Under heightened emotional states, individuals are more inclined to engage in ill-considered or rash actions than at other times. The authors present evidence for the existence of 2 related traits called positive and negative urgency. The traits refer to individual differences in the disposition to engage in rash action when experiencing extreme positive and negative affect, respectively. The authors provide evidence that these traits are distinct from other dispositions toward rash action and that they play distinct roles in predicting problem levels of involvement in behaviors such as alcohol consumption, binge eating, drug use, and risky sexual behavior. The authors identify facilitative conditions for the emergence of the urgency traits from neuroscience. Certain gene polymorphisms are associated with low levels of serotonin and high levels of dopamine; that pattern of neurotransmitter activity in a brain system linking the orbitofrontal cortex and the amygdala appears to facilitate the development of positive and negative urgency. The authors discuss the implications of this theory.

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Emotion-based dispositions to rash action: positive and negative urgency.

The affect regulation model of binge eating, which posits that patients binge eat to reduce negative affect (NA), has received support from cross-sectional and laboratory-based studies. Ecological momentary assessment (EMA) involves momentary ratings and repeated assessments over time and is ideally suited to identify temporal antecedents and consequences of binge eating. This meta-analytic review includes EMA studies of affect and binge eating. Electronic database and manual searches produced 36 EMA studies with N = 968 participants (89% Caucasian women). Meta-analyses examined changes in affect before and after binge eating using within-subjects standardized mean gain effect sizes (ESs). Results supported greater NA preceding binge eating relative to average affect (ES = 0.63) and affect before regular eating (ES = 0.68). However, NA increased further following binge episodes (ES = 0.50). Preliminary findings suggested that NA decreased following purging in bulimia nervosa (ES = -0.46). Moderators included diagnosis (with significantly greater elevations of NA prior to bingeing in binge eating disorder compared to bulimia nervosa) and binge definition (with significantly smaller elevations of NA before binge vs. regular eating episodes for the Diagnostic and Statistical Manual of Mental Disorders definition compared to lay definitions of binge eating). Overall, results fail to support the affect regulation model of binge eating and challenge reductions in NA as a maintenance factor for binge eating. However, limitations of this literature include unidimensional analyses of NA and inadequate examination of affect during binge eating, as binge eating may regulate only specific facets of affect or may reduce NA only during the episode.

Revisiting the Affect Regulation Model of Binge Eating: A Meta-Analysis of Studies using Ecological Momentary Assessment

Objective: The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed evidence on efficacy of treatment for anorexia nervosa (AN), harms associated with treatments, factors associated with treatment efficacy, and differential outcome by sociodemographic characteristics. Method: We searched six major databases for studies on the treatment of AN from 1980 to September 2005, in all languages against a priori inclusion/exclusion criteria focusing on eating, psychiatric or psychological, or biomarker outcomes. Results: Thirty-two treatment studies involved only medications, only behavioral interventions, and medication plus behavioral interventions for adults or adolescents. The literature on medication treatments and behavioral treatments for adults with AN is sparse and inconclusive. Cognitive behavioral therapy may reduce relapse risk for adults with AN after weight restoration, although its efficacy in the underweight state remains unknown. Variants of family therapy are efficacious in adolescents, but not in

/pdf/bulimia-nervosa-treatment-a-systematic-review-of-randomized-3yrhetqpf2.pdf

Bulimia nervosa treatment: A systematic review of randomized controlled trials

Background
Eating disorders are severe psychiatric disorders with a complex etiology involving transactions among sociocultural, psychological, and biological influences. Most research and reviews, however, focus on only one level of analysis. To address this gap, we provide a qualitative review and summary using an integrative biopsychosocial approach.

Methods
We selected variables for which there were available data using integrative methodologies (e.g., twin studies, gene-environment interactions) and/or data at the biological and behavioral level (e.g., neuroimaging). Factors that met these inclusion criteria were idealization of thinness, negative emotionality, perfectionism, negative urgency, inhibitory control, cognitive inflexibility, serotonin, dopamine, ovarian hormones. Literature searches were conducted using PubMed. Variables were classified as risk factors or correlates of eating disorder diagnoses and disordered eating symptoms using Kraemer et al.'s (1997) criteria.

Findings
Sociocultural idealization of thinness variables (media exposure, pressures for thinness, thin-ideal internalization, thinness expectancies) and personality traits (negative emotionality, perfectionism, negative urgency) attained ‘risk status’ for eating disorders and/or disordered eating symptoms. Other factors were identified as correlates of eating pathology or were not classified given limited data. Effect sizes for risk factors and correlates were generally small-to-moderate in magnitude.

Conclusions
Multiple biopsychosocial influences are implicated in eating disorders and/or disordered eating symptoms and several can now be considered established risk factors. Data suggest that psychological and environmental factors interact with and influence the expression of genetic risk to cause eating pathology. Additional studies that examine risk variables across multiple levels of analysis and that consider specific transactional processes amongst variables are needed to further elucidate the intersection of sociocultural, psychological, and biological influences on eating disorders.

Research Review: What we have learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research

BackgroundAnorexia nervosa is a potentially deadly psychiatric illness that develops predominantly in females around puberty but is increasingly being recognized as also affecting boys and men and women across the lifespan. The aim of this environmental scan is to provide an overview of best practices in anorexia nervosa treatment across the age spectrum.MethodA triangulation approach was used. First, a detailed review of randomized controlled trials (RCTs) for anorexia nervosa published between 1980 and 2011 was conducted; second, clinical practice guidelines were consulted and reviewed; third, information about RCTs currently underway was sourced. This approach facilitated a comprehensive overview, which addressed the extant evidence base, recent advances in evidence and improvements in treatment, and future directions.ResultsThe evidence base for the treatment of anorexia nervosa is advancing, albeit unevenly. Evidence points to the benefit of family-based treatment for youth. For adults no specific approach has shown superiority and, presently, a combination of renourishment and psychotherapy such as specialist supportive clinical management, cognitive behavioral therapy, or interpersonal psychotherapy is recommended. RCTs have neither sufficiently addressed the more complex treatment approaches seen in routine practice settings, such as multidisciplinary treatment or level of care, nor specifically investigated treatment in ethnically diverse populations. Methodological challenges that hinder progress in controlled research for anorexia nervosa are explained.ConclusionsThe review highlights evidence-based and promising treatment modalities for anorexia nervosa and presents a triangulated analysis including controlled research, practice guidelines, and emerging treatments to inform and support clinical decision making.

Update on the treatment of anorexia nervosa; review of clinical trials, practice guidelines and emerging interventions

One's expectancies for reinforcement from eating or from thinness are thought to represent summaries of one's eating-related learning history and to thus influence the development of binge-eating and purging behavior. In a 3-year longitudinal study, the authors tested this hypothesis and the hypothesis that binge eating also influences subsequent expectancy development. The authors used trajectory analysis to identify groups of middle school girls who followed different trajectories of binge eating, purging, eating expectancies, and thinness expectancies. Initial eating and thinness reinforcement expectancies identified girls whose binge eating and purging increased during middle school, and expectancies differentiated girls who began these problem behaviors from girls who did not. Initial binge-eating scores differentiated among eating expectancy developmental trajectories. The onset of most behaviors can be understood in terms of learned expectancies for reinforcement from these behaviors. The same model can be applied to the risk for eating disorders.

Thinness and eating expectancies predict subsequent binge-eating and purging behavior among adolescent girls.

Anorexia nervosa (AN) and bulimia nervosa (BN) are potentially fatal eating disorders which primarily affect adolescent females. Differentiating eating disorders from primary gastrointestinal (GI) disease may be difficult. GI disorders are common in eating disorder patients, symptomatic complaints being seen in over half. Moreover, many GI diseases sometimes resemble eating disorders. Inflammatory bowel disease, acid peptic diseases, and intestinal motility disorders such as achalasia may mimic eating disorders. However, it is usually possible to distinguish these by applying the diagnostic criteria for eating disorders and by obtaining common biochemical tests. The primary features of AN are profound weight loss due to self starvation and body image distortion; BN is characterized by binge eating and self purging of ingested food by vomiting or laxative abuse. GI complications in eating disorders are common. Recurrent emesis in BN is associated with dental abnormalities, parotid enlargement, and electrolyte disturbances including metabolic alkalosis. Hyperamylasemia of salivary origin is regularly seen, but may lead do an erroneous diagnosis of pancreatitis. Despite the weight loss often seen in eating disorders, serum albumin, cholesterol, and carotene are usually normal. However, serum levels of trace metals such as zinc and copper often are depressed, and hypophosphatemia can occur during refeeding. Patients with eating disorders frequently have gastric emptying abnormalities, causing bloating, postprandial fullness, and vomiting. This usually improves with refeeding, but sometimes treatment with pro-motility agents such as metoclopromide is necessary. Knowledge of the GI manifestations of eating disorders, and a high index of suspicion for one condition masquerading as the other, are required for the correct diagnosis and management of these patients.

Gastrointestinal and nutritional aspects of eating disorders

Objective

To demonstrate the validity of two measures of eating and dieting expectancies (The Eating Expectancy Inventory [EEI] and the Thinness and Restricting Expectancy Inventory, [TREI]) for use with adolescents.



Method

Seventh (N = 392) and tenth graders (N = 300) completed the Bulimia Test-Revised (BULIT-R), the Eating Disorder Inventory (EDI-II), and two factors of the Three-Factor Eating Questionnaire (TFEQ).



Results

Findings replicated for the two adolescent samples. The expectancy that thinness leads to overgeneralized life improvement correlated with measures of “successful” dieting, dieting plus disinhibition, and bulimic symptomatology. Expectancies for negative reinforcement from eating (e.g., eating helps manage negative affect and alleviate boredom) correlated with dieting plus disinhibition and bulimic symptoms, but not with successful dieting. Negative reinforcement from eating and reinforcement from thinness expectancies accounted for different bulimic symptom variance than that accounted for by the personality factors of perfectionism, interpersonal distrust, and ineffectiveness.



Discussion

Results were consistent with prior work on college and clinical samples, thus supporting use of the expectancy measures with adolescents. © 2002 by Wiley Periodicals, Inc. Int J Eat Disord 31: 461–473, 2002.

Validation of eating and dieting expectancy measures in two adolescent samples.

Objective: In anorexia nervosa (AN), medical stabilization and nutritional repletion are pivotal steps toward physical and psychological recovery. Nutritional stabilization is often difficult in this patient group. Recombinant human growth hormone (rhGH) has been safely used as adjuvant therapy in other groups of malnourished patients. We hypothesize that rhGH treatment will hasten medical stabilization in AN patients. Study Design: Fifteen patients admitted for inpatient treatment for AN, ages 12–18 years, were enrolled in a 28-day randomized, double-blind, placebo-controlled study. Patients received rhGH (0.05 mg/kg subcutaneously) or an equivalent volume of placebo daily. Outcome measures included time to reach medical/cardiovascular stability, rate of weight gain, and duration of hospitalization. All patients received a standard refeeding protocol. Results: Mean admission body mass index was 14.5 kg/m2. The rhGH and placebo groups did not differ significantly in admission weight, BMI or daily...

Pilot study of growth hormone administration during the refeeding of malnourished anorexia nervosa patients.

Anorexia nervosa (AN) can result in extreme malnutrition, and these patients frequently require inordinately large amounts of calories to gain weight during refeeding therapy. Insulin-like growth factor-I (IGF-I) is a polypeptide that mediates many of the anabolic effects of growth hormone. Low levels of IGF-I have been associated with malnutrition and can cause poor weight gain. To clarify the potential relationship of IGF-I to weight gain, serial serum IGF-I, retinol-binding protein and prealbumin levels were measured at admission, 2 weeks and 4 weeks, in 14 consecutive consenting patients admitted for treatment of AN. Baseline IGF-I levels were lower in the patients compared to age-matched controls (mean 20.8 +/− 2.5 vs 32.9 +/− 2.9 nmol/L, p < 0.01). In patients with no weight gain, IGF-I levels were static. There was a stepwise increment in the IGF-I values related to weight gain. Retinol-binding protein and prealbumin, proteins commonly used to assess nutritional status, did not demonstrate importan...

Kelly K. Hill

Papers

Thinness and eating expectancies predict subsequent binge-eating and purging behavior among adolescent girls.

Gastrointestinal and nutritional aspects of eating disorders

Validation of eating and dieting expectancy measures in two adolescent samples.

Pilot study of growth hormone administration during the refeeding of malnourished anorexia nervosa patients.

Serum insulin-like growth factor-I concentrations in the recovery of patients with anorexia nervosa.