Direct experience while eating: Laboratory outcomes among individuals with eating disorders versus healthy controls

Eating Behaviors 27 (2017) 23–26

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Direct experience while eating: Laboratory outcomes among individuals with eating disorders versus healthy controls

MARK

Matilde Elicesa,b, Cristina Carmonaa,b, Vanessa Narváezc, Victoria Setoa, Ana Martin-Blancoa,b, Juan C. Pascuala,b,d, José Sorianoa,b, Joaquim Solera,b,d,⁎ a

Department of Psychiatry, Santa Creu i Sant Pau Hospital, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Spain c Department of Psychiatry, Hospital Universitari Mútua Terrassa, Barcelona, Spain d Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain b

A R T I C L E I N F O

A B S T R A C T

Keywords: Eating disorders Direct experience Analytical focus Experiential focus Mindfulness

Objective: To compare individuals with eating disorders (EDs) to healthy controls (HCs) to assess for differences in direct engagement in the eating process. Method: Participants (n = 58) were asked to eat an orange slice. To assess the degree of direct engagement with the eating process, participants were asked to write down 10 thoughts about the experience of eating the orange slice. Next, the participants were instructed to classify the main focus of each thought as either experiential (“direct experience”) or analytical (“thinking about”). A direct experience index (DEI) was computed by dividing the number of times that participants classified an experience as a “direct experience” (the numerator) by the total number of all observations (i.e., direct experience + thinking about). Participants also completed the Five Facet Mindfulness Questionnaire (FFMQ) and the Experiences Questionnaire (EQ) to assess mindfulness facets and decentering, respectively. Results: Compared to controls, participants in the EDs group presented significantly lower levels of direct experience during the eating task (EDs group: mean = 43.54, SD = 29.64; HCs group: mean = 66.17, SD = 22.23, p = 0.03). Participants in the EDs group also scored significantly lower on other mindfulness-related variables. Discussion: These findings suggest that engagement with the direct experience of eating is lower in individuals with EDs. Future research should investigate the role of mindfulness-based interventions to address direct experience while eating in individuals with EDs.

1. Introduction Current classifications of eating disorders (EDs) propose six different diagnostic categories (pica; rumination disorder; avoidant/restrictive food intake disorder; anorexia nervosa; bulimia nervosa; and binge eating disorder) and two unspecific categories (American Psychiatric Association, 2013). In general, however, EDs are characterized by behavioral alterations related to food intake such as bingeing, purging, and the pursuit of extreme thinness. Research suggests that individuals with EDs tend to use rumination as a cognitive strategy to regulate emotions (Aldao, NolenHoeksema, & Schweizer, 2010; Nolen-Hoeksema, Stice, Wade, & Bohon, 2007). Rumination has been defined as a sustained focus on negative emotions and the causes and consequences of these, without engaging in problem-solving (Aldao & Nolen-Hoeksema, 2010). When individuals

ruminate, an “analytical mode” is activated, meaning that the individual thinks about the experience and compares his/her current emotional state to a desired or ideal state (Teasdale, Segal, & Williams, 1995). The opposite of the analytical mode is the “mindful or direct experience mode”, in which the individual focuses—in an accepting manner—on any thoughts, feelings, and/or physical sensations that arise (Watkins & Teasdale, 2004). In a study involving individuals with EDs, Rawal, Williams, and Park (2011) manipulated the participants' experience processing mode prior to exposing them to a food-related stressor (participants were asked to imagine eating a large meal). In half of the sample, the analytical mode was activated by instructing the participants to “think about the causes, meaning, and consequences” of eating a large meal. In the other half of the sample, the mindful mode was activated by asking the participants to focus their attention on the eating experience.

⁎ Corresponding author at: Department of Psychiatry, Santa Creu i Sant Pau Hospital, Universitat Autònoma de Barcelona (UAB), Av. Sant Antoni Mª Claret 167, 08025 Barcelona, Spain. E-mail address: [email protected] (J. Soler).

http://dx.doi.org/10.1016/j.eatbeh.2017.10.002 Received 23 January 2017; Received in revised form 23 October 2017; Accepted 23 October 2017 1471-0153/ © 2017 Published by Elsevier Ltd.

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2.2.2. Mindfulness Mindfulness was evaluated by the Five Facets Mindfulness Questionnaire (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Cebolla et al., 2012), a 39-item scale that assesses 5 different mindfulness facets: observing (i.e., noticing external and internal experiences, such as body sensations, thoughts, or emotions); describing (i.e., labeling the internal experience); non-judging (i.e., taking a non-evaluative stance towards the present experience); acting with awareness (i.e., focusing on the present activity instead of behaving mechanically); and non-reactivity (i.e., allowing thoughts and feelings to come, without getting caught up in or carried away by these thoughts). In the Spanish version, these five facets have been shown to provide adequateto-good internal consistency, with alpha coefficients ranging from 0.75 to 0.91 (Cebolla et al., 2012). In our sample, the internal consistency was 0.85. The Experience Questionnaire (EQ) is an 11-item instrument that assess decentering, understood as the ability to observe one's thoughts and emotions as temporary events of the mind (Fresco et al., 2007). The EQ items are scored on a 5-point scale, ranging from “never” to “all the time”. The Spanish version of the EQ (Soler et al., 2014) has demonstrated good psychometric properties. Internal consistency in our sample was 0.83.

Afterwards, participants in the mindful mode group more accurately estimated their own weight compared to those in the analytical group (Rawal et al., 2011). Another study (Soler et al., 2013) explored the relationship between the analytical and mindful processing modes and EDs symptom severity. In that study, individuals with an ED diagnosis were instructed to peel and eat an orange slice and to write down ten thoughts about that experience. Participants were then given a brief written explanation regarding the differences between the two processing modes and instructed to classify each of their 10 thoughts as either analytical or mindful. Activation of the mindful mode was negatively associated with ED and anxiety symptomatology (Soler et al., 2013). However, because that study lacked a control group, it remains unclear whether activation of the analytical mode while eating is truly characteristic of individuals with EDs. In this context, the aim of the current study was to determine whether individuals with EDs differ significantly from healthy controls (HCs) in how they process an eating experience. 2. Method 2.1. Participants and procedures A total of 58 women participated in the study. The clinical group consisted of 31 individuals diagnosed with one of the following EDs according to DSM–IV–TR criteria (American Psychiatric Association, 2000): anorexia nervosa (n = 9), bulimia nervosa (n = 10), or an EDs not otherwise specified (EDNOS; n = 12). Individuals with EDs were recruited from the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain) while the HCs (n = 27) were recruited from advertisements placed around the hospital and at the university. The study was approved by the hospital clinical ethics committee and conducted according to the Declaration of Helsinki principles. Inclusion criteria for both groups were: 1) age ≥ 18 years and 2) written consent to participate in the study. Exclusion criteria were: 1) diagnosis of psychosis, substance abuse disorder, affective disorder, or mental disability according to DSM-IV-TR criteria, and/or 2) previous experience in mindfulness, meditation, or yoga practices. Individuals in the EDs group who presented current affective symptoms were allowed to participate provided they did not fulfill diagnostic criteria for an affective disorder. Diagnostic interviews were conducted by an experienced psychiatrist and half of these interviews were re-rated by another professional (100% inter-rater agreement). The study consisted of a single session in which participants first completed the two self-report mindfulness measures (the Five Facet Mindfulness Questionnaire [FFMQ] and the Experiences Questionnaire [EQ]) and then were instructed to peel and eat an orange slice. Afterwards, participants were asked to write down ten thoughts about the experience and to code these thoughts as either a “direct experience” (i.e., mindful mode) or “thinking about” (i.e., analytical mode). The detailed procedure is described elsewhere (Soler et al., 2013). Two external researchers (both masked to the participants' group [i.e., HCs vs. EDs]) also coded the participants' ten thoughts.

2.3. Data analyses The demographic and clinical characteristics of the sample were analyzed using the chi-square test for categorical variables and the t-test for continuous variables. A direct experience index (DEI)—expressed as a percentage—was obtained by dividing the number of times that a participant classified an experience as a “direct experience” (the numerator) by the total number of all observations (“direct experience” + “thinking about”). The inter-rater reliability (kappa values) between the participants' classifications and that of the two independent researchers was calculated. Analyses of variance (ANOVA) were performed to explore between-group differences in the DEI and in other mindfulness-related factors (FFMQ and EQ). Pearson correlation analyses were performed to determine the association between the DEI and other mindfulness facets. An alpha level of 0.05 was used for all statistical tests. 3. Results The demographic and clinical characteristics of the participants are shown in Table 1. The inter-rater reliability between the participants' classifications and that of the two independent raters was strong (kappa values ranging from 0.80 to 0.91). Therefore, all analyses were conducted using the participant-reported DEI as the main outcome measure. Participants in the EDs group showed a significantly lower DEI (M = 43.54, standard deviation [SD] = 29.64) than those in the HCs group [M = 66.17, SD = 22.23, F = 5.25, p = 0.026, Cohen's d (95% confidence interval [CI]) = −0.85, (− 1.38, −0.30)]. Significant between-group differences were also found for most FFMQ facets (with the exception of “observing”) and for EQ scores (see Table 2). DEI scores were positively and significantly correlated with two FFMQ facets: Describing (r = 0.33, p = 0.01) and Non-Reacting (r = 0.37, p = 0.006) and with EQ scores (r = 0.35, p = 0.008).

2.2. Measures 2.2.1. Screening and diagnosis Psychiatric diagnosis were made using the Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998). To confirm the diagnosis, the eating disorders section of the Structured Clinical interview for DSM-IV (SCID-I; First, Spitzer, Gibbon, & Williams, 1999) was also administered. The Spanish version of the Eating Attitudes Inventory (EAT-26; Gandarillas, Zorrilla, Muñoz, Sepulveda, & Galan, 2003; Garner, Olmsted, Bohr, & Garfinkel, 1982) was used to screen for EDs. Internal consistency in our sample was high (Cronbach's alpha = 0.95).

4. Discussion The findings from this study indicate that, compared to health controls, individuals with EDs process the eating experience differently. During the eating experience, the analytical processing mode was more prevalent among individuals in the EDs group than among the HCs. Our results are consistent with the findings reported by Mantzios and Wilson (2015) who induced mindful eating by asking participants to 24

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Table 1 Demographic and clinical characteristics of the sample by group. Eating disorders Age, mean (SD) Single, % (n) Educational level, % (n) Less than high school High school graduate College graduate EAT-26, mean (SD) Psychotropic medication, % (n) SSRIS Anticonvulsants Benzodiazepines

X2

Healthy controls

31.2 75

(11.1) (21)

24.4 89

(4.9) (24)

3.6 39 57 32.3

(1) (11) (16) (18.1)

0 4 82 9.7

(0) (1) (23) (6.7)

64.5 41.9 32.3

(20) (13) (10)

t

p

2.4

0.02 0.36 0.01

−5.80

< 0.001

3.2 11.7

Note. EAT-26 = Eating Attitudes Test. SSRI = Selective serotonin reuptake inhibitor.

regulation skills. Moreover, targeted MBI may also help to foster healthy eating behaviors in individuals with mild EDs symptoms who are at risk of developing more severe symptoms (Taylor et al., 2015). Consistent with previous reports (Butryn et al., 2013; Levinson, Stoll, Kindy, Merry, & Davidson, 2014) the EDs group in the current study presented lower levels of mindfulness compared to HCs. In contrast to our previous findings (Soler et al., 2013), in this study we observed a positive and moderately significant association between the DEI level and decentering, and between the DEI and two FFMQ facets (Describing and Non-reactivity)—both of which are considered components of emotion regulation (Creswell, Way, Eisenberger, & Lieberman, 2007; Peters, Eisenlohr-moul, Upton, & Baer, 2013). Importantly, although the aforementioned associations with DEI were statistically significant, they were only moderately so, thus indicating that further research is needed to better understand the relationship between these constructs. The present study has several limitations. First, due to the small sample size, we cannot draw any specific conclusions about the specific EDs diagnosis (anorexia or bulimia). Second, the cross-sectional study design does not allow us to make causal inferences. Third, some of the specific characteristics of our sample (e.g., pharmacological treatment) could have affected the results. Additionally, arguments for and against using experts' or participants' classifications can be made. Using participant classifications implies a certain trust that they have correctly understood the instructions and classifications made by experts might be biased by the aims of the study. We decided to use participant's classifications because the inter-rater reliability between the participants' classifications and that of the two independent raters was strong

use food diaries that required them to focus either on concrete construals (i.e., how they are eating) or abstract construals (i.e, why they are eating). Specific questions such as “How does the food smell?” were used to promote mindful eating while purpose-oriented questions such as “Why is it important to eat less?” were used to promote abstract construals. Similar to the individuals in our sample who presented higher DEI scores (i.e., greater mindfulness), the concrete construal group in that study presented higher levels of mindfulness, less cognitive-behavioral avoidance, and fewer negative automatic thoughts versus the abstract construal group (Mantzios & Wilson, 2015). The tendency of some individuals to process eating experiences analytically may be related to the activation of dysfunctional cognitive schemas associated with the act of eating. Activation of impaired cognitive patterns may facilitate disengagement from the sensory attributes of food and avoidance of bodily sensations (Rawal et al., 2011). Our findings support previous research demonstrating the value of mindfulness-based interventions (MBI) for EDs (e.g., Kristeller & Wolever, 2010; Wildes & Marcus, 2011;Taylor, Daiss, & Krietsch, 2015), which can be used to teach individuals how to disengage from the analytical mode and from automatic eating behaviors (Holzel et al., 2011). Although additional research is needed, MBI might be useful for patients who eat to dissociate, as a way of regulating negative affect (Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring, 2012). Dissociative symptoms, which entail a marked detachment from the physical and emotional characteristics of the experience, are especially common among individuals suffering from binge eating disorder (Mason et al., 2017). Mindfulness could be a particularly beneficial treatment approach for these patients, as it could help them to develop effective emotion

Table 2 Between-group differences (ANOVAs) in direct experience and other mindfulness-related facets (FFMQ and EQ). Eating disorders

Healthy controls

F

p

Cohen's d [95% CI]

Mean

(SD)

Mean

(SD)

Direct Experience Index

43.54

(29.64)

66.17

(22.23)

5.25

0.26

−0.85 [− 1.38, − 0.30]

FFQM Observing

26.80

(4.75)

24.50

(4.58)

3.34

0.07

Describing

24.70

(7.73)

30.69

(3.90)

12.76

< 0.001

Acting with awareness

24.51

(6.65)

29.72

(5.71)

8.63

0.01

Non-judging

19.40

(6.29)

31.03

(5.24)

55.45

< 0.001

Non-reactivity

17.33

(3.90)

23.40

(4.41)

29.20

< 0.001

EQ

29.36

(6.77)

38.56

(4.55)

33.39

< 0.001

0.49 [− 0.05, −0.96 [− 1.50, −0.83 [− 1.40, −2.00 [− 2.61, −1.47 [− 2.09, −1.57 [− 2.15,

Note. FFMQ = Five Facet Mindfulness Questionnaire. EQ = Experiences Questionnaire. SD = standard deviation.

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1.02] − 0.39] − 0.24] − 1.33] − 0.85] − 0.94]

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How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspectives on Psychological Science, 6(6), 537–559. Kristeller, J. L., & Wolever, R. Q. (2010). Mindfulness-based eating awareness training for treating binge eating disorder: The conceptual foundation. Eating Disorders, 19(1), 49–61. Levinson, D. B., Stoll, E. L., Kindy, S. D., Merry, H. L., & Davidson, R. J. (2014). A mind you can count on: Validating breath counting as a behavioral measure of mindfulness. Frontiers in Psychology, 5, 1–10. Mantzios, M., & Wilson, J. C. (2015). Mindfulness, eating behaviours, and obesity: A review and reflection on current findings. Current Obesity Reports, 4(1), 141–146. Mason, T. B., Lavender, J. M., Wonderlich, S. A., Steiger, H., Cao, L., Engel, S. G., & Crosby, R. D. (2017). Comfortably numb. The role of momentary dissociation in the experience of negative affect around binge eating. The Journal of Nervous and Mental Disease, 205(5), 335–339. Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007). Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of Abnormal Psychology, 116(1), 198–207. Peters, J. R., Eisenlohr-moul, T. A., Upton, B. T., & Baer, R. A. (2013). Nonjudgment as a moderator of the relationship between present-centered awareness and borderline features: Synergistic interactions in mindfulness assessment. Personality and Individual Differences, 55(1), 24–28. Rawal, A., Williams, J. M. G., & Park, R. J. (2011). Effects of analytical and experiential self-focus on stress-induced cognitive reactivity in eating disorder psychopathology. Behaviour Research and Therapy, 49(10), 635–645. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., & Dunbar, G. (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSMIV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33. Soler, J., Franquesa, A., Feliu-Soler, A., Cebolla, A., Garcia-Campayo, J., Tejedor, R., & Portella, M. J. (2014). Assessing decentering: Validation, psychometric properties and clinical usefulness of the Experiences Questionnaire in a Spanish sample. Behavior Therapy, 45(6), 863–871. Soler, J., Soriano, J., Ferraz, L., Grasa, E., Carmona, C., Portella, M., & Pérez, V. (2013). Direct experience and the course of eating disorders in patients on partial hospitalization: A pilot study. European Eating Disorders Review, 21(5), 399–404. Svaldi, J., Griepenstroh, J., Tuschen-Caffier, B., & Ehring, T. (2012). Emotion regulation deficits in eating disorders: A marker of eating pathology or general psychopathology? Psychiatry Research, 197, 103–111. Taylor, M. B., Daiss, S., & Krietsch, K. (2015). Associations among self-compassion, mindful eating, eating disorder symptomatology, and body mass index in college students. Translational Issues in Psychological Science, 1(3), 229–238. Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control training help? Behavior Research and Therapy, 33, 25–39. Watkins, E., & Teasdale, J. D. (2004). Adaptive and maladaptive self-focus in depression. Journal of Affective Disorders, 82(1), 1–8. Wildes, J. E., & Marcus, M. D. (2011). Development of emotion acceptance behavior therapy for anorexia nervosa: A case series. International Journal of Eating Disorders, 44(5), 421–427.

and to be consistent with our previous work (Soler et al., 2013). Given that the task of peeling and eating a piece of fruit could be considered disorder-specific, it would be valuable to investigate if activation of the analytical mode in individuals with EDs also occurs during tasks unrelated to food intake. Acknowledgments The authors would like to thank Bradley Londres for his help in editing the manuscript. References Aldao, A., & Nolen-Hoeksema, S. (2010). Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy, 48(10), 974–983. Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217–237. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev). (Washington, DC). American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed). (Washington, DC). Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using selfreport assessment methods to explore facets of mindfulness. Assessment, 13(1), 27–45. Butryn, M. L., Juarascio, A., Shaw, J., Kerrigan, S. G., Clark, V., O'planick, A., & Forman, E. M. (2013). Mindfulness and its relationship with eating disorders symptomatology in women receiving residential treatment. Eating Behaviors, 14, 13–16. Cebolla, A., Garcia Palacios, A., Soler, J., Guillén, V., Baños, R., & Botella, C. (2012). Psychometric properties of the Spanish validation of the Five Facets of Mindfulness Questionnaire (FFMQ). The European Journal of Psychiatry, 26(2), 118–126. Creswell, J. D., Way, B. M., Eisenberger, N. I., & Lieberman, M. D. (2007). Neural correlates of dispositional mindfulness during affect labeling. Psychosomatic Medicine, 69(6), 560–565. First, M., Spitzer, R. L., Gibbon, M., & Williams, J. B. (1999). Structured clinical interview for DSM-IV Axis I disorders. Barcelona, Spain: Masson. Fresco, D. M., Moore, M. T., van Dulmen, M. H. M., Segal, Z. V., Ma, S. H., Teasdale, J. D., & Williams, J. M. G. (2007). Initial psychometric properties of the experiences questionnaire: Validation of a self-report measure of decentering. Behavior Therapy, 38(3), 234–246. Gandarillas, A., Zorrilla, B., Muñoz, E., Sepulveda, A. R., & Galan, I. (2003). Validation of the Eating Disorder Inventory (EDI) in a non-clinical population. Gaceta Sanitaria, 17(2), 141. Garner, D. M., Olmsted, M. P., Bohr, I., & Garfinkel, P. E. (1982). The eating attitudes test: Pyschometric features and clinical correlates. Psychological Medicine, 12, 871–878. Holzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., & Ott, U. (2011).

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