- Eating disorders
Clinical Instructor, Psychiatry and Behavioral Sciences - Child and Adolescent Psychiatry
Member, Wu Tsai Neurosciences Institute
Director, Stanford Child and Adolescent Outpatient Eating Disorders Clinic (2018 - 2021)
Boards, Advisory Committees, Professional Organizations
Co-Chair, Neuroimaging Special Interest Group, Academy of Eating Disorders (2014 - 2017)
Fellowship: Semel Institute for Neuroscience and Human Behavior (UCLA) (2012) CA
Internship: Semel Institute for Neuroscience and Human Behavior (UCLA) (2010) CA
PhD Training: University of Oregon Office of the Registrar (2010) OR
PhD, University of Oregon, Clinical Psychology (2010)
MS, University of Oregon, Clinical Psychology (2006)
BS, Vanderbilt University, Psychology (2004)
Current Research and Scholarly Interests
My research interests have focused on the neural bases of eating disorders. I am particularly interested in the way emotion and reward is processed in the brain and how that may contribute to eating behavior and food restriction. I hope to eventually translate biological research findings into treatments.
Confirming the Efficacy/Mechanism of Family Therapy for Children With Low Weight ARFID
This study is examining the efficacy and mechanism of family therapy compared to usual care for children between the ages of 6 and 12 who are diagnosed with Avoidant/Restrictive Food Intake Disorder. Preliminary data suggest that family therapy is superior to usual care and that improvement in parental self-efficacy related to feeding their children is the mechanism of treatment. In addition, this study will attempt to identify specific patient groups who respond to family therapy.
Emotion Regulation in Binge Eating and Purging Among Adolescents
The study will examine the neural and behavioral correlates of emotion regulation in adolescents engaging in binge eating and/or purging and healthy adolescents. Furthermore, it will look at the influence of executive function on emotion regulation in this population. This study will allow us to gain further understanding of the neural basis of emotion regulation in this age group. Moreover, this study supports the need to develop new treatment approaches based on a better understanding of the brain processes associated with eating disorders.
Implementing FBT for Adolescent AN for Providers in Private Practice
There is a critical need to disseminate efficacious psychosocial treatments for mental disorders as there is a significant gap between evidenced-based approaches and common clinical practice. One example of the need to improve dissemination and implementation of psychosocial treatments is for adolescent Anorexia Nervosa (AN), a serious mental disorder with an incidence rate of about 1% that can become life-threatening. Based on outcomes from a series of randomized clinical trials (RCTs), the first-line treatment for adolescent AN is Family-based Treatment (FBT); however, very few therapists are trained to use FBT for AN. Further, while approximately 45-50% of US mental health outpatient providers are in private practice, little attention has been paid to how best to train this group. Care for adolescent AN, in particular, is provided in private practice at high rates, because specialist programs in non-private settings are few and not readily accessible. Motivations, incentives, and rationale for learning evidence-based treatments (EBTs) differ in this group compared to therapists embedded in an organization or health care system. In this application, we propose to use an online training strategy to study the adoption of FBT to better understand factors that limit or enhance uptake and implementation of this treatment in private practice. We developed and piloted a self-directed enhanced online training (ET-FBT) aimed at improving therapist skills and knowledge related to key components of FBT for AN that predict patient outcome in a group of therapists of which 64% were in private practice. We propose to build on these findings to examine the feasibility of new methods to retain therapists during supervision, assess fidelity, and collect patient outcomes from clinicians in private practice. Thus, our specific aims are: Aim 1: The overall aim of the study is to assess the feasibility of conducting a randomized clinical trial comparing two implementation strategies (online training vs webinar training) for training clinicians in private practice in FBT for AN. We predict that those randomized to online training will be retained, receive supervision, and provide patient data at higher rates than those who receive webinar training. Aim 2: Patient outcomes (reflecting therapist effectiveness) will be assessed by comparing patient weight gain from session 1 to 4 of FBT before and after training (target for training effect) and compared between randomized groups. We predict a moderate efficacy signal difference favoring those who are received the online training. because of increased training in key components in the online training program. Aim 3: Validate training effect by examining the association between therapist fidelity to FBT and patient outcomes. We predict that fidelity will be correlated (target validation) with patient outcome. The effects of therapeutic alliance, participation in supervision, and self-efficacy on both fidelity and patient outcome will be explored. Aim 4: Explore BL factors associated with implementation processes (e.g. prior training, experience, family work).The primary significance of this study is its potential to increase the availability of FBT--the most effective treatment for adolescent AN. Increased availability of FBT will decrease cost, hospitalization, morbidity, mortality, and chronicity of the disorder.
Food and the Brain
The proposed study will examine the role of reward and emotion in women with and without a history of binge eating. It is important to understand how the brain responds to reward and emotion in binge eating in order to identify different pathways toward binge eating and provide individualized targets for treatment. This is particularly important in light of the fact that for many patients, the current treatments for binge eating are not effective.
Stanford is currently not accepting patients for this trial. For more information, please contact Hannah Welch, 650-723-5521.
Neural Links Between OCD and Anorexia
Individuals with anorexia nervosa (AN) have long been observed to demonstrate symptoms in common with obsessive-compulsive disorder (OCD), in particular, an obsessive fear of normal weight leading to dangerous food restriction, as well as many compulsive rituals about food. Both AN and OCD are seriously handicapping and often resistant to conventional therapies. Given that the two conditions often co-occur and are associated with still unknown genetic risk factors, the aim of this project is to identify their shared and distinct patterns of brain activity. The investigators propose to use functional magnetic resonance imaging to compare brain response among adolescents with AN, OCD, and age-matched healthy individuals. Specifically, this study will investigate function of distinct brain circuits related to core aspects of these related disorders. The investigators use three tasks related to set shifting, global vs. local processing, and reward. Based on evidence of deficits in cognitive flexibility and ability to change behavior, the investigators hypothesize that adolescents with AN and with OCD will show hypoactivity of frontostriatal circuitry during cognitive tasks, and adolescents with AN will show hyperactivity in limbic regions in a reward task. This study is the first to directly compare brain activation patterns using functional neuroimaging in AN and OCD. The goal is to determine how abnormal brain activity relates to symptom formation, what accounts for shared characteristics amongst these disorders, and whether deficits in specific circuitry underlie their unique defining features. The study of shared and unique elements of functional brain circuitry reflects a new, emerging approach to the classification of psychiatric illness, one based on identifying unique combinations of biological risk factors that link related conditions. This approach is widely believed to be a critical step forward in developing more brain-relevant targeted strategies for preventative interventions.
Stanford is currently not accepting patients for this trial. For more information, please contact Molly Vierhile, 650-723-7885.
Peer-Led Dissonance Eating Disorder Prevention: Virtual Delivery
This proposed pilot study will evaluate whether this body acceptance class produces greater reductions in eating disorder risk factor symptoms (pursuit of the thin ideal, body dissatisfaction, dieting, dietary restraint and negative affect), eating disorder symptoms, and future onset of eating disorders over 6-month follow-up in this population.
Stanford is currently not accepting patients for this trial. For more information, please contact Ayotola Onipede, B.S., 650-723-7885.
Taste Reward Processing in Pediatric Obesity
The study aims to provide a better understanding of the neural influence of eating behavior in the development of childhood obesity. Children ages 4-8 will be recruited to examine fMRI brain response to pictures that signal delivery of a chocolate milkshake and to the taste itself. The brain response will be compared to body mass index percentile scores for each child to help us determine whether brain differences present in adolescents and adults with obesity are present in young children.
Stanford is currently not accepting patients for this trial. For more information, please contact Talya Feldman, 650-723-7885.
Food and the Brain, Stanford University (September 22, 2015 - August 31, 2020)
In order to achieve the long-term goal of establishing a strong, independent research program examining the biological bases of eating disorders, this K23 Career Development Award will provide training in new methodology and data analysis methods through mentorship, didactic education, and hands-on implementation of a research project utilizing these skills. Binge eating is a primary symptom in binge eating disorder, bulimia nervosa, and anorexia nervosa - binge/purge type, disorders that are associated with comorbid psychiatric conditions and impaired psychosocial functioning. There is a great deal of heterogeneity among individuals engaging in binge eating, which can diminish treatment efficacy. For some patients, binge eating episodes are preceded by reports of negative affect, and thus thought of as reward-seeking in effort to regulate emotion. However, little is known about basic underlying emotion regulation in individuals who engage in binge eating, nor about the relation between emotional processes and reward function. The proposed study will utilize an established paradigm to examine implicit regulation of response to acute threat (using fMRI during completion of an emotion conflict task) in women who engage in binge eating. The study will also measure resting state functional connectivity using fMRI and dopamine receptor availability in order to examine how differences in emotion and binge eating may relate to underlying brain connection and neurochemical function related to approach motivation. These data will be utilized to differentiate subtypes of binge eaters who engage in binge eating either through emotional or reward-focused pathways. Findings will improve our understanding of how ability to regulate response to acute threat may function differently in some binge eaters and put them at risk for poor prognosis. This may suggest new directions for interventions that target underlying neural processes via computer tasks or biofeedback. In addition to providing preliminary data on individual differences in underlying emotion regulation, connectivity, and dopamine function among binge eaters, the award will provide extensive training in methods, including advanced fMRI analysis and PET imaging, statistics, and approaches to studying emotion in the context of eating disorders. The specific training goals for the duration of the award include (1) achieving competence in advanced neuroimaging techniques, such as resting-state connectivity, to better understand the biological basis for emotion regulation difficulties in eating disorders; (2) developing expertise in standardized measures of of emotion and its regulation; (3) expanding training in neuroimaging by adding PET imaging to my skillset; and (4) increasing ability to conduct multi-modal, multi-level statistical modeling to analyze complex datasets. To achieve these goals, appropriate seminars, scientific conferences, and courses have been identified, as well as specific plans for mentorship over the course of the applied research project by a team of mentors and consultants with expertise in eating disorders, neuroimaging, emotion, methodology, statistics, and career development.
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Anticipatory human subthalamic area beta-band power responses to dissociable tastes correlate with weight gain.
Neurobiology of disease
The availability of enticing sweet, fatty tastes is prevalent in the modern diet and contribute to overeating and obesity. In animal models, the subthalamic area plays a role in mediating appetitive and consummatory feeding behaviors, however, its role in human feeding is unknown. We used intraoperative, subthalamic field potential recordings while participants (n = 5) engaged in a task designed to provoke responses of taste anticipation and receipt. Decreased subthalamic beta-band (15-30 Hz) power responses were observed for both sweet-fat and neutral tastes. Anticipatory responses to taste-neutral cues started with an immediate decrease in beta-band power from baseline followed by an early beta-band rebound above baseline. On the contrary, anticipatory responses to sweet-fat were characterized by a greater and sustained decrease in beta-band power. These activity patterns were topographically specific to the subthalamic nucleus and substantia nigra. Further, a neural network trained on this beta-band power signal accurately predicted (AUC ≥ 74%) single trials corresponding to either taste. Finally, the magnitude of the beta-band rebound for a neutral taste was associated with increased body mass index after starting deep brain stimulation therapy. We provide preliminary evidence of discriminatory taste encoding within the subthalamic area associated with control mechanisms that mediate appetitive and consummatory behaviors.
View details for DOI 10.1016/j.nbd.2021.105348
View details for PubMedID 33781923
Quadratic relations of BMI with depression and brain volume in children: Analysis of data from the ABCD study.
Journal of psychiatric research
2021; 136: 421–27
Weight-related health conditions and depression peak during adolescence and show relations with brain structure. Understanding how these conditions relate to each other prior to adolescence may guide research on the co-development of unhealthy weight conditions (both underweight and overweight) and depression, with a potential brain-based link. This study examines the cross-sectional relations between body mass index (BMI), depressive symptoms, and brain volume (total and regional) to determine whether BMI has a linear or quadratic relation with depressive symptoms and brain volume and how depressive symptoms and brain volume are related.Cross-sectional study using structural magnetic resonance imaging, height and weight to calculate BMI z-scores, and Child Behavior Checklist withdrawn depression scores. Data were from the Adolescent Brain Cognitive Development Study, collected at 21 sites across the United States from 11,875 9- and 10-year-old children recruited as a national sample. Mixed models were used to examine the linear and quadratic effects of BMI z-score on both brain volume (total and regional) and withdrawn depression scores, as well as the relations between brain volume and depression scores. Intracranial volume, age, sex, race, site, and family were included in the models as covariates.Overall, BMI z-scores showed a quadratic relation with brain volumes and depressive symptoms. When including intracranial volume as a covariate, regional volumes investigated did not follow the same global pattern of effects except for right hippocampus and left lateral orbitofrontal cortex. Total brain volume was negatively related to depressive symptoms.Links between depressive symptoms and low or high weight could improve our understanding of brain structural differences in depression. These findings also emphasize the importance of including the full spectrum of BMI from underweight to overweight and testing for nonlinear effects in models.
View details for DOI 10.1016/j.jpsychires.2021.02.038
View details for PubMedID 33657461
- EVIDENCE-BASED TREATMENT OF BULIMIA NERVOSA AND BINGE-EATING DISORDER ELSEVIER SCIENCE INC. 2020: S133–S134
Descriptive analysis of binge eating in adult and adolescent females.
Eating and weight disorders : EWD
PURPOSE: Provide qualitative descriptions of context and characteristics of binge eating in adults and adolescents to explore consistency in precipitating factors.METHOD: Open-ended, qualitative interviews were administered to an adult sample (n=24) and an adolescent sample (n=20) to collect details about the context in which two binge episodes occurred.RESULTS: Factors and context of the binge episodes were similar between adults and adolescents. In contrast, the two binge episodes described by each individual were not consistent. Binge episodes were not strongly affect-driven or food cue-driven.CONCLUSIONS: Binge eating appears similar between adults and adolescents, which may have treatment implications. Similar treatment approaches may be used with both age groups and would benefit from covering a broad range of binge triggers rather than attempting to match individuals into an approach focused on particular triggers.LEVEL OF EVIDENCE: Level III, case-control analytic study.
View details for DOI 10.1007/s40519-020-01013-3
View details for PubMedID 32960440
Family-based treatment via videoconference: Clinical recommendations for treatment providers during COVID-19 and beyond.
The International journal of eating disorders
The necessity to employ distance-based methods to deliver on-going eating disorder care due to the novel coronavirus (COVID-19) pandemic represents a dramatic and urgent shift in treatment delivery. Yet, TeleHealth treatments for eating disorders in youth have not been adequately researched or rigorously tested. Based on clinical experience within our clinic and research programs, we aim to highlight the common challenges clinicians may encounter in providing family-based treatment (FBT) via TeleHealth for children and adolescents with anorexia nervosa and bulimia nervosa. We also discuss possible solutions and offer practical considerations for providers delivering FBT in this format. Additional research in TeleHealth treatment for eating disorders in youth may lead to improved access, efficiency, and effectiveness of FBT delivered via videoconferencing.
View details for DOI 10.1002/eat.23326
View details for PubMedID 32533799
Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy.
Journal of medical Internet research
2020; 22 (4): e16386
Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.
View details for DOI 10.2196/16386
View details for PubMedID 32324145
Brain-Responsive Neurostimulation for Loss of Control Eating: Early Feasibility Study.
Loss of control (LOC) is a pervasive feature of binge eating, which contributes significantly to the growing epidemic of obesity; approximately 80 million US adults are obese. Brain-responsive neurostimulation guided by the delta band was previously found to block binge-eating behavior in mice. Following novel preclinical work and a human case study demonstrating an association between the delta band and reward anticipation, the US Food and Drug Administration approved an Investigational Device Exemption for a first-in-human study.To assess feasibility, safety, and nonfutility of brain-responsive neurostimulation for LOC eating in treatment-refractory obesity.This is a single-site, early feasibility study with a randomized, single-blinded, staggered-onset design. Six subjects will undergo bilateral brain-responsive neurostimulation of the nucleus accumbens for LOC eating using the RNS® System (NeuroPace Inc). Eligible participants must have treatment-refractory obesity with body mass index ≥ 45 kg/m2. Electrophysiological signals of LOC will be characterized using real-time recording capabilities coupled with synchronized video monitoring. Effects on other eating disorder pathology, mood, neuropsychological profile, metabolic syndrome, and nutrition will also be assessed.Safety/feasibility of brain-responsive neurostimulation of the nucleus accumbens will be examined. The primary success criterion is a decrease of ≥1 LOC eating episode/week based on a 28-d average in ≥50% of subjects after 6 mo of responsive neurostimulation.This study is the first to use brain-responsive neurostimulation for obesity; this approach represents a paradigm shift for intractable mental health disorders.
View details for DOI 10.1093/neuros/nyaa300
View details for PubMedID 32717033
Confirming the Efficacy of an Adaptive Component to Family-Based Treatment for Adolescent Anorexia Nervosa: Study Protocol for a Randomized Controlled Trial.
Frontiers in psychiatry
2020; 11: 41
Family-based treatment (FBT) has the largest evidence base for treating adolescents with anorexia nervosa (AN); 35-50% of cases remit at the end-of-treatment and remain remitted 3-4 years after treatment. Studies of FBT demonstrate that weight restoration by session 4 (of 2.4 kgs) predicts remission at end of treatment in 85-90% of cases. One way to improve outcomes is to tailor treatments to patients depending on successful weight restoration at session 4. Pilot data found that by adding three sessions of Intensive Parental Coaching (IPC) after session 4 improved outcomes in early non-responders. Further, data suggest that the mechanism underlying FBT is early improvements in parental self-efficacy related to re-feeding their child. This manuscript describes a study protocol to examine whether adding IPC to FBT improves outcomes in early non-responders and confirm whether change in parental self-efficacy is the mechanism by which FBT works. This two-site randomized controlled trial (RCT) will randomize 60 adolescents with a DSM-5 diagnosis of AN (30 per site) who are between the ages of 12-18 years old and do not gain 2.4 kgs by session 4 of FBT. Randomized participants will either continue standard FBT or receive the three sessions of IPC and then continue FBT as usual. Both arms include up to 18 sessions over the course of 9 months. Blinded assessments will be conducted at baseline, 3-month within-treatment, end of treatment, and at 6 and 12-month follow-up. Parental-self efficacy will be assessed using the Parent versus Anorexia Scale at all major assessment time points and at each of the first eight sessions of treatment. The primary outcome is achievement of weight remission (> 94% expected mean percent body mass index (BMI) adjusted for age, height, and gender).Clinical Trial Registration: http://www.ClinicalTrials.gov, identifier NCT03097874.
View details for DOI 10.3389/fpsyt.2020.00041
View details for PubMedID 32116856
Investigating Early Response to Treatment in a Multi-Site Study for Adolescent Bulimia Nervosa.
Frontiers in psychiatry
2020; 11: 92
Background: This secondary data analysis seeks to replicate and extend findings that early response to treatment in adolescent bulimia nervosa (BN) predicts outcome, resulting in earlier identification of patients who might need a different treatment approach.Methods: Participants were 71 adolescents (M ± SD: 15.69 ± 1.55 years; 93% female; 75% non-Hispanic) with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnosis of BN or partial BN enrolled in a two-site treatment study. Participants were randomized to cognitive behavioral therapy for adolescents (CBT-A), family-based treatment for BN (FBT-BN), or supportive psychotherapy (SPT). The Eating Disorder Examination was administered at baseline, end-of-treatment (EOT), 6-month, and 12-month follow-up. Binge eating and purge symptoms were self-reported at each session. Outcome was defined as abstinence of binge eating and compensatory behaviors (self-induced vomiting, laxative use, diet pills, diuretics, compensatory exercise, fasting) in the 28 days prior to assessment. Receiver operating characteristic (ROC) analyses were utilized to assess the viability of predicting treatment outcomes based on reduction of symptoms within the first 10 sessions of treatment.Results: ROC analyses suggest that reduction in purging at session 2 (AUC =.799, p < .001) and binge eating at session 4 (AUC =.750, p < .01) were independently related to abstinence of symptoms at EOT, regardless of treatment type. Symptom reduction later in treatment predicted outcome at follow-up, as change in binge eating at session 8 and purging at session 9 were the strongest predictors of abstinence at 6-month follow-up (AUCs =.726-.763, ps < .01). Change in binge eating, but not purging behaviors, was significantly related to abstinence at 12-month follow-up (AUC =.766, p < .01). Only slight differences emerged based on treatment group, such that reductions in symptoms most predictive of abstinence at EOT occurred one session sooner in FBT-BN than SPT.Conclusion: Reductions in binge eating and purge symptoms early in adolescent BN treatment suggest better outcome, regardless of treatment modality. Additional research with larger samples is needed to better understand which treatments, if any, contribute to earlier change in BN symptoms and/or likelihood of improved patient response.
View details for DOI 10.3389/fpsyt.2020.00092
View details for PubMedID 32184746
Insulin Resistance and Structural Change in the Anterior Cingulate Cortex in Youth With Depression and Obesity
NATURE PUBLISHING GROUP. 2019: 143–44
View details for Web of Science ID 000509665600281
Training Models For Implementing Evidence-Based Psychological Treatment: A Cluster-Randomized Trial in College Counseling Centers.
Importance: Progress has been made in establishing evidence-based treatments for psychiatric disorders, but these are not often delivered in routine settings. A scalable solution for training clinicians in evidence-based treatments is needed.Objective: To compare 2 methods of training college (university) counseling center therapists to treat psychiatric disorders using interpersonal psychotherapy. The hypothesis was that the train-the-trainer condition would demonstrate superior implementation outcomes vs the expert condition. Moderating factors were also explored.Design, Setting, and Participants: This cluster-randomized trial was conducted from October 2012 to December 2017 in 24 college counseling centers across the United States. Therapist participants were recruited from enrolled centers, and student patients with symptoms of depression and eating disorders were recruited by therapists. Data were analyzed from 184 enrolled therapists.Interventions: Counseling centers were randomized to the expert condition, which involved a workshop and 12 months of follow-up consultation, or the train-the-trainer condition, in which a staff member from the counseling center was coached to train other staff members.Main Outcomes and Measures: The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, as assessed via audio recordings of therapy sessions. Therapist knowledge of interpersonal psychotherapy was a secondary outcome.Result: A total of 184 therapists (mean [SD] age, 41.9 [10.6] years; 140 female [76.1%]; 142 white [77.2%]) were included. Both the train-the-trainer-condition and expert-condition groups showed significant within-group improvement for adherence to interpersonal psychotherapy (change: 0.233 [95% CI, 0.192-0.274] and 0.190 [0.145-0.235], respectively; both P<.001), with large effect sizes (1.64 [95% CI, 1.35-1.93] and 1.34 [95% CI, 1.02-1.66], respectively) and no significant difference between conditions. Both groups also showed significant within-group improvement in interpersonal therapy competence (change: 0.179 [95% CI, 0.132-0.226] and 0.106 [0.059-0.153], respectively; both P<.001), with a large effect size for the train-the-trainer condition (1.16 [95% CI, 0.85-1.46]; P<.001) and a significant difference between groups favoring the train-the-trainer condition (effect size, 0.47 [95% CI, 0.05-0.89]; P=.03). Knowledge of interpersonal psychotherapy improved significantly within both groups (effect sizes: train-the-trainer, 0.64 [95% CI, 0.28-0.99]; P=.005; expert, 0.69 [95% CI, 0.38-1.01]; P<.001), with no significant difference between groups. The significant moderating factors were job satisfaction for adherence (b, 0.120 [95% CI, 0.001-0.24]; P=.048) and competence (b, 0.133 [95% CI, 0.001-0.27]; P=.048), and frequency of clinical supervision for competence (b, 0.05 [95% CI, 0.004-0.09]; P=.03).Conclusions and Relevance: Results demonstrate that the train-the-trainer model produced training outcomes comparable with the expert model for adherence and was superior on competence. Given its potential capability to train more therapists over time, it has the potential to facilitate widespread dissemination of evidence-based treatments.Trial Registration: ClinicalTrials.gov Identifier: NCT02079142.
View details for DOI 10.1001/jamapsychiatry.2019.3483
View details for PubMedID 31693069
Bariatric Surgery in Children and Adolescents with Cognitive Impairment and/or Developmental Delay: Current Knowledge and Clinical Recommendations.
Bariatric surgery is an effective treatment for children and adolescents with severe obesity. However, outcomes in youth with cognitive impairments and/or developmental delays are understudied. This paper reviewed the literature on bariatric surgery within this population. Fourteen studies published from 1975 to 2019 were identified. The majority (93%) of studies included patients with genetic disorders. Most studies reported no peri-operative complications (69%) and improved health outcomes (79%), with variable weight-loss results (29.2-86.2% excess weight loss). No significant differences were reported for youth with and without cognitive impairment and/or developmental delay in two studies. Limited available data suggest bariatric surgery may promote weight loss and improve health comorbidities for youth, irrespective of cognitive or developmental functioning. Clinical recommendations for working with patients and families are included.
View details for DOI 10.1007/s11695-019-04219-2
View details for PubMedID 31637672
- REWARD PROCESSING IN DEPRESSED AND OBESE CHILDREN ELSEVIER SCIENCE INC. 2019: S274
Performance and brain activity during the Wisconsin Card Sorting Test in adolescents with obsessive-compulsive disorder and adolescents with weight-restored anorexia nervosa.
European child & adolescent psychiatry
Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) both show a peak age of onset during adolescence and share a number of phenotypic features, such as rigid rule-bound behavior and perseverative thinking. There is evidence of difficulties with set shifting or task switching in adults with each disorder, but evidence in adolescents is limited. Furthermore, no studies have previously directly compared AN and OCD on this cognitive process or examined comparative neural correlates. This study provides exploratory analyses to address this gap by measuring brain activity with functional magnetic resonance imaging (fMRI) during a computerized version of the Wisconsin Card Sorting Test (WCST) in female adolescents with weight-restored AN (WR-AN) (n=14), OCD (n=11), and healthy controls (n=24). Results revealed greater perseverative errors in the OCD group than healthy controls and WR-AN, but no difference between WR-AN and healthy controls. Greater activity in the right front pole, inferior frontal gyrus, and middle frontal gyrus during the task (compared to a control matching task) was associated with more perseverative errors in the OCD group, but not healthy controls. The correlation between perseverative errors and brain response to the task in the WR-AN group was not different from either comparison group. These findings propose a hypothesis that behavioral similarities between OCD and AN, as well as difficulties with set shifting in adults with AN, are driven by obsessive-compulsive features present in AN rather than a shared underlying neurocognitive signature. This notion should be tested in larger samples in future studies.
View details for DOI 10.1007/s00787-019-01350-4
View details for PubMedID 31114967
Set-shifting in adolescents with weight-restored anorexia nervosa and their unaffected family members.
Journal of psychiatric research
2019; 112: 71–76
Set-shifting difficulties have been suggested to underlie rigid and inflexible thinking in patients with anorexia nervosa (AN). Studies reported set-shifting deficiencies in adults with AN and also in their unaffected family members, suggesting that set-shifting deficits are heritable in AN. Surprisingly, studies failed to show set-shifting difficulties in adolescents with AN. If set-shifting difficulties are heritable, it is not clear why they are absent in adolescents with AN. The current study aimed to elucidate this discrepancy by assessing several components of set-shifting in adolescents with weight-restored AN (WR-AN) and their unaffected parents and siblings. Twenty-one families that include an adolescent who was diagnosed with AN prior to weight restoration (N = 19), an unaffected parent (N = 18), and an unaffected sibling (N = 20) were recruited. Additionally, 28 healthy control families were recruited and included an age-matched adolescent (N = 27), a parent (N = 26), and a sibling (N = 17). Visual-motor set-shifting, verbal set-shifting, and set-shifting clean of inhibition were assessed using the Delis-Kaplan Executive Function System. The results revealed intact set-shifting in parents and siblings of adolescents with WR-AN. Surprisingly, the results revealed superior visual-motor and verbal set-shifting in adolescents with WR-AN compared to age-matched controls. However, when controlling for inhibition abilities, poorer set-shifting was revealed in adolescents with WR-AN. The results suggest that superior inhibition abilities in adolescents with WR-AN may compensate for their set-shifting deficiencies. The study emphasizes the importance of controlling for inhibition abilities when assessing neurocognitive functioning in adolescents with AN. Furthermore, the study does not support the notion that set-shifting deficits are heritable in adolescent AN.
View details for PubMedID 30856379
Superior response inhibition to high-calorie foods in adolescents with anorexia nervosa.
Behaviour research and therapy
2019; 124: 103441
Anorexia nervosa (AN) is a severe eating disorder that is characterized by significant weight loss as a result of self-starvation. Little is known about the mechanisms that allow these patients to endure self-starvation for long periods of time. It has been suggested that the neurocognitive mechanism responsible for stopping inappropriate actions (i.e., response inhibition) may contribute to this process. However, empirical evidence to support this notion is lacking. The goal of the current study was to assess if exposure to high-calorie food stimuli may trigger response inhibition to a greater extent in adolescents with AN compared to healthy adolescents. Thirty adolescents with restrictive type AN (AN-R) and 30 healthy adolescents completed a food-stop signal task wherein their ability to inhibit prepotent responses was assessed following exposure to high- and low-calorie food images. The results revealed superior ability of adolescents with AN-R to inhibit actions following exposure to high-calorie food images compared with controls. No such difference was found between the groups following exposure to low-calorie foods. The results indicate that high-calorie foods automatically trigger stronger activation of response inhibition in adolescents with AN compared to healthy adolescents. Such activation is likely a unique feature of AN that potentially contributes to patients' ability to severely restrict eating.
View details for DOI 10.1016/j.brat.2019.103441
View details for PubMedID 31743819
A Protocol for Integrating Neuroscience Into Studies of Family-Based Treatment for Anorexia Nervosa: An Approach to Research and Potential Benefits for Clinical Care.
Frontiers in psychiatry
2019; 10: 919
Anorexia nervosa (AN) is a life-threatening disorder with peak onset during adolescence. Prior research supports the effectiveness of family-based treatment (FBT) for AN in adolescents, but studies do not regularly include neuroimaging to investigate the effects of FBT on the brain. This is important because we know that malnutrition has a detrimental impact on brain volume, cortical thickness, and function, which often recover with weight restoration. Additionally, early weight gain in FBT has emerged as a robust predictor of treatment outcome, yet it is unclear whether it is associated with neural change. Understanding neural change during treatment, particularly in the early weeks, has the potential to improve outcome by enhancing motivation for rapid behavior change, while also highlighting mechanisms by which early treatment response leads to improved outcome. This manuscript describes a study protocol and discusses both challenges and implications for this type of integrative research.
View details for DOI 10.3389/fpsyt.2019.00919
View details for PubMedID 31920765
View details for PubMedCentralID PMC6930315
Binge Eating Disorder in Children and Adolescents.
Child and adolescent psychiatric clinics of North America
2019; 28 (4): 549–55
Binge eating disorder onset often occurs during adolescence, yet the diagnosis and treatment of the disorder in this age group has been inadequately studied. Criteria and challenges in making the diagnosis in children and adolescents are reviewed, as well as prevalence rates, current treatment options, and complications.
View details for DOI 10.1016/j.chc.2019.05.003
View details for PubMedID 31443873
Change in brain volume and cortical thickness after behavioral and surgical weight loss intervention.
Obesity is associated with reduced cortical thickness and brain volume, which may be related to poor nutrition. Given that brain atrophy in anorexia nervosa recovers with nutritional improvements and weight gain, it is worth examining how brain structure changes at the other end of the weight spectrum with weight loss. Thus, this study aimed to examine change in cortical thickness and brain volume in 47 patients with severe obesity who participated in no treatment, behavioral weight loss, or bariatric surgery. T1-weighted MRI scans were conducted pre-treatment and approximately four months later. Measures of cortical thickness, gray matter volume, and white matter volume were compared between time points. Despite overall reduction in BMI, there was no significant change in cortical thickness. There was a significant increase in left hemisphere gray matter and white matter volumes across the sample. At baseline and follow-up, there was no relationship between cortical thickness or brain volumes and BMI. This study is the first to examine changes in cortical thickness and brain volume with weight loss in adults with obesity and the findings show partial support for the hypotheses that weight loss results in increased cortical gray and white matter.
View details for PubMedID 30553762
Comorbid depressive symptoms and self-esteem improve after either cognitive-behavioural therapy or family-based treatment for adolescent bulimia nervosa
EUROPEAN EATING DISORDERS REVIEW
2018; 26 (3): 253–58
This study examined the effect of family-based treatment for bulimia nervosa (FBT-BN) and cognitive behavioral therapy for adolescents (CBT-A) on depressive symptoms and self-esteem in adolescents with BN. Data were collected from 110 adolescents, ages 12-18, who met Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, text revision criteria for BN or partial BN. Participants were randomly assigned to FBT-BN or CBT-A and completed measures of depressive symptoms and self-esteem before and after treatment and at 6- and 12-month follow-up assessments. Depressive symptoms and self-esteem significantly improved in both treatments, and neither treatment appeared superior on these clinical outcomes. Parents often worry whether FBT-BN addresses comorbid depressive symptoms and low self-esteem. Our findings address this concern, as they demonstrate that FBT-BN does not differ from CBT-A in improving depressive symptoms and self-esteem, and both treatments result in symptom improvement. These findings can help clinicians guide families to choose a treatment that addresses BN and depressive symptoms and low self-esteem.
View details for PubMedID 29446174
Changes in Cerebral Cortical Thickness Related to Weight Loss Following Bariatric Surgery.
Cerebral cortical thickness is associated with memory and intelligence test scores and serves as a measure for changes in cortical gray matter. Previous studies suggest reduced cortical thickness in patients with obesity. This study aimed to investigate changes in cortical thickness following bariatric surgery. Magnetic resonance imaging (MRI) data of five patients were analyzed preoperatively and 6 months postoperatively to assess changes in global measures of cortical thickness. No patients were lost to follow-up. This study provides preliminary evidence of brain change following surgery, suggests increases in cerebral cortical thickness in patients with greater excess weight loss, and indicates the need for further investigation using larger samples and correlation with neurocognitive measures, such as memory recall.
View details for PubMedID 29876838
Aberrant Dynamic Connectivity for Fear Processing in Anorexia Nervosa and Body Dysmorphic Disorder.
Frontiers in psychiatry
2018; 9: 273
Anorexia nervosa (AN) and body dysmorphic disorder (BDD) share distorted perceptions of appearance with extreme negative emotion, yet the neural phenotypes of emotion processing remain underexplored in them, and they have never been directly compared. We sought to determine if shared and disorder-specific fronto-limbic connectivity patterns characterize these disorders. FMRI data was obtained from three unmedicated groups: BDD (n = 32), weight-restored AN (n = 25), and healthy controls (HC; n = 37), while they viewed fearful faces and rated their own degree of fearfulness in response. We performed dynamic effective connectivity modeling with medial prefrontal cortex (mPFC), rostral anterior cingulate cortex (rACC), and amygdala as regions-of-interest (ROI), and assessed associations between connectivity and clinical variables. HCs exhibited significant within-group bidirectional mPFC-amygdala connectivity, which increased across the blocks, whereas BDD participants exhibited only significant mPFC-to-amygdala connectivity (P < 0.05, family-wise error corrected). In contrast, participants with AN lacked significant prefrontal-amygdala connectivity in either direction. AN showed significantly weaker mPFC-to-amygdala connectivity compared to HCs (P = 0.0015) and BDD (P = 0.0050). The mPFC-to-amygdala connectivity was associated with greater subjective fear ratings (R2 = 0.11, P = 0.0016), eating disorder symptoms (R2 = 0.33, P = 0.0029), and anxiety (R2 = 0.29, P = 0.0055) intensity scores. Our findings, which suggest a complex nosological relationship, have implications for understanding emotion regulation circuitry in these related psychiatric disorders, and may have relevance for current and novel therapeutic approaches.
View details for PubMedID 29997532
View details for PubMedCentralID PMC6028703
Brain response to taste in overweight children: A pilot feasibility study.
2017; 12 (2)
Understanding the neural response to food and food cues during early stages of weight gain in childhood may help us determine the drive processes involved in unhealthy eating behavior and risk for obesity. Healthy weight and overweight children ages 6-8 (N = 18; 10 with BMI between 5th and 85th %ile and 8 with BMI >85th %ile) underwent fMRI scans while anticipating and receiving tastes of chocolate milkshake. Parents completed a Children's Eating Behaviour Questionnaire. Results reveal greater response to milkshake taste receipt in overweight children in the right insula, operculum, precentral gyrus, and angular gyrus, and bilateral precuneus and posterior cingulate. No group differences were found for brain response to a visual food cue. Exploratory analyses revealed interactions between self-report measures of eating behavior and weight status on brain response to taste. This pilot study provides preliminary evidence of feasibility of studying young children's taste processing and suggests a possible developmental shift in brain response to taste.
View details for DOI 10.1371/journal.pone.0172604
View details for PubMedID 28235080
View details for PubMedCentralID PMC5325294
An interoceptive model of bulimia nervosa: A neurobiological systematic review.
Journal of psychiatric research
2017; 94: 36–46
The objective of our study was to examine the neurobiological support for an interoceptive sensory processing model of bulimia nervosa (BN). To do so, we conducted a systematic review of interoceptive sensory processing in BN, using the PRISMA guidelines. We searched PsychInfo, Pubmed, and Web of Knowledge databases to identify biological and behavioral studies that examine interoceptive detection in BN. After screening 390 articles for inclusion and conducting a quality assessment of articles that met inclusion criteria, we reviewed 41 articles. We found that global interoceptive sensory processing deficits may be present in BN. Specifically there is evidence of abnormal brain function, structure and connectivity in the interoceptive neural network, in addition to gastric and pain processing disturbances. These results suggest that there may be a neurobiological basis for global interoceptive sensory processing deficits in BN that remain after recovery. Data from taste and heart beat detection studies were inconclusive; some studies suggest interoceptive disturbances in these sensory domains. Discrepancies in findings appear to be due to methodological differences. In conclusion, interoceptive sensory processing deficits may directly contribute to and explain a variety of symptoms present in those with BN. Further examination of interoceptive sensory processing deficits could inform the development of treatments for those with BN.
View details for PubMedID 28651098
Differences in Emotion Regulation Difficulties Across Types of Eating Disorders During Adolescence.
Journal of abnormal child psychology
Emotion regulation appears to play a key role in eating disorders. However, prior attempts to associate specific emotion regulation abilities with specific types of eating disorders resulted in inconsistent findings. Moreover, far less is known about emotion regulation in eating disorders during adolescence, a critical period of emotional development. The current study addresses this gap, comparing emotion regulation characteristics between adolescents with restrictive types of eating disorders and those with binge eating or purging types of eating disorders. Ninety-eight adolescents with eating disorders (49 with restrictive and 49 with binge eating/purging eating disorders) completed a set of questionnaires including the Difficulties in Emotion Regulation Scale (DERS). The results revealed that binge eating/purging types of eating disorders were associated with greater difficulties in a variety of emotion regulation dimensions including impulse control, goal-directed behavior and access to effective emotion regulation strategies. Awareness and clarity of emotions were also worse in the binge eating/purging types of eating disorders, but this difference did not remain when comorbid psychopathology measures were controlled for. Moreover, the emotion regulation profile of adolescents with anorexia nervosa-binging/purging type was more similar to that of adolescents with bulimia nervosa than to that of adolescents with anorexia nervosa-restrictive type. While both restrictive and binge eating/purging eating disorders have been associated with emotion regulation difficulties, the current study shows that the presence of binge eating or purging episodes is linked with greater severity of emotion regulation deficits among adolescents with eating disorders.
View details for PubMedID 29101588
Intrinsic Brain Connectivity in Youth With Depression at High Risk for Insulin Insensitivity
NATURE PUBLISHING GROUP. 2016: S185–S186
View details for Web of Science ID 000440365600330
Functional connectivity for face processing in individuals with body dysmorphic disorder and anorexia nervosa
2015; 45 (16): 3491-3503
Body dysmorphic disorder (BDD) and anorexia nervosa (AN) are both characterized by distorted perception of appearance. Previous studies in BDD suggest abnormalities in visual processing of own and others' faces, but no study has examined visual processing of faces in AN, nor directly compared the two disorders in this respect.We collected functional magnetic resonance imaging data on 60 individuals of equivalent age and gender in each of three groups--20 BDD, 20 weight-restored AN, and 20 healthy controls (HC)--while they viewed images of others' faces that contained only high or low spatial frequency information (HSF or LSF). We tested hypotheses about functional connectivity within specialized sub-networks for HSF and LSF visual processing, using psychophysiological interaction analyses.The BDD group demonstrated increased functional connectivity compared to HC between left anterior occipital face area and right fusiform face area (FFA) for LSF faces, which was associated with symptom severity. Both BDD and AN groups had increased connectivity compared to HC between FFA and precuneous/posterior cingulate gyrus for LSF faces, and decreased connectivity between FFA and insula. In addition, we found that LSF connectivity between FFA and posterior cingulate gyrus was significantly associated with thoughts about own appearance in AN.Results suggest similar abnormal functional connectivity within higher-order systems for face processing in BDD and AN, but distinct abnormal connectivity patterns within occipito-temporal visual networks. Findings may have implications for understanding relationships between these disorders, and the pathophysiology underlying perceptual distortions.
View details for DOI 10.1017/S0033291715001397
View details for Web of Science ID 000364937200010
View details for PubMedID 26219399
View details for PubMedCentralID PMC4879882
Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information
2015; 45 (10): 2111-2122
Background. Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are characterized by distorted body image and are frequently co-morbid with each other, although their relationship remains little studied. While there is evidence of abnormalities in visual and visuospatial processing in both disorders, no study has directly compared the two. We used two complementary modalities - event-related potentials (ERPs) and functional magnetic resonance imaging (fMRI) - to test for abnormal activity associated with early visual signaling. Method. We acquired fMRI and ERP data in separate sessions from 15 unmedicated individuals in each of three groups (weight-restored AN, BDD, and healthy controls) while they viewed images of faces and houses of different spatial frequencies. We used joint independent component analyses to compare activity in visual systems. Results. AN and BDD groups demonstrated similar hypoactivity in early secondary visual processing regions and the dorsal visual stream when viewing low spatial frequency faces, linked to the N170 component, as well as in early secondary visual processing regions when viewing low spatial frequency houses, linked to the P100 component. Additionally, the BDD group exhibited hyperactivity in fusiform cortex when viewing high spatial frequency houses, linked to the N170 component. Greater activity in this component was associated with lower attractiveness ratings of faces. Conclusions. Results provide preliminary evidence of similar abnormal spatiotemporal activation in AN and BDD for configural/holistic information for appearance- and non-appearance-related stimuli. This suggests a common phenotype of abnormal early visual system functioning, which may contribute to perceptual distortions.
View details for DOI 10.1017/S0033291715000045
View details for Web of Science ID 000355757500009
Deep brain stimulation for obesity: rationale and approach to trial design.
2015; 38 (6): E8-?
Obesity is one of the most serious public health concerns in the US. While bariatric surgery has been shown to be successful for treatment of morbid obesity for those who have undergone unsuccessful behavioral modification, its associated risks and rates of relapse are not insignificant. There exists a neurological basis for the binge-like feeding behavior observed in morbid obesity that is believed to be due to dysregulation of the reward circuitry. The authors present a review of the evidence of the neuroanatomical basis for obesity, the potential neural targets for deep brain stimulation (DBS), as well as a rationale for DBS and future trial design. Identification of an appropriate patient population that would most likely benefit from this type of therapy is essential. There are also significant cost and ethical considerations for such a neuromodulatory intervention designed to alter maladaptive behavior. Finally, the authors present a consolidated set of inclusion criteria and study end points that should serve as the basis for any trial of DBS for obesity.
View details for DOI 10.3171/2015.3.FOCUS1538
View details for PubMedID 26030708
Deep Brain Stimulation for Obesity.
2015; 7 (3)
Obesity is now the third leading cause of preventable death in the US, accounting for 216,000 deaths annually and nearly 100 billion dollars in health care costs. Despite advancements in bariatric surgery, substantial weight regain and recurrence of the associated metabolic syndrome still occurs in almost 20-35% of patients over the long-term, necessitating the development of novel therapies. Our continually expanding knowledge of the neuroanatomic and neuropsychiatric underpinnings of obesity has led to increased interest in neuromodulation as a new treatment for obesity refractory to current medical, behavioral, and surgical therapies. Recent clinical trials of deep brain stimulation (DBS) in chronic cluster headache, Alzheimer's disease, and depression and obsessive-compulsive disorder have demonstrated the safety and efficacy of targeting the hypothalamus and reward circuitry of the brain with electrical stimulation, and thus provide the basis for a neuromodulatory approach to treatment-refractory obesity. In this study, we review the literature implicating these targets for DBS in the neural circuitry of obesity. We will also briefly review ethical considerations for such an intervention, and discuss genetic secondary-obesity syndromes that may also benefit from DBS. In short, we hope to provide the scientific foundation to justify trials of DBS for the treatment of obesity targeting these specific regions of the brain.
View details for DOI 10.7759/cureus.259
View details for PubMedID 26180683
Greater emotional eating scores associated with reduced frontolimbic activation to palatable taste in adolescents.
2014; 22 (8): 1814-1820
This study examined the relation between self-reported emotional eating scores and frontolimbic brain response to palatable taste in adolescents.Participants included 162 adolescents (mean BMI percentile = 52.7, range 3-90). Participants completed a self-report survey assessing emotional eating and underwent functional magnetic resonance imaging (fMRI) while viewing pictures signaling subsequent delivery of a chocolate milkshake or a control taste and receiving the corresponding taste.Results revealed no significant relation between emotional eating scores and brain response to anticipation of receipt of milkshake. In response to milkshake taste receipt, emotional eating scores were negatively related to activation in the right thalamus, the left insula and orbitofrontal cortex, and bilateral putamen and caudate. These findings remained significant after controlling for body mass index and body fat percentage.The current results are discussed in the context of findings of reduced reward activation to palatable taste receipt in obese adults and adolescents.
View details for DOI 10.1002/oby.20759
View details for PubMedID 24715468
Visual processing in anorexia nervosa and body dysmorphic disorder: Similarities, differences, and future research directions.
Journal of psychiatric research
2013; 47 (10): 1483-1491
Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are psychiatric disorders that involve distortion of the experience of one's physical appearance. In AN, individuals believe that they are overweight, perceive their body as "fat," and are preoccupied with maintaining a low body weight. In BDD, individuals are preoccupied with misperceived defects in physical appearance, most often of the face. Distorted visual perception may contribute to these cardinal symptoms, and may be a common underlying phenotype. This review surveys the current literature on visual processing in AN and BDD, addressing lower- to higher-order stages of visual information processing and perception. We focus on peer-reviewed studies of AN and BDD that address ophthalmologic abnormalities, basic neural processing of visual input, integration of visual input with other systems, neuropsychological tests of visual processing, and representations of whole percepts (such as images of faces, bodies, and other objects). The literature suggests a pattern in both groups of over-attention to detail, reduced processing of global features, and a tendency to focus on symptom-specific details in their own images (body parts in AN, facial features in BDD), with cognitive strategy at least partially mediating the abnormalities. Visuospatial abnormalities were also evident when viewing images of others and for non-appearance related stimuli. Unfortunately no study has directly compared AN and BDD, and most studies were not designed to disentangle disease-related emotional responses from lower-order visual processing. We make recommendations for future studies to improve the understanding of visual processing abnormalities in AN and BDD.
View details for DOI 10.1016/j.jpsychires.2013.06.003
View details for PubMedID 23810196
Functional Connectivity While Viewing Cues for Taste Delivery Related to Body Mass in Healthy-Weight Adolescents
ELSEVIER SCIENCE INC. 2013: 197S–198S
View details for Web of Science ID 000318671800610
Nonlinear relationships between anxiety and visual processing of own and others' faces in body dysmorphic disorder
2012; 204 (2-3): 132-139
Individuals with body dysmorphic disorder (BDD) often experience anxiety, as well as perceptual distortions of appearance. Anxiety has previously been found to impact visual processing. This study therefore tested the relationship between anxiety and visual processing of faces in BDD. Medication-free participants with BDD (N=17) and healthy controls (N=16) viewed photographs of their face and a familiar face during functional magnetic resonance imaging. Blood-oxygen-level dependent signal changes in regions involved in anxiety (amygdala) and detailed visual processing (ventral visual stream-VVS) were regressed on anxiety scores. Significant linear relationships between activity in the amygdala and VVS were found in both healthy controls and individuals with BDD. There was a trend of a quadratic relationship between anxiety and activity in the right VVS and a linear relationship between anxiety and activity in the left VVS for the BDD sample, and this was stronger for own-face stimuli versus familiar-face. Results suggest that anxiety symptoms in BDD may be associated with activity in systems responsible for detailed visual processing. This may have clinical implications related to heightened perceptual distortions associated with anxiety.
View details for DOI 10.1016/j.pscychresns.2012.09.003
View details for Web of Science ID 000314329200010
View details for PubMedID 23137801
View details for PubMedCentralID PMC3518613
Negative affect and neural response to palatable food intake in bulimia nervosa
2012; 58 (3): 964-970
Binge eating is often preceded by reports of negative affect, but the mechanism by which affect may lead to binge eating is unclear. This study evaluated the effect of negative affect on neural response to anticipation and receipt of palatable food in women with bulimia nervosa (BN) versus healthy controls. We also evaluated connectivity between the amygdala and reward-related brain regions. Females with and without BN (n=26) underwent functional magnetic resonance imaging (fMRI) during receipt and anticipated receipt of chocolate milkshake and a tasteless solution. We measured negative affect just prior to the scan. Women with BN showed a positive correlation between negative affect and activity in the putamen, caudate, and pallidum during anticipated receipt of milkshake (versus tasteless solution). There were no significant relations between negative affect and receipt of milkshake. Connectivity analyses revealed a greater relation of amygdala activity to activation in the left putamen and insula during anticipated receipt of milkshake in the bulimia group relative to the control group. The opposite pattern was found for the taste of milkshake; the control group showed a greater relation of amygdala activity to activation in the left putamen and insula in response to milkshake receipt than the bulimia group. Results show that as negative affect increases, so does responsivity of reward regions to anticipated intake of palatable food, implying that negative affect may increase the reward value of food for individuals with bulimia nervosa or that negative affect has become a conditioned cue due to a history of binge eating in a negative mood.
View details for DOI 10.1016/j.appet.2012.02.051
View details for Web of Science ID 000304336800030
View details for PubMedID 22387716
Effects of cranial electrotherapy stimulation on resting state brain activity.
Brain and behavior
2012; 2 (3): 211-220
Cranial electrotherapy stimulation (CES) is a U.S. Food and Drug Administration (FDA)-approved treatment for insomnia, depression, and anxiety consisting of pulsed, low-intensity current applied to the earlobes or scalp. Despite empirical evidence of clinical efficacy, its mechanism of action is largely unknown. The goal was to characterize the acute effects of CES on resting state brain activity. Our primary hypothesis was that CES would result in deactivation in cortical and subcortical regions. Eleven healthy controls were administered CES applied to the earlobes at subsensory thresholds while being scanned with functional magnetic resonance imaging in the resting state. We tested 0.5- and 100-Hz stimulation, using blocks of 22 sec "on" alternating with 22 sec of baseline (device was "off"). The primary outcome measure was differences in blood oxygen level dependent data associated with the device being on versus baseline. The secondary outcome measures were the effects of stimulation on connectivity within the default mode, sensorimotor, and fronto-parietal networks. Both 0.5- and 100-Hz stimulation resulted in significant deactivation in midline frontal and parietal regions. 100-Hz stimulation was associated with both increases and decreases in connectivity within the default mode network (DMN). Results suggest that CES causes cortical brain deactivation, with a similar pattern for high- and low-frequency stimulation, and alters connectivity in the DMN. These effects may result from interference from high- or low-frequency noise. Small perturbations of brain oscillations may therefore have significant effects on normal resting state brain activity. These results provide insight into the mechanism of action of CES, and may assist in the future development of optimal parameters for effective treatment.
View details for DOI 10.1002/brb3.45
View details for PubMedID 22741094
Reward Abnormalities among Women with Full and Subthreshold Bulimia Nervosa: A Functional Magnetic Resonance Imaging Study
INTERNATIONAL JOURNAL OF EATING DISORDERS
2011; 44 (7): 585-595
To test the hypothesis that women with full and subthreshold bulimia nervosa show abnormal neural activation in response to food intake and anticipated food intake relative to healthy control women.Females with and without full/subthreshold bulimia nervosa recruited from the community (N = 26) underwent functional magnetic resonance imaging (fMRI) during receipt and anticipated receipt of chocolate milkshake and a tasteless control solution.Women with bulimia nervosa showed trends for less activation than healthy controls in the right anterior insula in response to anticipated receipt of chocolate milkshake (vs. tasteless solution) and in the left middle frontal gyrus, right posterior insula, right precentral gyrus, and right mid dorsal insula in response to consumptions of milkshake (vs. tasteless solution).Bulimia nervosa may be related to potential hypofunctioning of the brain reward system, which may lead these individuals to binge eat to compensate for this reward deficit, though the hypo-responsivity might be a result of a history of binge eating highly palatable foods.
View details for DOI 10.1002/eat.20869
View details for Web of Science ID 000296417900003
View details for PubMedID 21997421
An fMRI study of obesity, food reward, and perceived caloric density. Does a low-fat label make food less appealing?
2011; 57 (1): 65-72
We tested the hypothesis that obese individuals experience greater activation of the gustatory and somatosensory cortex, but weaker activation of the striatum, in response to intake and anticipated intake of high-fat chocolate milkshake versus an isocaloric milkshake labeled low-fat and a tasteless solution using functional magnetic resonance imaging (fMRI) with 17 obese and 17 lean young women. Obese relative to lean women showed greater activation in somatosensory (Rolandic operculum), gustatory (frontal operculum), and reward valuation regions (amgydala, ventralmedial prefrontal cortex (vmPFC) in response to intake and anticipated intake of milkshake versus tasteless solution, though there was little evidence of reduced striatal activation. Obese relative to lean women also showed greater activation in the Rolandic operculum, frontal operculum, and vmPFC in response to isocaloric milkshakes labeled regular versus low-fat. Results suggest that hyper-responsivity of somatosensory, gustatory, and reward valuation regions may be related to overeating and that top-down processing influence reward encoding, which could further contribute to weight gain.
View details for DOI 10.1016/j.appet.2011.03.017
View details for Web of Science ID 000293677900010
View details for PubMedID 21497628
Weight Gain Is Associated with Reduced Striatal Response to Palatable Food
JOURNAL OF NEUROSCIENCE
2010; 30 (39): 13105-13109
Consistent with the theory that individuals with hypofunctioning reward circuitry overeat to compensate for a reward deficit, obese versus lean humans have fewer striatal D2 receptors and show less striatal response to palatable food intake. Low striatal response to food intake predicts future weight gain in those at genetic risk for reduced signaling of dopamine-based reward circuitry. Yet animal studies indicate that intake of palatable food results in downregulation of D2 receptors, reduced D2 sensitivity, and decreased reward sensitivity, implying that overeating may contribute to reduced striatal responsivity. Thus, we tested whether overeating leads to reduced striatal responsivity to palatable food intake in humans using repeated-measures functional magnetic resonance imaging. Results indicated that women who gained weight over a 6 month period showed a reduction in striatal response to palatable food consumption relative to weight-stable women. Collectively, results suggest that low sensitivity of reward circuitry increases risk for overeating and that this overeating may further attenuate responsivity of reward circuitry in a feedforward process.
View details for DOI 10.1523/JNEUROSCI.2105-10.2010
View details for Web of Science ID 000282571800021
View details for PubMedID 20881128
Relation of dietary restraint scores to cognitive biases and reward sensitivity
2010; 55 (1): 61-68
This study tested the hypotheses that dietary restraint scores are associated with greater reward sensitivity and cognitive bias for food-related cues, which might result in chronic overeating and efforts to curb this tendency through dietary restriction. Participants (N=63) with high versus low scores on the DEBQ-R did not differ on attentional bias for pictorial food-related cues on a visual probe task, or approach tendencies elicited by food cues, as assessed with a stimulus-response compatibility (SRC) task. Restraint was also unrelated to performance on an operant task that assessed how hard participants would work for snacks, or responding during a taste habituation paradigm. Dietary restraint scores were correlated with self-reported appetitive response to food, sensitivity to reward, and sensitivity to punishment. Results provide limited support for the hypothesis that individuals with elevated dietary restraint scores show greater reward sensitivity and cognitive bias for food stimuli, though it is possible that the null findings on the behavioral task resulted because of an approach-avoidance conflict to food cues in which heightened appetitive responses to food are inhibited by food-related anxiety.
View details for DOI 10.1016/j.appet.2010.04.001
View details for Web of Science ID 000280213300010
View details for PubMedID 20399819
Reward circuitry responsivity to food predicts future increases in body mass: Moderating effects of DRD2 and DRD4
2010; 50 (4): 1618-1625
To determine whether responsivity of reward circuitry to food predicts future increases in body mass and whether polymorphisms in DRD2 and DRD4 moderate these relations.The functional magnetic resonance imaging (fMRI) paradigm investigated blood oxygen level dependent activation in response to imagined intake of palatable foods, unpalatable foods, and glasses of water shown in pictures. DNA was extracted from saliva samples using standard salting-out and solvent precipitation methods.Forty-four adolescent female high school students ranging from lean to obese.Future increases in body mass index (BMI).Weaker activation of the frontal operculum, lateral orbitofrontal cortex, and striatum in response to imagined intake of palatable foods, versus imagined intake of unpalatable foods or water, predicted future increases in body mass for those with the DRD2 TaqIA A1 allele or the DRD4-7R allele. Data also suggest that for those lacking these alleles, greater responsivity of these food reward regions predicted future increases in body mass.This novel prospective fMRI study indicates that responsivity of reward circuitry to food increases risk for future weight gain, but that genes that impact dopamine signaling capacity moderate the predictive effects, suggesting two qualitatively distinct pathways to unhealthy weight gain based on genetic risk.
View details for DOI 10.1016/j.neuroimage.2010.01.081
View details for Web of Science ID 000276023500028
View details for PubMedID 20116437
A Meta-Analytic Review of Depression Prevention Programs for Children and Adolescents: Factors That Predict Magnitude of Intervention Effects
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2009; 77 (3): 486-503
In this meta-analytic review, the authors summarized the effects of depression prevention programs for youth as well as investigated participant, intervention, provider, and research design features associated with larger effects. They identified 47 trials that evaluated 32 prevention programs, producing 60 intervention effect sizes. The average effect for depressive symptoms from pre-to-posttreatment (r = .15) and pretreatment to-follow-up (r = .11) were small, but 13 (41%) prevention programs produced significant reductions in depressive symptoms and 4 (13%) produced significant reductions in risk for future depressive disorder onset relative to control groups. Larger effects emerged for programs targeting high-risk individuals, samples with more females, samples with older adolescents, programs with a shorter duration and with homework assignments, and programs delivered by professional interventionists. Intervention content (e.g., a focus on problem-solving training or reducing negative cognitions) and design features (e.g., use of random assignment and structured interviews) were unrelated to effect sizes. Results suggest that depression prevention efforts produce a higher yield if they incorporate factors associated with larger intervention effects (e.g., selective programs with a shorter duration that include homework).
View details for DOI 10.1037/a0015168
View details for PubMedID 19485590
Female Emotional Eaters Show Abnormalities in Consummatory and Anticipatory Food Reward: A Functional Magnetic Resonance Imaging Study
INTERNATIONAL JOURNAL OF EATING DISORDERS
2009; 42 (3): 210-221
To test the hypothesis that emotional eaters show greater neural activation in response to food intake and anticipated food intake than nonemotional eaters and whether these differences are amplified during a negative versus neutral mood state.Female emotional eaters and nonemotional eaters (N = 21) underwent functional magnetic resonance imaging (fMRI) during receipt and anticipated receipt of chocolate milkshake and a tasteless control solution while in a negative and neutral mood.Emotional eaters showed greater activation in the parahippocampal gyrus and anterior cingulate (ACC) in response to anticipated receipt of milkshake and greater activation in the pallidum, thalamus, and ACC in response to receipt of milkshake during a negative relative to a neutral mood. In contrast, nonemotional eaters showed decreased activation in reward regions during a negative versus a neutral mood.Results suggest that emotional eating is related to increased anticipatory and consummatory food reward, but only during negative mood.
View details for DOI 10.1002/eat.20615
View details for Web of Science ID 000264399100005
View details for PubMedID 19040270
Maintenance Factors for Persistence of Bulimic Pathology: A Prospective Natural History Study
INTERNATIONAL JOURNAL OF EATING DISORDERS
2009; 42 (2): 173-178
To characterize the natural course of bulimia nervosa and identify potential maintenance factors that predict persistence of bulimic pathology in order to advance knowledge of processes that perpetuate this eating disturbance and permit the design of more efficacious treatments.We followed 96 women with threshold or subthreshold bulimia nervosa over a 1-year period with quarterly interviews.There were high rates of remission and relapse on a month-to-month basis, but remission became more likely to persist after a period of approximately 4 months of symptom abstinence. Initial elevations in thin-ideal internalization, expectations for reward from eating, and binge frequency predicted greater time to remission of binge eating. Initial elevations in dietary restraint and compensatory behavior frequency predicted greater time to remission of compensatory behaviors.Results imply that treatments for eating disorder may be more effective if they can reduce thin-ideal internalization, eating expectancies, and ineffective dieting and produce rapid cessation of binge eating and compensatory behaviors.
View details for DOI 10.1002/eat.20600
View details for Web of Science ID 000263576700012
View details for PubMedID 18951457
Subtyping Women With Bulimia Nervosa Along Dietary and Negative Affect Dimensions: Further Evidence of Reliability and Validity
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2008; 76 (6): 1022-1033
Studies have found that individuals with bulimia nervosa can be classified into dietary and dietary-negative affect subtypes and that the latter exhibit greater eating pathology, psychiatric comorbidity, and functional impairment; a more protracted clinical course; and a worse treatment response. In this report, the authors describe 2 prospective studies that found that young women with threshold (n = 48) and subthreshold (n = 83) bulimic pathology can be classified into dietary and dietary-negative affect subtypes; that two subtyping approaches produced similar results (mean kappa = .94); that the subtyping distinction showed 4-week test-retest reliability (kappa = .61); and that the dietary-negative affect subtype showed greater eating pathology, emotional distress, functional impairment, treatment seeking, and lower likelihood of recovery over 6-month and 3-year follow-ups than the dietary subtype. The dieting-negative affect subtyping distinction evidenced greater test-retest reliability and concurrent and predictive validity than did the purging-nonpurging subtyping distinction. The additional evidence for the reliability and validity of this subtyping scheme, particularly the prognostic utility, suggests it is worth additional inquiry.
View details for DOI 10.1037/a0013887
View details for Web of Science ID 000261113000011
View details for PubMedID 19045970
View details for PubMedCentralID PMC2849665
Relation of Reward From Food Intake and Anticipated Food Intake to Obesity: A Functional Magnetic Resonance Imaging Study
JOURNAL OF ABNORMAL PSYCHOLOGY
2008; 117 (4): 924-935
The authors tested the hypothesis that obese individuals experience greater reward from food consumption (consummatory food reward) and anticipated consumption (anticipatory food reward) than lean individuals using functional magnetic resonance imaging (fMRI) with 33 adolescent girls (mean age = 15.7, SD = 0.9). Obese relative to lean adolescent girls showed greater activation bilaterally in the gustatory cortex (anterior and mid insula, frontal operculum) and in somatosensory regions (parietal operculum and Rolandic operculum) in response to anticipated intake of chocolate milkshake (vs. a tasteless solution) and to actual consumption of milkshake (vs. a tasteless solution); these brain regions encode the sensory and hedonic aspects of food. However, obese relative to lean adolescent girls also showed decreased activation in the caudate nucleus in response to consumption of milkshake versus a tasteless solution, potentially because they have reduced dopamine receptor availability. Results suggest that individuals who show greater activation in the gustatory cortex and somatosensory regions in response to anticipation and consumption of food, but who show weaker activation in the striatum during food intake, may be at risk for overeating and consequent weight gain.
View details for DOI 10.1037/a0013600
View details for Web of Science ID 000260974500017
View details for PubMedID 19025237
View details for PubMedCentralID PMC2681092
Relation between obesity and blunted striatal response to food is moderated by TaqIA A1 allele
2008; 322 (5900): 449-452
The dorsal striatum plays a role in consummatory food reward, and striatal dopamine receptors are reduced in obese individuals, relative to lean individuals, which suggests that the striatum and dopaminergic signaling in the striatum may contribute to the development of obesity. Thus, we tested whether striatal activation in response to food intake is related to current and future increases in body mass and whether these relations are moderated by the presence of the A1 allele of the TaqIA restriction fragment length polymorphism, which is associated with dopamine D2 receptor (DRD2) gene binding in the striatum and compromised striatal dopamine signaling. Cross-sectional and prospective data from two functional magnetic resonance imaging studies support these hypotheses, which implies that individuals may overeat to compensate for a hypofunctioning dorsal striatum, particularly those with genetic polymorphisms thought to attenuate dopamine signaling in this region.
View details for DOI 10.1126/science.1161550
View details for Web of Science ID 000260094500049
View details for PubMedID 18927395
A prospective test of cognitive vulnerability models of depression with adolescent girls
2008; 39 (1): 79-90
This study sought to provide a more rigorous prospective test of two cognitive vulnerability models of depression with longitudinal data from 496 adolescent girls. Results supported the cognitive vulnerability model in that stressors predicted future increases in depressive symptoms and onset of clinically significant major depression for individuals with a negative attributional style, but not for those with a positive attributional style, although these effects were small. This model appeared to be specific to depression, in that it did not predict future increases in bulimia nervosa or substance abuse symptoms. In contrast, results did not support the integrated cognitive vulnerability self-esteem model that asserts stressors should only predict increased depression for individuals with a confluence of negative attributional style and low self-esteem, and this model did not appear to be specific to depression.
View details for Web of Science ID 000257419000009
View details for PubMedID 18328873
Relations of bulilmic symptom frequency and intensity to psychosocial impairment and health care utilization: Results from a community-recruited sample
INTERNATIONAL JOURNAL OF EATING DISORDERS
2007; 40 (6): 505-514
To determine the frequency and intensity of bulimic symptoms related to psychosocial impairment and health care utilization.Females (N = 1231, M age = 17.7, range 13-55) from four community-recruited samples varying in bulimic pathology completed the eating disorder examination, social adjustment scale, and health survey utilization scale.Co-occurrence of binge eating and compensatory behaviors and solely compensatory behaviors >or=1 time/month were associated with elevations in psychosocial impairment. Co-occurrence of both binge eating and compensatory behaviors and solely compensatory behaviors >or=8 times/month were related to greater service utilization. Solely binge eating and duration of bulimic behaviors were unrelated to these functional outcomes. Overvaluation of body shape and weight showed significant linear relations to the functional outcomes.Results suggest that current diagnostic thresholds for bulimia nervosa may be too high when considering functional impairment and service utilization and that different cut-points need to be considered for different bulimic symptoms.
View details for DOI 10.1002/eat.20410
View details for PubMedID 17607700
Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents
JOURNAL OF ABNORMAL PSYCHOLOGY
2007; 116 (1): 198-207
The authors examined the reciprocal relations between rumination and symptoms of depression, bulimia, and substance abuse with longitudinal data from 496 female adolescents. Rumination predicted future increases in bulimic and substance abuse symptoms, as well as onset of major depression, binge eating, and substance abuse. Depressive and bulimic, but not substance abuse, symptoms predicted increases in rumination. Rumination did not predict increases in externalizing symptoms, providing evidence for the specificity of effects of rumination, although externalizing symptoms predicted future increases in rumination. Results suggest rumination may contribute to the etiology of depressive, bulimic, and substance abuse pathology and that the former two disturbances may foster increased rumination. Results imply that it might be beneficial for prevention programs to target this cognitive vulnerability.
View details for DOI 10.1037/0021-843X.116.1.198
View details for Web of Science ID 000244162200019
View details for PubMedID 17324030
Predicting school dropout and adolescent sexual behavior in offspring of depressed and nondepressed mothers
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
2007; 46 (1): 15-24
To examine predictors of school dropout and adolescent sexual behavior in offspring of depressed and nondepressed mothers. Possible moderators of the relation between maternal depression and these outcomes also were explored.Participants were 240 mothers and adolescents assessed annually from 6th through 12th grade. Interviews and questionnaires measured the chronicity and severity of the mother's depressive episodes, the mother's educational attainment, socioeconomic status, the presence of a father, the adolescent's IQ, externalizing behaviors, and substance use disorders.Substance use disorders before ninth grade significantly predicted higher rates of both school dropout and adolescent sexual behavior. Lower levels of mother's educational attainment and higher rates of adolescent's externalizing behaviors in grades 6 through 8 predicted higher school dropout. Higher IQ was associated with a lower likelihood of dropping out among offspring of never or moderately depressed mothers, but not for offspring of chronic/severely depressed mothers. Among offspring of never or moderately depressed mothers, the presence of a male head of household was associated with lower rates of adolescent sexual behavior, but not among offspring of chronically/severely depressed mothers.These findings have implications for the development of programs aimed at preventing behavior problems in high-risk adolescents.
View details for DOI 10.1097/01.chi.0000246052.30426.6e
View details for Web of Science ID 000243146600005
View details for PubMedID 17195725