Implicit bias to food and body cues in eating disorders: a systematic review

Abstract

Background Rigid, restrictive eating patterns, fear of gaining weight, body image concerns, but also binge eating episodes with loss of control leading to overweight, at times followed by compensatory measures to control weight, are typical symptoms in eating disorders (EDs). The regulation of food intake in EDs may underlie explicit processes that require cognitive insight and conscious control or be steered by implicit mechanisms that are mostly automatic, rapid, and associated with affective-rather than cognitive-processing. While introspection is not capable of assessing implicit responses, so-called indirect experimental tasks can assess implicit responses underlying a specific behavior bypassing the participant's consciousness. Here, we aimed to present the current evidence regarding studies on implicit biases to food and body cues in patients with EDs. Methods We performed a systematic review (PRISMA guidelines). We included controlled studies performed in clinical ED cohorts (vs. healthy control subjects or another control condition, e.g., restrictive vs. binge/purge AN) and using at least one indirect assessment method of interest. Results Out of 115 screened publications, we identified 29 studies fulfilling the eligibility criteria, and present a synthesis of the essential findings and future directions. Conclusion In this emerging field of research, the present work provides cornerstones of evidence highlighting aspects of implicit regulation in eating disorders. Applying both direct (e.g., self-reports) and indirect measures for the assessment of both explicit and implicit responses is necessary for a comprehensive investigation of the interplay between these different regulatory mechanisms and eating behavior. Targeted training of implicit reactions is already in use and represents a useful future tool as an add-on to standard psychotherapeutic treatments in the battle against eating disorders. Evidence level 1 (systematic review).

Exposure to the thin beauty ideal: Are there subliminal priming effects?

“…Recently, several authors (e.g., Paslakis et al, 2016; Paslakis et al, 2020; Steinglass & Walsh, 2016; Uniacke et al, 2018; Walsh, 2013) suggested that automatic, or implicit, processes might be an important mechanism in the development and maintenance of eating disorders. It is assumed that a shift from goal‐directed to habitual behavior, as observed in addictive behaviors (Everitt & Robbins, 2016), might also be relevant in eating disorders.…”

“…Only recently, several authors suggested that automatic processes and a shift from goal‐directed to habitual behavior might be an important aspect in the development and maintenance of eating disorders (e.g., Paslakis et al, 2016; Paslakis, Scholz‐Hehn, Sommer, & Kühn, 2020; Steinglass & Walsh, 2016; Uniacke, Walsh, Foerde, & Steinglass, 2018; Walsh, 2013). Walsh (2013) hypothesized that disorder‐compatible stimuli (e.g., pictures of underweight bodies) trigger the mesolimbic reward system and promote restraint eating habits.…”

All I Need Is Two: The Clinical Potential of Adding Evaluative Pairing Procedures to Cognitive Behavioral Therapy for Changing Self-, Body- and Food-Related Evaluations

“…Nevertheless, the available literature includes several examples of successful pairing procedures, including with clinical populations, related to improving negative self-concepts [15], body ideals [16], and food preferences [17]. Given the relevance of these and similar evaluations for the emergence and maintenance of disordered cognitions and behaviors [23][24][25][26][27][28][29][30][31][32][33], pairing procedures may indeed offer a simple yet effective means of complementing CBT.…”

“…Consistent with this idea, an increasing number of studies show that altered evaluations link to disordered cognitions and behaviors. For example, a generalized negative self-evaluation, i.e., negative self-esteem, both characterizes and predicts the onset of depressive symptoms [23][24][25]; shifted evaluations of body ideals and foods are associated with the development and maintenance of eating disorders [26][27][28][29][30][31]; phobic patients show evaluative biases in processing fear-relevant stimuli and situations [32,33]. These and similar evaluations need not be consistent with an individual's explicit beliefs or goals (e.g., people frequently desire sweets despite knowing the benefits of restraint [34]) and are less susceptible to conscious introspection and control [19].…”

Faster Grasping of High-Calorie Food Objects in Virtual Reality

“…The most common among them is the approach-avoidance task (AAT), which requires push or pull movements, mediated by a computer joystick, depending on whether the reaction is to avoid or to approach food pictures [7,9,[16][17][18][19]. AAT modi cation protocols are discussed as interventions in obesity and eating disorders, since they are hypothesized to overcome the low e cacy of conventional treatments by targeting early cognitive processing of food stimuli [16,20]. However, AAT modi cation studies did not always yield consistent results [21,22].…”