Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-18T06:43:34.708Z Has data issue: false hasContentIssue false
  • English
  • Français

Targeting habits in anorexia nervosa: a proof-of-concept randomized trial

Published online by Cambridge University Press:  19 February 2018

Joanna E. Steinglass ,
Deborah R. Glasofer ,
Emily Walsh ,
Gabby Guzman ,
Carol B. Peterson ,
B. Timothy Walsh ,
Evelyn Attia  and
Stephen A. Wonderlich
Joanna E. Steinglass*
Affiliation:
Department of Psychiatry, Center for Eating Disorders, New York State Psychiatric Institute, Columbia University Medical Center
Deborah R. Glasofer
Affiliation:
Department of Psychiatry, Center for Eating Disorders, New York State Psychiatric Institute, Columbia University Medical Center
Emily Walsh
Affiliation:
Department of Psychiatry, Center for Eating Disorders, New York State Psychiatric Institute, Columbia University Medical Center
Gabby Guzman
Affiliation:
Rutgers Graduate School of Applied and Professional Psychology
Carol B. Peterson
Affiliation:
Department of Psychiatry, University of Minnesota
B. Timothy Walsh
Affiliation:
Department of Psychiatry, Center for Eating Disorders, New York State Psychiatric Institute, Columbia University Medical Center
Evelyn Attia
Affiliation:
Department of Psychiatry, Center for Eating Disorders, New York State Psychiatric Institute, Columbia University Medical Center Department of Psychiatry, Weill Cornell Medical College
Stephen A. Wonderlich
Affiliation:
Neuropsychiatric Research Institute/Department of Psychiatry and Behavioral Science University of North Dakota School of Medicine and Health Sciences
*
Author for correspondence: Dr. Joanna Steinglass, E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Habits are behavioral routines that are automatic and frequent, relatively independent of any desired outcome, and have potent antecedent cues. Among individuals with anorexia nervosa (AN), behaviors that promote the starved state appear habitual, and this is the foundation of a recent neurobiological model of AN. In this proof-of-concept study, we tested the habit model of AN by examining the impact of an intervention focused on antecedent cues for eating disorder routines.

Methods

The primary intervention target was habit strength; we also measured clinical impact via eating disorder psychopathology and actual eating. Twenty-two hospitalized patients with AN were randomly assigned to 12 sessions of either Supportive Psychotherapy or a behavioral intervention aimed at cues for maladaptive behavioral routines, Regulating Emotions and Changing Habits (REaCH).

Results

Covarying for baseline, REaCH was associated with a significantly lower Self-Report Habit Index (SRHI) score and significantly lower Eating Disorder Examination-Questionnaire (EDE-Q) global score at the end-of-treatment. The end-of-treatment effect size for SRHI was d = 1.28, for EDE-Q was d = 0.81, and for caloric intake was d = 1.16.

Conclusions

REaCH changed habit strength of maladaptive routines more than an active control therapy, and targeting habit strength yielded improvement in clinically meaningful measures. These findings support a habit-based model of AN, and suggest habit strength as a mechanism-based target for intervention.

Keywords

Anorexia nervosaeating disorderhabithabit reversaloutcomessupportive psychotherapytreatment.
Type
Original Articles
Information
Psychological Medicine , Volume 48 , Issue 15 , November 2018 , pp. 2584 - 2591
Copyright
Copyright © Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

*

These authors contributed equally to this work.

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington, VA: American Psychiatric Publishing.Google Scholar
Arcelus, J, Mitchell, AJ, Wales, J, and Nielsen, S (2011) Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry 68, 724–731.Google Scholar
Attia, E and Walsh, BT (2009) Behavioral management for anorexia nervosa. New England Journal of Medicine 360, 500–506.Google Scholar
Balleine, BW and O'doherty, JP (2010) Human and rodent homologies in action control: corticostriatal determinants of goal-directed and habitual action. Neuropsychopharmacology 35, 48–69.Google Scholar
Barlow, DH (ed.) 2008. Clinical Handbook of Psychological Disorders. New York, NY: Guilford Press.Google Scholar
Beck, AT, Rush, AJ, Shaw, BR, and Emery, G (1979) Cognitive Therapy for Depression. New York, Guilford Press.Google Scholar
Beck, AT and Steer, RA (1993) Depression Inventory Manual. San Antonio, TX, Psychological Corporation, Harcourt, Brace.Google Scholar
Brostrom, A, Nilsen, P, Gardner, B, Johansson, P, Ulander, M, Fridlund, B et al. (2014) Validation of the CPAP habit index-5: a tool to understand adherence to CPAP treatment in patients with obstructive sleep apnea. Sleep Disorders 2014, Article 929057, 9 pages, 2014.Google Scholar
Cohen, J (1998) Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum.Google Scholar
Coniglio, KA, Becker, KR, Franko, DL, Zayas, LV, Plessow, F, Eddy, KT et al. (2017) Won't stop or can't stop? Food restriction as a habitual behavior among individuals with anorexia nervosa or atypical anorexia nervosa. Eating Behaviors 26, 144–147.Google Scholar
Curran-Everett, D and Williams, CL (2015) Explorations in statistics: the analysis of change. Advances in Physiology Education 39, 49–54.Google Scholar
Danner, UN, Aarts, H, and De Vries, NK (2008) Habit v. intention in the prediction of future behaviour: the role of frequency, context stability and mental accessibility of past behaviour. British Journal of Social Psychology 47, 245–265.Google Scholar
Deckersbach, T, Rauch, S, Buhlmann, U, and Wilhelm, S (2006) Habit reversal v. supportive psychotherapy in Tourette's disorder: a randomized controlled trial and predictors of treatment response. Behaviour Research and Therapy 44, 1079–1090.Google Scholar
Engel, SG, Wonderlich, SA, Crosby, RD, Mitchell, JE, Crow, S, Peterson, CB et al. (2013) The role of affect in the maintenance of anorexia nervosa: evidence from a naturalistic assessment of momentary behaviors and emotion. Journal of Abnormal Psychology 122, 709–719.Google Scholar
Fairburn, CG (2008) Cognitive Behavior Therapy and Eating Disorders. New York, Guilford Press.Google Scholar
Fairburn, CG, Marcus, MD, and Wilson, GT (1993) Cognitive-Behavioral therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In Fairburn, CG, Wilson, GT (eds). Binge Eating: Nature, Assessment, and Treatment. New York: The Guilford Press, pp. 361–404.Google Scholar
Fichter, MM and Quadflieg, N (2016) Mortality in eating disorders – results of a large prospective clinical longitudinal study. International Journal of Eating Disorders 49, 391–401.Google Scholar
First, M, Spitzer, RL, Gibbon, M, and Williams, JB (2002) Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version. New York: Biometrics Research, New York State Psychiatric Institute.Google Scholar
Foerde, K and Steinglass, JE (2017) Decreased feedback learning in anorexia nervosa persists after weight restoration. International Journal of Eating Disorders 50, 415–423.Google Scholar
Foerde, K, Steinglass, JE, Shohamy, D, and Walsh, BT (2015) Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nature Neuroscience 18, 1571–1573.Google Scholar
Gardner, B (2015) A review and analysis of the use of ‘habit’ in understanding, predicting and influencing health-related behaviour. Health Psychology Review 9, 277–295.Google Scholar
Gardner, B, De Bruijn, GJ, and Lally, P (2011) A systematic review and meta-analysis of applications of the self-report habit index to nutrition and physical activity behaviours. Annals of Behavioral Medicine 42, 174–187.Google Scholar
Gardner, B, De Bruijn, GJ, and Lally, P (2012) Habit, identity, and repetitive action: a prospective study of binge-drinking in UK students. British Journal of Health Psychology 17, 565–581.Google Scholar
Gianini, L, Liu, Y, Wang, Y, Attia, E, Walsh, BT, and Steinglass, J (2015) Abnormal eating behavior in video-recorded meals in anorexia nervosa. Eating Behaviors 19, 28–32.Google Scholar
Gillan, CM, Kosinski, M, Whelan, R, Phelps, EA, and Daw, ND (2016) Characterizing a psychiatric symptom dimension related to deficits in goal-directed control. Elife 5, e11305.Google Scholar
Gillan, CM, Papmeyer, M, Morein-Zamir, S, Sahakian, BJ, Fineberg, NA, Robbins, TW et al. (2011) Disruption in the balance between goal-directed behavior and habit learning in obsessive-compulsive disorder. American Journal of Psychiatry 168, 718–726.Google Scholar
Godier, LR, De Wit, S, Pinto, A, Steinglass, JE, Greene, AL, Scaife, J et al. (2016) An investigation of habit learning in anorexia nervosa. Psychiatry Research, 244, 214–222.Google Scholar
Gratz, KL and Roemer, L (2004) Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment 26, 41–54.Google Scholar
Graybiel, AM (2008) Habits, rituals, and the evaluative brain. Annual Review of Neuroscience 31, 359–387.Google Scholar
Haynos, AF, Roberto, CA, Martinez, MA, Attia, E and Fruzzetti, AE (2014) Emotion regulation difficulties in anorexia nervosa before and after inpatient weight restoration. International Journal of Eating Disorders 47, 888–891.Google Scholar
Kremers, SP and Brug, J (2008) Habit strength of physical activity and sedentary behavior among children and adolescents. Pediatric Exercise Science 20, 5–14, discussion 14–7.Google Scholar
Lally, P, Chipperfield, A, and Wardle, J (2008) Healthy habits: efficacy of simple advice on weight control based on a habit-formation model. International Journal of Obesity 32, 700–707.Google Scholar
Landis, JR and Koch, GG (1977) The measurement of observer agreement for categorical data. Biometrics 33, 159–174.Google Scholar
Lavender, JM, De Young, KP, Wonderlich, SA, Crosby, RD, Engel, SG, Mitchell, JE et al. (2013) Daily patterns of anxiety in anorexia nervosa: associations with eating disorder behaviors in the natural environment. Journal of Abnormal Psychology 122, 672–683.Google Scholar
Mansueto, CS, Golomb, RG, Thomas, AM, and Stemberger, RMT (1999) A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice 6, 23–43.Google Scholar
Marlatt, GA and Gordon, JR (1985) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, Guilford Press.Google Scholar
Mayer, LE, Schebendach, J, Bodell, LP, Shingleton, RM, and Walsh, BT (2012) Eating behavior in anorexia nervosa: before and after treatment. International Journal of Eating Disorders 45, 290–293.Google Scholar
Mcgowan, L, Cooke, LJ, Gardner, B, Beeken, RJ, Croker, H, and Wardle, J (2013) Healthy feeding habits: efficacy results from a cluster-randomized, controlled exploratory trial of a novel, habit-based intervention with parents. American Journal of Clinical Nutrition 98, 769–777.Google Scholar
Mcintosh, VV, Jordan, J, Carter, FA, Luty, SE, Mckenzie, JM, Bulik, CM et al. (2005) Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal of Psychiatry 162, 741–747.Google Scholar
Metropolitan Life Insurance (1959) New weight standards for men and women. Statistical Bulletin 40, 1–4.Google Scholar
Miles, J and Shevlin, M (2001) Applying Regression and Correlation: A Guide for Students and Researchers. London: Sage.Google Scholar
Orbell, S and Verplanken, B (2010) The automatic component of habit in health behavior: habit as cue-contingent automaticity. Health Psychology 29, 374–383.Google Scholar
Pike, KM, Carter, JC, and Olmsted, MP (2010) Cognitive-behavioral therapy for anorexia nervosa. In Grilo, CM, Mitchell, JE (eds). The Treatment of Eating Disorders: A Clinical Handbook. New York: Guilford Press, pp. 83–107.Google Scholar
Racine, SE, and Wildes, JE (2013) Emotion dysregulation and symptoms of anorexia nervosa: the unique roles of lack of emotional awareness and impulse control difficulties when upset. International Journal of Eating Disorders 46, 713–720.Google Scholar
Robbins, TW, Gillan, CM, Smith, DG, De Wit, S, and Ersche, KD (2012) Neurocognitive endophenotypes of impulsivity and compulsivity: towards dimensional psychiatry. Trends in Cognitive Science 16, 81–91.Google Scholar
Schebendach, JE, Mayer, LE, Devlin, MJ, Attia, E, Contento, IR, Wolf, RL et al. (2008) Dietary energy density and diet variety as predictors of outcome in anorexia nervosa. American Journal of Clinical Nutrition 87, 810–816.Google Scholar
Skinner, BF (1938) The Behavior of Organisms: An Experimental Analysis. New York, Appleton-Century.Google Scholar
Spielberger, CD, Gorsuch, RL, Lushene, R, Vagg, PR, and Jacobs, AG (1983) Manual for the State-Trait Anxiety Inventory. Palo Alto, Consulting Psychologists Press, Inc.Google Scholar
Steinglass, JE, Glasofer, DR, Walsh, E, Peterson, C, Walsh, BT, Attia, E et al. (2017) Targeting Habits in Anorexia Nervosa: A Pilot Randomized, Controlled Trial. Eating Disorders Research Society, Leipzig, Germany.Google Scholar
Steinglass, JE and Guzman, G (2015) Laboratory meal assessment. In Wade, T (ed). Encyclopedia of Feeding and Eating Disorders. Singapore: Springer Science + Business Media. doi: 10.1007/978-981-287-087-2_13-1.Google Scholar
Steinglass, JE and Walsh, BT (2016) Neurobiological model of the persistence of anorexia nervosa. Journal of Eating Disorders 4, 19.Google Scholar
Steinhausen, HC (2002) The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry 159, 1284–1293.Google Scholar
Sysko, R, Glasofer, DR, Hildebrandt, T, Klimek, P, Mitchell, JE, Berg, KC et al. (2015) The eating disorder assessment for DSM-5 (EDA-5): development and validation of a structured interview for feeding and eating disorders. International Journal of Eating Disorders 48, 452–463.Google Scholar
Tappe, K, Tarves, E, Oltarzewski, J, and Frum, D (2013) Habit formation among regular exercisers at fitness centers: an exploratory study. Journal of Physical Activity and Health 10, 607–613.Google Scholar
Teng, EJ, Woods, DW, and Twohig, MP (2006) Habit reversal as a treatment for chronic skin picking: a pilot investigation. Behavior Modification 30, 411–422.Google Scholar
Verplanken, B and Orbell, S (2003) Reflections on past behavior: a self-report index of habit strength. Journal of Applied Social Psychology 33, 1313–1330.Google Scholar
Vickers, AJ and Altman, DG (2001) Statistics notes: analysing controlled trials with baseline and follow up measurements. BMJ 323, 1123–1124.Google Scholar
Voon, V, Derbyshire, K, Ruck, C, Irvine, MA, Worbe, Y, Enander, J et al. (2014) Disorders of compulsivity: a common bias towards learning habits. Molecular Psychiatry 20, 345–352.Google Scholar
Walsh, BT (2013) The enigmatic persistence of anorexia nervosa. American Journal of Psychiatry 170, 477–484.Google Scholar
Winston, A, Pinsker, H, and Mccullough, L (1986) A review of supportive psychotherapy. Psychiatric Services 37, 1105–1114.Google Scholar
Wonderlich, SA, Peterson, CB, Smith, TL, Klein, MH, Mitchell, JE, and Crow, S (2015) Integrative Cognitive-Affective Therapy for Bulimia Nervosa: A Treatment Manual, New York, NY: Guilford Press.Google Scholar
Woods, DW, Piacentini, J, Chang, S, Deckersbach, T, Ginsburg, G, Peterson, A et al. (2008) Managing Tourette Syndrome: A Behavioral Intervention for Children and Adults. New York, NY, Oxford University Press.Google Scholar
Woods, DW, Wetterneck, CT, and Flessner, CA (2006) A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy 44, 639–656.Google Scholar
Supplementary material: File

Steinglass et al. supplementary material 1

Steinglass et al. supplementary material

Download Steinglass et al. supplementary material 1(File)
File 16 KB