The Core Symptoms of Bulimia Nervosa, Anxiety, and Depression: A Network Analysis

Bulimia nervosa (BN) is characterized by symptoms of binge eating and compensatory behavior, and overevaluation of weight and shape, which often co-occur with symptoms of anxiety and depression. However, there is little research identifying which specific BN symptoms maintain BN psychopathology and how they are associated with symptoms of depression and anxiety. Network analyses represent an emerging method in psychopathology research to examine how symptoms interact and may become self-reinforcing. In the current study of adults with a Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM–IV) diagnosis of BN (N = 196), we used network analysis to identify the central symptoms of BN, as well as symptoms that may bridge the association between BN symptoms and anxiety and depression symptoms. Results showed that fear of weight gain was central to BN psychopathology, whereas binge eating, purging, and restriction were less central in the symptom network. Symptoms related to sensitivity to physical sensations (e.g., changes in appetite, feeling dizzy, and wobbly) were identified as bridge symptoms between BN, and anxiety and depressive symptoms. We discuss our findings with respect to cognitive–behavioral treatment approaches for BN. These findings suggest that treatments for BN should focus on fear of weight gain, perhaps through exposure therapies. Further, interventions focusing on exposure to physical sensations may also address BN psychopathology, as well as co-occurring anxiety and depressive symptoms.

[1]  K. Bollen.  Latent variables in psychology and the social sciences. , 2002, Annual review of psychology.

[2]  Janet B W Williams,et al.  Diagnostic and Statistical Manual of Mental Disorders , 2013 .

[3]  C. Meyer,et al.  What cognitive behavioral techniques do therapists report using when delivering cognitive behavioral therapy for the eating disorders? , 2012, Journal of consulting and clinical psychology.

[4]  C. Fairburn,et al.  The Eating Disorders Examination , 1993 .

[5]  P Kuppens,et al.  Categories versus dimensions in personality and psychopathology: a quantitative review of taxometric research , 2011, Psychological Medicine.

[6]  Verena D. Schmittmann,et al.  Qgraph: Network visualizations of relationships in psychometric data , 2012 .

[7]  L. Freeman.  Centrality in social networks conceptual clarification , 1978 .

[8]  C. Gramaglia,et al.  Clinical, Psychopathological and Personality Correlates of Interoceptive Awareness in Anorexia nervosa, Bulimia nervosa and Obesity , 2004, Psychopathology.

[9]  S. Bauer,et al.  Construction, scoring and validation of the Short Evaluation of Eating Disorders (SEED) , 2005 .

[10]  James F. Boswell,et al.  Anxiety sensitivity and interoceptive exposure: a transdiagnostic construct and change strategy. , 2013, Behavior therapy.

[11]  John Skvoretz,et al.  Node centrality in weighted networks: Generalizing degree and shortest paths , 2010, Soc. Networks.

[12]  E. Walker,et al.  Diagnostic and Statistical Manual of Mental Disorders , 2013 .

[13]  Cheri A Levinson,et al.  Addressing the fear of fat: extending imaginal exposure therapy for anxiety disorders to anorexia nervosa , 2014, Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity.

[14]  Daniel J. Brass,et al.  Network Analysis in the Social Sciences , 2009, Science.

[15]  J. Fudge,et al.  Altered insula response to sweet taste processing after recovery from anorexia and bulimia nervosa. , 2013, The American journal of psychiatry.

[16]  R. McNally,et al.  Can network analysis transform psychopathology? , 2016, Behaviour research and therapy.

[17]  K. Vitousek,et al.  Cognitive‐Behavioral Theory of Eating Disorders , 2015 .

[18]  J. Ku,et al.  Functional and effective connectivity of anterior insula in anorexia nervosa and bulimia nervosa , 2012, Neuroscience Letters.

[19]  L. Krames,et al.  The continuity of depression in clinical and nonclinical samples. , 1997, Psychological bulletin.

[20]  R. Tibshirani,et al.  Sparse inverse covariance estimation with the graphical lasso. , 2008, Biostatistics.

[21]  Edsger W. Dijkstra,et al.  A note on two problems in connexion with graphs , 1959, Numerische Mathematik.

[22]  R A Steer,et al.  Further Evidence for the Construct Validity of the Beck Depression Inventory-II with Psychiatric Outpatients , 1997, Psychological reports.

[23]  Cynthia S. Q. Siew,et al.  Application of network analysis to identify interactive systems of eating disorder psychopathology , 2016, Psychological Medicine.

[24]  J. Polivy.  Psychological consequences of food restriction. , 1996, Journal of the American Dietetic Association.

[25]  S. Daniels,et al.  An empirical study of the typology of bulimia nervosa and its spectrum variants , 2005, Psychological Medicine.

[26]  R. Tibshirani.  Regression Shrinkage and Selection via the Lasso , 1996 .

[27]  C. Bockting,et al.  Network destabilization and transition in depression: New methods for studying the dynamics of therapeutic change. , 2015, Clinical psychology review.

[28]  D. Watson,et al.  Tripartite model of anxiety and depression: psychometric evidence and taxonomic implications. , 1991, Journal of abnormal psychology.

[29]  P. Sullivan,et al.  The role of exposure with response prevention in the cognitive-behavioural therapy for bulimia nervosa , 1998, Psychological Medicine.

[30]  J. Prisciandaro,et al.  A comparison of the predictive abilities of dimensional and categorical models of unipolar depression in the National Comorbidity Survey , 2008, Psychological Medicine.

[31]  Gordon Jackson-Koku,et al.  Beck Depression Inventory. , 2016, Occupational medicine.

[32]  C. Fairburn,et al.  Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment. , 2003, Behaviour research and therapy.

[33]  A. Wells.  A cognitive model of social phobia , 1995 .

[34]  K. Forbush,et al.  Clinicians' practices regarding blind versus open weighing among patients with eating disorders. , 2015, The International journal of eating disorders.

[35]  D. Borsboom,et al.  What are 'good' depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis. , 2016, Journal of affective disorders.

[36]  S. Matthews,et al.  Interoceptive sensitivity deficits in women recovered from bulimia nervosa. , 2013, Eating behaviors.

[37]  Eiko I. Fried,et al.  Estimating Psychological Networks and their Stability: a Tutorial Paper , 2016 .

[38]  N. Eaton.  Latent variable and network models of comorbidity: toward an empirically derived nosology , 2015, Social Psychiatry and Psychiatric Epidemiology.

[39]  C. Fairburn.  Cognitive Behavior Therapy and Eating Disorders , 2008 .

[40]  D. Anderson,et al.  The efficacy of cognitive-behavioral therapy on the core symptoms of bulimia nervosa. , 2001, Clinical psychology review.

[41]  D. Borsboom,et al.  A review of psychometric approaches to uncover the structure of psychiatric constructs , 2016 .

[42]  Eiko I. Fried,et al.  Development of Indirect Measures of Conscientiousness: Combining a Facets Approach and Network Analysis , 2015 .

[43]  H. Kordy,et al.  CBT4BN versus CBTF2F: comparison of online versus face-to-face treatment for bulimia nervosa. , 2012, Contemporary clinical trials.

[44]  K. Kendler,et al.  What kinds of things are psychiatric disorders? , 2010, Psychological Medicine.

[45]  W. F. Mathes,et al.  The biology of binge eating , 2009, Appetite.

[46]  D. Borsboom,et al.  Network analysis: an integrative approach to the structure of psychopathology. , 2013, Annual review of clinical psychology.

[47]  C. Fairburn,et al.  The Eating Disorder Examination (12th edition). , 1993 .