative errors on the WCST task (d=0.49),
indicating a higher degree of cognitive inflexibility. There was also a significant difference on the Style Index (SI, d=0.85),
and Central Coherence Index (CCI, d=0.55) of the ROCFT, indicating a more fragmented and detail-focused processing
style in the AN group. Regression analysis demonstrated that ‘group’ (AN or HC) accounted for the largest proportion of
variance in the results (WCST: B=-.239, p=.039, R2=0.57; SI: B=-.287, p=.012, R2=.083; CCI: B=-.267, p=.021, R2=.058),
over other variables such as weight for height, depression and anxiety. This is the first study to provide convincing
evidence of inefficient cognitive processing in children and adolescents with AN, and it adds support to the
endophenotype hypothesis. The findings will be discussed from both neuropsychological and neurobiological perspectives,
and the treatment implications for young people with AN will be considered.
Learning Objectives:
• Understand the importance of elucidating the neuropsychological profile of children and adolescents with AN.
• Understand what these results mean for the endophenotype hypothesis.
• Understand both a neuropsychological and neurobiological explanation of such findings and understand how such
findings impact on the treatment of children and adolescents with AN.
Child versus Adolescent Eating Disorders: A Comparison of Clinical Characteristics in a Treatmentseeking Sample
Anna Ciao, PhD, Western Washington University, Bellingham, Washington, USA; Erin Accurso, PhD, University of
Chicago, Chicago, Illinois, USA; Daniel Le Grange, PhD, FAED, University of Chicago, Chicago, Illinois, USA
Few studies report on the clinical differences between children and adolescents with eating disorders (EDs). The current
study aimed to fill this gap by examining children (< 12 years) and adolescents (13-18 years) presenting for outpatient ED
treatment in a hospital-based clinic (N = 313, 90% female, 85% Caucasian). Independent sample t-tests, Mann-Whitney U
tests, and Pearson chi-square analyses compared children and adolescents on demographic factors (gender, race,
ethnicity, family status), ED-specific clinical characteristics (ED diagnosis, ED pathology, binge eating episodes, purging
episodes, duration of illness, and percent of expected body weight), and general clinical characteristics (depressive
symptoms, self-esteem, psychiatric comorbidity, and prior psychological treatment). Results indicated that children were
more likely to be African-American while adolescents were more likely to be Caucasian (p = .018). Adolescents also were
more likely to have had prior psychological treatment (p = .005) and a diagnosis of bulimia nervosa (p = .012).
Adolescents had significantly lower self-esteem (p = .013), greater ED pathology (p = .001) and more frequent episodes of
objective binge eating (p = .008) and self-induced vomiting (p = .002) than children. Notably, several differences that
were anticipated based on a small number of prior studies were not present in this sample. Specifically, children and
adolescents were equivalent in terms of gender, duration of illness, and episodes of subjective binge eating, fasting,
laxative use, diuretic use, or driven exercise (ps > .10). There also were no differences between age groups in terms of
ethnicity, family status, psychiatric comorbidity, percent of expected body weight, or depressive symptoms (ps > .10).
These results are partially consistent with prior literature and suggest that adolescents presenting for treatment may be
more clinically severe than children, irrespective of other features like length of ED illness.
Learning Objectives:
• Describe the clinical presentation of eating disorders in children and adolescents.
• Assess the differences between child and adolescent eating disorders.
• Discuss implications for assessment and treatment of child and adolescent eating disorders.
Empirical Examination of Risk and Resilience Factors in the Cognitive Interpersonal Maintenance Model
of Adolescent Anorexia Nervosa
Charlotte Rhind, MSc, BSc, King's College London, Institute of Psychiatry, London, London, United Kingdom (Great
Britain) Laura Salerno, PhD, MSc, BSc, University of Palermo, Palermo, Palermo, Italy; Rebecca Hibbs, PhD, MSc, BSc,
King's College London, Institute of Psychiatry, London, London, United Kingdom (Great Britain); Nadia Micali, MD,
MRCPsych, PhD, FAED, University College London, Institute of Child Health, London, London, United Kingdom (Great
Britain); Ulrike Schmidt, MD, MRCPsych, FAED, King's College London, Institute of Psychiatry, London, London,
United Kingdom (Great Britain); Simon Gowers, MD, MRCPsych, University of Liverpool, Liverpool, Liverpool, United
Kingdom (Great Britain); Pamela Macdonald, PhD, MSc, King's College London, Institute of Psychiatry, London,
London, United Kingdom (Great Britain); Elizabeth Goddard, PhD, MSc, BSc, King's College London, Institute of
Psychiatry, London, London, United Kingdom (Great Britain); Gillian Todd, MSc, King's College London, Institute of
Psychiatry, London, London, United Kingdom (Great Britain); Kate Tchanturia, DClinPsy, King's College London,
Institute of Psychiatry, London, London, United Kingdom (Great Britain); Gianluca Lo Coco, DClinPsy, PhD, University
of Palermo, Palermo, Sicily, Italy; Janet Treasure, MD, MRCPsych, PhD, FAED, King's College London, Institute of
Psychiatry, London, London, United Kingdom (Great Britain)
There is empirical support for the cognitive interpersonal maintenance model of eating disorders in adults with severe
and/or enduring anorexia nervosa (AN). The aim of the present study was to examine this model in adolescents in the
early stage of illness and to identify factors that might contribute to risk (Expressed Emotion [EE] and accommodating
and enabling behaviours) and resilience (carer skills). One hundred and three adolescents referred for outpatient AN
treatment and their primary carers (mostly mothers) completed standardized measures of clinical impairment (patient
only) psychological distress (patient and carer), obsessive compulsive symptoms, eating traits, EE, accommodating and
enabling behaviour and carer skills (carers only). Structural equation modelling was used to understand the relationship
between these components. A structural equation analysis confirmed the link between patients’ clinical impairment and
distress. Accommodating behaviour was associated with patient distress and carer distress. However, accommodating
behaviour was not associated with carers’ own eating difficulties or contact time. Both carer emotional over-involvement
and critical comments were associated with carer distress. There was a positive association between carer emotional overinvolvement and the Body Mass Index of patients. Carer skills were negatively associated with carer distress. When
comparing these variables and the model between adolescent and adult patients there are some differences. Carer
accommodating behaviour is higher in the early phase of the illness. In order to further test the maintenance model,
longitudinal studies are needed to examine whether improving carer skills and reducing accommodating behaviour are
mediating, and/or moderating factors, which impact on outcome.
Learning Objectives:
• Understand the cognitive-interpersonal maintenance model of eating disorders and identify factors that might
contribute to risk and resilience.
•
•
Summarize empirical findings that support the cognitive interpersonal maintenance model at the early stage of
anorexia nervosa.
Discuss the implications of risk and resilience factors for the treatment of eating disorders at different stages of
illness.
Diagnosis of Adolescent Anorexia Nervosa: The Dual Influence of Multiple Informants and the
Transition to DSM-5
Lisa Hail, MA, Fairleigh Dickinson University, Teaneck, New Jersey, USA; Katharine L. Loeb, PhD, Fairleigh Dickinson
University, Teaneck, New Jersey, USA; Stuart B. Murray, PhD, University of California, San Diego, San Diego,
California, USA; Daniel Le Grange, PhD, FAED, The University of Chicago, Chicago, Illinois, USA; Amy Parter, BA,
Fairleigh Dickinson University, Teaneck, New Jersey, USA; Robert E. McGrath, PhD, Fairleigh Dickinson University,
Teaneck, New Jersey, USA; Christopher Fairburn, MD, FAED, University of Oxford, Oxford, England, United Kingdom
(Great Britain)
Much has been written about the diagnosis of anorexia nervosa (AN) in children and adolescents being a challenging
pursuit given deficits in the DSM-IV criteria and the incompatibility of reliance on traditional self-report in the context of
an ego syntonic disorder. With the introduction of DSM-5, the diagnostic criteria have moved towards being more
developmentally sensitive; moreover, a multiple informant approach taking into account behavioral indicators is
hypothesized to increase the identification of clinically significant behaviors in youth. The Eating Disorder Examination
(EDE) has been the gold standard in eating disorder diagnosis and a parent version of the EDE (PEDE) was developed to
capitalize on using parents as informants of observed symptoms in the case identification process. The PEDE assesses fear
of weight gain, both without and with behavioral indicators (e.g., tantrums, yelling, throwing food, threatening to harm
self in response to renourishment attempts), with the latter consistent with DSM-5 criteria. This study examines shifts in
rates of AN diagnosis in DSM-IV versus DSM-5 via both parent and child report in a research-based treatment-seeking
sample (N=59; Age 9-18, M=13.7; 84.7% female). McNemar’s test determined a statistically significant increase in the
proportion of individuals identified as AN when using DSM-5 rather than DSM-IV diagnostic criteria for both child
(p<.001) and parental (p<.001) reports. Additionally, McNemar’s test determined a statistically significant increase in the
proportion of individuals identified as DSM-5 AN with the addition of parental reports (p=.001). These findings speak to
the improvements in the DSM-5 in capturing clinically significant symptoms in youth, with a multiple informant approach
further increasing case identification.
Learning Objectives:
• Describe the unique challenges of diagnosing anorexia nervosa in children and adolescents
• Identify the ways in which the transition to DSM-5 allows for increased case identification
• Explain the value of utilizing multiple informants in AN case identification
Self-reported Dieting Behavior of Five-year-old Girls and Boys: Associations with Sociocultural Variables
Siân McLean, BSc, La Trobe University, Melbourne, VIC, Australia; Stephanie Damiano, PhD, La Trobe University,
Melbourne, VIC, Australia; Karen Gregg, BA, La Trobe University, Melbourne, VIC, Australia; Susan Paxton, PhD,
FAED, La Trobe University, Melbourne, VIC, Australia
As dieting is a risk factor for the development of eating disorders and there is emerging literature that young children are
reporting dieting, there is a need to understand factors that influence the development of such behaviours in young
children. In line with the sociocultural thin ideal for females and muscular ideal for males, the aim of this study was to
explore sociocultural correlates of dieting, described as cognitive control of eating (CCE) to avoid getting fat in girls and
practices for muscle gain (PMG), including CCE and exercise, in boys. Participants were 216 five-year-old children (55%
girls) who were interviewed about their dieting, internalization of societal body ideals and weight bias. Their mothers (N =
210) and fathers (N = 157) completed questionnaires assessing their dieting behaviors and internalization of societal body
ideals, as well as their child’s media exposure and peer appearance interest. Approximately 25% of girls reported CCE to
avoid getting fat, while 28% of boys reported PMG. For girls, higher levels of CCE to avoid getting fat was associated with
positive perceptions of thinner figures, greater internalization of general societal body ideals, more time exposed to media,
and greater peer appearance interest. For boys, higher levels of PMG was associated with greater awareness of weight loss
strategies, internalization of general societal body ideals, internalization of the rewards of muscularity, and wishing to look
different. These findings suggest that some five-year-old girls are reporting CCE to avoid getting fat and that this is related
to a number of sociocultural factors, while boys appear to be internalizing the muscular ideal and this is related to them
reporting PMG. Given the proportion of children reporting some level of CCE and PMG at age five, prevention
interventions targeting eating disorder risk factors from an early age are indicated.
Learning Objectives:
• Describe the prevalence of dieting behaviors in five-year-old girls and boys
• Analyze the relationships between sociocultural factors and dieting behaviors of young children
• Assess the need for prevention interventions for eating disorder risk factors in young children
Weight Bias in Four-year-old Boys and Girls: The Influence of Parents
Siân McLean, BSc, La Trobe University, Melbourne, VIC, Australia; Stephanie Damiano, PhD, La Trobe University,
Melbourne, VIC, Australia; Karen Gregg, BA, La Trobe University, Melbourne, VIC, Australia; Emma Spiel, DPsych, La
Trobe University, Melbourne, VIC, Australia; Susan Paxton, PhD, FAED, La Trobe University, Melbourne, VIC,
Australia
A growing literature suggests that children’s body size attitudes and body image are formed in early childhood, and that
parents influence the development of these attitudes. There is, however, little research that has explored the relationships
between parental influence and body size attitudes of preschool-aged children, in particular the influence of fathers on
sons. The aim of this study was to examine relationships between the weight bias and body image of preschool children
and their fathers and mothers. Participants were 279 four-year-old children (46% boys) and their fathers (N = 205) and
mothers (N = 270). Children were interviewed to assess their weight bias and body image. Parents completed
questionnaires assessing their weight stigma, internalisation of societal body ideals, body image, dieting, and concern
about their child being overweight. Both boys and girls showed weight bias consistent with societal anti-fat attitudes and
idealization of thin figures. For boys, attributing positive qualities to thinner figures and negative qualities to larger figures
was associated with paternal negative attitudes towards obese people. For girls, attributing positive qualities to thinner
figures was associated with maternal dieting. Boys’ wanting to be larger (than their currently perceived very thin bodies)
was associated with paternal concern about their son’s weight. No relationships emerged between girls’ body image and
parental variables. Results suggest that even at a very young age, children may be influenced by parental attitudes and
provide some evidence for a gender-linked model. Specifically, fathers may convey the muscular ideal to their sons and
mothers may convey the thin ideal to their daughters. These findings have important implications for the development of
body image interventions early in childhood and suggest that including fathers is very important.
Learning Objectives:
• Describe the presence of weight bias in four-year-old boys and girls
• Analyze the relationships between parental body size attitudes and those of their four-year-old sons and daughters
• Illustrate the importance of including fathers in body image prevention efforts
Diagnosis, Classification and Measurement
Chairs: Kelsie Forbush PhD & Robyn Sysko PhD
The Eating Disorder Assessment for DSM-5 (EDA-5): Development and Validation of a Structured
Interview for Feeding and Eating Disorders
Robyn Sysko, PhD, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Deborah Glasofer, PhD, New
York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA; Tom Hildebrandt,
PsyD, FAED, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Patrycja Klimek, BA, ,Icahn School of
Medicine at Mount Sinai, New York, New York, USA; James Mitchell, MD, FAED, Neuropsychiatric Research Institute &
University of North Dakota School of Medicine, Fargo, North Dakota, USA; Stephen Wonderlich, PhD, FAED,
Neuropsychiatric Research Institute & University of North Dakota School of Medicine, Fargo, North Dakota, USA; Kelly
Berg, PhD, University of Minnesota, Minneapolis, Minnesota, USA; Carol Peterson, PhD, FAED, University of
Minnesota, Minneapolis, Minnesota, USA; B. Timothy Walsh, MD, FAED, New York State Psychiatric Institute,
Columbia University Medical Center, New York, New York, USA
Existing measures for assessing DSM-IV eating disorder diagnoses have notable limitations, and there are important
differences between DSM-IV and DSM-5 feeding and eating disorders. The purpose of this study was to develop and
validate a new semi-structured interview called the Eating Disorders Assessment for DSM-5 (EDA-5). Two studies
evaluated the utility of the EDA-5. Study 1 compared the diagnostic validity of the EDA-5 to the Eating Disorder
Examination (EDE) and evaluated the test-retest reliability of the new measure. Study 2 compared the diagnostic validity
of a modified electronic application (“app”) of the EDA-5 to clinician interview and self-report assessments. In Study 1, the
EDE and EDA-5 eating disorder diagnoses had a kappa of 0.74 across all diagnoses (n= 64). When considering individual
diagnostic categories, a range of κ= 0.65 for Other Specified Feeding or Eating Disorder (OSFED) and Unspecified
Feeding or Eating Disorder (USFED) to κ= 0.90 for Binge Eating Disorder (BED) was observed. For Study 2, a kappa of
0.83 was observed for all eating disorder diagnoses (n=71). Across individual diagnostic categories, kappa ranged from
0.56 for OSFED/USFED to 0.94 for BED. High rates of agreement were found between diagnoses assigned by the EDA-5
and the EDE, and by the EDA-5 and clinical interviews, in these two studies. Given that this study supports the validity
and reliability of the EDA-5, it may be considered as an option for the assessment of DSM-5 eating disorders in clinical
and research settings. Additional research is needed to evaluate the use of the EDA-5 with DSM-5 feeding disorders.
Learning Objectives:
•
•
•
Describe the diagnostic validity of a novel assessment for DSM-5 feeding and eating disorder diagnoses (the
Eating Disorder Assessment for DSM-5; EDA-5) in comparison to the Eating Disorder Examination and clinician
interview.
Discuss the test-retest reliability of the EDA-5.
Consider the benefits and drawbacks of an electronic application assessment tool for DSM-5 feeding and eating
disorders.
Using the Eating Disorder Examination (EDE) to diagnose DSM5 eating disorders: Discrepancies
between different algorithms
Anthea Fursland, PhD, MSc, FAED, Centre for Clinical Interventions, Perth, Western Australia, Australia; Susan Byrne,
PhD, DPhil, University of Western Australia, Perth, Western Australia, Australia; David Erceg-Hurn, BSc, Centre for
Clinical Interventions, Perth, Western Australia, Australia
The Eating Disorder Examination (EDE) is a structured diagnostic interview that is the ‘gold standard’ for diagnosing
eating disorders in research studies and clinical practice. Well established algorithms exist for diagnosing DSM-IV eating
disorders using the EDE, but this is not the case for DSM-5. Several DSM-5 diagnostic algorithms have been proposed,
but they differ in terms of how they use EDE items to operationalize diagnostic criteria such as low weight, episodes of
binge eating, and compensatory behaviours to prevent weight gain. In the present study we compared four DSM-5 EDE
diagnostic algorithms, to evaluate whether the choice of algorithm has a practical impact on what diagnosis is given to a
patient. In other words, do patients receive the same diagnosis irrespective of the algorithm used, or does their diagnosis
depend critically on the algorithm? Participants were over 400 patients referred by health professionals to a specialist
West Australian eating disorders outpatient service. Clinical psychologists administered the EDE to each patient and
these EDE scores were analysed using four different algorithms. We found that, for a significant minority of patients, the
diagnosis they were assigned changed depending on what diagnostic algorithm was used. The results indicate that
competing algorithms for diagnosing DSM-5 eating disorders using the EDE are not interchangeable, and that the choice
of algorithm has a practical impact on what diagnoses patients are assigned. The significant implications of these findings
for research and clinical practice will be discussed.
Learning Objectives:
• Understand the similarities and differences between four DSM-5 EDE diagnostic algorithms
• Understand how each algorithm affects diagnoses that are assigned to patients
• Select an appropriate diagnostic algorithm for use in clinical practice or research
The ED-10: Development and validation of a brief, session-by-session measure of eating disorder
cognitions and behaviors
Glenn Waller, DPhil, MPhil, BA, FAED, Clinical Psychology Unit, University of Sheffield, Sheffield, Yorkshire, United
Kingdom (Great Britain); Hannah Turner, PhD, DClinPsy, Southern Counties NHS Trust, Southampton, Hampshire,
United Kingdom (Great Britain); Madeleine Tatham, DClinPsy, Norfolk Eating Disorders Service, Norwich, Norfolk,
United Kingdom (Great Britain); Victoria Mountford, DClinPsy, King's College London, London, England, United
Kingdom (Great Britain); Ashley Tritt, BSc, McGill University, Montreal, Quebec, Canada
In many psychological disorders, there is a move towards session-by-session symptom measurement. This strategy allows
us to monitor and shape treatment, and to identifying processes of change across the course of therapy. The necessary
measures need to be brief, focused on core features since the last session, and readily available to clinicians. There is no
measure in the eating disorders that meets those criteria. Therefore, this research reports on the development and
validation of such a self-report questionnaire - the ED10. The authors generated and refined a brief set of attitudinal and
behavioral items, related to eating pathology over the past week. The resulting questionnaire was completed by a large
non-clinical adult sample (N = 521, including a retest sample of N = 149) and eating disorder sufferers (N = 63). Factor
analysis identified two scales, with good internal consistency and test-retest reliability. The ED-10 was validated against
the Eating Disorders Examination-Questionnaire (EDE-Q) and measures of depression and anxiety, The correlation with
the EDE-Q was very strong (r = .889), indicating that they measure near-identical constructs. The ED-10 successfully
differentiated eating-disordered and non-clinical groups to the same degree as the longer EDE-Q. The ED-10 is not
proposed as an alternative to measures such as the EDE-Q, but as a complementary tool, used to measure session-bysession symptoms for clinical and research purposes. Future research will track changes in ED-10 scores across therapy, to
determine the importance of very early response to therapy and sudden changes, as found in other disorders.
Learning Objectives:
• Understand the need for a session-by-session measure of eating pathology
• Use and interpret the ED-10
• Shape therapy to reflect changes in eating pathology across sessions
The Disturbed Eating Characteristics Scale (DECS-58): Development and Validation of a Self-Report
Measure of the Characteristic Features of Eating Disturbances.
Kim Woodward, BA, DiplPsych, Macquarie University, Sydney, New South Wales, Australia; Doris McIlwain, PhD, BA,
Macquarie University, Sydney, New South Wales, Australia
Why is a new measure of disturbed eating necessary? While a growing literature identifies links between eating
disturbances and certain emotion regulation and relational styles, much contention and contradictory evidence exist
regarding the distinction between different specific eating disorder (ED) diagnoses within such relationships. This may be
due, at least in part, to the common and overlapping features of different ED diagnoses and rather what is needed is
exploration of the link between certain emotional and relational styles and specific ED characteristics at a symptom level.
Although, in order to explore such relationships, what is first required is an investigative tool that reliably and validly
identifies specific discrete characteristics of EDs. However, such a scale did not exist in the literature. To fill this void, the
current studies aimed to develop and validate a freely available self-report measure of the specific characteristics of eating
disturbances. To this end an initial 66-item pool was devised and tested in Study 1 with a sample of 403 women. An
exploratory factor analysis revealed a four-factor structure retaining 58 items. A preliminary confirmatory factory analysis
(CFA) supported this factor structure and lead to the identification of four sub-scales: ‘Drive for thinness’ (29-items),
‘Binge’ (9-items), ‘Purge’ (9-items), and ‘Extreme-restraint’ (11-items). These four sub-scales showed very high internal
consistency, good test-retest reliability, strong convergent validity (with measures of shame, self-esteem, depression,
happiness, and life satisfaction), and strong concurrent and criterion-related validity. In Study 2, a CFA in a sample of 841
women supported the four-factor structure of the Disturbed Eating Characteristics Scale (DECS-58), which again
demonstrated strong psychometric properties. Importantly the DECS-58 sub-scales were found to validly distinguish
between DSM-5 diagnostic groups with varying constellations of ED symptoms. As such, the DECS-58 appears useful as a
measure of the varying characteristic features of EDs.
Learning Objectives:
• Understand the need for reliable and valid measurement of the varying characteristic features of eating
disturbances.
• Describe the use of the Disturbed Eating Characteristics Scale (DECS-58) to assess the characteristic features of
eating disturbances.
• Appraise the utility for future research of measuring eating disturbance characteristics, in order to enable
exploration of links between certain emotional and relational styles and specific ED characteristics at a symptom,
rather than diagnosis, level.
The Fear of Food Measure: A Novel Measure for Use in Exposure Therapy for Eating Disorders
Cheri Levinson, MA, Washington University in St. Louis; University of North Carolina School of Medicine, Chapel Hill,
North Carolina, USA; Meghan Byrne, BA, Washington University, St. Louis, Missouri, USA
Exposure therapy for mealtime anxiety has preliminarily been effective at increasing food intake and decreasing anxiety in
individuals with anorexia nervosa (AN) (Levinson et al., 2014; Steinglass et al., 2014). To enhance our knowledge of
exposure therapy for AN researchers and clinicians need a comprehensive measure that assesses outcomes relevant to
exposure therapy for AN. Therefore, the purpose of this study is to develop a measure that clinicians and researchers can
use when utilizing exposure therapy for AN. In four samples we developed the Fear of Food Measure (FOFM) that assesses
three cognitive and behavioral outcomes: trait anxiety about eating, food avoidance behaviors, and feared concerns related
to eating. In a community (N = 399) and undergraduate female sample (N = 203) the FOFM exhibited a good 3-factor
structure and convergent and divergent validity. In a sample of women (N = 72) we showed that the anxiety about eating
subscale significantly predicted in-vivo food intake over and above other established predictors of eating (e.g., restraint).
In a clinical sample diagnosed with an eating disorder (N = 41) we showed that anxiety about eating was associated with
food intake and anxiety during an exposure meal and that all subscales of the FOFM significantly decreased over the
course of a 4-session exposure intervention. Finally, we found that participants diagnosed with an eating disorder had
higher levels of fear of food than did matched controls (N = 23). The FOFM is a psychometrically valid measure that can
assess if patients are improving while undergoing exposure therapy and could be used to pinpoint problematic behaviors
that can be addressed in exposure therapy. This measure is a tool that both clinicians and researchers can utilize when
implementing exposure therapy for eating disorders, perhaps specifically for AN.
Learning Objectives:
• To describe the current literature on exposure therapy for eating disorders, specifically for anorexia nervosa.
• To describe and provide results on a new measure of Fear of Food that can be utilized in exposure therapy for
anorexia nervosa.
• To discuss how to utilize the Fear of Food Measure as a clinical and research outcome when implementing
exposure therapy for anorexia nervosa.
The Dimensional Nature of Disordered Eating: Evidence from a Direct Comparison of Dimensional,
Categorical and Hybrid Models
Xiaochen Luo, MS, Michigan State University, East Lansing, Michigan, USA; Brent Donnellan, PhD, Michigan State
University, East lansing, Michigan, USA; S. Alexandra Burt, PhD, Michigan State University, East Lansing, Michigan,
USA; Kelly Klump, PhD, FAED, Michigan State University, East Lansing, Michigan, USA
The classification of eating disorders has been debated, with the current major diagnostic system (DSM-5) assuming a
categorical nature rather than a dimensional nature for eating disorders. However, previous studies suffered from several
issues including using unexamined assumptions of a categorical nature in modeling, not being able to examine hybrid
models with both dimensional and categorical features, or using only clinical samples and only categorical diagnostic
indicators that limited the ability to capture the full variation of eating pathology. The current study aimed to directly
compare categorical, dimensional and hybrid models for disordered eating in a community twin sample of 2,389 female
and male participants ages 9-30 years (67% female, mean age=14.43(5.00). The Minnesota Eating Behaviors Scale
(MEBS) was used to assess disordered eating symptoms. We first examined the factor structure of the MEBS and found
that the four-factor structure established previously (i.e., scales for body dissatisfaction, weight preoccupation, binge
eating, and compensatory) fit the data well and was invariant to sex, age and puberty status. We then fit a categorical
model (i.e., a latent class model), a dimensional model (i.e., a latent trait model) and a hybrid model (i.e., a nonparametric factor model) to each of the factors. Results showed that a dimensional model fit the data best for binge eating,
weight preoccupation, and compensatory behaviors. For body dissatisfaction, a four-class model, which categorized people
who were dissatisfied with different parts of their bodies into four groups, fit the data best, while the dimensional model
was the second best model. We conclude that despite an a priori preference for categorical models in the current
classification system, a dimensional framework should be included in conceptualizing eating pathology. Our results also
emphasize the importance of assessing and understanding symptoms of eating disorders along the entire spectrum rather
than only focusing on a narrow part of this continuum.
Learning Objectives:
• recognize the importance of understanding the latent structure of eating pathology for the classification, research
and treatment of eating disorders
• describe the debate on the dimensional versus the categorical nature of eating disorders and critically evaluate
methods and results from previous studies that examined the latent structure of eating pathology
• understand how to examine dimensional and categorical models for eating pathology from the categoricaldimensional framework and how to evaluate different models to determine the best fitting model empirically
Innovative Uses of Technology
Chairs: Stephanie Bauer PhD & Paulo Machado PhD
Personalized motivational text-message intervention: A single case alternating treatment design pilot
study
Rebecca Shingleton, MA, Boston University, Boston, Massachusetts, USA; Heather Thompson-Brenner, PhD, Boston
University, Boston, Massachusetts, USA; Tibor Palfai, PhD, Boston University, Boston, Massachusetts, USA; Elizabeth
Pratt, PhD, Boston University, Boston, Massachusetts, USA; David Barlow, PhD, Boston University, Boston,
Massachusetts, USA
Research has demonstrated that new strategies to increase motivation to change in eating disorders are needed. Using an
intensive single case experimental design, specifically, an alternating treatment design (ATD), the current pilot study
examined the influence of a motivational text-message intervention on eating behaviors and motivation-to-change in
individuals with AN-like restrictive behaviors over the first eight weeks of treatment. Participants were treatment seeking
men and women recruited from the community and local universities. All participants (N=11) were under to normal
weight (BMI=16.5-25.0 kg/m2) and participants with a BMI>19.0 reported significant restriction. Individuals completed a
motivational interviewing session focused on exploring reasons to change. These reasons were used to develop
personalized text-messages that were sent prior to mealtimes as reminders of why the participants wanted to change.
Participants then began cognitive-behavioral therapy with a clinician. One week text-message versus no text-message
phases were randomly alternated over the study period. Participants also completed daily food logs and a nightly
questionnaire. The primary outcomes were data compliance, acceptability, motivation to change, kilocalorie intake, and
restriction. Participants were compliant with the protocol (mean data completion=91%) and found the intervention
acceptable (p=.03). Overall, motivation to change increased (e.g., 36% mean reduction in desire to restrict) and restriction
reduced (p<.01) over the course of the study. As is customary in ATDs, the primary form of data analysis was visual
inspection. N=6 reported increased motivation to change and/or reduced restriction during the text-message phases (e.g.,
Participant 1 generally reported greater levels of motivation and lower restriction during the text-message phases). Two
participants reported negative effects (i.e., lower motivation, greater restriction) during the text-message phases. These
findings offer initial support for using text-messages with a subset of individuals as a treatment adjunct. Identification of
responders and non-responders will be one of the important directions for future research.
Learning Objectives:
• To describe a novel motivational text-message intervention for individuals with highly restrictive behaviors.
• To analyze and discuss pilot data investigating the influence of text-messages on motivation-to-change and
restriction.
• To discuss future research directions regarding developing and testing text-messages as a motivational treatment
adjunct for individuals with eating disorders.
Promoting Health Behaviour in Portuguese Children via Short Message Service (SMS): The Efficacy of a
Text-Messaging Program
Paulo Machado, PhD, FAED, University of Minho, Braga, PT, Portugal; Cátia Silva, MA, University of Minho, Braga,
PT, Portugal; Ana Vaz, PhD, University of Minho, Braga, PT, Portugal; Eva Conceição, PhD, University of Minho,
Braga, PT, Portugal; Ross Crosby, PhD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota, USA
A Short Message Service (SMS) program was adapted to monitor three health behaviours and provide supportive
feedback. The study aimed to evaluate the effectiveness of the program to increase fruit/vegetable consumption and
physical activity, and to decrease screen time. One-hundred and thirty-nine Portuguese children, aged 8-10, grouped by
classroom, were randomly assigned to an intervention (8 weeks of monitoring/feedback) or a control condition.
Participants had their key behaviours assessed at baseline, post-intervention and follow-up. A 3-level hierarchical linear
model was developed. Results showed that the monitoring and feedback program significantly increased fruit and
vegetable consumption over time.
Learning Objectives:
• Describe use of SMS to monitor and promote behavior change
• Assess the efficiency of a SMS program to provide feedback to school aged children
• Assess the efficiency of a SMS program to encourage health behaviors in school aged children
Can smartphones be used to improve eating disorders symptoms? An exploration of outcome and
symptom profiles using a signal detection analysis.
Alison Darcy, PhD, Stanford University School of Medicine, Stanford, California, USA; James Lock, MD, PhD, FAED,
Stanford School of Medicine, Stanford, California, USA; Jenna Tregarthen, BA, Recovery Record Research Inc, Palo
Alto, California, USA
The purpose of the study was to explore the longitudinal outcomes of users of a widely available smartphone application
(app) for eating disorders (ED) and to identify baseline variables related to clinically significant change. Participants in the
study were 12,355 females over the age of 13 years who used a smartphone app and completed the ED ExaminationQuestionnaire (EDEQ) on at least one occasion. In a retrospective cross-sectional study data were drawn from the 607
users who completed an EDE-Q on 3 occasions. Using these data we conducted a signal detection analysis (SDA) to
identify baseline clinical, demographic and app-usage characteristics that reliably classified individuals who achieved a
normal EDEQ Global score (i.e. within 1SD of age-matched norms) by the third assessment point. A normal level of ED
symptomatology was achieved by 26.69% of the sample. A decision tree classifier delineated 8 unique symptom
combinations that varied according to likelihood of achieving this level of clinically significant change. The worst
performing groups had severely distorted cognitions, extreme difficulty eating with others, and food avoidance. The best
performing groups reported at least one binge-eating episode with symptom duration less than 13 years. While response
rates vary according to symptom profile, the overall rate of clinically significant symptom reduction is in line with current
response rates to guided self-help treatments.
Learning Objectives:
• Understand the characteristics of users of a commercially available smartphone app for individuals with eating
disorders.
• Critically appraise the usefulness of a commercially available smartphone app as self-help vehicle.
• Consider the potential impact of mobile health technologies for individuals with eating disorders.
Relation between craving produced by virtual reality food, craving trait and bulimic symptomatology in a
non-clinical sample
Marta Ferrer-Garcia, PhD, Universitat de Barcelona, Barcelona, Barcelona, Spain; José Gutiérrez-Maldonado, PhD,
Universitat de Barcelona, Barcelona, Barcelona, Spain; Joana Pla-Sanjuanelo, MSc, Universitat de Barcelona,
Barcelona, Barcelona, Spain
This study assessed the ability of virtual food to elicit different levels of food craving depending on the craving trait level
and bulimia nervosa symptomatology in a non-clinical sample. The results are part of the preliminary data regarding the
validation of a software package incorporating virtual reality technology for treating binge eating behavior in patients with
bulimia nervosa and binge eating disorder. Eighty-four college students (68 females and 16 males) were exposed to ten
virtual foods (the ones that each participant assessed as eliciting the highest levels of craving from a list of 30 foods) in
four different non-immersive virtual environments (kitchen, dining room, bedroom, and café). After 20 seconds of
exposure to each dish, food craving was assessed on a visual analog scale from 0 (not at all) to 100 (extreme). Food craving
as a trait and bulimic symptoms were also assessed using the Food Craving Questionnaire-Trait (FCQ-T) and the Bulimia
scale of the Eating Disorders Inventory-3 (EDI-3). Several analyses of variance were conducted to assess food craving
experienced when participants were exposed to a pizza (an example of salty food) and to a cake (an example of sweet
food). Scores obtained on the FCQ-T and the Bulimia scale of the EDI-3 were introduced as independent categorical
variables (low, moderate, and high). Time elapsed since the participant’s last meal was introduced as a covariate in all the
analyses. As expected, participants with higher levels of craving trait showed higher levels of food craving than
participants with low craving trait when exposed to the cake in the kitchen and the bedroom, and when exposed to the
pizza in the kitchen, the dining room, and the bedroom. Participants with higher levels of bulimic symptomatology also
showed higher levels of food craving when exposed to the pizza in the kitchen, the dining room, and the bedroom, and
when exposed to the cake in all the virtual environments. The results suggest that virtual reality may be a useful
technology for producing food craving, especially in participants with higher levels of craving trait and bulimic symptoms.
However, further research with clinical samples is needed to assess its ability to induce craving in the context of cueexposure therapy.
Learning Objectives:
• Extend the knowledge about the ability of in virtual reality exposure to elicit food craving
• Describe the association between craving produced by virtual food and the craving as a trait of participants in a
non-clinical sample
• Describe the association between craving produced by virtual food and the presence of bulimic symptoms in a
non-clinical sample
Enhancing healthy eating, positive body image and psychological health of university students with an
online self-help programme: A pilot study
Sau Fong Leung, DPhil, BSc, The Hong Kong Polytechnic University, Hong Kong; Lili Ma, School of Nursing, Capital
Medical University, Beijing, China
The purpose of this study was to pilot an online self-help prevention programme developed for promoting healthy eating,
positive body image and psychological health of university students. It was an open trial of the programme which involved
an experimental group and a control group from Hong Kong and Mainland China. The participants were recruited
through personal approach at different university campuses and social network sampling using strategies, such as e-mails,
facebook, whatsapp and electronic promotional posters. Participants in the experiment group had access to all
components of the programme including healthy eating, health assessment, psychological health promotion and useful
links whereas those in the control group had access limited to the health assessment component and useful links. Eightyfive participants completed a 3-month study of the programme in an experimental group (n=47) and a control group
(n=38). There were 62 females and 23 males. The Wilcoxon Signed Ranks Test showed that both groups had significant
improvement in their eating disorder psychopathology, body shape concern and psychological health over a 3-month
period of using the programme as measured by Eating Disorder Examination Questionnaire (EDE-Q5), Body Shape
Questionnaire (BSQ-14) and Depression Anxiety Stress Scale (DASS-21). In comparing the experimental group with the
control group at post-intervention, the former group had more significant reduction in the body shape dissatisfaction than
the latter group as revealed from the Mann-Whitney Test. The online self-help preventive programme has potential
benefit in enhancing healthy eating, positive body image and psychological health of university students.
Learning Objectives:
• Explore the issues of healthy eating, body image and psychological health of university students
• Assess the effectiveness of online self-help prevention programme for enhancing healthy eating, positive body
image and psychological health of university students
• Identify the potential benefits of online self-help prevention programme for eating disorders
Influence of pro-eating disorder websites exposure on body image and eating pathology: a meta-analysis
Rachel Rodgers, PhD, Northeastern University, Boston, Massachusetts, USA; Debra Franko, PhD, FAED, Northeastern
University, Boston, Massachusetts, USA; Alice Lowy, MA, Boston University, Northeastern University, Boston,
Massachusetts, USA; Daniella Halperin, MA, Northeastern University, Boston, Massachusetts, USA
Pro-eating disorder websites promote eating disorders as a lifestyle choice rather than a mental health disorder.
Experimental and correlational research has indicated that exposure to such websites might increase poor body image and
eating pathology; however, to date, estimates of the size of this effect are unknown. The aim of the present study was to
conduct a meta-analysis to examine the effect of exposure to pro-eating disorder websites on body image and eating
pathology. We conducted a systematic review of the literature using the keywords “pro-ana,” “pro-mia,” pro-anorexia,”
“pro-bulimia,” “pro-eating disorder.” Studies were included if they provided an estimate of the relationship between
exposure to pro-eating disorder websites and an eating pathology-related outcome. The systematic review identified 11
studies that fit our criteria. Preliminary findings from the meta-analysis revealed significant effect sizes of exposure to
pro-eating disorders websites on body image dissatisfaction (7 studies), ES = .38, 95% CI [.16 - .60], p = .001; dieting (7
studies), ES = .62 95% CI [.36 – .88], p < .000; bulimic symptoms (3 studies), ES = .85, 95% CI [.66 – 1.03}, p < .000;
and negative affect (3 studies), ES = .88, 95% CI [.185- 1.57], p = .013. Our findings revealed large effect sizes for the effect
of pro-eating disorder websites exposure on body image and eating pathology, highlighting the need for increased
prevention and policy regulating these websites.
Learning Objectives:
• Describe the content of pro-eating disorder websites and understand their potential dangers.
• Summarize the findings of the literature to date regarding the association between pro-eating disorder website
viewing and disordered eating.
• Identify practice considerations, and the need for targeted policy and prevention.
Neuroscience and Genetics
Chairs: Kristen Culbert, PhD & Howard Steiger, PhD
Core-Exome Chip study of low-frequency variants identifies genome-wide significant hits associated with
anorexia nervosa
Laura Huckins, MSc, Wellcome Trust Sanger Institute, Cambridge, UK, United Kingdom (Great Britain); Konstantinos
Hatzikotoulas, PhD, Wellcome Trust Sanger Institute, Cambridge, UK, United Kingdom (Great Britain); Laura
Thornton, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Lorraine Southam, BSc,
Wellcome Trust Sanger Institute, Cambridge, UK, United Kingdom (Great Britain); David Collier, PhD, Institute of
Psychiatry, King's College London, London, UK, United Kingdom (Great Britain); Patrick Sullivan, PhD, Department of
Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Cynthia Bulik, PhD,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Eleftheria Zeggini, PhD, Wellcome Trust
Sanger Institute, Cambridge, UK, United Kingdom (Great Britain)
Twin studies of anorexia (AN) reveal considerable heritability, but little is known about the exact biological mechanisms
which underlie AN. This study is the first to investigate the role of low frequency and rare variants in the development of
AN. Our study comprises 2,376 female AN cases and >22,000 controls, genotyped on the Core-Exome Chip. Samples
derive from eight different populations; cases and controls are carefully ancestrally matched. The CoreExome Chip
enables us to study both common and low frequency variants simultaneously. Analysis is currently complete across three
of the eight contributing populations: Norway (87 cases/100 controls); Finland (163/5300); and the UK (181/10034). We
have performed a meta-analysis across these three populations and thus far have identified four genome-wide significant
signals: exm370124, exm462797, exm464785, exm2116552; all are low frequency, mis-sense variants. SNPs were
extremely low frequency in both the case and the control populations, with highest MAF between 0.005 and 0.1. Effect
sizes for each SNP were high, and the same direction of effect was noted for every SNP in at least 2/3 populations.
Maximum effect sizes for each SNP were between 6.6 and 74.5. One of these associated variants (exm464785) lies in
RASGRF2, a gene that has previously been associated with eating disorders, albeit not at a genome-wide significant level.
These are the first genome-wide significant variants that have been associated with AN. We hope that this will enable
further studies into the functional mechanisms underlying AN, and provide direction for establishing effective
medications and treatment. Further, all four hits that were identified are very low frequency and could not possibly have
been identified in previous GWAS studies. This may be a good indication that low frequency, Core-Exome chip type
studies have potential to reveal new associated variants across a range of psychiatric disorders.
Learning Objectives:
• Discuss the role of low-frequency variants in anorexia nervosa
• Describe the previous evidence for a genetic role in anorexia nervosa from twin studies.
• Understand the process involved in a core-exome chip analysis
Epigenomewide Methylation Signature in Women with Anorexia Nervosa: Preliminary Results
Howard Steiger, PhD, FAED, Douglas Institute and McGill University, Montreal (Verdun), Quebec, Canada; Linda
Booij, PhD, Researcfh Centre, University of Montreal, Montreal, Quebec, Canada; Kevin Casey, PhD, Research Centre,
University of Montreal, Montreal, Quebec, Canada; Juliana Mazanek Antunes, MSc, University of Quebec at Montreal,
Montreal, Quebec, Canada; Moshe Szyf, PhD, McGill University, Montreal, Quebec, Canada; Ridha Joober, MD, PhD,
Douglas Institute and McGill University, Montreal (Verdun), Quebec, Canada; Mimi Israel, MD, FAED, Douglas
Institute and McGill University, Montreal, Quebec, Canada
Preliminary evidence associates Anorexia Nervosa (AN) with epigenetic alterations that are hypothesized to contribute to
illness risk or entrenchment. We investigated the extent to which AN is associated with a methylation profile distinct from
that seen in normal-eater women. Genome-wide methylation profiles, obtained using DNA from whole blood, were
determined in 29 AN patients (10 with AN-restrictive subtype and 19 with AN-Binge/Purge subtype) and 15 normalweight, normal-eater control women, using 450K illumina bead arrays. Regardless of subtype, AN patients showed higher
and less variable global methylation patterns than did controls. False Discovery Rate corrected comparisons identified 14
probes that were hypermethylated in women with AN relative to levels obtained in normal-eater controls, representing
genes associated with histone acetylation, RNA modification, cholesterol storage and lipid transport, and dopamine and
glutamate signalling. Age of onset was significantly associated with differential methylation in gene pathways involved in
development of the brain and spinal cord, while chronicity of illness was significantly linked to differential methylation in
pathways involved with synaptogenesis, neurocognitive deficits, anxiety, altered social functioning, and bowel, kidney,
liver and immune function. Our findings are consistent with the idea of secondary alterations in methylation at genomic
regions relevant to the social-emotional impairments and physical complications commonly seen in AN patients. Further
investigation is needed to establish the clinical relevance of the affected genes and, importantly, reversibility of effects with
nutritional rehabilitation.
Learning Objectives:
• Provide background epigenetic theory in Anorexia Nervosa
• Assess the extent to which global DNA methylation differs between people with and without Anorexia Nervosa
• Examine the probe-wise methylation "signature" that occurs in Anorexia nervosa
Changes in Bulimic Symptoms over Three-year Period: The Interaction Effect of Impulsivity and
Tryptophan Hydroxylase-2 (TPH2) rs4570625 Polymorphism.
Kirsti Akkermann, PhD, Institute of Psychology, University of Tartu, Tartu, Estonia, Estonia; Jaanus Harro, MD, PhD,
Institute of Psychology, University of Tartu, Tartu, Estonia, Estonia; Kadri Kaasik, MA, University of Helsinki, Helsinki,
Estonia, Estonia; Mariliis Vaht, MA, Institute of Psychology, University of Tartu, Tartu, Estonia, Estonia
As there is some evidence that tryptophan hydroxylase-2 (TPH2) rs4570625 polymorphism may be associated to eating
disorders we aimed to explore whether changes in bulimic symptoms are associated to TPH 2 rs4570625 polymorphism in
the population representative sample of young females. The sample was based on the longitudinal Estonian Children
Personality, Behavior and Health Study (n=251). Eating behavior was measured both at the age of 15 and 18 using EDI-2
Bulimia subscale. Also Barratt Impulsiveness Scale (BIS-11) was used at both ages to measure impulsivity. The sample was
genotyped for TPH2 SNP rs4570625 polymorphism. Although impulsivity mean scores did not differ between two
measurements, there was general increase in bulimic symptoms between ages 15 and 18, mean bulimia scores 2.25 and
4.91 respectively. The difference between two measurements of bulimic symptoms was calculated by subtracting the value
measured at 15-years old from respective measurement performed at age of 18. One-way ANOVA was used to to analyze
the differences between group means. There was no main effect of TPH2 rs457062 polymorphism or impulsivity on the
changes in bulimic symptoms. However, there was an interaction effect of impulsivity and TPH2 rs4570625
polymorphism on the changes in bulimia scores, F(3, 197) = 3.65; p = 0.01 ; R2 = 0.053. Females with TPH2 G/G
genotype and high impulsivity exhibited the greatest increase in bulimic symptoms compared to other groups.
Interestingely T-allele carriers with low impulsivity had significantly greater increase in bulimic symptoms compared to Tallele carriers with high impulsivity. This data suggest that changes in bulimic behaviour in late adolescence is influenced
by the combination of the TPH2 polymorphism and impulsivity than by either factor alone.
Learning Objectives:
• Describe the role of serotonin-related biomarkers in relation to eating disorders.
• Assess the effect of TPH2 genotype and impulsivity on bulimic symptoms.
•
Describe possible interaction of biological and psychological risk factors contributing to the maintenance of
bulimic symptoms. Dopamine D2/3 Receptor Antagonism Reduces Activity-Based Anorexia: Implications for Anorexia
Nervosa Treatment
Stephanie Klenotich, PhD, University of Chicago, Chicago, Illinois, USA
Activity-based anorexia (ABA) refers to the dramatic weight loss, hypophagia, and paradoxical hyperactivity that develops
in rodents exposed to running wheels and scheduled feeding, and provides a model for aspects of AN. The atypical
antipsychotic olanzapine was recently shown to reduce ABA in rodents and symptoms of AN. We examined which
component of the complex pharmacological profile of olanzapine reduces ABA behavior. In separate studies, mice received
chronic treatment of 5-HT2A/2C, 5-HT3, dopamine D1, D2, D3, or D2/3 antagonists, and were assessed for food intake,
bodyweight, wheel running, and survival in the ABA paradigm. Furthermore, we directly compared the effects of
olanzapine and the D2/3 antagonist amisulpride on ABA. Chronic treatment with the D2/3 receptor antagonists eticlopride
or amisulpride robustly increased bodyweight, food intake, and survival, defined as the number of days remaining above
75% of initial bodyweight. Furthermore, amisulpride produced larger increases in body weight and food intake than
olanzapine. Finally, treatment with either the D3 receptor antagonist SB 277011A or the D2 receptor antagonist L-741,626
also increased survival. The remaining drug treatments either had no effect, or worsened ABA. All observed effects were
absent during ad libitum feeding conditions. In sum, selective antagonism of D2 and/or D3 receptors robustly reduces ABA
behavior. Further studies investigating the mechanisms by which D2 and/or D3 receptors regulate ABA, and the efficacy
for D2/3 antagonists to treat AN, are warranted.
Learning Objectives:
• Understand data from animal models of anorexic-like behaviors
• Understand the potential therapeutic mechanism of olanzapine to reduce anorexic behaviors
• Translate findings to clinical trials assessing the efficacy of amisulpride in human patients
Restrictive Food Choice Shows Neurological Signature of Habit
Joanna Steinglass, MD, Columbia University/New York State Psychiatric Institute, New York, New York, USA; Karin
Foerde, PhD, New York University, NY, New York, USA; Daphna Shohamy, PhD, Columbia University, New York, New
York, USA; B. Timothy Walsh, MD, FAED, NYSPI/Columbia University, New York, New York, USA
Inadequate intake and preference for low calorie foods is a well-documented phenomenon in Anorexia Nervosa (AN). The
basic mechanisms underlying maladaptive food choice have not been characterized. In this study, we used our recently
published Food Choice Task with neuroimaging to study the neural systems associated with food choice. We hypothesized
that individuals with AN would show increased activation in the dorsal striatum during choice, as compared with healthy
controls (HC). Individuals with AN (n=21) and HC (n=21) participated in a computer-based Food Choice Task during
fMRI scanning. Participants rated food images (high and low fat items) for Healthiness and Tastiness; one item rated
neutral on both blocks was selected as the Reference item. On each of 76 trials participants rated whether they chose the
food item presented or the Reference item. The AN group was less likely to choose high fat foods relative to HC (z=-5.6,
p<0.0001). Health ratings more strongly influenced choice in AN (z=3.4, p<0.001), whereas taste more strongly
influenced choice in HC (z=-6.4, p<0.001), consistent with previous findings. Additionally, health and taste ratings were
more strongly correlated in AN than in HC (Χ2=5.3, p=0.02). Supporting the ecological validity of the task in AN, selection
of high fat foods in the task was significantly associated with caloric intake in a multi-item meal (r=0.61, p=0.01). fMRI
analysis showed significant differences between groups in neural activity during choice. Among AN, choice was associated
with increased activity in the caudate (p<0.05). Among HC, choice was associated with increased amygdala and
hippocampal activation (p<0.005). These findings, in particular the activation of the dorsal striatum, suggest that
maladaptive food choice in AN is driven by habit neural mechanisms. Habit systems may represent an important new
treatment target in AN.
Learning Objectives:
• describe food choice in anorexia nervosa
• summarize a neurocognitive assessment of anorexia nervosa
• discuss neural systems related to food choice in anorexia nervosa
Ovarian Hormones Significantly Enhance Genetic Risk for Binge Eating
Kelly Klump, PhD, FAED, Michigan State University, East Lansing, Michigan, USA; S. Alexandra Burt, PhD, Michigan
State University, East Lansing, Michigan, USA; Pamela Keel, PhD, FAED, Florida State University, Tallahassee,
Florida, USA; Michael Neale, PhD, Virginia Commonwealth University, Richmond, Virginia, USA; Cheryl Sisk, PhD,
Michigan State University, East Lansing, Michigan, USA; Steven Boker, PhD, University of Virginia, Charlottesville,
Virginia, USA
Developmental twin studies have indirectly implicated ovarian hormones in genetic risk for binge eating. Genetic variance
increases substantially during times of ovarian hormone activation (e.g., puberty), leading to theories that the
transcriptional effects of these hormones directly contribute to genetic risk for eating disorder phenotypes. To date, only
one pilot study has directly examined the effects of hormones on genetic risk for binge eating. Although results were
suggestive of hormone effects, small sample sizes prohibited formal biometric testing of gene x hormone interactions.
Thus, the goal of this study was to directly test for these interactions in a larger sample of female twins. Participants
included 628 female twins from the Michigan State University Twin Registry who were assessed daily for 45 days. Binge
eating was measured using the emotional eating subscale of the Dutch Eating Behavior Questionnaire, while saliva
samples were used to obtain estradiol and progesterone levels. Twin moderation models confirmed the presence of
significant gene x hormone interactions, whereby genetic effects were significantly enhanced across estradiol and
progesterone levels. These findings replicate pilot study data and corroborate phenotypic analyses where higher levels of
both estradiol and progesterone predicted higher emotional eating scores across the menstrual cycle. Future studies
should combine the biometrical genetic modeling approach used herein with animal models and molecular genetic
approaches to identify the specific processes contributing to gene x hormone interaction effects.
Learning Objectives:
• Describe the effects of ovarian hormones on rates of binge eating.
• Describe the genetic mechanisms underlying these effects.
• Describe areas for future research, including the potential prevention and treatment implications of this work.
Risk and Maintaining Factors
Chairs: Kelly Berg PhD & Nadia Micali, MD, PhD
Restrictive Eating in Anorexia Nervosa: Examining Maintenance and Consequences in the Natural
Environment
Ellen Fitzsimmons-Craft, PhD, Washington University School of Medicine, St. Louis, Missouri, USA; Erin Accurso, PhD,
The University of Chicago, Chicago, Illinois, USA; Anna Ciao, PhD, Western Washington University, Bellingham,
Washington, USA; Ross Crosby, PhD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Li Cao,
MS, Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Emily Pisetsky, PhD, University Minnesota,
Minneapolis, Minnesota, USA; Daniel Le Grange, PhD, FAED, The University of Chicago, Chicago, Illinois, USA; Carol
Peterson, PhD, FAED, University of Minnesota, Minneapolis, Minnesota, USA; Scott Crow, MD, FAED, University of
Minnesota, Minneapolis, Minnesota, USA; Scott Engel, PhD, Neuropsychiatric Research Institute, Fargo, North Dakota,
USA; James Mitchell, MD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Stephen Wonderlich,
PhD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota, USA
We examined negative and positive affect in relation to restrictive eating episodes (i.e., meals or snacks perceived as
restrictive) and whether restrictive eating was associated with likelihood of subsequent eating disorder behaviors (i.e.,
binge eating, vomiting, laxative use, weighing, exercising, meal skipping, drinking fluids to curb appetite, body checking,
restrictive eating) among 118 women with anorexia nervosa using ecological momentary assessment. Multilevel modeling
revealed that for both restrictive and non-restrictive eating, negative affect significantly increased from pre-behavior to the
time of the behavior but remained stable thereafter (ps<.001) while positive affect remained stable from pre-behavior to
the time of the behavior but decreased significantly thereafter (ps<.002). Across time, negative affect was significantly
lower (p=.002) and positive affect was significantly higher (p<.001) in restrictive eating episodes than in non-restrictive
eating episodes. Generalized estimating equation models showed that engagement in a restrictive eating episode was
associated with an increased likelihood of engagement in restrictive eating, laxative use, and body checking at the next
report (ps<.021). Engagement in a non-restrictive eating episode was associated with a decreased likelihood of subsequent
binge eating, vomiting, laxative use, weighing, meal skipping, drinking fluids to curb appetite, and body checking
(ps<.034). Despite similar patterns of affect across eating episode type over time, results suggest that affect may be
involved in the maintenance of restrictive eating on some level (i.e., in that restrictive eating episodes were associated with
lower negative and greater positive affect across time compared to non-restrictive episodes). Further, while restrictive
eating episodes did not always increase the likelihood of later eating disorder behaviors, non-restrictive eating episodes
often decreased their likelihood and were protective.
Learning Objectives:
• Demonstrate a greater understanding of the relations among negative and positive affect and restrictive and nonrestrictive eating
• Consider the effects of restrictive and non-restrictive eating on later eating disorder behaviors
• Acquire an understanding of ecological momentary assessment and multilevel modeling and the advantages of
using these techniques
Emotional, Behavioral, and Environmental Context of Purging Episodes in Anorexia Nervosa
Andrea Goldschmidt, PhD, The University of Chicago, Chicago, Illinois, USA; Erin Accurso, PhD, The University of
Chicago, Chicago, Illinois, USA; Ross Crosby, PhD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota,
USA; Li Cao, MS, Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Scott Engel, PhD, Neuropsychiatric
Research Institute, Fargo, North Dakota, USA; James Mitchell, MD, FAED, Neuropsychiatric Research Institute, Fargo,
North Dakota, USA; Scott Crow, MD, FAED, University of Minnesota, Minneapolis, Minnesota, USA; Carol Peterson,
PhD, FAED, University of Minnesota, Minneapolis, Minnesota, USA; Daniel Le Grange, PhD, The University of Chicago,
Chicago, Illinois, USA; Stephen Wonderlich, PhD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota,
USA
Purging behaviors including self-induced vomiting and laxative misuse are common in anorexia nervosa (AN), and are
associated with negative health outcomes. Although these behaviors are typically preceded by binge eating episodes, it is
unclear whether overeating, loss of control, or their combined effects are most strongly related to subsequent purging.
Furthermore, although purging often occurs in the context of non-pathological eating, predictors of purging in the absence
of overeating and loss of control are currently unclear. We studied 118 women with AN who completed a 2-week ecological
momentary assessment protocol involving daily reports of eating disorder behaviors, mood, and stressful events. Using
generalized estimating equations, we examined the likelihood of purging following eating episodes involving both
overeating and loss of control (objective binge eating; OBE); loss of control without overeating (subjective binge eating;
SBE); overeating without loss of control (objective overeating; OO); and neither loss of control nor overeating (nonpathological eating; NE). We also examined affective, behavioral, and environmental predictors of purging following NE.
Purging was more likely to occur following OBE, SBE, and OO relative to NE. While OBE was more strongly associated
with subsequent purging than SBE, SBE did not differ from OO (Wald chi-square=18.05; p<.001). In a simultaneous
prediction model, only negative affect predicted purging following NE episodes (p=.03); neither body checking, eating a
high risk food, nor the occurrence of stressful events were significant predictors (ps>.05). Results suggest that overeating
is a salient predictor of purging in the context of pathological eating, while negative affect is most salient in the context of
non-pathological eating among women with AN. Future studies should examine whether negative affect mediates the
relation between behavioral and environmental factors and subsequent purging in AN.
Learning Objectives:
• To understand the emotional, behavioral, and environmental antecedents to purging episodes in women with
anorexia nervosa.
• The identify predictors of purging in the absence of binge eating.
• To apply findings to maintenance models of purging in anorexia nervosa.
Thin-Ideal Internalization and Dietary Restraint: Potential Moderators of the Association between
Negative Urgency and Binge Eating
Sarah E. Racine, PhD, Ohio University, Athens, Ohio, USA; Jessica L. Van Huysse, PhD, Genesys Regional Medical
Center, Grand Blanc, Michigan, USA; S. Alexandra Burt, PhD, Michigan State University, East Lansing, Michigan,
USA; Pamela K. Keel, PhD, FAED, Florida State University, Tallahassee, Florida, USA; Michael Neale, PhD, Virginia
Commonwealth University, Richmond, Virginia, USA; Steven Boker, PhD, University of Virginia, Charlottesville,
Virginia, USA; Cheryl L. Sisk, PhD, Michigan State University, East Lansing, Michigan, USA; Kelly L. Klump, PhD,
FAED, Michigan State University, East Lansing, Michigan, USA
Accumulating evidence suggests that negative urgency (i.e., the tendency towards rash action when distressed) is a robust
risk factor for the development of binge eating. However, negative urgency also increases vulnerability for additional
maladaptive behaviors (e.g., alcohol/substance use), suggesting divergent trajectories. It is currently unclear why an
individual with high levels of negative urgency may develop binge eating versus another type of impulsive behavior.
Investigation of interactions between negative urgency and risk factors specific to binge eating/eating pathology may help
clarify how negative urgency leads to binge eating. The current study examined these interactions with two risk factors
specified in the dual-pathway model of bulimic pathology: thin-ideal internalization (distal risk factor) and dietary
restraint (proximal risk factor). Participants were 916 post-pubertal female twins between the ages of 10-25 years from the
Michigan State University Twin Registry. Hierarchical linear models revealed significant main effects for negative
urgency, thin-ideal internalization, and dietary restraint in the prediction of binge eating, after controlling for age and
body mass index. Negative urgency and thin-ideal internalization significantly interacted to predict binge eating, such that
individuals with high levels of both negative urgency and thin-ideal internalization reported the greatest binge eating
pathology. In contrast, dietary restraint did not significantly moderate negative urgency-binge eating associations. Results
advance theoretical models of binge eating development, such as the dual-pathway model, by suggesting that negative
urgency may be more likely to interact with distal rather than proximal risk factors for binge eating. Future research on
divergent trajectories must identify the mechanisms by which thin-ideal internalization shapes vulnerability created by
negative urgency into binge eating versus another impulsive behavior.
Learning Objectives:
• Describe the role of negative urgency in the development of binge eating.
• Recognize thin-ideal internalization as a significant moderator of the association between negative urgency and
binge eating.
• Discuss directions for future research that aims to identify mechanisms underlying this moderation relationship.
Examining the Temporal Precedence of the Association between Emotional Eating and Weight
Preoccupation
Britny Hildebrandt, MA, Michigan State University, East Lansing, Michigan, USA; Sarah Racine, PhD, Ohio University,
Athens, Ohio, USA; Pamela Keel, PhD, FAED, Florida State University, Tallahassee, Florida, USA; S. Alexandra Burt,
PhD, Michigan State University, East Lansing, Michigan, USA; Michael Neale, PhD, Virginia Commonwealth
University, Richmond, Virginia, USA; Steven Boker, PhD, University of Virginia, Charlottesville, Virginia, USA; Cheryl
Sisk, PhD, Michigan State University, East Lansing, Michigan, USA; Kelly Klump, PhD, FAED, Michigan State
University, East Lansing, Michigan, USA
Research has shown significant cross-sectional associations between emotional eating (EE) and weight preoccupation
(WP). However, little is known about longitudinal associations, i.e., if EE leads to WP, or if increased levels of WP lead to
EE. Understanding the direction of associations could be invaluable for designing prevention and treatment efforts aimed
at decreasing the likelihood of both behaviors. The current study investigated both proximal (day after) and longer-term
(several days later) associations between EE and WP using longitudinal daily data. Participants (N = 352 women)
completed daily ratings of WP (assessed using the Minnesota Eating Behaviors Survey) and EE (examined using the Dutch
Eating Behavior Questionnaire) for 45 consecutive days. Time-lagged prospective analyses investigated whether withinperson EE scores on 1 day predicted WP scores on later days, and vice versa. We considered both proximal (i.e., 1-, 2-, and
3-day) and more distal (i.e., 5- and 10-day) time-lagged associations. Results indicated that EE significantly predicted
within-person changes in WP, 1, 2, and 3 days later (p < .05), and associations 5- and 10-days later were marginally
significant (ps = .07 - .08). Analyses examining the reverse relationship demonstrated that WP did not significantly
predict subsequent EE scores. Findings confirm that negative affect often associated with WP does not lead to EE, but
other factors (e.g., ovarian hormones) likely predict EE, which leads to increases in WP. Given that increases in WP due to
EE might confer risk for the subsequent occurrence of behaviors aimed at preventing weight gain (e.g., dietary restriction,
compensatory behaviors), future studies should examine the relationships between changes in WP and changes in these
other eating disorder symptoms to identify temporal associations across the spectrum of eating disorder
attitudes/behaviors.
Learning Objectives:
• Describe the association between emotional eating and weight preoccupation.
• Discuss the temporal relationship between emotional eating and weight preoccupation.
• Consider the implications of increased weight preoccupation after emotional eating.
Weight Suppression Predicts Bulimic Symptoms at 20-year Follow-up: Examination of Potential
Psychological Mediators
Lindsay Bodell, MS, Florida State University, Tallahassee, Florida, USA; Tiffany Brown, MS, Florida State University,
Tallahassee, Florida, USA; Pamela Keel, PhD, FAED, Florida State University, Tallahassee, Florida, USA
Weight suppression (the difference between one’s highest previous and current weight) has been found to predict both the
onset and maintenance of bulimic syndromes. Despite this robust finding, no studies have specifically examined whether
the effect of weight suppression in young adulthood affects bulimic symptoms in midlife. Further, no studies have
examined possible mediators of this effect. Given societal pressures to be thin, it is possible that higher weight suppression
contributes to desire to maintain weight loss, which may further increase preoccupation with being thin and dieting
frequency. These cognitions and behaviors may then contribute to vulnerability to binge eat. The present study aimed to
examine whether weight suppression continues to be associated with bulimic symptoms at 20-year follow-up and whether
increased dieting frequency and thinness preoccupation mediate this effect. Participants were women (n=855) and men
(n=329) from a larger study on health and eating behaviors who completed self-report surveys in college (mean age=20)
as well as 10- and 20- years later (mean ages= 30 and 40). Higher weight suppression at baseline significantly predicted
higher bulimic symptoms at 20-year follow-up, even after controlling for sex, cohort, baseline bulimic symptoms, BMI,
and dieting frequency (p<.001). Additionally, increased dieting frequency and thinness preoccupation at 10-year follow-up
partially mediated this effect. Findings highlight the long-lasting effect of weight suppression on bulimic symptoms and
suggest that cognitive and behavioral consequences of weight suppression may help maintain this association. The fact
that dieting and preoccupation with thinness only partially mediated the association between weight suppression and
bulimic symptoms suggests that other consequences of weight suppression, including biological factors, may be involved
in driving this association and should be examined in future studies.
Learning Objectives:
• Describe the relationship between weight suppression and bulimic symptoms over long-term follow-up.
• Identify potential psychological mechanisms of the association between weight suppression and bulimic
symptoms.
• Discuss potential consequences of weight suppression and how they may influence onset and maintenance of
bulimia nervosa.
Food Fear and Body Disgust Predict EDE-Q Scores
Lisa Anderson, MA, University at Albany, State University of New York, Albany, New York, USA; Jennifer Thomas,
PhD, FAED, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Kamryn Eddy,
PhD, FAED, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Debra Franko,
PhD, FAED, Northeastern University, Boston, Massachusetts, USA; Heather Thompson-Brenner, PhD, Boston
University, Boston, Massachusetts, USA; Erin Reilly, PhD, University at Albany, State University of New York, Albany,
New York, USA; Drew Anderson, PhD, University at Albany, State University of New York, Albany, New York, USA
In spite of promising outcomes thus far, current fear-focused exposure interventions for eating disorders may not address
another important treatment target and difficult-to-extinguish emotion: disgust. The current study evaluated the whether
disgust and fear responses to eating disorder-relevant visual stimuli (food and bodies) significantly predicted eating
disorder symptoms. Using a visual analogue scale (VAS), 400 undergraduate participants reported disgust and fear
reactions to eating disorder-relevant (high-calorie food, low-calorie food, low-weight bodies, normal-weight bodies, and
high-weight bodies) and general fear- or disgust-eliciting images. Eating disorder symptomatology was assessed using the
Eating Disorder Examination Questionnaire (EDE-Q). Among females, a model evaluating the contributions of overall,
non-specific disgust and fear to eating disorder symptomatology was not significant (adjusted R2=.35, ∆R2=.02,
F(2,190)=2.98, p >.05). However, a more nuanced analysis of responses to eating disorder-relevant stimuli improved the
overall model fit (adjusted R2 = .42, ∆R2 =.09, F(13, 214) = 12.73, p < .001). Specifically, female fear responses to normal
weight body images emerged as significant predictors of EDE-Q global scores (β = -.26, t = -.20, p < .01). Analyses for
male participants revealed that greater disgust to high calorie foods predicted higher EDE-Q global scores (β = .20, t =
1.78, p = .07). These results suggest that fear reactions to disorder-relevant stimuli are potential maintaining mechanisms
for eating disorder psychopathology, and that there may be gender-specific relationships between fear, disgust, and eating
disorders. This is notable, as recent research has suggested that disgust may be more resistant to extinction than fear.
Therefore, future work should evaluate whether the implementation of disgust hierarchies, in addition to the morecommon fear-focused interventions for eating disorders, enhances treatment efficacy.
Learning Objectives:
• Evaluate and discuss differences between disgust and fear, and their relevance to eating disorders
• Understand how disgust and fear are associated with eating disorder symptom severity
• Extend findings to current exposure interventions and future treatment development
Treatment of Eating Disorders (adult)
Chairs: Heather Thompson-Brenner, PhD & Eva Trujillo, MD
Bridging the Knowledge-to-Action Gap in Primary Care for Eating Disorders: Implementing and
Evaluating a Training Program for Health Care Professionals
Myra Piat, PhD, MSW, Douglas Mental Health University Institute, Montreal, Quebec, Canada; Alexis Pearson, Student,
Douglas Mental Health University Institute Research Centre, Montreal, Quebec, Canada; Jessica Spagnolo, MSW,
Douglas Mental Health University Institute Research Centre, Montreal, Quebec, Canada
The Douglas Eating Disorders Program in Montreal, Canada is an international centre of expertise on Eating Disorders
(EDs) in the Anorexia and Bulimia spectrum. Every year, patients who could be treated in primary care are referred to the
Douglas because primary care professionals lack knowledge and skills to effectively assess and treat EDs; as a result, wait
times are problematic. The Douglas recently developed and implemented an evidence-informed training program to
strengthen the capacity of primary healthcare teams to deliver services to ED patients. The training program adopts an
interactive learning approach including workshops, clinical supervision meetings, observation of group therapy sessions,
and documentation. From 2012 to 2014, 1404 hours of training were delivered to 123 primary healthcare professionals in
10 community healthcare organizations. Seventy patients were treated in primary care as a result of training. The purpose
of this study is to examine healthcare professionals’ assessment of the training, its impact on their work, and barriers and
facilitators to using the knowledge translated. Focus group interviews were conducted with 9 multidisciplinary healthcare
teams. Three researchers read transcripts from the first three interviews and identified implicit themes, then organized
themes into analytical categories. The subsequent transcripts were coded; categories and themes were expanded and
refined as necessary to incorporate new data. Professionals described the training as interesting and clinically relevant.
Training improved professionals’ knowledge and practices by demystifying EDs, increasing professionals' sensitivity to
EDs, and increasing their assessment skills. Trainers were perceived as competent and engaging. Supervision and group
observation were viewed as essential to connect theory to practice. After training, some participants described themselves
as ill-equipped to treat EDs. They expressed the need to integrate knowledge through more practical learning.
Learning Objectives:
• Develop an eating disorders training program adapted to the needs of professionals working in community
healthcare organizations.
• Understand the perspective and experiences of primary healthcare professionals implementing knowledge and
skills from a training program on eating disorders.
• Tailor training messages and activities to facilitate the uptake of knowledge and skills for primary healthcare
professionals participating in a training program on eating disorders.
The ANTOP Study - a Randomized Multicentre Outpatient Treatment Trial in Anorexia Nervosa
Stephan Zipfel, PhD, MD, Dept.Psychosomatic Medicine and Psychotherapy, University of Tuebingen, Tuebingen,
Baden-Wuerttemberg, Germany
1. Introduction Psychotherapy is the treatment of choice for patients with anorexia nervosa, although evidence of efficacy
is weak. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study aimed to assess the efficacy and safety of two
manual-based outpatient treatments for anorexia nervosa—focal psychodynamic therapy (FPT) and enhanced cognitive
behaviour therapy (CBT-E) - versus optimised treatment as usual (TAU-O). 2. Methods The ANTOP study is a
multicentre, randomised controlled effi cacy trial in adults with anorexia nervosa. We recruited patients from ten
university hospitals in Germany. Participants were randomly allocated to 10 months of treatment with either FPT, CBT-E,
or TAU-O. The primary outcome was weight gain, measured as increased body-mass index (BMI) at the end of treatment.
A key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psycho
pathology). 3. Results Of 727 adults screened for inclusion, 242 underwent randomisation: 80 to focal FPT, 80 to CBTE, and 82 to TAU-O. At the end of treatment, 54 patients (22%) were lost to follow-up, and at 12-month follow-up a total
of 73 (30%) had dropped out. At the end of treatment, BMI had increased in all study groups (FPT 0·73 kg/m², CBT-E
0·93 kg/m², TAU-O 0·69 kg/m²); no differences were noted between groups. At 12-month follow-up, the mean gain in
BMI had risen further (1·64 kg/m², 1·30 kg/m², and 1·22 kg/m², respectively), but no differences between groups were
recorded Study groups did not differ in terms of global outcome between baseline and the end of treat ment. At 12-month
follow-up, however, patients assigned FPT had a significantly higher recovery rate compared with TAU-O (full recovery,
35% vs 13%; p=0·036). No serious adverse events attributable to weight loss or trial participation were recorded. 4.
Conclusions TAU-O, combining psychotherapy and structured care from a family doctor, should be regarded as solid
baseline treatment for adult outpatients with anorexia nervosa. FPT proved advantageous in terms of recovery at 12month follow-up, and CBT-E was more eff ective with respect to speed of weight gain and improvements in eating disorder
psychopathology. Long-term outcome data will be helpful to further adapt and improve these novel manual-based
treatment approaches.
Learning Objectives:
• Describe the study design of the RCT
• Describe the treatments applied
• Summerize the results with respect to weight gain and recovery rates at teh end of treatment and follow-up
Mental capacity, the Association with Decision Making and Effect on Outcome in Anorexia Nervosa
Patients
Isis Elzakkers, MSc, MD, Altrecht Eating Disorders Rintveld, Zeist, Utrecht, Netherlands; Unna Danner, PhD, MSc,
Altrecht Eating Disorders Rintveld, Zeist, Utrecht, Netherlands; Hans Hoek, PhD, MD, Parnassia Bavo Psychiatric
Institute, The Hague, Zuid Holland, Netherlands; Annemarie van Elburg, PhD, MD, Altrecht Eating Disorders Rintveld,
Zeist, Utrecht, Netherlands
The aim of our study is to examine the prevalence of diminished mental capacity in adults with anorexia nervosa (AN) and
to test the association of diminished mental capacity with clinical and neuropsychological characteristics. Data have been
collected at the start of treatment and one year follow-up. In total,70 patients were included in the study comprising a
severely ill group with a mean BMI of 15.5, an illness duration of 8.6 years and severe comorbidity. One third of this group
had diminished mental capacity as assessed by the clinician. This group had a significantly lower mean BMI, more
previous AN treatment and a significantly lower appreciation of their disorder as measured by the MacCAT-T (a
semistructured interview to assess mental capacity). Lower appreciation was associated with higher alexithymia scores.
Also the group with diminished mental capacity showed impaired decision making on the Iowa Gambling Task (IGT),
indicating an association between inadvantageous decision making and diminished mental capacity. Results after 1 year
follow up show that both the group with diminished mental capacity as with full mental capacity gain 2 BMI points (from
14.3 to 16.4 and 16.3 to 18.3 respectively), had higher appreciation scores (no longer different from the other group) and
were less alexithymic. Symptom levels between groups did not differ after 1 year. Other results are currently being
analyzed and will be presented at the conference together with implications for clinical practice.
Learning Objectives:
• describe clinical and neuropsychological parameters that point towards diminished mental capacity
• discuss the relevance of diminished mental capacity on treatment effect after 1 year
• discuss the stability of the degree of mental capacity during treatment and factors influencing this
Autonomous Versus Controlled Motivation: An Examination of the Role of Self-Determination Theory in
Predicting Treatment Outcome in Women with Eating Disorders.
Sabina Sarin, PhD, MPhil, MS, Douglas Institute, Montreal, Quebec, Canada; Juliana Mazanek Antunes, MSc,
L'Université du Québec à Montréal, Montreal, Quebec, Canada; Lea Thaler, PhD, Douglas Institute, Montreal, Quebec,
Canada; Geneviève Brodeur, BA, Douglas Institute, Montreal, Quebec, Canada; Niamh Leonard, BA, Douglas Institute,
Montreal, Quebec, Canada; Samantha Wilson, BA, L'Université du Québec à Montréal, Montreal, Quebec, Canada;
Ashley Wanamaker, BA, Douglas Institute, Montreal, Quebec, Canada; Mimi Israel, MD, Douglas Institute, Montreal,
Quebec, Canada; Howard Steiger, PhD, Douglas Institute, Montreal, Quebec, Canada
We compared the extent to which autonomous versus controlled motivation predicted changes in eating-disorder, mood
and impulsive symptoms in women undergoing inpatient treatment for eating disorders. Questionnaires assessing
admission and discharge levels of motivation, eating-disordered symptoms, depression, anxiety and impulsivity were
available for 35 patients with Anorexia Nervosa (AN) who were admitted to the Douglas Institute’s inpatient Eating
Disorders Program (EDP). In addition, we assessed admission and discharge BMI, length of treatment, and comorbid
psychiatric diagnoses. Multiple regression analyses revealed that higher levels of autonomous motivation at admission
significantly predicted lower post-treatment eating disorder symptom scores, whereas higher pre-treatment levels of
controlled motivation predicted increased weight concerns at discharge and smaller reductions in impulsivity scores. Our
findings suggest that levels of autonomous and controlled motivation at admission may be important predictors of
treatment outcome in patients with AN undergoing inpatient treatment, with higher internal motivation predicting
favorable outcomes, and controlled motivation predicting unfavorable ones. These findings will be compared with
preliminary results from an outpatient sample of women with both anorexia and bulimia nervosa. Further studies are
warranted to evaluate the impact of these distinct types of motivation (autonomous versus controlled) on eating disorder
treatment outcomes and, eventually, of interventions aimed at altering patients’ motivational status.
Learning Objectives:
• Describe the relevance of self-determination theory to eating disorders
• Discuss the impact of autonomous (versus controlled) motivation on treatment outcome
• Consider the clinical implications of these distinct types of motivation, and the utility of interventions aimed at
altering them
Physical Activity and 12-month Follow-Up Weight Outcomes in Anorexia Nervosa
Christine Call, BA, Columbia Center for Eating Disorders, New York State Psychiatric Institute, New York, New York,
USA; Gabriella Guzman, BA, Columbia Center for Eating Disorders, New York State Psychiatric Institute, New York,
New York, USA; Loren Gianini, PhD, Columbia Center for Eating Disorders, New York State Psychiatric Institute, New
York, New York, USA; Diane Klein, MD, New York University Langone Medical Center, New York, New York, USA;
Evelyn Attia, MD, FAED, Columbia Center for Eating Disorders, New York State Psychiatric Institute, New York, New
York, USA; Yuanjia Wang, PhD, Department of Biostatistics, Mailman School of Public Health, Columbia University,
New York, New York, USA; Guangwei Qiu, MA, Department of Biostatistics, Mailman School of Public Health, Columbia
University, New York, New York, USA; B. Timothy Walsh, MD, FAED, Columbia Center for Eating Disorders, New York
State Psychiatric Institute, New York, New York, USA
Previous findings from questionnaire and interview-based measures suggest that patients with anorexia nervosa (AN)
report more physical activity than individuals without eating disorders, but little research has explored the impact of
objectively-measured physical activity on post-treatment weight outcomes in this population. This study aimed to explore
the relationship between objectively-measured physical activity prior to discharge from inpatient treatment and BMI
across a 12-month follow-up period in patients with AN. We examined non-exercise physical activity, specifically total
time on feet, time spent fidgeting, and time spent standing still. We hypothesized that higher levels of physical activity
upon acute weight restoration in patients with AN would predict lower BMI at post-treatment follow-up assessments. 61
patients with AN wore the Intelligent Device for Energy Expenditure and Activity (IDEEA), which attaches to the body via
five sensors, to measure various components of physical activity for up to 72 hours at a time. Patients with AN wore the
IDEEA on an inpatient unit following acute weight restoration. Results of linear mixed effects modeling showed that the
interaction between time spent on feet and time since discharge predicted decreases in BMI up to one year after hospital
discharge (t(40)=-2.03, p=.049). The interaction between fidgeting and time since discharge approached significance in
predicting follow-up BMI (t(173)=1.78, p=.076), as did the interaction between time standing still and time since
discharge (t(39)=-1.73, p=.091). These findings may have important clinical implications as they demonstrate that nonexercise physical activity, even after weight-restoration, may be related to lower BMI months after treatment. Future
research could examine the motivations driving non-exercise physical activity in this population and explore interventions
to help individuals with AN who continue to engage in these behaviors post-treatment.
Learning Objectives:
• Describe a method of monitoring non-exercise physical activity
• Assess how physical activity may relate to post-treatment outcome in patients with AN
• Consider possible clinical implications of physical activity in patients with AN
Are We Underusing Antidepressants in the Treatment of Eating Disorders?
Suzanne Straebler, APRN-BC, BA, University of Oxford, Oxford, oxford, United Kingdom (Great Britain); Zafra Cooper,
DPhil, DClinPsy, University of Oxford, Oxford, Oxford, United Kingdom (Great Britain); Christopher G Fairburn, MD,
FAED, University of Oxford, Oxford, Oxford, United Kingdom (Great Britain)
Comorbidity is common among individuals with eating disorders. Features of depression are especially prevalent and are
often viewed as secondary to the eating disorder. However, we have found that in a significant subgroup of cases the
depressive features respond well to a specific form of antidepressant treatment. We present a case series of 150
consecutive referrals to a well-established catchment area-based eating disorder clinic. In this sample almost half of the
patients (43.3%; n=65) were classed as having a co-existing clinical depression. These diagnoses were made jointly by the
second and third authors, both experienced clinicians, using DSM-IV criteria, but with the additional requirement that
certain specific features also be present (e.g. recent loss of drive and outside interests; recent social withdrawal; global
negative thinking). Sixty-three of these patients (96.9%) agreed to take antidepressant medication and were treated with
fluoxetine. They were started on either 20mg or 40mg. The dose of fluoxetine was then increased by 20mg at three week
intervals until an unambiguous and sustained response was obtained. This occurred in 100% of the cases. The dose of
fluoxetine required was: 20mg (3.2% of the patients); 40mg (12.7%); 60mg (52.4%); 80mg (26.9%); 100mg (4.8%). The
successful treatment of the depressive features did not result in a resolution of the accompanying eating disorder. These
findings require replication. If replicated, we suggest that they will have important theoretical and clinical implications.
Learning Objectives:
• Participants will learn that in a particular subgroup of individuals with an eating disorder accompanying
depressive features respond to fluoxetine.
• Participants will learn that to obtain an antidepressant response in individuals with an eating disorder a higher
than usual dose of fluoxetine may be required.
• Participants will learn that the resolution of the depressive features does not remove the eating disorder.
Oral Scientific Paper Session II
Saturday, April 25
3:00 – 4:30p.m.
Adult Treatment: Cognitive-Behavorial Therapy
Chairs: Christopher Thornton, MClinPsy & Kristin von Ranson, Phd
CBT4BN: A Randomized Controlled Trial of Cognitive Behavioral Chat Group Therapy for Bulimia
Nervosa
Stephanie Zerwas, PhD, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA; Marsha Marchus,
PhD, FAED, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Hans Kordy, PhD, University of Heidelberg,
Heidelbergh, Germany, Germany; Robert Hamer, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina, USA; Sara Hofmeier, MA, LPC, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA;
Michele Levine, PhD, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Benjamin Zimmer, PhD, University of
Heidelberg, Heidelberg, Germany, Germany; Cristin Runfola, PhD, University of North Carolina at Chapel Hill, Chapel
Hill, North Carolina, USA; Christine Peat, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina, USA; Hunna Watson, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA;
Cynthia Bulik, PhD, FAED, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
Although cognitive-behavioral therapy (CBT) is an efficacious treatment for bulimia nervosa (BN), dissemination has been
suboptimal. We evaluated whether CBT delivered through a moderated chat-group (chat) was as effective as face-to-face
group CBT (F2F). Over the past 4 years, 196 participants were recruited to participate in the CBT4BN clinical trial. Of
participants, 97 were randomized to the online chat group condition (16 sessions of therapist-moderated group CBT) and
99 were randomized to the F2F group condition (16 face-to-face sessions). Participants were 29 years on average. The
groups were diverse (4% Latino, 6% African-American, 3% Asian, 3% male). Group size averaged 3-4 participants.
Diagnostic structured interviews (SCID and EDE) were conducted before enrollment in the trial and at the end of
treatment. We hypothesized that chat and F2F group therapy would have similar outcomes. Specifically, participants in
the two groups were expected to have no significant differences in the frequency of binge eating and vomiting episodes or
rates of abstinence from binge eating and purging (defined as 0 episodes over the past 28 days) by the end of treatment.
Results documented that binge eating and vomiting episodes decreased significantly between enrollment and end of
treatment in both treatment groups (15.93 vs. 5.79 episodes/month of objective binge eating, p<.05 and 27.98 vs. 8.7
episodes/month of vomiting, p<.05). As hypothesized, there were no significant differences between the chat and F2F
groups in the frequency of binge eating (8.9 vs. 8.1 episodes, respectively) or vomiting (8.8 vs. 8.6 episodes) at the end of
treatment. In addition, at the end of treatment, 30.4% participants in the chat condition were abstinent in comparison to
31.3% of participants in the F2F condition (X2=0.018, ns). Data from the 1-year follow-up assessment will be collected and
analyzed by ICED 2015. Results will be discussed with respect to the acceptability of new technology for the dissemination
of CBT to reduce the suffering and burden of those with BN. We will also frame the discussion with regard to the pros and
cons of anonymity and convenience that accompany online chat therapy.
Learning Objectives:
• Compare and contrast chat group therapy to face-to-face group therapy for bulimia nervosa.
• Describe the efficacy of chat group therapy in comparison to face-to-face group therapy.
• Evaluate the advantages and disadvantages of conducting therapy online.
Randomized Controlled Trial Testing Behavioral Weight Loss versus Stepped-Care Treatment of Binge
Eating Disorder
Carlos Grilo, PhD, Yale University School of Medicine, New Haven, Connecticut, USA
This randomized controlled trial tested the effectiveness of a stepped-care approach to behavioral weight loss (BWL) for
patients with obesity and binge eating disorder (BED). 191 patients (mean age 48, 71% female, 79% white) with BED and
co-morbid obesity (mean BMI 39) were randomly assigned to 6 months of BWL (N=39) or stepped-care (N=152). Within
stepped-care, patients started with BWL for one month; treatment-responders continued with BWL while non-responders
switched to specialist treatment (CBT) and all stepped-care patients were additionally randomized to either anti-obesity
medication or placebo (double-blind) for the remaining five months. Independent assessments were performed by
research-clinicians at baseline, throughout treatment, and post-treatment (90% assessed) with reliably-administered
structured interviews and measures. ITT analyses of remission rates (zero binges/month) revealed BWL and stepped-care
did not differ significantly overall (74% vs 64%); within stepped-care, however, remission rates differed (range 40% - 79%)
with medication significantly superior to placebo overall (p<0.005) and among initial non-responders switched to CBT
(p<0.002). Mixed-models regression analyses of binge eating frequency revealed significant time effects but that BWL and
stepped-care did not differ overall; within stepped-care, however, medication was significantly superior to placebo overall
and among initial non-responders switched to CBT. Mixed models revealed significant weight loss over time but that BWL
and stepped-care did not differ overall; within stepped-care, however, medication was significantly superior to placebo
overall and among both initial responders continued on BWL and non-responders switched to CBT. Overall, BWL and
stepped-care treatments produced significant improvements in binge-eating and weight loss in obese patients with BED.
Anti-obesity medication enhanced outcomes achieved with behavioral treatments within a stepped-care model.
Learning Objectives:
• Following the training, participants will be able to recognize available behavioral and anti-obesity treatments for
binge eating disorder.
• Following the training, participants will be able to describe expected outcomes associated with behavioral weight
loss and stepped-care treatment methods for binge eating disorder.
• Following the training, participants will be able to describe potential effects associated with adding anti-obesity
medications to different behavioral treatment methods for binge eating disorder.
Comparative Efficacy of Two Guided Self-Help Treatments for Binge Eating Disorder: 12 Month FollowUp Results
Athena Robinson, PhD, Stanford University, Stanford, California, USA; Lilya Osipov, PhD, Stanford University,
Stanford, California, USA
Cognitive Behavioral Therapy Guided Self-Help (CBT-GSH) is an efficacious treatment for Binge Eating Disorder (BED)
yet it yields high attrition rates and leaves a significant minority of patients symptomatic at follow-up. The current study
evaluated the comparative efficacy of CBT-GSH and an affect regulation GSH treatment for BED, Integrative Response
Therapy (IRT), which may be a viable alternative to CBT-GSH. Adult subjects who met DSM-5 criteria for BED (n=86;
87% women; mean(sd) age= 47.96(14.44)) were randomly assigned to 10 sessions of either group CBT-GSH or group IRT.
The Eating Disorder Examination assessed binge eating and associated disordered eating pathology at baseline, posttreatment, and 6- and 12-month follow-up (12M). Preliminary repeated measures analysis revealed no significant between
group differences on disordered eating pathology, binge eating frequency, or binge eating abstinence at any assessment
point, with approximately 50% of participants abstinent in either group at both follow-ups. Moderator analyses indicated
that participants who, at baseline, had low emotional clarity (i.e., greater difficulty knowing and understanding how they
feel) had significantly fewer objective binge episodes over the previous 28 days at 12M when in CBT-GSH compared to IRT
(p=.001). Of note, CBT-GSH had significantly higher attrition than IRT (CBT-GSH=29%, IRT=14%, p=.038). Results: a)
provide the first available evidence for the efficacy of an affect regulation, group based treatment for BED, and b) confirm
the efficacy of GSH treatments for BED, as both CBT-GSH and IRT achieved 12M abstinence rates comparable to those of
non-GSH treatments, but in about half the number of therapy sessions and without advanced degree-holding therapists.
Since CBT-GSH and IRT have comparable efficacy in reducing binge eating and associated disordered eating pathology,
IRT may be a viable alternative treatment to CBT-GSH.
Learning Objectives:
• Understand the rationale for the development of IRT, the first affect regulation and group based GSH treatment
for BED.
• Articulate the differences between CBT-GSH and IRT in their theoretical basis and intervention approach.
• Describe the comparative efficacy of CBT-GSH and IRT on disordered eating pathology, binge eating frequency,
and binge eating abstinence, and contextualize such findings within the broader BED treatment efficacy literature.
Homework and Self-Monitoring Compliance as a Predictor of Binge Eating Abstinence in Group CBT for
Binge Eating Disorder
Kelly Berg, PhD, University of Minnesota, Minneapolis, Minnesota, USA; James Mitchell, MD, FAED, Neuropsychiatric
Research Institute/University of North Dakota, Fargo, North Dakota, USA; Scott Crow, MD, FAED, University of
Minnesota, Minneapolis, Minnesota, USA; Ross Crosby, PhD, FAED, Neuropsychiatric Research Institute/University of
North Dakota, Fargo, North Dakota, USA; Stephen Wonderlich, PhD, FAED, Neuropsychiatric Research
Institute/University of North Dakota, Fargo, North Dakota, USA; Carol Peterson, PhD, FAED, University of Minnesota,
Minneapolis, Minnesota, USA
Cognitive behavioral therapy (CBT) has demonstrated efficacy for reducing binge eating among individuals with Binge
Eating Disorder (BED), yet little is known about the mechanisms of change in CBT for BED. Homework is one of the
hallmark components of CBT and homework compliance (HC) has been related to outcome in the treatment of anxiety
and mood disorders. A second important component of CBT for BED is self-monitoring daily food intake. Researchers
have found that self-monitoring is reactive, suggesting that self-monitoring itself may be effective at reducing binge eating.
However, there is no published research examining whether either HC or self-monitoring compliance (SMC) is associated
with binge eating abstinence in treatment for BED. Thus, the purpose of the current study was to examine whether HC
and/or SMC predicted binge eating abstinence in a randomized controlled trial of group CBT for BED. Adults seeking
treatment for BED (n=235, 88.1% female) received one of three group treatments: therapist-led CBT, therapist-assisted
CBT, or self-help CBT. HC and SMC were defined as the percentage of homework assignments and self-monitoring
records attempted. Both HC and SMC varied substantially among participants (range of HC=0.0% - 98.0%; range of
SMC=0.0% - 100.0%) and both decreased significantly over the course of treatment (p’s<.001), from 63.9% and 72.3% in
the first week of treatment to 11.8% and 17.3% in the last week of treatment, respectively. On average, participants were
significantly less compliant homework assignments than self-monitoring assignments (p<.001), attempting 33.1% versus
46.4% of the assignments. Neither HC nor SMC were significant predictors of binge eating abstinence at EOT. These data
indicate that, in this sample, neither HC nor SMC predicted binge eating abstinence at the end of treatment. These data
suggest that individuals may do well in group CBT for BED even if they appear to be noncompliant with homework and
self-monitoring.
Learning Objectives:
• Describe the variability in homework and self-monitoring compliance in group CBT for binge eating disorder.
• Describe the trajectory of homework and self-monitoring compliance over the course of group CBT for binge
eating disorder.
• Describe whether homework and/or self-monitoring compliance predicts binge eating abstinence in group CBT
for binge eating disorder.
Clinicians’ Practices Regarding Blind versus Open Weighing among Patients with Eating Disorders
Kelsie Forbush, DPhil, University of Kansas, Lawrence, Kansas, USA; Jonathan Richardson, DPsych, Indiana
University School of Medicine, Charis Center for Eating Disorders, Indianapolis, Indiana, USA; Brittany Bohrer, BS,
University of Kansas, Lawrence, Kansas, USA
Empirically supported treatments for eating disorders, such as cognitive-behavioral therapy and family-based treatment,
stress the importance of weighing patients during therapy and using this information as part of treatment. However,
weighing practices vary widely across eating disorders professionals, including those that purport to provide empirically
supported interventions. The objective of this study was to characterize clinicians’ practices regarding the decision to
share (open weighing) or withhold (blind weighing) weight information with patients, a topic that has received limited
prior attention. Clinicians (N=114; 85% female) who regularly treat individuals with an eating disorder completed an
online survey to identify factors that might impact their decision to practice blind or open weighing. Results indicated that
approximately half of the clinicians reported generally using open weighing procedures (n=53; 46.49%). Endorsement of
cognitive-behavioral or family-based therapeutic orientation was not significantly associated with open weighing,
although effect sizes were in the predicted direction. Clinicians who endorsed therapeutic modalities that do not
specifically encourage open weighing were significantly more likely to engage in blind weighing. Clinicians working with
clients with anorexia nervosa were significantly more likely to practice blind weighing, compared to clients with other
eating disorder diagnoses, and cognitive or emotional impairment from malnutrition emerged as the strongest predictor
of clinicians’ decisions to practice blind weighing, controlling for all other variables. In conclusion, our findings indicate
that the development of specific training modules may be useful for improving adherence to empirically supported
protocols that recommend open weighing. More importantly, however, our results highlight the need for future treatment
studies to identify whether blind or open weighing is beneficial for improving patient outcomes.
Learning Objectives:
• Define blind and open weighing, and discuss the theoretical rationale for each approach to weighing patients with
eating disorders.
• Explain clinicians' practices with regard to weighing their patients with eating disorders.
•
Identify factors that are associated with increased or decreased likelihood of blind (vs. open) weighing among
eating disorder clinicians.
Meal Patterning in the Treatment of Bulimia Nervosa
Jo Ellison, PhD, Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Heather Simonich, MA,
Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Steve Wonderlich, PhD, FAED, Neuropsychiatric
Research Institute/University of North Dakota Medical School, Fargo, North Dakota, USA; Carol Peterson, PhD, LP,
FAED, University of Minnesota, Minneapolis, Minnesota, USA; Ross Crosby, PhD, FAED, Neuropsychiatric Research
Institute, Fargo, North Dakota, USA; Li Cao, MS, Neuropsychiatric Research Institute, Fargo, North Dakota, USA;
James Mitchell, MD, FAED, Neuropsychiatric Research Institute/University of North Dakota Medical School, Fargo,
North Dakota, USA; Tracey Smith, PhD, Baylor University, Waco, Texas, USA; Marjorie Klein, PhD, University of
Wisconsin Medical School, Madison, Wisconsin, USA; Scott Crow, MD, University of Minnesota, Minneapolis,
Minnesota, USA
The objective of this study is to examine the impact of meal patterning on the recovery from bulimia nervosa (BN) in a
randomized controlled trial (Wonderlich et al., 2014). Participants all met criteria for subclinical or full-threshold BN and
received one of two psychological treatments (Cognitive Behavioral Therapy-Enhanced or Integrative Cognitive Affective
Therapy). Sixty participants were included in the analyses, 20 were excluded due to missing data at end of treatment. Meal
patterning variables used in the study were change in the number of meals and snacks over the past 28 days from pre- to
post-treatment assessment, as reported on the Eating Disorder Examination (EDE). Outcome variables used in this study
were reports of binge eating and purging behavior on the EDE as well as the Global score from the EDE. Results from
binomial linear regression analyses revealed that increased regularity of breakfast and dinner consumption was related to
a greater likelihood of abstinence from binge eating and purging at end of treatment. Increasing breakfast consumption
over of the course of treatment was related to a 7% increase in likelihood of binge/purge abstinence (OR=1.07; p=.048).
Increasing dinner consumption over the course of treatment was related to a 14% increase in likelihood of binge/purge
abstinence (OR=1.14; p=.038). Additionally, results from linear regression analyses suggest that increasing consumption
of dinner over the course of treatment resulted in a decrease in Global EDE scores at end of treatment when controlling
for baseline global EDE scores (β=-.062; p=.006). These findings support previous literature that suggests that
normalizing eating, particularly in the evenings, is an important intervention to decrease binge-eating behavior (Smyth,
2009; Crosby, 2009; Lavender, 2013).
Learning Objectives:
• Describe the importance of meals and snacks in the treatment of eating disorder.
• Discuss the evidence for the importance of evening meals in models of binge-eating.
• Extrapolate potential for clinical utility of findings in meal patterning among patients with binge-eating behaviors.
Comorbidity and Transdiagnosis Processes
Chairs: Timothy Brewerton MD & Sarah Fisher PhD
Probing the Shared Polygenic Underpinnings of Anorexia Nervosa and Five Other Major Psychiatric
Disorders
Laura Huckins, MSc, Wellcome Trust Sanger Institute, Cambridge, UK, United Kingdom (Great Britain); Karen
Mitchell, PhD, Boston University, Boston, Massachusetts, USA; Laura Thornton, PhD, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina, USA; David Collier, PhD, Institute of Psychiatry, King's College London,
London, UK, United Kingdom (Great Britain); Patrick Sullivan, PhD, University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina, USA; Cynthia Bulik, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North
Carolina, USA; Eleftheria Zeggini, PhD, Wellcome Trust Sanger Institute, Cambridge, UK, United Kingdom (Great
Britain)
Anorexia Nervosa (AN) is commonly comorbid with other psychiatric disorders (up to 56.2%). We evaluated shared
genetic determinants of AN and comorbid psychiatric disorders by testing whether polygenic risk scores derived from
genome-wide data of other psychiatric disorders can predict AN status. We obtained allele risk scores for major depressive
disorder (MDD), bipolar disorder (BPD), autism (AUT), attention deficit hyperactivity disorder (ADHD) and
schizophrenia (SCZ), and a set of cross-disorder risk alleles, from the Psychiatric Genomics Consortium (PGC). We
divided each of these sets into 10 Pt significance level thresholds, according to the level of association with each psychiatric
disorder. The test set comprised AN cases and controls from a published WTCCC3 AN GWAS study. Examining
comorbidity patterns of samples used in this study shows that certain classes of psychiatric disorders are significantly
more likely to be co-diagnosed than others. We compute diagnostic spectra of AN cases using PCA plots, and show that
distinct spectra may be identified, driven by MDD diagnosis. We probed the existence of shared polygenetic aetiology
between AN and five co-occurring psychiatric disorders (ADHD, ASD, BIP, MDD, SCZ). Significantly more variance was
explained that might be expected by chance at the lowest Pt threshold (Pt<0.001) for AN vs AUT (p=0.0009), MDD
(p=0.009), and SCZ (0.0008), and at the second lowest Pt threshold (Pt <0.01) for BPD (p=0.0004). We demonstrated
for the first time a shared genetic aetiology between AN and other psychiatric disorders using genome-wide data. Crossdisorder analyses may prove to be a powerful approach to identifying overlapping susceptibility loci across psychiatric
disorders.
Learning Objectives:
• Discuss comorbidity between anorexia nervosa and other psychiatric disorders
• Understand that comorbidity patterns are due to shared polygenic aetiology
• Understand the application of polygenic risk scores between disorders
Shared Risk Factors for Disordered Eating, Depressive Symptoms, and Overweight Status in Communitybased Adolescents and Young Adults
Andrea Goldschmidt, PhD, The University of Chicago, Chicago, Illinois, USA; Melanie Wall, PhD, Columbia University,
New York, New York, USA; Tse-Hwei Choo, MS, Columbia University, New York, New York, USA; Carolyn Becker, PhD,
FAED, Trinity University, San Antonio, Texas, USA; Dianne Neumark-Sztainer, PhD, MPH, RD, FAED, University of
Minnesota, Minneapolis, Minnesota, USA
In light of the high prevalence and possible overlap of disordered eating, depressive symptoms, and obesity, along with the
need to develop interventions targeting multiple health problems, the current study aimed to identify shared risk factors
for these pathologies so as to inform the development of preventive interventions. A population-based sample of male and
female participants involved in Project EAT (Eating Among Teens and Young Adults; n=1,902) self-reported their
disordered eating behaviors (binge eating, self-induced vomiting, and/or laxative, diuretic, or diet pill use for weight
control), depressive symptoms, and weight status, along with several putative psychosocial risk factors (i.e., self-esteem,
body satisfaction, weight-related teasing, and dieting frequency) at 5-year intervals spanning early/middle adolescence
(Time 1), late adolescence/early young adulthood (Time 2) and early/middle young adulthood (Time 3). Structural
equation models controlling for demographic factors revealed that Time 1 dieting was a shared risk factor for Time 2
disordered eating (p=.03) and overweight/obesity (p<.001); Time 1 low self-esteem was a risk factor for depressive
symptoms (p=.002) while being protective against overweight/obesity (p=.001). Time 2 dieting was a shared risk factor
for Time 3 disordered eating and overweight/obesity (ps<.001), and Time 2 body dissatisfaction was a shared risk factor
for Time 3 overweight/obesity and depressive symptoms (ps<.001). Overall, results suggest that disordered eating,
depressive symptoms, and elevated weight status share several psychosocial risk factors. Clinically, interventions targeting
the simultaneous prevention of these overlapping pathologies should aim to reduce dieting and body dissatisfaction. The
effect of self-esteem on the later development of overweight/obesity should be further explored.
Learning Objectives:
• Understand the overlap among disordered eating behaviors, depressive symptoms, and overweight status in
community-based adolescents and young adults.
• Identify shared risk factors for the development of these pathologies.
• Apply findings to the development of interventions targeting the simultaneous prevention of all three pathologies.
Guilt and Shame as Shared Risk Factors for Social Anxiety and Bulimic Symptoms: Shame Prospectively
Predicts Both Social Anxiety and Bulimic Symptoms
Cheri Levinson, MA, Washington University in St. Louis; University of North Carolina, Chapel Hill, North Carolina, ,
USA; Meghan Byrne, BA, Washington University in St. Louis, St. Louis, Missouri, USA; Thomas Rodebaugh, PhD,
Washington University in St. Louis, St. Louis, Missouri, USA
Social anxiety and bulimia nervosa are highly comorbid (Swinbourne & Touyz, 2007). However, little is known about the
shared risk factors that prospectively predict both SA and BN. Two potential risk factors that have not yet been tested are
shame and guilt. Independently, shame and guilt have been shown to contribute to both social anxiety and bulimia
nervosa (e.g., Berg et al., 2013; Fergus et al., 2010). In fact, Berg et al. (2013) demonstrated that after controlling for other
aspects of negative affect, guilt maintained a significant relationship with bulimic behaviors. In the current study, women
(N = 300) completed measures of social anxiety, bulimic symptoms, state shame and guilt, and trait negative affect at two
time points, two months apart. Utilizing structural equation modeling we tested a cross-sectional and prospective model
of social anxiety and bulimic symptom risk. Shame prospectively predicted both social anxiety and bulimic symptoms. We
did not find that guilt prospectively predicted either social anxiety or bulimic symptoms. However, higher levels of both
bulimic and social anxiety symptoms predicted increased guilt over time. We found support for shame as a shared risk
factor between bulimic and social anxiety symptoms. Interventions, such as Acceptance and Commitment Therapy, which
focus on decreasing shame could potentially alleviate symptoms of bulimia and social anxiety in one protocol (Luoma,
2012).
Learning Objectives:
• To discuss the role of shame and guilt in social anxiety and bulimic symptomatology.
•
•
To present results showing that shame may be a shared risk factor for both bulimia nervosa and social anxiety
symptoms.
To discuss treatment strategies that target shame, which may address symptoms of both social anxiety and
bulimia nervosa in one intervention.
Adolescent Eating Disorders are Prospectively Associated with Mental Health Symptoms and Negative
Health Behaviours
Cheri Levinson, MA, Washington University in St. Louis; University of North Carolina, Chapel Hill, North Carolina, ,
USA; Meghan Byrne, BA, Washington University in St. Louis, St. Louis, Missouri, USA; Thomas Rodebaugh, PhD,
Washington University in St. Louis, St. Louis, Missouri, USA
Eating disorders (ED) are associated with a range of physical and psychiatric comorbidities. Few studies have used
population-based prospective data to investigate whether adolescent ED predict adverse psychiatric outcomes. We
investigated whether DSM5 ED at ages 14 and 16 are prospectively associated with depression, anxiety disorders, alcohol
and substance use, and self-harm in the UK-based Avon Longitudinal Study of Parents and Children. ED were ascertained
at 14 (n=6,140) and 16 years of age (n=5,202), all outcomes were measured about 2 years later. Logistic regression models
on complete cases adjusting for gender, socio-demographic variables and occurrence of the mental health outcome at
previous waves estimated the odds of each outcome in those with ED compared to those without. ED at age 14 were
prospectively associated with depression [Odds Ratios (ORs) respectively: Anorexia nervosa (AN) OR=2.93(95%CI:1.485.85), purging disorder-PD OR=9.16(1.83-45.84), sub-threshold bulimia nervosa-S-BN OR=2.15(1.06-4.36), and Other
Specified Feeding and Eating Disorders-other OSFED OR=2.14 (1.53-2.99); anxiety disorders [respectively other OSFED
OR=2.32(0.99-5.44) and PD OR=10.93(2.55-46.97); drug use [respectively Binge Eating Disorder-BED OR= 5.12(1.4018.69), PD OR=6.19(1.64-23.37), S-BN OR=3.79(1.53-9.38) and other OSFED OR=2.49(1.56-3.97) . ED at 16 years were
prospectively associated with: depression [BED OR=2.71(1.00-7.50), S-BN OR=3.12(1.56-6.23), and other OSFED
OR=1.43(1.00-2.04)]; anxiety disorders (sub-threshold S-BED OR= 6.23(1.12-33.13) and BN OR=6.60(1.84-23.59)]; drug
use (S-BED OR=8.90(1.75-45.32) and BN OR=5.44(1.68-17.67)]; self-harm was associated with all ED but AN and BED.
Adolescent ED are prospectively associated with mental health disorders and substance and alcohol use. Both DSM5
threshold diagnoses and OSFED sub-types were predictive of negative outcomes, highlighting the high public health
impact of ED adolescent presentations across the severity spectrum.
Learning Objectives:
• Describe potential adverse (mental health and behavioural) outcomes of adolescent ED
• Understand differences in adverse outcomes across ED types
• discuss the usefulness of threshold vs sub-threshold ED diagnoses in relation to adverse mental health outcomes
Sadness and Hostility Associated with Episodes of Binge Drinking in Women with Bulimia Nervosa
Emily Pisetsky, PhD, University of Minnesota, Minneapolis, Minnesota, USA; Ross Crosby, PhD, FAED,
Neuropsychiatric Research Institute, Fargo, North Dakota, USA; Li Cao, MS, Neuropsychiatric Research Institute,
Fargo, North Dakota, USA; Ellen Fitzsimmons-Craft, PhD, Washington University School of Medicine, St. Louis,
Missouri, USA; Carol Peterson, PhD, FAED, University of Minnesota, Minneapolis, Minnesota, USA; Scott Crow, MD,
FAED, University of Minnesota, Minneapolis, Minnesota, USA; Scott Engel, PhD, Neuropsychiatric Research Institute,
Fargo, North Dakota, USA; James Mitchell, MD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota,
USA; Stephen Wonderlich, PhD, FAED, Neuropsychiatric Research Institute, Fargo, North Dakota, USA
The current study examined the association between affect and binge drinking behavior in women with bulimia nervosa
(BN; n = 133). Participants completed a two week ecological momentary assessment protocol. Momentary assessments of
positive affect (PA) and negative affect (NA) were measured using the PANAS. Binge drinking was assessed based on
participant self-report. There were no differences in mean PA or NA on days characterized by binge drinking compared to
days with no binge drinking (ps>0.05). Trajectories of PA, NA, and the facets of NA (Fear, Guilt, Hostility, and Sadness)
were modeled prior to and following binge drinking events. Multilevel modeling revealed that there were no significant
changes in trajectories for PA or NA before or after binge drinking events. However, examination of the facets of NA
revealed that Sadness increased prior to (p=0.002) and decreased following binge drinking events (p=0.010) whereas
Hostility decreased prior to (p=0.013) and increased following binge drinking events (p=.012). There were no significant
changes in trajectories for Fear or Guilt (ps>0.05). These results indicate that, while there is no association between broad
measures of positive or negative affect and binge drinking, binge drinking may be reinforced by reductions in sadness.
However, individuals with BN may also experience increases in hostility following these episodes. Together, these findings
highlight the importance of delineating the facets of negative affect when investigating precipitants and consequences of
binge drinking behaviors in individuals with BN, as well as potential functions of this type of alcohol consumption
behavior.
Learning Objectives:
•
•
•
Demonstrate a greater understanding of the associations among negative and positive affect and binge drinking
behavior.
Consider the relationships between binge drinking and specific facets of negative affect.
Develop an understanding of ecological momentary assessment and the advantages of using this technique to
investigate changes in affect.
Lifetime Prevalence of ADHD in Adults with Eating Disorders: Results from the National Comorbidity
Survey Replication Study
Timothy Brewerton, MD, FAED, Department of Psychiatry & Behavioral Sciences, Medical University of South
Carolina, Charleston, South Carolina, USA; Alexis Duncan, PhD, Brown School at Washington University in St. Louis,
St. Louis, Missouri, USA
Several studies suggest links between eating disorders (ED) and attention deficit hyperactivity disorder (ADHD), yet data
on the prevalence rates of ADHD in individuals with ED are sparse, especially from representative samples. Using data
generated by the National Comorbidity Survey Replication Study, the lifetime (LT) prevalence rates of DSM-IV defined
ADHD were compared in men and women with and without LT and current (C) diagnoses of anorexia nervosa (AN),
bulimia nervosa (BN), binge eating disorder (BED), and any binge eating (BE) using chi-square analyses. Analyses were
weighted and controlled for gender. Mean ages of onset of ADHD and EDs were evaluated using the Mann-Whitney Utest. In men, the C and LT prevalence rates of BE and BED (but not AN or BN) were significantly higher in those with
lifetime ADHD than those without. In women, the C and LT prevalence rates of BE, BED, and BN were significantly higher
in those with LT ADHD than those without. In addition, women with LT ADHD had significantly higher rates of LT AN.
The average age of onset of ADHD was much earlier than that of the ED in both men and women. These results imply a
significant association between ADHD and ED, especially bulimic spectrum ED, in both sexes. Given that the average age
of onset of ADHD was much earlier than that of the ED in both men and women, ADHD may serve as an important risk
factor in the development of BE and related ED. ADHD and ED may also share common causes, e.g., impulsivity. Studies
examining underlying genetic/neurobiological mechanisms, as well as treatments, may be warranted.
Learning Objectives:
• Describe new findings from the National Comorbidity Survey – Replication showing higher than expected lifetime
prevalence rates of ADHD in subjects with eating disorders.
• List four hypotheses that could explain the associations between eating disorders and ADHD.
• Discuss treatment implications of these findings.
Epidemiology
Chairs: Hans Hoek, MD, PhD & Anna Keski-Rahkonen, MD, PhD, MPH
Eating Disorders Associated With Reduced Quality of Life in Young Adult Women and Men
S. Bryn Austin, ScD, MS, FAED, Boston Children's Hospital, Boston, Massachusetts, USA; Jerel P. Calzo, PhD, Boston
Children's Hospital, Boston, Massachusetts, USA; Allegra R. Gordon, MPH, MS, Harvard School of Public Health,
Boston, Massachusetts, USA; Benita Jackson, PhD, Smith College, Northampton, Massachusetts, USA; Najat J. Ziyadeh,
MS, MPH, Boston Children's Hospital, Boston, Massachusetts, USA; Mihail Samnaliev, PhD, Boston Children's Hospital,
Boston, Massachusetts, USA
The consequences of eating disorders (ED) for health-related quality of life (HRQL) in young adult women and men are
not well understood. We used data from 10,091 women and men in the Growing Up Today Study, a prospective cohort of
U.S. youth, to examine associations of ED behaviors and diagnoses with HRQL in young adulthood. In 2013, participants
(ages 18-31 years) reported past-year ED behaviors (vomiting or use of diet pills or laxatives for weight control, binge
eating) and lifetime history of an ED diagnosis. We used EQ-5D-5L, a preference-based measure recommended in costeffectiveness analysis, to assess HRQL (range: 0 [death] to 1 [perfect health]). We examined cross-sectional, multivariable
linear regression models to estimate associations of ED variables with HRQL score (outcome), controlling for age,
ethnicity, weight status, and gender with additional gender interactions with weight status and ED variables. Separate
models were examined for each ED variable. Overall, mean HRQL scores were higher in men (0.917) than in women
(0.903; p<0.0001). In fully adjusted models, all ED behaviors were associated with significant (all p <0.05) decrements in
HRQL (Betas: vomiting -0.022; diet pills -0.007; laxatives -0.026; binge eating -0.054), as were all ED diagnoses (Betas:
anorexia -0.057; bulimia -0.040; binge eating disorder -0.044; other ED -0.061). Furthermore, most behaviors/diagnoses
conferred larger decrements in HRQL scores for men vs. women; additional reductions for men ranged from -0.016 for
diet pill use to -0.207 for binge eating disorder diagnosis; p<0.05 for gender interactions). In young adults, ED behaviors
and diagnoses are associated with reduced HRQL, with greater decrements observed for men than women. Our findings
provide important new data to inform estimates of the cost-effectiveness of interventions to prevent and treat ED.
Learning Objectives:
• Evaluate the association of eating disorder behavior and diagnoses on health-related quality of life (HRQL).
•
•
Discuss plausible explanations for gender differences in the negative effects of these disorders on HRQL.
Describe the value of using preference-based measures of HRQL in cost-effectiveness analyses of interventions to
prevent or treat eating disorders.
Sex- and Age-Specific Incidence of Healthcare-Detected Eating Disorders in Sweden: Differences by Birth
Cohort and Diagnostic Period
Kristin N. Javaras, PhD, DPhil, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Cristin
D. Runfola, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Laura M. Thornton,
PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Esben Agerbo, PhD, Aarhus
University, Aarhus, Denmark; Andreas Birgegård, PhD, Karolinska Institutet, Stockholm, Sweden; Shuyang Yao, MSc,
Karolinska Institutet, Stockholm, Sweden; Maria Råstam, PhD, MD, University of Lund, Lund, Sweden; Henrik
Larsson, PhD, Karolinska Institutet, Stockholm, Sweden; Paul Lichtenstein, PhD, Karolinska Institutet, Stockholm,
Sweden; Cynthia M. Bulik, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
Information on how incidence (a measure of new cases of a disorder in a given population) varies with respect to age, sex,
and birth cohort provides valuable insight into the etiology of the disorder and essential information for service planning.
Most studies of eating disorder incidence are based on small samples, narrow age ranges, and population subgroups (e.g.,
females, hospitalized or primary care patients only), or fail to cover the full range of eating disorders. Thus, using Swedish
population and healthcare registers, we 1) examined the sex- and age-specific incidence of healthcare-detected anorexia
nervosa (AN) and any other eating disorder (OED) identified between 1987-2009 for a cohort of individuals born in
Sweden between 1979-2001 and 2) assessed whether incidence varied by diagnostic period and birth cohort. We used ageperiod-cohort Poisson models with censoring for first emigration, death, or end of study period to model incidence rates
as a function of age in years, diagnostic period (several intervals subdividing 1987-2009), and birth cohort (two intervals
subdividing 1979-2001), among 1.2 million males and (separately) 1.1 million females. Incidence of AN peaked at 12-17
years old at 0.7-0.8 cases per 100,000 person-years (CPPY) for males, compared to 15 years old at 65.0 CPPY for females.
Incidence of OED peaked at 14-17 years old at 3.3 CPPY for males, compared to 17-18 years old at 48.6 CPPY for females.
For both sexes, incidence of AN and OED increased substantially and significantly for diagnostic periods after 2000, likely
reflecting expansion in the coverage of the healthcare registers and better detection. Incidence did not differ by birth
cohort, with the exception of a slightly but significantly higher incidence rate of OED for females born in the 1990s versus
the 1980s. These findings may aid healthcare planning and provide insight into the optimal timing for primary prevention
efforts in males and females.
Learning Objectives:
• Describe age and sex differences in the incidence of healthcare-detected eating disorders
• Describe how the incidence of healthcare-detected eating disorders differs for birth cohorts and diagnostic periods
• Understand the pros and cons of determining incidence based on healthcare registers
The Impact of Revised DSM-5 Diagnostic Criteria on the Population Prevalence and Incidence of
Anorexia Nervosa
Anna Keski-Rahkonen, MD, PhD, MPH, University of Helsinki, Helsinki, Finland; Linda Mustelin, MD, PhD, University
of North Carolina, Chapel Hill, North Carolina, USA; Hans Hoek, MD, PhD, FAED, Parnassia, Hague, Netherlands
Objective The impact of the recent revision of DSM criteria for anorexia nervosa (AN) on the population prevalence,
incidence, and recovery rates has not been quantified. Method Women (N=2825) from the 1975-79 birth cohorts of
Finnish twins were screened for lifetime eating disorders: 92 women fulfilled DSM-5 criteria for lifetime AN. Of them, 55
(60%) also fulfilled DSM-IV criteria for AN. We assessed incidences, prevalences, and differences in outcomes between
DSM-IV and DSM-5 anorexia nervosa. Results The inclusion of new cases increased the lifetime prevalence by 1.6 from
2.2% to 3.6% (95% confidence interval [CI] 2.7-4.2%). There was a similar increase in 10-24 year incidence to 230 per
100000 person-years (95% CI 180-280 per 100000 person-years). Among ‘new’ DSM-5 vs. DSM-IV cases, the age of
onset was 18.8 vs. 16.5 years (p=0.002), the mean minimum BMI was 16.9 vs. 15.5 (p=0.0004), the median illness
duration was 3 vs. 1 years. The probability of recovery within 5 years was 81% for the ‘new’ cases vs. 67% for the DSM-IV
cases (log-rank p=0.01). Conclusions We found that the broadening of diagnostic threshold in DSM-5 criteria caused a
60% increase in the lifetime prevalence of anorexia nervosa in the community. However, the ‘new’ cases may increase
phenomenological and prognostic heterogeneity: compared to DSM-IV anorexia cases, the new DSM-5 cases had a
shorter duration of illness and significantly higher likelihood of recovery.
Learning Objectives:
• Describe the change in prevalence of anorexia nervosa after the revision of DSM criteria
• Understand that the new cases of anorexia nervosa are milder and more transient
• Assess the likelihood of recovery among women suffering from anorexia nervosa.
The Incidence of Broad and Narrow Anorexia Nervosa In a Nationwide Study: Associations with Sex,
Age, and Suicide Risk .
Stephanie Zerwas, PhD, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA; Janne Larsen, MA,
Aarhus University, Aarhus, Denmark, Denmark; Liselotte Petersen, PhD, Aarhus University, Aarhus, Denmark,
Denmark; Laura Thornton, PhD, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Preben
Bo Mortensen, MD, Aarhus University, Aarhus, Denmark, Denmark; Cynthia Bulik, PhD, FAED, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
Since 1995, the Danish Psychiatric Central Research Register has included medical surveillance of broad and narrow AN
diagnoses using the ICD-10 in both outpatient and hospital care and, thus, offers a unique opportunity to extend our
understanding of age trends of AN diagnosis in both males and females. We investigated: 1) the cumulative risk for broad
and narrow AN, 2) patterns of peak age of risk for AN across sex and 3) associations between AN and suicide attempts.
All individuals were born in Denmark between 1989 and 2006 (~1 million individuals) and followed until 2012. Age- and
sex-specific incidence rates were calculated as the number of new cases occurring at each age in males and females
separately. Sex-specific hazard ratios (HR) of death and suicide attempt were calculated using Cox proportional hazards
regression for broad and narrow AN. At age 24, the cumulative incidence of narrow and broad AN was 0.78/100 and
1.19/100 females and 0.05/100 and 0.08/100 males. In the smoothed hazard curves for both broad and narrow AN, the
peak hazard for diagnosis occurred at approximately age 15 years in females and 13 years in males. Risk of violent suicide
attempt was significantly elevated in females with broad AN (8.6 times greater hazard) and narrow AN (7.3 times greater
hazard) compared with the referent of females with no eating disorder. The risk of suicide attempt was not elevated in
males with broad or narrow AN but, in some cases, hazards were not able to be estimated due to sparse counts. These
results will be discussed with respect to the limitations of medical surveillance to detect AN, the implications of relaxing of
diagnostic criteria for AN in DSM-5, and potential explanations for sex differences in peak age of risk.
Learning Objectives:
• Describe the incidence of anorexia nervosa in Denamrk
• Assess the risk of suicide in patients with narrow and broad anorexia nervosa.
• Compare the age of peak hazard for an anorexia nervosa diagnosis in males and females.
Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder in Midlife and Beyond
Roni Elran-Barak, PhD, MSW, Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel; Ellen
Fitzsimmons-Craft, PhD, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri,
USA; Yael Benyamini, PhD, Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel; Scott Crow, MD,
FAED, Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA; Carol
Peterson, PhD, FAED, Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota,
USA; Laura Hill, PhD, FAED, The Center for Balanced Living, Worthington, Ohio, USA; Ross Crosby, PhD, FAED,
University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA; James Mitchell, MD,
FAED, Department of Clinical Neuroscience, University of North Dakota School of Medicine, Fargo, North Dakota, USA;
Daniel Le Grange, PhD, FAED, Department of Psychiatry and Behavioral Neuroscience, The University of Chicago,
Chicago, Illinois, USA
We examined eating disorders in midlife and beyond by comparing frequency of anorexia nervosa (AN), bulimia nervosa
(BN), binge eating disorder (BED), and other specified feeding or eating disorder (OSFED) among midlife treatmentseeking individuals and younger controls. We also compared demographic and eating disorder-related characteristics
across diagnoses and age groups. Data were collected as part of the initial psychological evaluation at four outpatient
eating disorder treatment centers in the United States. Participants included 2118 adults who self-reported their eatingrelated symptoms on the Eating Disorder Questionnaire. Younger participants were defined as 18-25 years
(41.5%;n=880), midlife participants were defined as 40+ years (17.2%;n=364), and participants 26-39 years
(41.3%;n=874) were excluded from analyses. Percent of patients with BN was significantly lower while percent of patients
with BED and OSFED was significantly higher among midlife relative to younger patients (ps<.005). Percent of patients
with AN did not differ across groups (p=.347). Additionally, midlife and younger patients with BED and OSFED differed
on several demographic (e.g., marital status) (ps<.009) and eating disorder-related characteristics (e.g., BMI, compulsive
exercising) (ps<.004). This study suggests that BN is less common while BED and OSFED are more common among
midlife treatment-seeking individuals relative to younger controls. In addition, AN and BN present fairly similarly while
BED and OSFED present fairly differently among midlife patients relative to younger controls. Lastly, eating disorder
behavioral symptoms were generally less severe among midlife patients with BN, BED, and OSFED, while eating disorder
cognitive symptoms, and especially body dissatisfaction, were generally more alike among midlife patients with AN, BN,
and BED relative to younger controls. Attention to these differences and similarities is necessary to understand eating
disorders in midlife.
Learning Objectives:
• Review the literature about eating disorders in midlife
•
•
Identify similarities and differences between young and midlife patients with eating disorders
Describe future treatment development for midlife individuals with eating disorders
DSM-5 Binge Eating Disorder Among Young Women in the Community
Linda Mustelin, PhD, MD, University of Helsinki / University of North Carolina at Chapel Hill, Helsinki / Chapel Hill,
North Carolina, USA/Finland; Anu Raevuori, PhD, MD, University of Helsinki, Helsinki, Uusimaa, Finland; Hans
Wijbrand Hoek, PhD, MD, FAED, Parnassia Psychiatric Institute / Groningen University / Columbia University, The
Hague, The Hague, Netherlands; Jaakko Kaprio, PhD, MD, University of Helsinki / National Institute for Health and
Welfare, Helsinki, Uusimaa, Finland; Anna Keski-Rahkonen, PhD, MD, MPH, FAED, University of Helsinki, Helsinki,
Uusimaa, Finland
Background: Few studies have assessed the population prevalence and incidence of binge eating disorder (BED) and little
is known about its earliest phases. Method: Young adult women (N=2835) from the 1975-79 birth cohorts of Finnish
twins underwent 2-stage screening for eating disorders at 22-28 years. We assessed the lifetime prevalence, incidence and
clinical characteristics of DSM-5 BED. Results: We detected 16 women who met DSM-5 criteria for BED, yielding a
lifetime prevalence of 0.6% (95% confidence interval [CI] 0.3-0.9). The incidence of BED in women between 10 and 24 yrs
of age was 30 (95% CI 20-50) per 100 000 person-years. The mean age of onset of BED was 19 years (range 13-27 years).
Of the cases, 13/16 (81%) were currently ill. Duration of illness at the time of assessment ranged from less than a year to 13
years (median 6 years). Of women with BED, only two had a history of other eating disorders, but six had co-morbid major
depressive disorder. Two thirds of the women with BED belonged to the highest 25th weight percentile at age 16, and their
mean BMI at age 22-28y was 26.2 kg/m2 (range 22.1-32.5 kg/m2). Conclusion: Incident BED as defined by DSM-5 is
relatively rare in the youngest age groups and is often preceded by relative overweight. It often occurs without a history of
other eating disorders. Comorbidity with major depressive disorder is common.
Learning Objectives:
• Describe the prevalence and incidence of BED in young women in the community.
• Describe the comorbidity of BED with other eating disorders and major depressive disorder.
• Describe how incident BED is associated with overweight and weight-loss attempts in adolescence and young
adulthood.
Neuromodulation and Neuroanatomy
Chairs: Guido Frank MD & Hunna Watson, PhD
A Therapeutic Case Series of Neuronavigated Repetitive Transcranial Magnetic Stimulation in Enduring
Anorexia Nervosa.
Jessica McClelland, BSc, Institute of Psychiatry, King's College London, London, London, United Kingdom (Great
Britain); Maria Kekic, MSc, BSc, Institute of Psychiatry, King's College London, London, London, United Kingdom
(Great Britain); Iain Campbell, PhD, MSc, BSc, Institute of Psychiatry, King's College London, London, London, United
Kingdom (Great Britain); Ulrike Schmidt, PhD, MD, FAED, Institute of Psychiatry, King's College London, London,
London, United Kingdom (Great Britain)
Given the growing neuroimaging data and arising neural based models of anorexia nervosa (AN), there is a strong need for
research into possible brain-directed treatment adjuncts. Neuromodulation techniques such as repetitive transcranial
magnetic stimulation (rTMS) have the ability to non-invasively alter neural activity. Given the demonstrated therapeutic
efficacy of rTMS in other neurocircuit based psychiatric disorders such as depression, and the existing preliminary
research involving rTMS in eating disorders (ED), this study investigates the potential of rTMS in the treatment of AN.
Five individuals with severe and enduring AN (illness durations > 5 years) had 20 daily sessions of neuronavigated rTMS,
combined with food-cue exposure. Subjective ED experiences were measured within each session, whilst weight, ED
symptomatology and mood were assessed pre and post the 20 sessions, and also at one and six month follow up. Results
suggest moderate reductions in ED experiences within sessions. On average, across all five cases, there were
improvements in ED symptoms and mood following the intervention and these were sustained or continued to show
improvements at one and six month follow up. The intervention was well accepted and no severe side effects were
reported. These findings add to preliminary evidence for the therapeutic effects of rTMS in AN and thus warrants further
investigations in larger, controlled trials.
Learning Objectives:
• Following the training, participants will be able to describe the rationale and preliminary evidence for the use of
repetitive transcranial magnetic stimulation (rTMS) in anorexia nervosa.
• Following the training, participants will be able to evaluate the robustness of the therapeutic effects reported
following repetitive transcranial magnetic stimulation (rTMS) within these five cases of enduring anorexia.
• Following the training, participants will be able to generalise these findings and consider the wider clinical
implications of these results supporting the use of brain-directed interventions for eating disorders.
A Randomized Single-session Sham-controlled Trial of Neuronavigated Repetitive Transcranial Magnetic
Stimulation in Anorexia Nervosa.
Jessica McClelland, BSc, Institute of Psychiatry, King's College London, London, London, United Kingdom (Great
Britain); Maria Kekic, MSc, BSc, Institute of Psychiatry, King's College London, London, London, United Kingdom
(Great Britain); Frederique Van den Eynde, PhD, MSc, MD, Douglas Mental Health University Institute, Montreal,
Montreal, Canada; Iain Campbell, PhD, MSc, BSc, Institute of Psychiatry, King's College London, London, London,
United Kingdom (Great Britain); Ulrike Schmidt, PhD, MD, FAED, Institute of Psychiatry, King's College London,
London, London, United Kingdom (Great Britain)
There is an urgent need for novel treatment approaches to anorexia nervosa (AN). Advances in neuroscience have led to a
deeper understanding of the neurocircuitry nature of AN and investigations into brain-directed treatment approaches are
warranted. Repetitive transcranial magnetic stimulation (rTMS) is a neuromodulation technique, which has the ability to
non-invasively alter neural activity. It has demonstrated therapeutic efficacy in other neurocircuit- based psychiatric
disorders and preliminary research also suggests potential in eating disorders (ED). This study investigated the effects of a
single-session of real versus sham (placebo) neuronavigated (MRI-guided) high-frequency rTMS to the left dorsolateral
prefrontal cortex in 51 individuals with AN in a randomized controlled trial. Subjective ED related experiences (e.g. urge to
restrict, levels of feeling full and fat) were combined into a core AN symptom variable, which was assessed before and after
a single session of real/sham rTMS. There was a statistical trend (p = 0.056) for real rTMS to reduce core AN symptoms
compared to sham. Participants also expressed an increased liking of specific foods types (e.g. biscuits) following real
rTMS. These results suggest the potential of rTMS to alter the core symptoms of AN and food related experiences, at least
in the short term. Further investigations are warranted in order to establish the therapeutic potential of rTMS in AN.
Learning Objectives:
• Following the training, participants will be able to recognise the need for neuromodulation research within eating
disorders and will be familiarised with common techniques such as repetitive transcranial magnetic stimulation
(rTMS).
• Following the training, participants will be able to evaluate and critique the scientific protocol used within such
research involving neuromodulation in eating disorder samples.
• Following the training, participants will be able to asses the potential of repetitive transcranial magnetic
stimulation in the treatment of anorexia nervosa.
The Effects of Prefrontal Cortex Transcranial Direct Current Stimulation (tDCS) on Food Craving and
Impulsivity in Women with Frequent Food Cravings
Maria Kekic, MSc, BSc, Institute of Psychiatry, King's College London, London, London, United Kingdom (Great
Britain); Jessica McClelland, BSc, Institute of Psychiatry, King's College London, London, London, United Kingdom
(Great Britain); Iain Campbell, DSc, Institute of Psychiatry, King's College London, London, London, United Kingdom
(Great Britain); Ulrike Schmidt, DPhil, MD, FAED, Institute of Psychiatry, King's College London, London, London,
United Kingdom (Great Britain)
Bulimia nervosa, binge-eating disorder, and some forms of obesity are characterised by compulsive overeating that is
often precipitated by food craving. Cravings for food can be as intense as those for drugs, and appear to be mediated by
overlapping brain regions that are also involved in impulsivity. Transcranial direct current stimulation (tDCS) can
manipulate the activation of localised cortical areas, and therefore has potential utility as a tool for reducing cravings. A
randomised within-subjects design was used to investigate whether a single session of placebo-controlled bilateral tDCS to
the dorsolateral prefrontal cortex would transiently modify food cravings and impulsivity in 17 women with frequent food
cravings. We also examined whether the effects of tDCS were moderated by individual differences in impulsive behaviour
measured with a temporal discounting task. Craving for sweet foods was reduced following active versus placebo tDCS,
and less impulsive participants were more susceptible to this anti-craving effect than more impulsive participants. These
findings have important clinical implications; suggesting that this brain-directed procedure has potential for development
as a treatment, or as an adjunct to existing treatments, for disordered eating behaviours.
Learning Objectives:
• Describe the mechanisms of action of transcranial direct current stimulation (tDCS)
• Summarise existing research on tDCS and food cravings
• Discuss the theoretical framework for how tDCS reduces food cravings
Transcranial Direct Current Stimulation (TDCS) Over the Left Dorsolateral Prefrontal Cortex (DLPFC)
Leads to Decreased Binge Eating (BE) Scores, Reduced Fat Consumption and Weight Loss in Obese
Individuals
Marci Gluck, PhD, NIH/NIDDK, Phoenix, Arizona, USA; Colleen Venti, RD, NIH/NIDDK, Phoenix, Arizona, USA;
Susanne Votruba, PhD, NIH/NIDDK, Phoenix, Arizona, USA; Miguel Alonso-Alonso, MD, MPhil, Beth Israel Deaconess
Medical Center, Boston, Massachusetts, USA; Eric Wassermann, MD, NIH/NINDS, Bethesda, Maryland, USA;
Jonathan Krakoff, MD, NIH/NIDDK, Phoenix, Arizona, USA
Anodal TDCS increases prefrontal cortex activity, implicated in BE and obesity. We compared energy intake (EI) and
weight change in participants who received active (cathodal) vs. sham TDCS (study 1) and subsequent active (anodal) vs.
sham TDCS (study 2) to the left DLPFC. Nine (3m,6f) healthy obese volunteers (94±15kg [M±SD]; 42±8 y) were admitted
as inpatients for 9d and completed the Binge Eating Scale (BES). Study 1: following 3d of a weight-maintaining diet,
participants received cathodal (2m,3f) or sham (1m,3f) TDCS (2mA, 40 min) on 3 consecutive mornings and then ate ad
libitum from a computerized vending machine, which recorded EI. Weight was measured daily. Study 2: participants
returned for a repeat study, maintaining original assignment to active (this time anodal) and sham. We compared
differences in BES scores, weight change and ad libitum EI (mean kcal/d, % weight maintaining energy needs [WMEN],
macronutrient content) between: a) cathodal v. anodal conditions and b) sham v. sham conditions. Individuals receiving
active TDCS had lower BES scores (p=.04) compared to sham. Participants who received active TDCS tended to consume
fewer kcal/d (p=0.076) and %WMEN (p=0.11) during anodal vs. cathodal TDCS. They also consumed significantly fewer
kcal from soda (p=0.02) and fat (p=0.03). At the end of the inpatient period, the anodal TDCS condition had a greater
%weight loss (p=0.05) compared to the cathodal condition. There were no differences in BES scores, EI or weight change
for those who received sham on both occasions. In this cross-over study, individuals consumed less fat and a tendency
toward fewer total calories during ad libitum EI after anodal v. cathodal TDCS, and lost more weight. Additionally, binge
eating scores decreased in the active vs. sham conditions. These findings indicate a role for the DLPFC in controlling EI
and a potential application of TDCS to improve binge eating behavior and facilitate weight loss.
Learning Objectives:
• Describe the role of the prefrontal cortex in eating behavior
• Have a basic understanding of TDCS, a type of non-invasive brain stimulation
• Understand the potential application of TDCS for treatment of binge eating and weight loss
Altered Mammillary Body Volume in Anorexia Nervosa
Sahib Khalsa, MD, PhD, UCLA, Los Angeles, California, USA; Rajesh Kumar, PhD, UCLA, Los Angeles, California, USA;
Vandan Patel, Student, UCLA, Los Angeles, California, USA; Michael Strober, PhD, FAED, UCLA, Los Angeles,
California, USA; Jamie Feusner, MD, UCLA, Los Angeles, California, USA
Cerebral atrophy, ventricular enlargement and hippocampal volume reductions have been documented in underweight
anorexia nervosa (AN), and to a lesser extent, in weight restored AN. Beyond general effects of starvation, thiamine
deficiency is a potential source for some of these neural alterations. Thiamine deficiency may result in Wernicke’s
encephalopathy, which typically occurs in alcoholic malnutrition states. It is classically associated with damage to the
mammillary bodies (MB) and fornix, sites connecting with the hippocampus and anterior thalamus. Although frank
Wernicke’s encephalopathy is rare in AN, shared neuropathology may occur due to overlapping nutritional deficiencies.
Neuropathological case reports have detailed evidence of MB injury due to non-alcoholic starvation states, but systematic
studies examining MB integrity in AN are lacking. We evaluated whether underweight and weight restored individuals
with AN demonstrate abnormal MB morphology using high resolution T1-weighted MRI images. We examined global MB
volumes in 12 underweight AN, 22 weight restored AN, and 30 age- and sex- matched healthy controls. A blinded expert
rater traced MB manually in MRIcron. Global MB volumes were calculated and compared between groups using
ANCOVAs, with intracranial volume as a covariate. Underweight AN exhibited smaller MB volumes than controls (115.6
mm3+/-21.4 vs. 133.8 mm3+/-21.4, p = .048). In contrast, weight restored AN exhibited larger MB volumes than controls
(151.5 mm3+/-24.9 vs. 133.8 mm3+/-21.4, p = .003). MB volumes also correlated positively with Eating Disorder
Examination severity in underweight (r = .73, p = .007) but not weight restored AN. These findings confirm that MB
volumes are altered in AN. The significance of enlarged volumes in weight restored states is unclear, but it could reflect
morphological reorganization following injury to this neural structure during underweight states. Longitudinal studies are
needed to confirm whether volumetric MB changes represent an illness marker and/or predict certain cognitive deficits.
Learning Objectives:
• Appreciate the most common causes of thiamine deficiency
• Describe the symptoms of cognitive impairment and neurological injury typically occurring in Wernicke's
encephalopathy as a result of thiamine deficiency.
• Discuss the effects of different stages of anorexia nervosa (underweight and weight restored) on mammillary body
morphology.
Reduced Thickness of Frontal Cortices and Cognitive Control Deficits in Bulimia Nervosa
Laura A. Berner, MS, Drexel University, Philadelphia, Pennsylvania, USA; Zhishun Wang, PhD, Columbia University
Medical Center and the New York State Psychiatric Institute, New York, New York, USA; Mihaela Stefan, MA, Columbia
University Medical Center and the New York State Psychiatric Institute, New York, New York, USA; Kristin Klahr, PhD,
Columbia University Medical Center and the New York State Psychiatric Institute, New York, New York, USA; Joanna
Steinglass, MD, Columbia University Medical Center and the New York State Psychiatric Institute, New York, New York,
USA; B. Timothy Walsh, MD, FAED, Columbia University Medical Center and the New York State Psychiatric Institute,
New York, New York, USA; Rachel Marsh, PhD, Columbia University Medical Center and the New York State
Psychiatric Institute, New York, New York, USA
Individuals with bulimia nervosa (BN) exhibit deficient activation, compared with healthy controls (HC), in frontostriatal
circuits. Aberrant function of the frontal cortical portions of these circuits, which mature through early adulthood and are
key to cognitive control, may especially contribute to behavioral dysregulation in BN; however, relatively little BN research
has focused on structural differences in these cortices or the potential impact of age on cognitive control in BN. The
current study examined cortical thickness and neuropsychological task performance in a large sample of adolescents and
adults. High-resolution anatomical MRI data were collected for 65 females with BN (ages 12-46) and 65 age-matched HCs
who completed the Conners’ Continuous Performance Test-II (CPT-II), a classic cognitive and attentional control task.
Covarying for age, significant reductions in cortical thickness were detected in the left posterior cingulate cortex and right
inferior frontal gyrus in BN subjects compared with HCs (ps< .001). Participants with BN across all ages made
significantly more commission errors (p = .003) and demonstrated reduced sustained attention (p = .002). A significant
diagnosis x age interaction indicated that the BN, but not the healthy, adolescents showed an exaggerated preference for
speed over accuracy that decreased with advancing age (p = .042). This improved self-regulation with age was attenuated
among participants with more frequent binge episodes (p = .001). Analyses examining diagnosis x age x CPT-II score
interactions in relation to structural abnormalities are in progress. Our findings indicate cortical thinning in inferior
frontal and posterior cingulate cortices in BN that may relate to observed deficits in cognitive and self-regulatory control
processes. With greater illness severity, these deficits seem to improve less with age. Results further support the potential
role of cognitive-control-related brain and behavioral abnormalities in BN development and persistence.
Learning Objectives:
• Understand why reductions in cortical thickness may be relevant to the mechanisms underlying bulimia nervosa
• Describe deficits in cognitive control in adolescents and adults with bulimia nervosa and the relation of these
deficits to eating disorder symptomatology
• Relate presented findings to 1) potential interventions for bulimia nervosa that could target processes that rely on
frontostriatal circuits and 2) the results of neuroimaging and behavioral research focused on other
psychopathologies
Prevention
Chairs: Phillipa Diedrichs PhD & Dianne Neumark-Sztainer, PhD, MPH, RD
Progress in Overcoming the Unhealthy Pursuit of Thinness: Continued Reach and Self-Reported Impact
of the Québec Charter for a Healthy and Diverse Body Image
Lise Gauvin, PhD, Centre de recherche du CHUM & Université de Montréal, Montreal, Quebec, Canada; Howard
Steiger, PhD, FAED, Douglas Institute & McGill University, Montreal (Verdun), Quebec, Canada
In 2009, the Québec Charter for a Healthy and Diverse Body Image was launched to overcome the unhealthy pursuit of
thinness. A population-based telephone survey (Gauvin & Steiger, 2012) showed that 7.3% and 35.1% of adults reported
spontaneous and prompted recognition of the Charter 6 months later. We examined the evolution of Charter recognition
between 2010 and 2014, describe self-reported impact, and identify associated characteristics. A sample of 2008 adult
internet panelists responded (response rate=41.3%) to an online survey probing knowledge of and reactions to the Charter
and socioeconomic characteristics. Complete data were available for 1910 (95.1%) people with good representation across
sexes, ages, family structure, income, education, and country of birth. Unweighted prevalence of spontaneous and
prompted Charter recognition were 9.5% (95%CI: 8.2, 10.9) and 38.1% (95%CI: 35.9, 40.3). Unweighted logistic
regression showed that women were more likely (OR=1.89, 95%CI: 1.35, 2.65; OR=1.30, 95%CI: 1.07, 1.57) and individuals
with no more than high school education (OR=0.43, 95%CI: 0.28, 0.68; OR=0.77, 95%CI: 0.62, 0.97) less likely to report
spontaneous and prompted recognition. Individuals 55 years or more were more likely to report prompted recognition
(OR=1.39, 95%CI: 1.08, 1.77). About 20.3% (95%CI: 18.5, 22.2) indicated that reading the Charter changed their views and
actions on body image. Women (OR=1.37, 95%CI: 1.08, 1.74), less-educated (OR=1.62, 95%CI: 1.26, 2.09), lower income
(OR=1.46, 95%CI: 1.04, 2.06), and non-Canadian/US-born individuals (OR=1.70, 95%CI: 1.17, 2.48) were more likely to
report change. Five years after its launch, an ongoing initiative to promote healthy body image still reaches a substantial
portion of the population, especially women. However, less-educated individuals remain hard-to-reach. Findings point to
potential targets for future intervention. Funded by the Secrétariat à la condition féminine.
Learning Objectives:
• Describe the evolution of the prevalence of recognition of the Québec Charter for a Healthy and Diverse Body
Image between 2010 and 2014 in the adult population of Québec.
• Describe the prevalence of significant yet self-reported impact of the Charter on views regarding body image and
maladaptive eating among the adult population of Québec.
•
Identify socioeconomic factors associated with current reach and self-reported impact of the Charter in the adult
population of Québec.
Life and Death on the Runway: Viable Legal Strategies to Improve Working Conditions for Professional
Models and Reduce Risk of Eating Disorders
Katherine Record, JD, MPH, MA, Harvard Law School, Jamaica Plain, Massachusetts, USA; S. Bryn Austin, ScD, FAED,
Harvard School of Public Health, Boston, Massachusetts, USA
The fashion industry is a widely recognized contributing factor to body dissatisfaction. Professional, particularly runway,
models are at increased risk for eating disorders, especially anorexia nervosa (AN), due to demands for extreme thinness.
Professional models have a mean BMI in the clinically underweight category, significantly higher drive for thinness and
rates of dysfunctional investment in appearance, and higher rates of AN or partial-syndrome AN than comparison groups.
Professional models also face a host of other hazards, including child labor and sexual abuse. Inability to enter into
collective bargaining perpetuates these problems. A rash of deaths in the modeling world spurred action in other nations
(Israel, Spain, Italy) to protect the health of models. Yet the US government has been silent on the issue, and the Council
of Fashion Designers of America adamantly opposes regulation. To address this deficit in US action, we reviewed
international and US federal, state, and selected municipal laws to comprehensively assess government’s authority to
regulate the fashion industry to protect the health of professional models. The results of our study indicate there are legal
mechanisms to address the workplace hazards runway models face, which may also indirectly change societal perceptions
of beauty as it is defined by fashion. The US Occupational Safety and Health Administration has the duty and authority to
protect the health of most American employees and could prohibit agents and designers from making employment
contingent on maintenance of dangerously low BMIs. This strategy requires demonstrating that models are employees
(rather than independent contractors) and that such regulatory action does not violate the Americans with Disabilities Act
(e.g., by imposing a cut-off BMI on runway models). In addition, our findings indicate that intervention is feasible at all
levels of government, including New York City, where the industry is centered.
Learning Objectives:
• Evaluate federal authority to regulate employers to protect employee health in the fashion industry context.
• Describe other legal action that has been taken to address this problem in other nations and municipalities around
the world.
• Identify state/municipal regulation that could be enacted in the short term before changes at the federal level are
achieved to protect the health of professional models participating in New York Fashion Week.
Cost-Effectiveness of School-based Strategies for the Dissemination of an Internet-based Eating Disorder
Prevention Program: Results from an RCT
Markus Moessner, PhD, DiplPsych, Center for Psychotherapy Research, University Hospital Heidelberg, Heidelberg,
Baden-Württemberg, Germany; Carla Minarik, DiplPsych, Center for Psychotherapy Research, University Hospital
Heidelberg, Heidelberg, Baden-Württemberg, Germany; Fikret Oezer, BA, Center for Psychotherapy Research,
University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany; Stephanie Bauer, PhD, DiplPsych, Center
for Psychotherapy Research, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
Theoretically, Internet-based interventions have an enormous reach. Especially for the field of prevention, this seems
promising. Yet, to make young people engage in eating disorder prevention programs is challenging. As a result, only few
interventions have been successfully transferred from the research setting into routine care. Cost-effective dissemination
strategies are crucial for the sustained implementation of prevention programs. However, only little is known about costs
and efficacy of specific dissemination strategies. In the present study, we investigated the costs and effects of five different
dissemination strategies to engage adolescents in an Internet-based prevention program for eating disorders. The five
strategies addressed secondary schools and ranged from low intense (i.e., sending information materials and asking the
school to distribute them among the students) to high intense approaches (i.e., organizing workshops at the schools). 395
schools were randomly assigned to one of the five strategies. Costs associated with each strategy were assessed in detail
and effects were defined as the number of page visits, the number of screening assessments, and the number of
registrations to the online intervention. Both costs and effects varied significantly between the strategies, with more
intense strategies being more expensive and more effective. The cost-effect ratio was lowest for the most intense strategy
(organizing workshops at schools) with 6.86€ per registration and highest for the mere distribution of information
materials (431.10€ per registration). The relevance of the results for the sustained implementation of Internet-based
prevention programs will be discussed, and key ingredients of successful dissemination strategies will be identified.
Learning Objectives:
• Describe the challenges inherent to the sustained implementation of eating disorder prevention programs
• Describe key ingredients of successful dissemination strategies
• Estimate the costs associated with the dissemination of Internet-based prevention programs
A Peer-Based Body Dissatisfaction Intervention For Early Adolescent Females: Does Classroom Setting
Make A Difference To Outcomes?
Candice Dunstan, BSc, La Trobe University, Melbourne, Victoria, Australia; Susan Paxton, PhD, FAED, La Trobe
University, Melbourne, Victoria, Australia; Sian McLean, BSc, La Trobe University, Melbourne, Victoria, Australia;
Karen Gregg, BA, La Trobe University, Melbourne, Victoria, Australia
Body dissatisfaction is highly prevalent among adolescent females, and is a cause for concern in light of its negative
consequences. Hence, prevention or reduction of body dissatisfaction and associated risk factors is essential. However,
research highlights that school-based interventions for females have been only modestly successful, and have typically
been evaluated in single-sex rather than co-educational settings. Thus, in addition to the need to strengthen interventions,
there is a need to identify whether interventions are equally effective when delivered in co-educational rather than singlesex classes. This study evaluated a six-session, co-educational version of the body image intervention, Happy Being Me.
Participants were Grade 7 females from 5 high schools randomly allocated to receive the intervention either in coeducational (n=73) or single-sex (n=74) settings, or were allocated to a no intervention control group (n=53). Self-report
questionnaires assessed body dissatisfaction, disturbed eating patterns, internalisation of media ideals, appearance
comparisons, self-esteem, weight-related teasing, and appearance conversations at baseline, post-intervention, and 6month follow-up. Improvements were found in body dissatisfaction, internalisation, appearance comparisons, and selfesteem, from baseline to post-intervention in the intervention groups compared with the control group. Intervention gains
were maintained for internalisation, appearance comparisons, and self-esteem at 6-month follow-up. Baseline appearance
conversations and self-esteem moderated body dissatisfaction and eating concerns outcomes. There were no significant
differences in outcomes between co-educational and single-sex delivery formats. These findings provide further evidence
of the efficacy of Happy Being Me and most importantly, for planning of school-based intervention delivery, suggest that
this intervention is equally valuable in co-educational or single-sex settings.
Learning Objectives:
• Describe the importance of examination of the impact of school setting in delivery of a body image intervention.
• Evaluate the impact of a six-session co-educational body image intervention for early adolescent females.
• Discuss the implications of the study findings for implementation of Happy Being Me.
Efficacy of the New ‘Confident Body Confident Child’ Body Image and Disordered Eating Prevention
Resource for Parents of Pre-school Children: a Randomised Controlled Trial.
Laura Hart, PhD, La Trobe University, Melbourne, Victoria, Australia; Stephanie Damiano, PhD, La Trobe University,
Melbourne, Victoria, Australia; Susan Paxton, PhD, FAED, La Trobe University, Melbourne, Victoria, Australia
Confident Body Confident Child (CBCC) is a new resource to assist parents in providing a positive body image and healthy
eating environment for 2-6 year-old children. The print materials, website, poster and information session were developed
from research on child risk factors for body dissatisfaction and disordered eating and a Delphi expert consensus study.
The CBCC resource was evaluated using a four arm Randomised Controlled Trial; A) CBCC resource + face-to-face
information session, B) CBCC resource only, C) Nutrition resource only and D) waitlist control. Parent participants
completed online self-report measures of parenting variables (knowledge, behavioural intentions, family meals and
parental feeding practices), parent body image and dieting behaviors (BAQ and DEBQ), and parent-report of child
variables such as eating and media viewing habits. 340 participants completed baseline measures and were followed-up 6
weeks after receiving the resource, 6-months and 12months after. Focussing on the first round of results, repeated
measures analyses comparing baseline to post-test revealed that receiving the CBCC resource was associated with
significant reductions in parents’ appearance-based stigma and instrumental feeing practices. Parents reported high
engagement with the CBCC resource and enjoying face-to-face sessions. Conversely, the nutrition resource was associated
with increases in unhealthy parent feeding practices and appearance-based stigma. Implications for the future
dissemination of the CBCC resource is discussed.
Learning Objectives:
• Describe the Confident Body Confident Child prevention resource for parents of 2-6 year old children.
• Compare the differences between parents in the four trial groups on measures of parenting variables over time.
• Provide a rationale for the further dissemination of the evidence-based CBCC resource to parents of preschool
children.
Effects of menu calorie labeling on restaurant ordering among individuals with eating disorders
Ann Haynos, MA, Duke University Medical Center, Durham, North Carolina, USA; Christina Roberto, PhD, Harvard
University School of Public Health, Boston, Massachusetts, USA
There is some concern from eating disorder advocates that public health policies designed to address obesity will promote
disordered eating. One such policy is menu labeling, which requires restaurants to post caloric information on menus.
However, no studies have examined whether these concerns are warranted. In this study, 633 female college students
participated in an online study in which they were randomized to receive the same restaurant menu with or without
caloric content displayed and asked to select items they would choose to consume at a dinner meal. Participants
completed questions about their food selections and the Eating Disorder Examination Questionnaire (EDE-Q). Linear
regressions were conducted examining the impact of EDE-Q scores, menu type, and the interaction between these
variables, on dependent variables related to menu selections. The results indicated that individuals endorsing greater
eating disorder (ED) symptoms by the EDE-Q largely did not have differential responses based on menu labeling.
However, independent of menu type, those reporting more ED symptoms ordered fewer calories (β=-.252, p<.001), and
were more likely to make food selections based on emotional response (β=.304, p<.001) and less likely make selections
based on taste (β=-.252, p=.036). Individuals endorsing higher ED symptoms also reported greater distress about
consuming menu items (β=.404, p<.001) and lower likelihood that they would eat at the restaurant (β=-.152, p = .007).
There were two significant menu type by EDE-Q interactions. Menu labels significantly affected the accuracy of caloric
estimates of food ordered only when ED symptoms were low (β=-.207, p=.001). Menu labels also increased the salience of
health concerns in food selection only when ED symptoms were elevated (β=.116, p=.033). These results suggest that ED
symptoms affect how individuals order at restaurants, but calorie labels on restaurant menus may not profoundly affect
this experience.
Learning Objectives:
• Examine how calorie labels on restaurant menus differentially affect individuals based on level of eating disorder
symptoms
• Highlight any differences in restaurant ordering between individuals with and without eating disorder concerns
• Discuss whether prevention measures for one issue (i.e., obesity) can be implemented without negative impact on
other issues (i.e., eating disorders)
Sex and Gender
Chairs: Martha Peaslee Levine MD & Theodore Weltzin MD
Perceived Sexual Orientation of Men and Women with Eating Disorders
Jamal Essayli, MA, University of Hawaii at Manoa, Honolulu, Hawaii, USA; Jessica Murakami, MA, University of
Hawaii at Manoa, Honolulu, Hawaii, USA; Janet Latner, PhD, University of Hawaii at Manoa, Honolulu, Hawaii, USA
Little is known about the perceived sexual orientation of men and women with eating disorders, and no study to date has
explored the relationship between perceived sexual orientation and stigma. In a 2 x 4 between-subjects experimental
design, 318 participants were randomly assigned to read vignettes describing a male or female target diagnosed with
Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge-Eating Disorder (BED), or obesity. Participants then completed
questionnaires assessing for perceived sexual orientation, stigma, and attitudes towards gay men and lesbians. When
answering a forced-choice question, a greater percentage of participants rated male targets with AN and BN as probably
homosexual or bisexual relative to females targets with AN (p < .01) and BN (p < .001), respectively. No significant
differences in perceived sexual orientation emerged between male and female targets diagnosed with BED or obesity.
Additionally, significant differences in perceived sexual orientation emerged between the four male targets (p < .001). The
target was rated as homosexual or bisexual by 53% of participants in the male BN condition, 31% in the male AN
condition, 26% in the male BED condition, and 6% in the male obesity condition. Female targets in the AN, BN, BED, and
obesity conditions were perceived similarly with respect to sexual orientation. Although participants who perceived the
target as homosexual or bisexual were significantly more likely to hold stigmatizing attitudes towards the target (p < .05),
regression analyses indicated that this relationship was fully mediated by negative attitudes towards lesbians and gay men.
These results suggest that males with eating disorders, particularly BN and AN, are more likely to be perceived as gay or
bisexual. While the perception of individuals with eating disorders as gay or bisexual might increase stigma towards those
individuals, this stigma appears to be better explained by overall negative attitudes towards lesbians and gay men.
Learning Objectives:
• Understand differences in the perceived sexual orientation of men and women with eating disorders
• Understand differences in the perceived sexual orientation of men and women with anorexia nervosa, bulimia
nervosa, binge-eating disorder, and obesity
• Understand the relationship between perceived sexual orientation and stigma
Weight and Shape Control Behaviors Among Young Transgender Women: Preliminary Findings from
Project Body Talk
Allegra Gordon, MPH, Harvard School of Public Health and The Fenway Institute, Boston, Massachusetts, USA;
Sari Reisner, ScD, The Fenway Institute and Harvard School of Public Health, Boston, Massachusetts, USA; Jaclyn
White, MPH, The Fenway Institute and Yale School of Public Health, Boston, Massachusetts, USA; S. Bryn Austin, ScD,
FAED, Children's Hospital Boston and Harvard School of Public Health, Boston, Massachusetts, USA
Transgender populations face significant health inequities. Little is known about eating disorders and unhealthy weight
control behaviors in transgender populations. Recent research suggests eating disorders may be an important concern. A
survey of 280,000 U.S. college students found transgender students had two-fold greater odds of a past-year diagnosis of
anorexia nervosa or bulimia nervosa compared to non-transgender women. We undertook the present study to explore
high-risk weight and shape control practices among low-income, ethnically diverse young transgender women in the
Boston area using in-depth, individual interviews. Target enrollment is 20 participants; 12 interviews have been
completed to date (sample mean age: 24 years; mean annual income: <$10,000; ethnic identity: Multiracial [n=4], Black
[n=3], Latina [n=2], White [n=2], Asian [n=1]). Preliminary findings indicate that young women in the study use a variety
of strategies to address body image concerns in the context of transgender-related discrimination. Gender-affirming,
cross-sex hormone use was linked to both body satisfaction and concerns about weight gain. Experiences of discrimination
took many forms and shaped participants’ access to social and material resources as well as stress and coping behaviors.
For several participants, weight was a significant source of distress and was linked to high-risk weight loss practices. Of 12
participants, 8 reported engaging in disordered eating and weight-control behaviors in the past year, including binge
eating (7), fasting (3), vomiting (1), and laxative use (1). No participants reported receiving a referral from a healthcare
provider for treatment for their eating disorder symptoms. This study provides novel insight into disordered eating and
weight-control behaviors among young transgender women, illuminating avenues for future research, treatment, and
prevention efforts sensitive to the needs of this underserved population.
Learning Objectives:
• Discuss current health inequities faced by transgender populations and forms of discrimination that may drive
these inequities.
• Discuss a gender affirmation model and its potential application to understanding and contextualizing disordered
eating behaviors in young transgender women.
• Describe two potential pathways via which young transgender women may be at risk of eating disorders.
Childhood Gender Conformity and use of Laxatives and Muscle-building Products in Heterosexual and
Sexual Minority Females and Males
Jerel Calzo, PhD, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Kendrin
Sonneville, ScD, RD, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Emily
Scherer, PhD, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Benita Jackson, PhD, Smith
College, Northampton, Massachusetts, USA; S. Bryn Austin, ScD, FAED, Boston Children's Hospital and Harvard
Medical School, Boston, Massachusetts, USA
Using laxatives for weight loss and products to build muscle (e.g., creatine, steroids) differs by gender and sexual
orientation (i.e., heterosexual vs. sexual minority [e.g., bisexual, lesbian/gay]); little is known about factors contributing to
these disparities. Conformity to gender norms could underlie these differences, with greater conformity to femininity
associated with laxative use to achieve thinness, and greater conformity to masculinity associated with muscle-building
product use to achieve muscularity. This study examined associations between childhood gender conformity and laxative
and muscle-building product use from ages 13-25 years in a sample of 13,683 males and females in the US prospective
Growing Up Today Study. Multivariable logistic regression models of repeated measures estimated the odds of past-year
laxative and muscle-building product use by quartiles of greater childhood gender conformity, adjusting for sexual
orientation, age and weight status. Separate models examined laxatives (females only, due to low use in males) and
muscle-building products (males only, due to low use in females) and tested interactions between sexual orientation and
gender conformity. From ages 13-25 years, 3.3% of females reported using laxatives in the past year and 9.1% of males
reported using muscle-building products in the past year. Sexual minority females were twice as likely as heterosexual
females to use laxatives (p<.0001). The most gender conforming females were 50% more likely than the least conforming
females to use laxatives (p<.01). Heterosexual males who were moderately or highly gender conforming were most likely
to use muscle-building products (p's<.001). Conformity to gender norms was associated with laxative and muscle-building
product use in females and males, respectively, of all sexual orientations. Findings can help inform prevention efforts to
target youth who may be at risk for laxative or muscle-building product use.
Learning Objectives:
• Evaluate the associations between childhood gender conformity and laxative and muscle-building product use.
• Describe how the effect of childhood gender conformity on laxative and muscle-building product use differs by sex
and sexual orientation.
• Discuss the implications for incorporating findings from gender-based analyses into prevention efforts to reduce
risk for laxative and muscle-building product use in heterosexual and sexual minority adolescents.
Efficacy of The Body Project 4 All Targeting Male and Female Body Image: A Randomized Controlled
Trial
Kerstin Blomquist, PhD, Furman University, Greenville, South Carolina, USA; Catherine Circeo, Student, Furman
University, Greenville, South Carolina, USA; Amanda Hock, Student, Furman University, Greenville, South Carolina,
USA; Salome Wilfred, Student, Trinity University, San Antonio, Texas, USA; Christina Verzijl, Student, Trinity
University, San Antonio, Texas, USA; Aaron Harwell, Student, Trinity University, San Antonio, Texas, USA; Tyler
Howard, Student, Trinity University, San Antonio, Texas, USA; Victoria Perko, Student, Trinity University, San
Antonio, Texas, USA; Lisa Kilpela, PhD, Trinity University, San Antonio, Texas, USA; Carolyn Becker, PhD, Trinity
University, San Antonio, Texas, USA
Body dissatisfaction is a known risk factor for eating disorders, depression, stress, and reduced physical activity. The Body
Project is a cognitive dissonance-based body image intervention that has been shown to reduce onset of eating disorders
(Stice et al., 2012). The Body Project’s efficacy and effectiveness in young adult females has been documented in numerous
trials conducted by 6 different research groups (Becker et al., in press). The present ongoing study examines whether the
peer-led female version of the Body Project could be expanded to males via a co-ed format and whether the presence of
males impacted outcomes on females. Participants from two small universities (N=170) were randomly assigned to a co-ed
(n=76), female-only (n=32), or waitlist condition (n=62). Participants complete pre, post, 2- and 6-month follow-up
measures of body dissatisfaction, negative affect, and eating disorder pathology. Pre-post analyses indicated that males in
the co-ed intervention reported significantly improved body satisfaction (F(1,63)=9.73, p<0.01) and male body attitudes
(F(1,62)=20.19, p<0.01), as well as diminished eating pathology (F(1,63)=13.68, p<0.01), internalization of the muscular
ideal (F(1,63)=6.95, p=0.01) from pre to post compared to waitlisted males. Females in the female-only and co-ed
conditions reported significantly improved body satisfaction (F(2,102)=7.25, p<0.01) as well as diminished eating
pathology (F(2,102)=3.54, p=0.03), appearance comparison (F(2,102)=6.64, p<0.01), and body surveillance
(F(2,102)=6.11, p<0.01) from pre to post compared to waitlisted females (female-only vs waitlist and co-ed vs waitlist
post-hoc comparisons, all p’s<0.03). Post-hoc comparisons revealed no significant differences between the female-only
and co-ed conditions. Findings provide preliminary support for efficacy of this co-ed body image intervention.
Learning Objectives:
• Identify a peer-led, cognitive-dissonance-based body image promotion, eating disorder prevention program with
preliminary efficacy for use with college-aged males in co-ed format.
• Describe the immediate and sustained impact of this co-ed body image intervention on male and female college
students' body image, affect, and disordered eating behaviors.
• Compare and contrast the effects of a female-only body image intervention versus a co-ed body image
intervention for female college students.
Results from a Randomized Controlled Trial of The PRIDE Body Project: A Dissonance-Based Eating
Disorder Prevention Program for Gay Men
Tiffany Brown, MS, Florida State University, Tallahassee, Florida, USA; Pamela Keel, PhD, FAED, Florida State
University, Tallahassee, Florida, USA
Research supports that gay males may be at increased risk for eating disorders compared to heterosexual males,
establishing a need to develop and empirically evaluate programs to reduce risk for this population. The present study
investigated the acceptability, efficacy, and specificity of a cognitive dissonance-based (DB) intervention in reducing
eating disorder risk factors among gay males in a university-based setting. Eighty-seven gay males were randomized to
either a 2-session DB intervention (n=47) or a waitlist control condition (n=40). Participants completed validated
measures assessing eating disorder risk factors pre-intervention, post-intervention, and at 1-month follow-up, along with
post-treatment acceptability measures. Hierarchical Linear Modeling was used to assess differences between conditions
across time. Regarding acceptability, the retention rate for the DB intervention was 86%. Acceptability ratings for the
program were highly favorable for all items (overall mean = 6.18 on a 7-point scale). Regarding efficacy, the DB condition
was associated with significantly greater decreases in body-ideal internalization, body dissatisfaction, self-objectification,
romantic partner-objectification, dietary restraint, and bulimic symptoms compared to waitlist control from pre- to postintervention (all p-values <.02). Improvements in the DB group were maintained for all variables at 1-month follow-up
(all p-values <.04), with the exception of body-ideal internalization. Demonstrating the specificity of the intervention to
eating pathology, conditions did not differ over time on changes in reported alcohol use problems (p =.25). Results
support the acceptability, efficacy, and specificity of The PRIDE Body Project, up to one-month post-intervention.
Learning Objectives:
• Describe the acceptability of The PRIDE Body Project, a dissonance-based eating disorder prevention program for
gay men.
• Describe the efficacy of The PRIDE Body Project, a dissonance-based eating disorder prevention program for gay
men.
• Describe the specificity of The PRIDE Body Project, a dissonance-based eating disorder prevention program for
gay men.
A Qualitative Analysis of Male Eating Disorder Symptoms
Katherine Arnow, BA, Stanford University, Palo Alto, California, USA; Talya Feldman, BA, Stanford University, Palo
Alto, California, USA; Elizabeth Fichtel, BS, Park Nicollet, Minneapolis, Minnesota, USA; Hsiao-Jung Iris Lin, MS,
PGSP-Stanford PsyD Consortium, Palo Alto, California, USA; Marcus Westerman, MD, Park Nicollet, Minneapolis,
Minnesota, USA; Alison Darcy, PhD, FAED, Stanford University, Palo Alto, California, USA
Eating disorders have long been thought to manifest similarly in males and females yet male symptomatology may not be
adequately captured with current measures because they were developed primarily for females. Improved understanding
of the male experience of eating disorders is likely to facilitate better detection and treatment of male cases. To eliminate
bias that treatment and the therapeutic language surrounding symptoms therapy may introduce, the current study is the
first to include initial presentation adolescent males who have not spent significant time in treatment. New male patients
ages 12-19 at the Stanford University Eating Disorders Clinic with 4 or fewer therapy sessions were invited to participate.
Ten adolescent males and 10 age- and Ideal Body Weight (IBW)- matched females were interviewed using open-ended
questions. Interview data codes were generated systematically, grouped into “thematic maps” and applied to the data set
to generate frequencies. Twenty percent of the interviews were randomly selected to examine inter-rater reliability.
Participants also completed a battery of standard questionnaires. Differences between male and female participants on
these quantitative measures were analyzed using independent t-tests. Females scored significantly higher than males on
depression (p<.05), state anxiety (p<.05), emotional awareness (p<.05) and on all subscales of the Eating Disorder
Examination Questionnaire (EDE-Q) with the exception of Shape Concerns. With the exception of emotional awareness
(p<.05), males and females did not significantly differ on Difficulty in Emotion Regulation (DERS) subscales or on
obligatory exercise or drive for muscularity. Interview and quantitative findings suggest that males have different avenues
to treatment than do females and several key differences in symptoms including greater focus on sports performance, a
muscular ideal, and more awareness of the consequences of their illness.
Learning Objectives:
• Evaluate how adolescent males with eating disorders experience their symptoms.
• Elucidate our understanding our understanding of how to facilitate better detection and treatment of male cases
• Help us to better understand the role of gender in eating disorders
Social and Executive Functioning
Chairs: Unna Danner PhD & Youl-Ri Kim MD, PhD
Neural Differences in Processing Social Relationships is Related to Recovery in Anorexia.
Carrie McAdams, MD, PhD, UT Southwestern Medical School, Dallas, Texas, USA; Terry Lohrenz, PhD, Virginia Tech
Carilion Institute, Roanoke, Virginia, USA; P. Read Montague, PhD, Virginia Tech Carilion Research Institute, Roanoke,
Virginia, USA
Problems with social relationships contribute to illness in anorexia nervosa. Neuroeconomic games allow assessment of
behavioral and neural responses using a simulated social relationship. We examined how processing dynamic social
interactions related to weight recovery from anorexia by comparing three groups of adult women: healthy controls (HC, n
= 21), subjects currently with anorexia nervosa (AN-C, n = 23, met DSM IV criteria for anorexia within last 12 months),
and subjects with long-term weight recovery from anorexia (AN-WR, n = 19, minimum of 2 years at BMI > 19.0). In a 3T
MRI scanner, all subjects played the multi-round trust game, an interactive social neuroeconomic game. Neural responses
on viewing their opponent’s investment were sorted based on whether their opponent's behavior demonstrated
benevolence, a signal of an improving relationship, or malevolence, a signal of deteriorating relationship, toward the
subject. Whole brain ANOVAs identified group differences; whole-brain regressions related psychological variables with
the neural responses (threshold for significance: cluster p corrected < 0.05). In the ANOVAs, responses to benevolence
were diminished in social cognitive regions, including the fusiform, precuneus, and temporoparietal junction, in both the
AN-C and AN-WR groups compared to the HC group, but neural responses in the fusiform to malevolence were
diminished only in AN-C group. Furthermore, on regression, the positive personalizing bias (PPB), a self-report measure
of how often one believes that kindness comes from others rather than the situation, was inversely correlated with neural
activity throughout many social cognitive regions during benevolence (total voxels, 1113, Pearson’s r = -0.58, P < 0.001),
including the bilateral temporoparietal junctions, bilateral fusiform gyri, the precuneus, and the dorsal anterior cingulate.
Problems in perceiving kindness may contribute to the development of anorexia, but recognizing malevolence may be a
significant cognitive shift important for recovery from anorexia. Future research should assess if the PPB can be altered by
treatment, and whether outcomes following treatment are associated with changes in the PPB.
Learning Objectives:
• Understand that different brain regions are responsive to kindness and meanness in healthy people, and can be
assessed with interactive social game played in an MRI scanner.
•
•
Recognize that both patients currently with anorexia and those with long-term weight recovery have less neural
activity in response to kindness but only currently ill patients show reduced neural responses to meanness.
Understand that a self-report psychological measure, the positive personalizing bias, is strongly correlated with
the amount of neural activations in response to kindness in patients with anorexia, both recovered and current, as
well as healthy people.
An Examination of Autistic Spectrum Traits in Adolescents with Anorexia Nervosa and Their Parents
Charlotte Rhind, MSc, BSc, King's College London, Institute of Psychiatry, London, London, United Kingdom (Great
Britain); Elena Bonfioli, PhD, University of Verona, Public Health and Community Medicine, Verona, Verona, Italy;
Rebecca Hibbs, PhD, MSc, BSc, King's College London, Institute of Psychiatry, London, London, United Kingdom (Great
Britain); Elizabeth Goddard, PhD, MSc, BSc, King's College London, Institute of Psychiatry, London, London, United
Kingdom (Great Britain); Pamela Macdonald, PhD, BSc, King's College London, Institute of Psychiatry, London,
London, United Kingdom (Great Britain); Simon Gowers, MD, University of Liverpool, Psychological Sciences,
Liverpool, Liverpool, United Kingdom (Great Britain); Ulrike Schmidt, MD, MRCPsych, FAED, King's College London,
Institute of Psychiatry, London, London, United Kingdom (Great Britain); Kate Tchanturia, DClinPsy, FAED, King's
College London, Institute of Psychiatry, London, London, United Kingdom (Great Britain); Nadia Micali, MD,
MRCPsych, PhD, FAED, University College London, Institute of Child Health, London, London, United Kingdom (Great
Britain); Janet Treasure, MD, MRCPsych, PhD, King's College London, Institute of Psychiatry, London, London, United
Kingdom (Great Britain)
There may be a link between anorexia nervosa and autistic spectrum disorders. The aims of this study were: to examine
whether adolescents with anorexia nervosa have autistic spectrum and/or obsessive-compulsive traits, how many would
meet diagnostic criteria for autistic spectrum disorder, and whether these traits are shared by parents. A total of 150
adolescents receiving outpatient treatment for anorexia nervosa and their parents completed the autistic spectrum
disorder and eating disorder sections of the Development and Well-being Assessment. Patients also completed the
Children Yale-Brown Obsessive-Compulsive Scale and other measures of psychiatric morbidity; and parents completed
the short Autism Quotient and Obsessive-Compulsive Inventory Revised. Adolescents with anorexia nervosa had below
average social aptitude (19% below cut-off) and high levels of peer relationship problems (39% above cut-off) and
obsessive-compulsive symptoms (56% above cut-off). Six cases (4%, all females) were assigned a possible (n = 5) or
definite (n = 1) diagnosis of autistic spectrum disorder. Parental levels of autistic spectrum and obsessive-compulsive
traits were within the normal range. This study suggests that adolescents with anorexia nervosa have elevated levels of
autistic spectrum traits, obsessive-compulsive symptoms and a small increase in the prevalence of autistic spectrum
disorder. These traits did not appear to be familial. This comorbidity has been associated with a poorer prognosis.
Therefore, adapting treatment for this subgroup may be warranted.
Learning Objectives:
• Understand the overlap between anorexia nervosa, autistic spectrum disorder and obsessive-compulsive disorder.
• Summarize findings on the level of autistic spectrum and obsessive-compulsive traits and prevalence of autistic
spectrum disorder in adolescents with early-onset anorexia nervosa.
• Critically evaluate the use of a dimensional approach to diagnosis and implications for assessment and treatment
in early-onset anorexia nervosa.
Social Emotional Functioning in Active and Weight-Recovered Anorexia Nervosa
Cindy Schmelkin, BS, Harvard Medical School, Boston, Massachusetts, USA; Kamryn Eddy, PhD, FAED, Massachusetts
General Hospital/Harvard Medical School, Boston, Massachusetts, USA; Jennifer Thomas, PhD, FAED, Massachusetts
General Hospital/Harvard Medical School, Boston, Massachusetts, USA; Emily Gray, MD, Massachusetts General
Hospital/Harvard Medical School, Boston, Massachusetts, USA; Karen Miller, MD, Massachusetts General
Hospital/Harvard Medical School, Boston, Massachusetts, USA; Nouchine Hadjikhani, MD, PhD, Massachusetts
General Hospital/Harvard Medical School, Boston, Massachusetts, USA; Debra Franko, PhD, FAED, Massachusetts
General Hospital/Harvard Medical School; Northeastern University, Boston, Massachusetts, USA; Anne Klibanski, MD,
Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA; Elizabeth Lawson, MD,
Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
Social emotional deficits, including social anxiety, alexithymia, and difficulty recognizing emotions in others, have been
described in anorexia nervosa (AN). Whether these represent an endophenotype (increasing illness risk and persisting as a
trait marker), or exist due to starvation as a state marker associated with more severe illness (that may persist as a scar), is
not understood. We therefore investigated the effects of weight recovery and self-reported lowest adult body mass index
(BMI; as a proxy for illness severity) on social emotional functioning in women with DSM-5 AN. We examined 38 active
AN, 41 weight-recovered AN (ANWR), and 44 healthy controls (HC). Height and weight were assessed and participants
completed the Dimensional Assessment of Personality Pathology–Basic Questionnaire: Suspiciousness and Inappropriate
Attachment subscales, Leibowitz Social Adjustment Scale–Self Report, and, in 63 subjects, the Toronto Alexithymia Scale.
BMI was similar in ANWR and HC. AN and ANWR did not differ in suspiciousness, difficulty identifying feelings, and
alexithymia; both groups reported greater difficulties than HC (p<.005). ANWR reported social and public fear
intermediate between AN and HC (p<.02), whereas social and public avoidance was increased in AN (p<0.003), but did
not differ between HC and ANWR. AN reported greater insecure attachment than HC (p=.008), and ANWR did not
significantly differ from either group. Lowest BMI in AN (but not ANWR) was negatively correlated with social fear (r=0.64), social avoidance (r=-0.59), public fear (r=-0.51), and public avoidance (r=-0.56) (p<0.007), independent of current
BMI, and was not associated with other social emotional measures. These data show that social emotional deficits in AN
only partially improve with weight restoration and may be more pronounced in those with the most severe illness. Further
studies are needed to determine whether these social deficits are a cause, correlate, or consequence of AN.
Learning Objectives:
• Summarize the social emotional deficits often found in women with anorexia nervosa.
• Describe social emotional functioning in weight-recovered women with anorexia nervosa.
• Describe the relationship between lowest adult body mass index (BMI; as a proxy for disease severity) and social
emotional functioning in AN.
Do Executive Functioning Deficits Underpin Binge Eating Disorder?: A Comparison of Overweight
Women with and without Binge Eating Pathology.
Stephanie Manasse, BA, Drexel University, Philaelphia, Pennsylvania, USA; Evan Forman, PhD, Drexel University,
Philadelphia, Pennsylvania, USA; Anthony Ruocco, PhD, University of Toronto Scarborough, Toronto, Ontario,
Canada; Meghan Butryn, PhD, Drexel University, Philadelphia, Pennsylvania, USA; Adrienne Juarascio, PhD, Drexel
University, Philadelphia, Pennsylvania, USA; Kara Fitzpatrick, PhD, Stanford University, Palo Alto, California, USA
The current study sought to examine the executive functioning (EF) profile of individuals with binge eating disorder
(BED). We compared several dimensions of EF, including problem-solving, planning, delayed discounting, inhibitory
control, cognitive flexibility and working memory in a sample of overweight and obese (BMI = 26-50 kg/m2) women with
(n=31) and without (n=43) full or sub-threshold BED. The Eating Disorders Examination and a neuropsychological
battery were administered to all participants before entry into either a group treatment for BED or weight control. After
controlling for IQ and age, individuals with BED displayed poorer performance on tasks of problem-solving (p < .01, η p2 =
.10) and inhibitory control (p = .02, η p2 = .08), and displayed steeper discounting of delayed rewards (p = .02, η p2 = .09)
compared to controls. The pattern of results remained unchanged when depression was added as a covariate. EF was not
associated with frequency of binge episodes (ps = .4-9, η p2 = .00-.03). Exploratory analyses indicated full and subthreshold BED groups did not appear to differ in performance on any EF tasks (ps = .5-.8, η p2 = .00-.03). Results indicate
overweight individuals with BED may show distinct EF deficits compared to overweight controls, suggesting that BED
may be maintained by neuropsychological factors unique from that of obesity. Poor problem-solving, prioritization of
immediate reward, and poor inhibitory control may lead to 1) irregular eating patterns and 2) reliance on binge eating as
method of reducing negative affect. Additionally, full and sub-threshold groups did not appear to differ from each other,
and EF was not associated with binge eating frequency, suggesting that loss-of-control, rather than size or frequency of
binge episodes, may be the construct most associated with EF deficits. Results have implications for treatment
components that may be useful in the treatment of BED.
Learning Objectives:
• Describe the relation of executive function with binge eating disorder
• Summarize specific tenants of EF deficits associated with binge eating
• Identify potential treatment implications of EF deficits in those with binge eating disorder
Problem Solving in Eating Disorders: An Investigation of Effective and Ineffective Problem-Solving
Processes and their Relation to a Low Tolerance for Uncertainty
Lot Sternheim, PhD, MSc, Department of Clinical and Health Psychology, Utrecht University, The Netherlands, Utrecht,
Netherlands
Effective problem solving is crucial across all areas of life. A handful of studies confirm problem-solving difficulties in
people with eating disorders (ED). Studies however focus largely on problem-solving outcomes, thereby failing to examine
problem-solving processes, Moreover, little is known about possible factors contributing to effective versus ineffective
problem-solving processes. This study examined, firstly, differences between ED subjects and Healthy Control subjects
(HC) in problem-solving styles and beliefs about one’s own problem-solving abilities, and secondly, relations between
these processes and a low tolerance for uncertainty (IU). Hundred twenty-seven adult women with ED (screened with the
Eating Disorder Diagnostic Scale) and 69 HC completed the Intolerance of Uncertainty Scale (12-item) and the Social
Problem Solving Inventory–R which assesses (impulsive, rational and avoidance) problem-solving styles and (negative
and positive) beliefs individuals hold about their own problem-solving abilities. ANOVA analyses were run to examine
group differences. Regression analyses were run to investigate associations between IU and problem-solving styles and
beliefs in both groups. Compared to HC subjects ED subjects had higher levels of impulsive and avoidance problemsolving styles and more negative beliefs about their abilities. No group differences were found for the rational problem-
solving style nor for positive beliefs about their own ability. For both the ED and HC subjects, higher levels of IU were
associated to more negative and less positive beliefs about their problem-solving abilities, and to higher levels of an
avoidance problem-solving style. IU was not associated to either the rational or impulsive problem-solving styles. Findings
confirm that people with ED employ ineffective problem-solving styles, and feel unconfident about their own problemsolving abilities, both which are likely to contribute to actual problem-solving difficulties. Moreover, findings suggest that
an intolerance for uncertainty, typical for people with ED, may be an important contributor to ineffective problem solving.
Learning Objectives:
• Following the training, participants will be able to name both effective and ineffective processes related to
problem solving, and to describe which processes are most typical for people with eating disorders.
• Following the training, participants will be able to explain the relation between a low tolerance for uncertainty and
various effective and ineffective problem-solving processes.
• Following the training, participants will be able to describe the potential benefit of employing a training aiming to
increase the use of effective problem-solving processes, thereby increasing tolerance levels for uncertainty, for
people with eating disorders
The Role of Affect in Decision Making in Women with Restrictive and Binge-Purge Type Anorexia
Nervosa
Unna Danner, PhD, FAED, Altrecht Eating Disorders Rintveld, Zeist, Utrecht, Netherlands; Lot Sternheim, PhD, FAED,
Altrecht Eating Disorders Rintveld, Zeist, Utrecht, Netherlands; Alexandra Dingemans, PhD, FAED, Centre for Eating
Disorders Ursula, Leiden, zuid-holland, Netherlands; Annemarie van Elburg, PhD, MD, FAED, Altrecht Eating
Disorders Rintveld, Zeist, Utrecht, Netherlands
Anorexia nervosa (AN) has a serious negative effect on quality of life, lowering cognitive, interpersonal and societal
functioning. Still, patients are often reluctant to engage in treatment. It seems that the decisions they make are based on
the here and now, i.e. on the expected short-term consequences of their behavior (having to eat) despite of on the longerterm outcome (recovering from AN). Research has demonstrated decision making difficulties in patients with AN.
Affective problems seen in many AN patients (e.g. depressive symptoms) might be an underlying factor. Additionally,
differences may also exist between AN subtypes, since binge-purge (ANBP) type patients are more inclined to behave
more impulsively in response to negative affect than restrictive (ANR) type patients. The aim of our study was to examine
the influence of negative affect on decision making in patients with ANR (n=32) and ANBP (n=31) in comparison to
healthy women (n=30). Negative affect was 1) manipulated by asking half of the participants to watch a sad movie and the
other half a neutral movie, and 2) measured before the manipulation using questionnaires (about current sadness and
depressive symptoms, BDI). Subsequently decision making was assessed using the Bechara Gambling Task (BGT) and the
Game of Dice Task (GDT). No effect of the sadness manipulation on decision making performance was found in the AN
groups, but correlational analyses revealed a positive relation between sadness and disadvantageous decision (BGT) in
women with ANBP, and depressive symptoms (a sadness-related state) and advantageous decision making (GDT) in
women with ANR. Furthermore independent of emotional state, decision making was found to be impaired in women with
ANBP, but not in women with ANR. In the context of a sad emotional state, decision making was influenced differently in
women with ANBP and ANR.
Learning Objectives:
• Following the presentation, participants will be able to describe decision making problems in anorexia nervosa
• Following the presentation, participants will be able to relate decision making problems to affective and emotions
issues in patients with anorexia nervosa
• Following the presentation, participants will be able to relate differences between anorexia nervosa subtypes in
behavior and personality to decision making problem.
Treatment of Eating Disorders (Child and Adolescent)
Chairs: Rachel Bryant-Waugh DPhil & Andrea Garber, PhD, RD
A Randomized Controlled Trial of Inpatient Treatment for Anorexia Nervosa in Medically Unstable
Adolescents.
Sloane Madden, MBBS, FAED, Sydney Children's Hospital Network, Sydney, NSW, Australia; Jane Miskovic, DPsych,
Sydney Children's Hospital Network, Sydney, NSW, Australia; Andrew Wallis, MSW, Sydney Children's Hospital
Network, Sydney, NSW, Australia; Michael Kohn, MBBS, Sydney Children's Hospital Network, Sydney, NSW,
Australia; Jim Lock, PhD, FAED, Stanford University, Paolo Alto, California, USA; Daniel LeGrange, PhD, FAED,
University of Chicago, Chicago, Illinois, USA; Simon Clarke, MBBS, Westmead Hospital, Westmead, NSW, Australia;
Phillipa Hay, PhD, MBBS, The University of Western Sydney, Sydney, NSW, Australia; Stephen Touyz, PhD, FAED, The
University of Sydney, Sydney, NSW, Australia
Background Anorexia Nervosa (AN) is a serious disorder, with high costs due to hospitalization. International treatments
vary with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest
longer initial hospitalizations that normalize weight produce better outcomes and less admissions than shorter
hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of longer hospitalization for
weight restoration (WR) to shorter hospitalization for medical stabilization (MS) in medially unstable adolescents with AN
both followed by family based treatment (FBT). Methods A randomized controlled trial of 82 adolescents, 12-18 years,
with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were
randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for
gender, age, and height, both followed by 20 sessions of outpatient, manualized FBT. Results Primary outcome was
hospital days, following initial admission, at 12-month follow-up. Secondary outcomes were total hospital days used to 12months and full remission defined as healthy weight (>95% EBW) and global Eating Disorder Examination score within 1
SD of published means. There was no significant difference between groups in hospital days used following initial
admission. There were significantly more total hospital days used and post-protocol FBT sessions in the WR group. There
were no moderators of primary outcome, but participants with higher eating psychopathology and compulsive features
reported better clinical outcomes in the MS group. Conclusions Outcomes are similar with hospitalizations for MS or WR
when combined with FBT. Cost savings would result from combining shorter hospitalization with FBT.
Learning Objectives:
• Assess the role of hospital treatment in adolescent Anorexia Nervosa
• Assess the role of family based treatment in adolescent Anorexia Nervoda
• Compare costs of short and long hospital stays for adolescent Anorexia Nervosa
The Association of Refeeding Calorie Level and Recovery Over One-Year Follow-Up in Adolescents with
Anorexia Nervosa
Andrea K. Garber, PhD, RD, University of California San Francisco, San Francisco, California, USA; Joan F. HIlton,
PsyD, MPH, University of California San Francisco, San Francisco, California, USA; Micaela T. Scarpulla, MS,
University of California San Francisco, San Francisco, California, USA; Sara M. Buckelew, MD, MPH, University of
California San Francisco, San Francisco, California, USA; Anna-Barbara Moscicki, MD, University of California San
Francisco, San Francisco, California, USA
We previously reported faster weight gain and shorter hospital stay in adolescents with anorexia nervosa (AN) starting on
800-1200 vs. 1400-2400 calories per day. Other studies support this finding that higher calorie refeeding speeds hospital
recovery. However, the long-term impact is unknown. The purpose of this study was to examine the relationship between
calories in hospital and 1-yr recovery in adolescents with AN. Follow-up data on our longitudinal, observational cohort
(SHAAN) was gathered via retrospective chart review. Patients age 9-20, hospitalized for the first time with AN from
2002-2012 were eligible. Refeeding with 3 meals and 3 snacks from 800-2400 cal/d on Day 1 and increased by 200 cal
every other day. Study groups were defined by Day 1 calorie (Cal) quartiles. Weight was measured daily in hospital until
Day 14 and collected from medical records at 1, 2, 3, 4 wk and 3, 6, 9, 12 mo after discharge. Percent median BMI
(%MBMI) and expected height were calculated using CDC data. We examined 12-mo trends in %MBMI and readmission
rates. Adolescents were age 16.2(0.3). Upon admission, admit %MBMI did not differ among groups (p=0.40). Through
Day 14, %MBMI increased from 80.1(53.0-103.1) to 84.9(60.0-116.3)%, at a faster rate in higher Cal (p=0.033). Through
12-mo, there was no association between %MBMI and Cal, adjusted for %MBMI at admission and 14-d change in %MBMI.
However, Cal was associated with rehospitalization: between the lowest and highest Cal, mean(SEM) readmission rates
were 8.8% vs. 4.2% (hazard ratio, 0.85(95% CI 0.27-2.7); logrank p=0.78) at 3 mo and the mean difference in total days
readmitted over 12-mo was 6.5 d (p<0.001). This is the first study to examine 1-yr recovery in adolescents with AN refed
on varying calorie levels in hospital. Although we did not observe a difference in weight recovery, participants refed on
higher calories were readmitted later and spent fewer total days readmitted to hospital over 1-yr.
Learning Objectives:
• Describe meal-based refeeding in adolescents hospitalized for anorexia nervosa
• Discuss the relationship between refeeding calorie level and weight gain over one-year follow-up
• Discuss the relationship between refeeding calorie level and rehospitalization rates (relapse) over one-year followup
Evaluation of the Efficacy and Safety of Olanzapine as an Adjunctive Treatment for Anorexia Nervosa in
Children and Adolescents: An Open-Label trial
Wendy Spettigue, MD, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Mark Norris, MD, Children's
Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Nicole Obeid, PhD, Children's Hospital of Eastern Ontario,
Ottawa, Ontario, Canada; Danijela Maras, MA, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada;
Katherine Henderson, PhD, Anchor Psychological Associates, Ottawa, Ontario, Canada; Stephen Feder, MD, Children's
Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Megan Harrison, MD, Children's Hospital of Eastern Ontario,
Ottawa, Ontario, Canada
The present study aimed to evaluate the efficacy and safety of adjunctive olanzapine treatment for low weight youth (11-17
years) with restrictive eating disorders (EDs). An open-label trial was conducted from 2010-2014. Of 239 youth assessed
at our center during the study time-frame, 65 met inclusion criteria and 38 enrolled. Participants were given the option to
accept, continue or discontinue olanzapine on weekly intervals over 12 weeks. Of the 38 participants, 13 remained in the
comparison arm and 25 received medication at some interval; 31 were retained for the analysis. Preliminary results are
presented for patients who took olanzapine consecutively up until week 4 of the trial compared to those not on olanzapine.
Participants did not differ at baseline on depression, anxiety or ED cognition scores. Weight was objectively measured
weekly, and participants, parents, and clinicians completed psychological measures throughout the study. Groups were
compared using a Mann-Whitney U test. Mean IBW did not differ between the comparison (Mdn=79.61%) and medication
(Mdn=79.82%) groups at baseline, U=91.50, z=-0.57, p=0.57, or at week 2 (comparison Mdn=83.10, medication
Mdn=84.71, U=71.50, z=-1.42, p=0.16). However, the medication group’s IBW (Mdn=90.09) was significantly higher than
that of the comparison group’s (Mdn=86.21) at week 4, (U=44.00, z=-2.46, p=0.014, r=-0.45; medium/large effect size).
There were no significant differences in depression or anxiety between groups over the same time period. No serious
adverse events were noted, although overall more side effects were noted in those patients taking olanzapine. Although
results are preliminary, the study suggests that olanzapine may help facilitate weight gain in underweight patients when
compared to those who do not receive medication. Further analysis is required in order to determine the clinical
significance of these findings and whether olanzapine should be considered as adjunctive treatment for youth with
restrictive EDs.
Learning Objectives:
• To describe an open label trial of olanzapine for the treatment of adolescents with anorexia nervosa conducted at
our center between 2010 and 2014.
• To describe the adverse effects noted in those adolescent patients with anorexia nervosa who were treated with
olanzapine
• To compare and contrast the outcomes between those patients treated with olanzapine and those in the
comparison arm, including comparing results of psychological measure and rates of weight gain between the two
groups.
From Efficacy to Effectiveness: Comparing Outcomes for Youth with Anorexia Nervosa who are Treated
in a Research Trial Versus Clinical Care
Erin Accurso, PhD, The University of Chicago, Chicago, Illinois, USA; Ellen Fitzsimmons-Craft, PhD, Washington
University School of Medicine, St. Louis, Missouri, USA; Anna Ciao, PhD, Western Washington University, Bellingham,
Washington, USA; Daniel Le Grange, PhD, FAED, The University of Chicago, Chicago, Illinois, USA
This study examined differences in treatment outcomes between youth who received family-based treatment (FBT) for
anorexia nervosa (AN) as part of a research trial versus fee-for-service within the same outpatient specialty eating disorder
clinic in an academic medical center. Participants were 84 youth with AN; 32 received randomized trial care (RTC) and 52
received specialty clinical care (SCC). Youth in RTC received an average of 19.5 (SD = 6.6; range: [1,24]) sessions over 8.7
(SD = 3.9; range: [0.3,13.0]) months. Youth in SCC received an average of 17.9 (SD = 16.5; range: [1,47]) sessions over 8.1
(SD = 5.3; range: [0.3,25.0]) months. Despite differences in delivery of FBT (i.e., fixed number of sessions with a fixed
timeline with RTC, compared to more flexible number and spacing of sessions over time in SCC), there were no significant
differences in treatment length or dose (ps > .10). Survival curves were used to examine time to weight restoration across
12 months of treatment. There was a significant interaction between type of care and initial percent of expected body
weight (%EBW) (p = .005), such that weight restoration was achieved faster in RTC compared to SCC for youth with an
initial %EBW ≤ 81, but time to weight restoration was comparable for those with an initial %EBW > 81. Across types of
care, youth who were younger (p = .012) and who reported greater depressive symptoms (p = .012) achieved faster weight
restoration. Youth with AN who have lower initial body weights demonstrate poorer treatment response to FBT delivered
in SCC, despite good treatment response in RTC. Factors that might account for this difference in outcome include shorter
waitlist length, increased motivation or goal-oriented focus due to predetermined treatment dose, and greater monitoring
of treatment adherence in the research trial.
Learning Objectives:
• Describe differences in the delivery of family-based treatment (i.e., number of sessions delivered over number of
weeks) to youth with AN in a randomized trial compared to clinical care
• Demonstrate differences in outcome between youth with AN who are treated in a randomized trial compared to
clinical care
• Discuss potential reasons for differences in outcomes between types of care
Impact of Disordered Eating Behaviors on the Treatment of Children with Type 1 Diabetes
Denise Claudino, MD, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil; Christina Morgan, DPsych,
CPsychol, FAED, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil; Angelica Claudino, PhD, DPsych,
MA, MD, FAED, UNIFESP, São Paulo, Sao paulo, Brazil; Marly palavras, MA, CPsychol, UNIFESP, Sao Paulo, sao
paulo, Brazil
Pathological eating behaviors and attitudes are relatively common in adolescents and young adults with diabetes mellitus
type 1 (DM type 1). Diet and excessive preoccupation with weight are present within the whole treatment of diabetes, and
maintains close relationship with the pathogenesis of disordered eating. Furthermore, eating disorders (EDs) seem to
affect negatively the metabolic control of patients with type 1 diabetes. Objectives. 1) Investigate psychological, biological
and family factors involved in the manifestation of ED behaviors in children and adolescents with type 1 diabetes, and 2)
assess the association between eating symptoms and inadequate glycemic control. Children and adolescents (N=90) age 8
to 16 years old, attending a university (UNIFESP) outpatient pediatric endocrinology clinic were assessed with the ED
session of the Development and Well-Being Assessment (DAWBA) and the Child Eating Disorder Examination 12.0
(ChEDE) to determine presence of disordered eating behavior (DEB) and ED diagnosis. Problems and symptoms related
to self esteem and body image were investigated by the Childhood Depression Inventory (CDI) and the Body Image
Questionnaire (BSQ).The clinical impairment assessment (CIA) was used to evaluate the role of DEB on psychosocial
functioning. Glycosylated hemoglobin were measured and correlated to eating behaviors. One third of patients (31/90)
had DEB. Children and adolescents who presented high scores in Child EDE had more severe body image disturbance (r =
0,714, p=0,001). Global score of Child EDE was also positively correlated with depressive symptoms (CDI) (r=0.538; p<
0,001). DEB increased 10,52 times the scores of CIA (β= 10.52 Standard error= 2.53; p <0.001). No association was found
between DEB, ED, depressive symptoms, length of DM type 1 and nutritional state with glycemic control. Children and
adolescents with DM type 1 and DEB had more depressive symptoms, more body image dissatisfaction and worse
psychosocial functioning.DEB in chlidren with DM type 1. This study suggests that early interventions on eating behavior
are required.
Learning Objectives:
• Investigate psychological, biological and family factors involved in the manifestation of ED behaviors in children
and adolescents with type 1 diabetes,
• Assess the association between eating symptoms and inadequate glycemic control
• Assess the impact of disordered eating behavior on pschological functioning in children and adolescents wiith DM
type 1
A Combined Treatment Approach for Avoidant-Restrictive Food Intake Disorder: Development,
Implementation, and Clinical Outcomes
Joan Orrell-Valente, PhD, Center for the Treatment of Eating Disorders, Childrens' Hospital, Minneapolis, Minnesota,
USA; Julie Lesser, MD, Center for the Treatment of Eating Disorders, Childrens/ Hospital, Minneapolis, Minnesota,
USA; Linsey Utzinger, PsyD, Center for the Treatment of Eating Disorders, Childrens' Hospital, Minneapolis,
Minnesota, USA; Elin Lantz, BA, Center for the Treatment of Eating Disorders, Children's Hospital, Minneapolis,
Minnesota, USA; Beth Brandenburg, MD, Center for the Treatment of Eating Disorders, Children's Hospital,
Minneapolis, Minnesota, USA
Avoidant-Restrictive Food Intake Disorder (ARFID) is varied in clinical presentation and can include
avoidance/restriction of oral intake associated with either a medical condition (e.g., gastrointestinal disease);
developmental disorder (e.g., autism spectrum); anxiety disorder (e.g., vomiting phobia); or history of selective eating.
Little data exist on treating ARFID. We have developed and are implementing a combined treatment approach that
includes elements of Family-Based Treatment (e.g., early-stage parent refeeding), the Unified Protocol for the Treatment
of Emotional Disorders (e.g., psychoeducation on the cognitive triad and emotional processing, graduated exposures),
food chaining (e.g., flavor mapping), nutrition counseling (e.g., strategies for weight regain), behavior modification, and
parent skills enhancement (e.g., contingent reinforcement, establishing a pattern of regular eating). Selected components
are implemented based on ARFID sub-type. A minority of patients requires hospitalization for medical stabilization and
may be prescribed psychiatric medications (e.g., hydroxyzine) for nausea or sensations of fullness. Patients are
medically/psychiatrically monitored. We will describe our approach, with case examples, and present case series data
from an ongoing study to evaluate clinical outcomes. Preliminary results (N=32; mean age 12.0 [±3.3] years, range 5-18
years), using unadjusted paired t-test to assess within-group change, show significant weight regain, with mean (SD)
weight increase of 7.9 (±6.7) kg; mean body mass index (BMI) increase of 2.5 (±1.8), and mean BMI%ile increase of 25.0%
(±20.7); p’s <0.001. Pre-treatment scores on the Eating Disorder Examination – Questionnaire, the Clinical Impairment
Assessment Questionnaire, and Patient Health Questionnaire-9 were all in the non-clinical range (completed by patients
13 years or older). Use of this combined approach appears to show early promise as an effective means of treating the
ARFID sub-types.
Learning Objectives:
• Summarize and identify gaps in extant literature on Avoidant-Restrictive Food Intake Disorder (ARFID);
recognize the various clinical presentations of the ARFID sub-types.
•
•
Describe a combined treatment approach developed to treat ARFID sub-types that incorporates key elements of
Family-Based Treatment, the Unified Protocol, medical/psychiatric intervention, food chaining, nutrition
consultation, behavior modification, and
Select and implement the components of this combined treatment approach that are appropriate for each ARFID
sub-type.