Mealtime Eating Disorder Cognitions Predict Eating Disorder Behaviors: A Mobile Technology Based Ecological Momentary Assessment Study Cheri A. Levinson, Ph.D. Assistant Professor University of Louisville Department of Psychological & Brain Sciences Director, Eating Anxiety Treatment (EAT) Lab Cheri.Levinson@louisville.edu www.louisvilleeatlab.com

Disclosures I, Cheri Levinson, have no commercial relationships to disclose.

Anorexia Nervosa (AN) Background AN has highest mortality rate of any mental illness Many patients with AN treated in intensive treatment centers Goal of treatment is refeeding and weight stabilization After discharge from intensive treatment approximately 50% of patients relapse It is this RELAPSE AFTER STABILIZATION that leads to the chronicity, disability, and mortality of AN

Relapse after Intensive Treatment Constant exposure to food in treatment but… Learning from intensive treatment settings does not seem to occur or generalize to treatment in outpatient settings Why then such high rates of relapse? Patients should be learning (but aren’t) AN seems different from other common mental disorders (depression, anxiety) in this specific way Patients still struggle with disordered eating behaviors and low weight Most patients continue to struggle around food and mealtime What is happening around mealtime?

Which Cognitions & When? Mealtime should be the time of focus Fears of Weight Gain Core fear in the eating disorders Perfectionism May not learn because of fears of making mistakes Rumination May be engaging in cognitive rituals that interfere with learning Bulik et al., 2003; Curci, Lanciano, Soleti, & Rime, 2013; Fairburn, Cooper, & Shafran, 2003; Levinson et al. (2017). Journal of Abnormal Psychology

Do these cognitions predict later eating disorder behaviors? Are there self-perpetuating cycles between cognitions and behaviors? These could impair learning Identifying which cognitions lead to later behaviors may lead to personalized interventions Now how to measure cognitions???

Why a mobile application for eating disorder cognitions? Responses in daily life Hard to recruit populations Eating disorders Responses right after/during a meal Why aren’t patients learning?? What is happening during mealtime?? Kahneman et al., 2006; Schneider & Stone, 2015; Shiffman, Stone, & Hufford, 2008

Hypotheses There would be specific cognitions and behaviors that predict each other across ensuing mealtimes, representing a self-reinforcing cycle. These cognitions would predict subsequent higher anxiety (or alternatively lower anxiety if they serve an avoidance function) and higher eating disorder symptoms at one-month follow-up.

Participants N = 66 patients with eating disorders Most participants are female (n = 64; 97%) Most participants are European American (n = 56; 84.8%) Average age is 24.98 (SD = 7.31) Most participants primary diagnosis is AN (n = 54; 81.8%) Most have comorbid anxiety (n = 41;62.1%) or depression (n = 38; 57.6%) Most are currently in treatment (n = 49; 74.2%) On average 7.32 hours a week of treatment

Procedure Participants never set foot in the lab! Participants recruited from intensive treatment center All participants have diagnosis of an eating disorder Based on treatment team diagnosis, as well as Eating Disorder Diagnostic Inventory Participants complete self-report measures online Use status-post iphone application for one week 4 times a day 1 month later complete measures of eating disorder symptoms We used hierarchical linear models using cross-lag analyses

Status-Post

Status-Post

Cognitions Seven cognitions in three categories Worries about weight gain/feelings of fatness I felt worried about gaining weight during the meal I felt fat during the meal I am preoccupied with the desire to be thinner Perfectionistic thoughts I was concerned about making mistakes during the meal I had high standards for myself during the meal Rumination about the meal Once I started thinking about the meal, I couldn’t stop I had thoughts or images of the meal that I tried to resist thinking about.

Eating Disorder Behaviors Five eating disorder behaviors Restriction Weighing oneself Body checking Vomiting or other compensatory behavior Excessive exercise

Additional Measures Anxiety before, during, and after last meal Eating disorder symptoms (at one month follow up)

Hypothesis 1 There would be specific cognitions and behaviors that predict each other across ensuing mealtimes, representing a self-reinforcing cycle.

Mealtime Cognitions Predict Subsequent Eating Disorder Behaviors   Restriction Weighing oneself Body checking Compensatory behaviors Excessive exercise Fears of Weight gain/Feelings of Fatness Fear of wt gain ns .08* .04*+ Felt fat .14** .08** .06* Preoccupation with Thinness .14**+ Perfectionism thoughts Concern about mistakes .06*+ .11* .05* .07* High Standards .12* Rumination about Meal Couldn’t stop thinking .09* Thoughts or Images .13** ns = non-significant; + indicates a reciprocal relationship between cognition & behavior

Hypothesis 2 These cognitions would predict subsequent higher anxiety (or alternatively lower anxiety if they serve an avoidance function) and higher eating disorder symptoms at one-month follow-up.

Do these cognitions predict subsequent anxiety? Higher worry about feeling fat significantly predicted lower subsequent anxiety before a meal (b = -.12, SE = .05, p = .02). Higher worry about weight gain significantly predicted lower subsequent anxiety during a meal (b = -.10, SE = .05, p = .03). Higher preoccupation with thinness significantly predicted higher subsequent anxiety during a meal (b = .10, SE = .05, p = .05). Higher inability to stop thinking about the meal significantly predicted lower subsequent anxiety during a meal (b = -.15, SE = .07, p = .02). Higher thoughts or images about the meal significantly predicted higher subsequent anxiety during a meal (b = .13, SE = .06, p = .05).

Do these cognitions predict eating disorder symptoms at one month follow up?   Drive for thinness Bulimic symptoms Body dissatisfaction Fears of Weight gain/Feelings of Fatness Fear of wt gain .26* ns Felt fat .23* Preoccupation with Thinness Perfectionism thoughts Concern about mistakes .12* High Standards Rumination about Meal Couldn’t stop thinking Thoughts or Images .20*

Conclusions There were self-perpetuating cycles between mealtime cognitions & eating disorder behaviors Targeting cognitions while disrupting behaviors may decrease anxiety and eating disorder symptoms across time When targeting high standards patient must also refrain from engaging in excessive exercise For non-self perpetuating cycles interventions to disrupt eating disorder behaviors should target specific, related cognition Targeting concern over mistakes may disrupt compensatory behaviors, body checking, and excessive exercise Mealtime cognitions predicted subsequent anxiety and eating disorder symptoms (at one month follow up) Targeting these cognitions may decrease high rates of relapse

Future Directions Develop personalized interventions for mealtime cognitions Using EMA can create a personalized network of symptoms Levinson et al., (2017) Journal of Abnormal Psychology

Future Directions Then use ecological momentary interventions to target specific cognitions and behaviors Can communicate to clinicians which symptoms to target for that specific individual

QUESTIONS? Contact: Cheri A. Levinson Clinical Treatment & cheri.levinson@louisville.edu Research Opportunities 502-852-7710 for Individuals with Eating www.louisvilleeatlab.com Disorders are Available!!