Cheri Levinson Stephanie Zerwas Benjamin CALEBS Kelsie Forbush Hunna Watson Hans Kordy Sara Hofmeier Michele Levine Benjamin Zimmer Markus MOESSNER Christine Peat ID: 529621
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Identifying the Core Symptoms of Bulimia Nervosa and Associated Anxiety and Depression
Cheri Levinson, Stephanie Zerwas, Benjamin CALEBS, Kelsie Forbush, Hunna Watson, Hans Kordy, Sara Hofmeier, Michele Levine, Benjamin Zimmer, Markus MOESSNER, Christine Peat, Cristin Runfola, Marsha Marcus, Cynthia BulikSlide2
What is at the CORE OF BULIMIA NERVOSA?
Bulimia nervosa (BN) is characterized by symptoms of:binge eating and compensatory behavioroverevaluation of weight and shapeBN symptoms often co-occur with symptoms of anxiety and depressionWhich specific BN symptoms maintain BN psychopathology? How are these symptoms associated with symptoms of depression and anxiety?Fairburn, Cooper, &
Shafran, 2003; Palister & Waller, 2008Slide3
Models of Psychopathology
Latent variable theory often used to describe why mental disorders develop & persistSymptoms arise from a common causeBN is the
cause that leads to each of these common symptoms.
Bollen, 2002; Borsboom et al., 2016; Clark & Watson, 1991; Eaton, 2015; Haslam, Holland, & Kuppens, 2012BN
Fear of weight gain
Binge eating
Purging
Avoidance of foodSlide4
Network Theory
Network theory proposes that symptoms of disorders cause each otherSymptoms are part of a dynamic network which can produce, sustain, and underlie mental disorders These interact with each other to strengthen (or weaken) the disorder
Borsboom & Cramer, 2010; Borsboom & Cramer, 2013;
Kendler, Zachar, & Craver, 2011Fear of Weight Gain
Avoidance of food
Purging
Binge eatingSlide5
What can network analysis teach us?
Determine the symptoms that are central to the BN psychopathology network Examine how symptoms of comorbid disorders interact with symptoms of BNSlide6
Clinical Utility
Reducing core symptoms in treatment should theoretically also decrease related symptomsFocus interventions to target: core symptoms−symptoms play a crucial role in the networkcomorbid symptoms that link between multiple disorders
Hayes, Yasinski, Barnes, &
Bockting, 2015Slide7
Current study
Examined: A network of BN symptoms:Which symptoms are most central (i.e. core symptoms)? The networks of BN, depression, and anxiety symptoms:
Which depression and anxiety symptoms are most strongly related to BN symptoms?Slide8
Participants
196 patients recruited for a clinical trialAll patients had DSM-IV diagnosis of BNPrimarily female (n = 187; 95.4%)European American (n = 165; 84.2%)Majority had comorbid depression and/or anxiety (n = 136; 69.4%)Slide9
Measures
Eating Disorder ExaminationBinge eating, restriction, fears of fatnessShort Evaluation of Eating DisordersVomiting, purging, excessive exerciseBeck Anxiety InventoryScared, dizzinessBeck Depression Inventory-IISad, fatigue, self-dislikeBauer et al., 2005; Beck, Steer, & Brown, 1996; Fairburn & Cooper, 1993; Steer & Beck, 1997Slide10
Network analyses
Partial Correlation Networks (Glasso Estimator)Explains how symptoms relate while also considering the impact of all other symptomsBridge SymptomsSymptoms that link adjacent symptoms together and are theorized to be pathways that could causally connect symptoms or behaviorsCentrality MeasuresBetweenness – number of times symptom is passed throughCloseness
– closeness to other symptoms in the networkStrength – having many connections to other symptomsSlide11
Bulimia Nervosa Psychopathology Network
BN NetworkSlide12
**
weight preoccupation
**
**
**
Higher peaks on right side indicate higher centrality
**highest centrality items
BETWEENESS
CLOSENESS
STRENGTH
**
weight dissatisfaction
**
lose weight
**
fear weight gainSlide13
BN AND anxiety Network
Bulimia Nervosa
&
Anxiety NetworkSlide14
Higher peaks on right side indicate higher centrality
**highest centrality items
**
****
**
**
**
**
weight preoccupation
**
unsteady
**
terrified
**
shape dissatisfaction
**
fear weight gain
**
lose control
**
choking
**
avoid eating
BETWEENESS CLOSENESS STRENGTHSlide15
BN and depression network
Bulimia Nervosa
&
Depression NetworkSlide16
Higher peaks on right side indicate higher centrality
**highest centrality items
**
****
**
**
BETWEENESS CLOSENESS STRENGTH
**
weight preoccupation
**
fear weight gain
**sad
**irritable
**concentrateSlide17
CONCLUSIONS
Core BN symptomsfear of weight gain & overevaluation of weight and shapeBridge symptoms - connect anxiety or depression symptoms to BN Physical sensations: unsteady, fears of losing control, choking, difficulty concentrating may be bridge symptoms Slide18
Fear of weight gain
Fear of weight gain is central to BN networkBinge eating and purging on the peripheryTreatments that focus on fear of weight gain may have maximal impact Weekly weighingExposureSlide19
Physical Sensations
Physical sensations bridge BN & anxiety/depressionExaggerated insula response in eating disorders?Sensitivity to physical sensationsInteroceptive ExposuresKim et al., 2012; Fassino
, Pierò, Gramaglia, & Abbate-Daga, 2004;
Klabunde et al., 2013; Oberndorfer et al., 2013Slide20
Limitations
Data is cross-sectional – no causalityLimited measurement of each symptomApplying network analysis to psychopathology is newNo fit indicesNo measures of reliabilityLimited by measures and symptoms chosen for the networkSlide21
Future directions
Does change in a core symptom produce changes in other network symptoms?Do symptom networks become less strong after treatment and with symptom remission?Slide22
Acknowledgments & Disclosures
Dr. Bulik is a grant recipient and consultant for Shire Pharmaceuticals and has consulted for Ironshore. Dr. Marcus is on the Scientific Advisory Board of Weight Watchers International, Inc. Dr. Peat is recipient of a contract from RTI and Shire Pharmaceuticals and has consulted for Sunovion Pharmaceuticals, L.E.K consulting, and Nexus Global Solutions. Dr. Watson is supported by a research grant from Shire awarded to UNC-Chapel Hill. Dr. Zerwas has consulted for L.E.K consulting. This research was supported by a National Institute of Mental Health (NIMH) grant (R01MH080065), a Clinical Translational Science Award (UL1TR000083), and the Alexander von Humboldt-
Stiftung. Dr. Zerwas is supported by a NIMH career development grant (K01MH100435). Drs. Peat and Runfola were supported by a NIMH post-doctoral training grant (T32MH076694). Dr. Runfola was supported by the Global Foundation for Eating Disorders (PIs:
Bulik and Baucom; www.gfed.org). Benjamin Zimmer was supported by a Fellowship for Postdoctoral Researchers from the German Academic Exchange Service (DAAD). Dr. Bulik acknowledges support from the Swedish Research Council (VR Dnr: 538-2013-8864). We wish to honor the incredible contribution and legacy of our colleague Dr. Robert Hamer, who passed away in December 2015.