Parent-Facilitated Behavioral Treatment for Avoidant/Restrictive Food Intake Disorder: A Case Report

Avoidant/restrictive food intake disorder (ARFID), which was introduced in DSM-5, may be one of the most functionally impairing eating disorders, yet little is known regarding risk factors, prevalence, or efficacious treatment models for the disorder. With no empirically supported treatment for ARFID, it is important to investigate the clinical utility of innovative therapeutic approaches. Here we describe a novel parent-facilitated behavioral treatment for youth with ARFID (PBT-ARFID) that is grounded in learning theory, as well as components of well-established family-based treatment (FBT) for eating disorders. We propose a two-factor theory of avoidance learning within a biopsychosocial model to explain behavior in ARFID and utilize counterconditioning as a core intervention to reverse paired, classically conditioned association between food and aversive state (i.e., disgust and/or anxiety). This report details a step-by-step comprehensive treatment approach for ARFID that can be adapted to a broad range of youth and their families, along with a case study illustrating application of the model. This pilot case provides preliminary evidence that the PBT-ARFID model incorporating counterconditioning may be a powerful treatment for youth with ARFID. More case and pilot studies are needed to justify formally investigating its efficacy in a randomized controlled trial.     

Psychophysiological responses during analogue systematic desensitization and non-relaxation control procedures

This investigation tested the hypotheses than an analogue systematic desensitization procedure (SD) would be both more effective and more efficient than a comparable non-relaxation control procedure (NRC) with respect to subjective report, behavioral and psychophysiological variables. Phobic subjects responded to slides depicting a feared aversive stimulus. The SD procedure resulted in significantly less reported fear, fewer trials to a criterion level of decrease in subjective fear, and significantly greater decreases in ANS baseline measures. However, measures of behavioral avoidance and measures of decrease in psychophysiological responsivity to the aversive stimuli revealed significant changes within both SD and NRC groups, and no significant differences between the groups, whether or not the groups were equated for number of stimulus presentations. The results, indicating equivalent efficacy and efficiency for the SD and NRC procedures, suggested a limited role for relaxation in systematic desensitization. An extinction or habituation hypothesis was supported at the expense of a counterconditioning hypothesis.     

OBSERVATION AND COMPARISON OF MEALTIME BEHAVIORS IN A SAMPLE OF CHILDREN WITH AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDERS AND A CONTROL SAMPLE OF CHILDREN WITH TYPICAL DEVELOPMENT

Despite widespread use of behavioral observations to evaluate child feeding behaviors in research and clinical practice, few studies have comprehensively characterized mealtimes or identified features that differentiate children with and without disordered feeding; these were the aims of the current study. Mealtime observations were conducted for 18 children with avoidant restrictive food intake disorder (ARFID) and 21 typically developing children. Observations were coded inductively, and associations between disorder and observed mealtime actions were examined. Most behaviors were observed across both clinical and nonclinical mealtimes, and many did not differ in frequency between children with and without ARFID. However, significant group differences were observed in the frequencies of behaviors relating to food intake, visual and physical engagement with feeding, and movement during mealtimes. The comparability of behaviors across clinical and nonclinical groups suggests that eating behaviors exist on a continuum from “normal” to “abnormal,” with group differences relating to frequency rather than type of behavior. The behavioral differences observed in this study suggest that identification of children with ARFID should focus on child engagement with food and restlessness during mealtimes. Reliance on emotional and escape‐maintained behaviors will lead to underrecognition of families in need of clinical support.     

Facilitation of Extinction of Conditioned Fear by D-Cycloserine

Abstract— Excessive fear and anxiety are characteristic of disorders such as post-traumatic stress disorder (PTSD) and phobias and are believed to reflect abnormalities in neural systems governing the development and reduction of conditioned fear. Conditioned fear can be suppressed through a process known as extinction, in which repeated exposure to a feared stimulus in the absence of an aversive event leads to a gradual reduction in the fear response to that stimulus. Like conditioned fear learning, extinction is dependent on a particular protein (the N-methyl-D-aspartate or NMDA receptor) in a part of the brain called the amygdala. Blockade of this receptor blocks extinction and improving the activity of this receptor with a drug called D-cycloserine speeds up extinction in rats. Because exposure-based psychotherapy for fear disorders in humans resembles extinction in several respects, we investigated whether D-cycloserine might facilitate the loss of fear in human patients. Consistent with findings from the animal laboratory, patients receiving D-cycloserine benefited more from exposure-based psychotherapy than did placebo-treated controls. Although very preliminary, these data provide initial support for the use of cognitive enhancers in psychotherapy and demonstrate that preclinical studies in rodents can have direct benefits to humans.     

Eye movements during recall of aversive memory decreases conditioned fear

Cognitive-behavioral therapy for anxiety disorders typically involves exposure to the conditioned stimulus (CS). Despite its status as an effective and primary treatment, many patients do not show clinical improvement or relapse. Contemporary learning theory suggests that treatment may be optimized by adding techniques that aim at revaluating the aversive consequence (US) of the feared stimulus. This study tested whether US devaluation via a dual task – imagining the US while making eye movements – decreases conditioned fear. Following fear acquisition one group recalled the US while making eye movements (EM) and one group merely recalled the US (RO). Next, during a test phase, all participants were re-presented the CSs. Dual tasking, relative to the control condition, decreased memory vividness and emotionality. Moreover, only in the dual task condition reductions were observed in self-reported fear, US expectancy, and CS unpleasantness, but not in skin conductance responses. Findings provide the first evidence that the dual task decreases conditioned fear and suggest it may be a valuable addition to exposure therapy.     

Eating Disorder Symptom and Fear Change Trajectories During Imaginal Exposure Therapy: A Slope Network Analysis

Eating disorders (EDs) are characterized by fears related to food, body image, and social evaluation. Exposure-based interventions hold promise for targeting a range of ED fears and reducing ED psychopathology. We investigated change mechanisms and optimal fear targets in imaginal exposure therapy for EDs using a novel approach to network analysis. Individuals with an ED (N = 143) completed up to four online imaginal exposure sessions. Participants reported ED symptoms and fears at pretreatment, posttreatment, and 6-month follow-up. We constructed networks of symptoms (Model 1), fears (Model 2), and combined symptoms and fears (Model 3). Change trajectory networks from the slopes of symptoms/fears across timepoints were estimated to identify how change in specific ED symptoms/fears related to change in other ED symptoms/fears. The most central changing symptoms and fears were feeling fat, fear of weight gain, guilt about one’s weight/shape, and feared concerns about consequences of eating. In Model 3, change in ED fears bridged to change in desire to lose weight, desiring a flat stomach, following food rules, concern about eating with others, and guilt. As slope networks present averages of symptom/fear change slopes over the course of imaginal exposure therapy, further studies are needed to examine causal relationships between symptom changes and heterogeneity of change trajectories. Fears of weight gain and consequences of eating may be optimal targets for ED exposure therapy, as changes in these fears were associated with maximal change in ED pathology. Slope networks may elucidate change mechanisms for EDs and other psychiatric illnesses.     

Psychological Impairment as a Predictor of Suicide Ideation in Individuals with Anorexia Nervosa

Anorexia nervosa (AN) is an eating disorder characterized by severe food restriction resulting in low body weight and an intense fear of gaining weight. This disorder has one of the highest suicide rates of any psychiatric illness; however, few studies have investigated prospective predictors of suicide ideation (SI) in this population. Quality‐of‐life impairment may be particularly relevant for understanding suicide risk in AN, given associations with SI in other psychiatric disorders and associations with chronicity and severity in AN. This study explored associations between eating disorder‐related impairment and SI in individuals with AN (n = 113) who completed assessments at treatment discharge and 3, 6, and 12 months after discharge. Greater psychological impairment predicted future occurrence of SI controlling for age, depression, history of SI, and eating disorder variables. Associations were specific to psychological impairment as other domains of impairment did not predict SI over time. Findings highlight the potential importance of targeting interpersonal–psychological consequences of AN to decrease future suicide risk.     

Reevaluating Cue Exposure and Response Prevention in a Pilot Study: An Updated Treatment for Binge Eating Disorder

Approximately half of individuals with binge eating disorder (BED) fail to improve when treated with cognitive behavioral therapy; thus, better treatments are needed. Cue exposure and response prevention (CERP) may be one option, but its full potential for reducing binge eating remains unknown because prior applications for binge eating have not utilized the broad range of strategies believed to optimize exposure therapy. The current single-subject AB design investigated the acceptability and effectiveness of a comprehensive CERP treatment among 8 women who met DSM-5 criteria for binge eating disorder. Changes in the number of binges were measured from baseline to the end of treatment, and desire to eat, salivation, and idiographic expectancies of aversive outcomes to food-cue exposure (idiographic CS-US expectancies), including expectancies about ability to tolerate distress when exposed to food cues were measured across the course of treatment. Statistical analysis revealed a significant reduction in the number of binges from baseline to the end of treatment. Across the course of treatment, desire to eat and idiographic CS-US expectancies reduced, and distress tolerance expectancies increased. No participants dropped out and all reported being maximally satisfied with the treatment. Based on these findings, future randomized-control trials with larger samples should examine the efficacy of CERP and mechanisms underlying change with the aim of establishing a more effective treatment for binge eating disorder.     

Exploring Mechanisms of Action in Exposure-Based Cognitive Behavioral Therapy for Eating Disorders: The Role of Eating-Related Fears and Body-Related Safety Behaviors

Evidence-based cognitive behavioral therapy for eating disorders includes a component of exposure therapy, which involves patients confronting feared eating and body-related stimuli while preventing safety behaviors. With recent research demonstrating that eating-related fears and safety behaviors are central to eating disorder pathology, there is increased emphasis on improving the efficacy of exposure therapy in eating disorders. Doing so will require a better understanding of important mechanisms of action in this treatment. The present study explored how changes during treatment in eating-related fears and avoidance as well as body-related safety behaviors influence overall treatment outcomes. Individuals with eating disorders (N = 71) receiving exposure-based treatment completed measures of global eating disorder severity at admission and discharge. Hypothesized mechanisms of action were also assessed at admission and discharge as well as at a 2-week time point after beginning treatment. Path modeling analyses showed that decreased eating-related cognitions (feared concerns about eating) and emotions (anxiety about eating) at the 2-week time point were prospectively predictive of lowered global eating disorder symptom severity at discharge. Additionally, reduced body checking and avoidance behaviors after 2 weeks of treatment were also associated with lower eating disorder severity at discharge. These findings highlight the importance of exposure-based therapy in eating disorders and the need to uniquely address eating-related fears and safety behaviors.     

Evidence for an encounter expectancy bias in fear of spiders

Whereas research has demonstrated that phobic or fearful individuals overestimate the likelihood of incurring aversive consequences from an encounter with feared stimuli, it has not yet been systematically investigated whether these individuals also overestimate the likelihood (i.e., the frequency) of such encounters. In the current study, spider-fearful and control participants were presented with background information that allowed them to estimate the overall likelihood that different kinds of animals (spiders, snakes, or birds) would be encountered. Spider-fearful participants systematically overestimated the likelihood of encountering a spider with respect to the likelihood of encountering a snake or a bird. No such expectancy bias was observed in control participants. The results thus strengthen our idea that there indeed exist two different types of expectancy bias in high fear and phobia that can be related to different components of the fear response. A conscientious distinction and examination of these two types of expectancy bias are of potential interest for therapeutic applications.     

Evidence for an encounter expectancy bias in fear of spiders

Whereas research has demonstrated that phobic or fearful individuals overestimate the likelihood of incurring aversive consequences from an encounter with feared stimuli, it has not yet been systematically investigated whether these individuals also overestimate the likelihood (i.e., the frequency) of such encounters. In the current study, spider-fearful and control participants were presented with background information that allowed them to estimate the overall likelihood that different kinds of animals (spiders, snakes, or birds) would be encountered. Spider-fearful participants systematically overestimated the likelihood of encountering a spider with respect to the likelihood of encountering a snake or a bird. No such expectancy bias was observed in control participants. The results thus strengthen our idea that there indeed exist two different types of expectancy bias in high fear and phobia that can be related to different components of the fear response. A conscientious distinction and examination of these two types of expectancy bias are of potential interest for therapeutic applications.     

Treatment of covert food stealing in an individual with Prader-Willi syndrome

Covert food stealing is common among individuals with Prader-Willi syndrome. We found that verbal reprimands, delivered contingent upon eating prohibited foods, were sufficient to decrease the food stealing of a girl with Prader-Willi syndrome. Warning stimuli were then used to help her discriminate between permitted and prohibited foods during sessions in which food stealing was not directly observed. This procedure resulted in decreases in food stealing from containers labeled with the warning stimuli.     

Social facilitation of eating novel food in tufted capuchin monkeys (Cebus apella): input provided by group members and responses affected in the observer

Learning about food palatability from watching what conspecifics eat might be one of the advantages of group living. A previous study investigated whether group members' presence or eating activity account for social facilitation of eating of foods never previously tasted. Capuchins encountered novel colored foods when (1) alone (Alone condition) or (2) with group members visible in the nearby cage (Group-present condition) or (3) with group members present and eating a familiar food that had not been colored (Group+food condition). Social facilitation of eating occurred when group members were eating, despite the difference in color between the familiar food eaten by them and the novel food presented to the experimental subject. To clarify what subjects learnt from group members when social facilitation occurred, we further analyze here the data from the previous study. The number of visual exposures to the colored novel food (as a group member) correlated with increased consumption of that novel food when encountered later (as experimental subject). In contrast, the number of times that an individual fed on the familiar food (as a group member) did not decrease its consumption of novel food (as experimental subject). Therefore, capuchins (1) habituated to the colors of the novel foods, and (2) did not take into account that seeing group members eating a food does not provide information about the palatability of a differently colored food. Since social facilitation of eating occurs when foods do not match in color, at least in capuchins, social facilitation of eating should not be considered as a way of learning about a safe diet, but rather as a way of overcoming neophobia. Accepted after revision: 18 August 2001 Electronic Publication     

情绪对饮食行为的影响

人类的饮食行为受到诸多因素的影响, 包括生理因素、心理因素及社会文化因素等, 其中情绪对饮食行为的影响日益受到研究者的重视, 这种影响一般表现为摄入量的多少和食物(热量)的选择。通过探讨不同情绪下临床和非临床个体食物摄入量的表现, 总结发现消极情绪导致个体暴饮暴食的可能更大。积极情绪影响下的饮食行为的研究结果则存在分歧: 生理角度解释为积极情绪能够促进个体的享乐机制, 导致进食行为增加; 而自我控制理论则认为积极情绪增加了个人资源以抵制美食诱惑。此外, 进一步探讨了情绪影响下饮食行为的神经生理机制。未来在饮食相关的临床研究和治疗上, 需要对情绪影响下的饮食行为有更深入的神经机制方面的探究。     

Heart Rate Reactivity in HAD and LAD Rats during Pavlovian Fear Conditioning

Recently, we reported that High-Alcohol-Drinking (HAD) rats exhibited selective deficits in active avoidance learning under alcohol-naive conditions, and that administration of moderate doses of alcohol (0.5 and 1.0 g/kg) facilitated learning in these rats (Blankenship et al., 2000; Rorick et al., 2003b). We hypothesized that the deficits resulted from excessive fear in the aversive learning context and that the anxiolytic properties of alcohol may have contributed to the improved learning that was observed after alcohol administration. This hypothesis was supported by a recent study in which prolonged freezing in HAD rats was seen after a classical fear conditioning procedure (Rorick et al., 2003a). To provide additional evidence that HAD rats indeed exhibit behaviors consistent with the expression of increased fear in aversive learning contexts, we employed a Pavlovian fear conditioning task to measure heart rate in HAD and Low-Alcohol-Drinking (LAD) rats. In this study, HAD (HAD-1 and HAD-2) and LAD (LAD-1 and LAD-2) rats were assigned to one of three pre-exposure conditions: Context Only, Context/Tone, or Sequential (Context Only followed by Context/Tone) Pre-Exposure. Following pre-exposure, fear conditioning acquisition and extinction procedures were identical for all groups. Results indicated that although no baseline differences were observed between HAD and LAD rats, HAD rats receiving Context-Only pre-exposure exhibited excessive heart rate reactivity to the tone conditional stimulus during fear conditioning acquisition, compared to LAD rats receiving the same pre-exposure conditions. These findings support the hypothesis that HAD rats exhibit behaviors consistent with increased fear in aversive learning contexts, as measured by autonomic conditioning.     

Heart rate reactivity in HAD and LAD rats during Pavlovian fear conditioning

Recently, we reported that High-Alcohol-Drinking (HAD) rats exhibited selective deficits in active avoidance learning under alcohol-naive conditions, and that administration of moderate doses of alcohol (0.5 and 1.0 g/kg) facilitated learning in these rats (Blankenship et al., 2000; Rorick et al., 2003b). We hypothesized that the deficits resulted from excessive fear in the aversive learning context and that the anxiolytic properties of alcohol may have contributed to the improved learning that was observed after alcohol administration. This hypothesis was supported by a recent study in which prolonged freezing in HAD rats was seen after a classical fear conditioning procedure (Rorick et al., 2003a). To provide additional evidence that HAD rats indeed exhibit behaviors consistent with the expression of increased fear in aversive learning contexts, we employed a Pavlovian fear conditioning task to measure heart rate in HAD and Low-Alcohol-Drinking (LAD) rats. In this study, HAD (HAD-1 and HAD-2) and LAD (LAD-1 and LAD-2) rats were assigned to one of three pre-exposure conditions: Context Only, Context/Tone, or Sequential (Context Only followed by Context/Tone) Pre-Exposure. Following pre-exposure, fear conditioning acquisition and extinction procedures were identical for all groups. Results indicated that although no baseline differences were observed between HAD and LAD rats, HAD rats receiving Context-Only pre-exposure exhibited excessive heart rate reactivity to the tone conditional stimulus during fear conditioning acquisition, compared to LAD rats receiving the same pre-exposure conditions. These findings support the hypothesis that HAD rats exhibit behaviors consistent with increased fear in aversive learning contexts, as measured by autonomic conditioning.     

Flooding therapy: Effectiveness,stimulus characteristics,and the value of brief in vivo exposure

Three analogue experiments examined flooding therapy. Experiment 1 showed that flooding was more effective than standardized desensitization in reducing snake phobia. Experiment 2 examined three different modes of presenting the feared stimuli in flooding: taped auditory presentation, pictorial presentation, and a combination of these two. An additional combination group were given a brief in vivo exposure to the feared object immediately after each of three treatment sessions. Both a behavioral test and subjective estimates of fear showed advantages for the combined group that had the in vivo exposure, although it appeared that auditory instructions to imagine interaction with the snake was the best method for presenting the feared stimuli. Experiment 3 compared the auditory imagined method with and without ‘aversive’ or ‘implosive’ scenes, and with either an immediate or a delayed in vivo exposure. The only procedure to produce marked effects was the one that omitted ‘aversive’ scenes and provided immediate post-treatment in vivo exposure.     

Linking Pavlovian Disgust Conditioning and Eating Disorder Symptoms: An Analogue Study

Although the experience of disgust is commonly endorsed among women with eating disorders, it remains unclear how to best model this emotion in relation to disordered eating. The present study sought to identify potential disgust conditioning abnormalities that may underlie the development of eating disorder symptoms. Individuals high and low in eating disorder symptoms (HED, n = 19; LED, n = 18) completed a Pavlovian conditioning procedure in which one neutral food item (conditioned stimulus; CS +) was followed by disgusting videos of individuals vomiting (unconditioned stimulus; US) and another neutral food item (CS–) was not reinforced with the disgusting video. Following this acquisition procedure, there was an extinction procedure in which both CSs were presented unreinforced. The results showed that ratings of disgust, fear, and willingness to eat the CS + and CS- did not significantly vary as a function of the conditioning phase for the LED group. However, the HED group rated the CS + as significantly more disgusting and fear inducing than the CS- after the acquisition phase and this pattern persisted after extinction. These conditioning effects were also observed to be significantly larger for disgust compared to fear. The HED group also reported being significantly less willing to eat the CS + compared to the CS- after the acquisition phase and this pattern also persisted after extinction. In the full sample, only discriminant disgust responding after acquisition was associated with the amount of calorie consumption over the 24-hour period after conditioning. These findings suggest that eating disorder symptoms may result from a heightened proneness to associate disgusting outcomes with otherwise neutral food items. This pattern of disgust learning may reinforce food avoidance in eating disorders and appears to be difficult to fully unlearn.     

Fear Develops to the Conditioned Stimulus and to the Context during Classical Eyeblink Conditioning in Rats

In classical eyeblink conditioning, non-specific emotional responses to the aversive shock unconditioned stimulus (US), which are presumed to coincide with the development of fear, occur early in conditioning and precede the emergence of eyeblink responses. This two-process learning model was examined by concurrently measuring fear and eyeblink conditioning in the freely moving rat. Freezing served as an index of fear in animals and was measured during the inter-trial intervals in the training context and during a tone conditioned stimulus (CS) presented in a novel context. Animals that received CS-US pairings exhibited elevated levels of fear to the context and CS early in training that decreased over sessions, while eyeblink conditioned responses (CRs) developed gradually during acquisition and decreased during extinction. Random CS-US presentations produced a similar pattern of fear responses to the context and CS as paired presentations despite low eyeblink CR percentages, indicating that fear responding was decreased independent of high levels of learned eyeblink responding. The results of paired training were consistent with two-process models of conditioning that postulate that early emotional responding facilitates subsequent motor learning, but measures from random control animals demonstrate that partial CS-US contingencies produce decrements in fear despite low levels of eyeblink CRs. These findings suggest a relationship between CS-US contingency and fear levels during eyeblink conditioning, and may serve to clarify further the role that fear conditioning plays in this simple paradigm.     

Fear develops to the conditioned stimulus and to the context during classical eyeblink conditioning in rats

In classical eyeblink conditioning, non-specific emotional responses to the aversive shock unconditioned stimulus (US), which are presumed to coincide with the development of fear, occur early in conditioning and precede the emergence of eyeblink responses. This twoprocess learning model was examined by concurrently measuring fear and eyeblink conditioning in the freely moving rat. Freezing served as an index of fear in animals and was measured during the inter-trial intervals in the training context and during a tone conditioned stimulus (CS) presented in a novel context. Animals that received CS-US pairings exhibited elevated levels of fear to the context and CS early in training that decreased over sessions, while eyeblink conditioned responses (CRs) developed gradually during acquisition and decreased during extinction. Random CS-US presentations produced a similar pattern of fear responses to the context and CS as paired presentations despite low eyeblink CR percentages, indicating that fear responding was decreased independent of high levels of learned eyeblink responding The results of paired training were consistent with two-process models of conditioning that postulate that early emotional responding facilitates subsequent motor learning, but measures from random control animals demonstrate that partial CS-US contingencies produce decrements in fear despite low levels of eyeblink CRs. These findings suggest, a relationship between CS-US contingency and fear levels during eyeblink conditioning, and may serve to clarify further the role that fear conditioning plays in this simple paradigm.