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ORIGINAL INVESTIGATION
Social reward and rejection sensitivity in eating disorders: An
investigation of attentional bias and early experiences
VALENTINA CARDI
1,2, * , ROSALIA DI MATTEO
2 * , FREYA CORFIELD
1 &
JANET TREASURE
1
1 King ’ s College London, Institute of Psychiatry, Psychological Medicine, Section of Eating Disorders, London, UK, and
2 Department of Neuroscience and Imaging, University of Chieti-Pescara, Italy
Abstract
Objectives. People with eating disorders (EDs) have diffi culties with social functioning. One explanatory mechanism is a
problem with over-sensitivity to rejection and/or low sensitivity to social reward. The aim of this study is to investigate
attentional bias to facial stimuli in people with a lifetime diagnosis of EDs and healthy controls (HCs) and to test whether
these attentional biases are linked to adverse early experiences. Methods. Forty-six participants with a current diagnosis of
EDs (29 with anorexia nervosa (AN) and 17 with bulimia nervosa (BN)), 22 participants recovered from an eating disor-
der (13 with past AN and nine with past BN) and 50 HCs completed a dot-probe task with faces expressing rejection and
acceptance. Participants reported on parental style and adverse early experiences. Results. People with a lifetime diagnosis
of EDs show an attentional bias to rejecting faces and a diffi culty disengaging attention from these stimuli. Also, they had
a sustained attentional avoidance of accepting faces. HCs demonstrated the opposite attentional pattern. The attentional
bias to rejection was correlated with adverse childhood experiences. Conclusions. People with an EDs show vigilance to
rejection and avoidance of social reward. This may contribute to the causation or maintenance of the illness.
Key words: Eating disorders , attentional bias , rejection sensitivity , social reward , early experiences , social functioning
Introduction
People with eating disorders (EDs) have a wide vari-
ety of problems with social and emotional function-
ing which have been detailed in systematic reviews
(Zucker et al. 2007; Oldershaw et al. 2011). The
question of whether these diffi culties are state or trait
characteristics is still debated. Premorbid diffi culties
in the interpersonal domain have been reported in
EDs (Anderluh et al. 2003) and patterns of comor-
bidity with social anxiety have been consistently
found (Godart et al. 2002; Kaye et al. 2004; Godart
et al. 2006).
Negative social evaluation has been proposed as a
key causal and maintaining feature in EDs (Rieger
et al. 2010). Sensitivity to rejection (RS) is one of the
biased cognitive processes linked to the perception of
being negatively evaluated by others (Downey and
Feldman 1996). The rejection sensitivity model
(Downey et al. 1997) proposes that prior exposure to
rejection, in conjunction with a biological vulnerability,
leads individuals to prioritize the detection of threats
of rejection (Dandeneau et al. 2007), through the acti-
vation of the defensive motivational system (Berenson
et al. 2009).
Rejection sensitivity may explain the biased atten-
tional processing found in EDs towards angry faces
(Cserj é si et al. 2010; Harrison et al. 2010). Diffi cul-
ties attending to positive facial expressions (Cserj é si
et al. 2010) and reduced facial expressions of positive
affect to pleasant pictures and video clips (Davies
et al. 2010; Soussignan et al. 2010, 2011) have also
been reported in this population.
Two different brain – behavior systems are thought
to regulate approach to appetitive stimuli and avoid-
ance of aversive stimuli (e.g., Cloninger 1987; Carver
et al. 2009). The approach system, the Behavioural
Activation System (BAS), is linked to personality dis-
positions refl ecting reward sensitivity (Pickering and
Correspondence: Valentina Cardi, | Department of Psychological Medicine, 5th Floor Bermondsey Wing, Guy ’ s Hospital, London SE1
9RT, UK. Tel: 44 207 1880190. Fax: 44 207 1880167. E-mail: valentina.cardi@kcl.ac.uk
(Rece ived 26 August 2011; accepte d 24 Januar y 2012)
The World Journal of Biological Psychiatry, 2012; Early Online: 1–12
ISSN 1562 -2975 pri nt/ISSN 1814-1412 online © 2012 Inform a Healt hcare
DOI : 10. 3109 /156229 75.2012.665 479
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2 V. C a r di et al.
sensitivity to rejection (greater attentional bias
towards rejecting faces) than people with AN.
An abnormal response to social stimuli, compa-
rable to that found in people currently ill, will be
found in recovered people (RECs).
Methods and materials
Participants
Participants were recruited from the Institute of
Psychiatry Eating Disorders Unit ’ s volunteer data-
base, through advertisements placed on the BEAT
(Beating Eating Disorders) website and through a
circular email sent out to the staff and students at
King’s College London. Inclusion criteria were:
females between 16 and 65 years old, fl uent in Eng-
lish, with normal visual acuity and no motor impair-
ment. The Structured Clinical Interview for DSM-IV
(First et al. 2002) was used to screen past or current
mental health disorder in the healthy controls (HCs)
and recovered participants (RECs), and to confi rm
the diagnosis of eating disorders (EDs). The recov-
ered group consisted of participants who had recov-
ered from an ED (either AN or BN) for at least 1 year
(Bailer et al. 2007) and who did not suffer from any
other axis 1 clinical disorder. Participants were con-
sidered recovered if they have had regular menstrua-
tion, did not report clinically signifi cant scores on the
Eating Disorder Examination Questionnaire (EDE-Q;
Fairburn and Beglin 1994) a nd had a Body Mass
Index (BMI) in the normal range (18.5 – 25). Ethical
approval was obtained from the Psychiatry, Nursing
and Midwifery Research Ethics Sub-Committee,
King’s College London. All participants provided
informed consent in order to take part in the study.
Measures
The following measures were completed by all
participants:
Eating Disorder Examination Questionnaire (EDE-Q;
Fairburn and Beglin 1994). This questionnaire is a
36-item self-report version of the original interview.
The EDE-Q is composed of four subscales: weight
concern, shape concern, eating concern, dietary
restraint and a global score (a composite mean score
of the four subscales). Scores ranging from 0 to 6 on
a Likert scale correspond to the number of days over
the past 4 weeks the respondent had experienced a
specifi c attitude, feeling or behavior. The EDE-Q has
high internal consistency (Luce and Crowther 1999)
and moderate to high concurrent and criterion validity
(Mond et al. 2004).
Smillie 2008), whereas the avoidance system, the
Behavioral Inhibition System (BIS), is related to pun-
ishment sensitivity (Corr et al. 1997). A systematic
review of reward processes in EDs concluded that
there were decreased sensitivity to reward and
increased sensitivity to punishment (Harrison et al.
2010). Moreover a recent study found this pattern
both in those currently ill and in those who had recov-
ered suggesting that this may be a trait associated
with the illness (Harrison et al. 2011). Low sexual
functioning and desire may be clinical markers of a
defi cit in the hedonic system (Pinheiro et al. 2010).
In experimental studies, such as the startle paradigm,
people with EDs showed an aversive response to
appetitive stimuli (Friederich et al. 2006).
There is uncertainty about the mechanisms that
underpin the attentional bias away from reward and
towards threat. One possibility is that there are
learned responses to adverse early experience.
Increased sensitivity to angry expressions and an
attentional bias towards angry faces has been found
in people who reported a history of childhood abuse
(Gibb et al. 2009). Traumatic experiences such as
childhood abuse and early separation from parents
are more common in people with EDs (Jahng 2011)
and may lead to abnormal cognitive processing of
social stimuli.
Traumatic experiences are reported more often in
bulimic compared to non-bulimic EDs (Schmidt
et al. 1997; Smolak and Murnen 2002; Striegel-
Moore et al. 2002). This could lead to a greater
impairment of the socio-emotional processing in this
population.
Aim
The aim of this study was to examine the attentional
processes to social stimuli in people with a lifetime
history of an ED (both currently ill and recovered)
and to examine whether there was an association
with early adverse experiences.
Hypothesis
People with a current ED will manifest the traits of
high sensitivity to rejection (attentional bias to faces
that depict expressions of rejection, criticism) and low
sensitivity to reward (attentional disengagement
from faces that depict expressions of acceptance,
compassion) and this will be associated with negative
early experiences (traumatic early experiences will
predict attentional bias to rejection and acceptance).
People suffering from bulimia nervosa (BN) will
report greater childhood adversity than people with
anorexia nervosa (AN). Thus, they will show higher
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Reward and rejection sensitivity in eating disorders 3
Following a fi xation point (500 ms), a picture pair
appeared (500 or 1250 ms inter-trial interval – ITI)
followed by a probe (two dots either arranged verti-
cally or horizontally) replacing the picture on either
the left or the right of the screen. The probe remained
on the screen until the participant made a response
by pressing the appropriate labeled key on the key-
board. Participants were instructed to indicate, as
quickly and accurately as possible, which probe
appeared on the screen after the presentation of the
picture pair. The task was programmed using
E-Prime psychology software (Psychology Software
Tools, Inc., Pittsburgh, PA).
Analysis
Data was obtained from people with a lifetime diag-
nosis of EDs (participants with current EDs 46
(AN 29; BN 17)), RECs 22 (recovered from
AN 13; recovered from BN 9)) and from HCs
( N 50). The attentional bias scores were calculated
following the analytical plan of Macleod and Mathews
(1988). The RTs for the trials when the probe
replaced the neutral picture were subtracted from
the RTs for the trials when the probe replaced the
emotional picture (accepting or rejecting face). Data
from participants with an error rate greater than
20% was excluded. Following Posner and Petersen ’ s
(1990) attentional framework, a mean attentional
score (reaction time: RT) was calculated for each
inter-trial interval (ITI: either 500 or 1250 ms).
An attentional bias score (ITI of 500 ms) refl ects
an enhanced orienting of attention towards the
critical stimulus ( “ immediate attentional bias ” : AB).
An attentional disengagement score (ITI of 1250
ms) refl ects a slowed disengagement of the atten-
tion from the stimulus ( “ delayed attentional bias ” :
lateAB). Repeated measure ANOVAs were used to
compare the AB and lateAB scores between groups
(EDs vs. RECs vs. HCs; AN vs. BN; people with a
lifetime diagnosis of AN vs. people with a lifetime
diagnosis of BN vs. HCs). One-way ANOVA was
employed to compare the scores on questionnaires
and Bonferroni post-hoc correction was adopted.
Chi-square tests were used for categorical variables
(marital status, shared accommodation, early separa-
tion from parents, loss of parents, closeness to chil-
dren and adults, physical and sexual abuse). A
composite score was calculated combining the cat-
egorical items of the CECA questionnaire which
were signifi cantly different between groups. A regres-
sion model was calculated using this composite score
as predictor of the attentional bias to rejection and
acceptance.
All the statistical analyses were calculated using
SPSS version 15.0.
Depression Anxiety Stress Scales (DASS; Lovibond and
Lovibond 1995). The DASS is a 21-item three-scale
self-report measure of depression, anxiety, and stress.
Higher scores are related to a higher level of depres-
sion, anxiety and stress. The scale has been validated
and found to possess good reliability with Cron-
bach ’ s alpha to be 0.94 for Depression, 0.87 for
Anxiety and 0.91 for Stress (Antony et al. 1998).
Parental Bonding Instrument (PBI; Parker et al.
1979). This self-report questionnaire is a measure
designed for adults to rate their parents on 25 atti-
tudinal and behavioral items (each with a four-point
scale) from the fi rst 16 years of the respondent’s
development. The PBI is comprised of two subscales:
“ Care ” (12 items) and “
Overprotection ” or “ Con-
trol ” (13 items). This questionnaire has good reli-
ability and validity (Parker et al. 1979).
The Childhood Experience of Care and Abuse Question-
naire (CECA; Bifulco et al. 2005). This self-report
questionnaire assesses loss or separation from par-
ents before age 17, close relationships to adults and
children, physical punishment and unwanted sexual
experiences. Two subscales comprise eight items
related to parental antipathy (e.g., “ He/she was very
critical of me ” ) and eight related to neglect (e.g.,
“ He/she was concerned about my whereabouts ” ).
Items were scored as 1 “ yes defi nitely ” to 5 “ not at
all ” . The mid-point “ 3 ” was labeled as “ unsure ” . Sat-
isfactory internal scale consistency for antipathy
(alpha 0.81) and neglect (alpha 0.80) was found
(Bifulco et al. 2005). Satisfactory test – retest for both
the abuse and care subscales has been demonstrated
(Bifulco et al. 2005).
Dot-probe task. This test assesses attentional bias. It
is a visual probe-detection task originally developed
by Posner et al. (1980). The participant’s task is to
respond to a probe stimulus that is initially hidden
from view behind one of two stimuli. A positive reac-
tion time (RT) suggests that attention has been
directed to the stimulus that obscured the probe.
The stimuli consisted of 64 gray-scale pictures of
faces of different people (male and female) providing
neutral and rejecting poses and neutral and accept-
ing poses (Dandeneau and Baldwin 2004). Each
neutral picture was matched with the rejecting or
accepting pose of the same person (Dandeneau and
Baldwin 2004). The task consisted of 16 practice and
64 experimental trials (16 rejecting-neutral pairs and
16 accepting-neutral pairs, repeated twice, once with
the emotional faces on the right and once on the left)
presented in random order for each participant.
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4 V. C a r di et al.
ill group and three participants in the recovered
group reported a lifetime diagnosis of anxiety disor-
ders. The socio-demographic variables are illustrated
in Table I. Ethnicity, age and education were similar
between the groups. As expected the people with
current AN had a lower BMI than the other groups.
The people with a lifetime eating disorder were less
likely to have a partner. Table I shows the demo-
graphic and social variables for each group.
As expected, people with current illness scored
higher on all of the clinical measures. The recovered
group had scores on some domains (Eating Concern
subscale of the EDE-Q and on the Stress subscale
of the DASS) that remained higher than HCs albeit
lower than those who were acutely ill. Table II shows
the clinical measures for each group.
Participants with AN and BN did not differ for age
( t (44) 0.01; P 0 . 9), education ( t (44) 0.7;
P 0 . 5), length of disease ( t (44) 0.6; P 0 . 5)
and severity of eating (EDE-Q total score: t (44) 1.1;
P 0 . 2) and mood symptomatology (DASS Anxiety:
t (44) 0.6; P 0 . 5; DASS Stress: t (44) 0.8;
P 0 . 4; DASS Depression: t (44) 0.1; P 0 . 9).
More people in the bulimic than the anorexic group
classifi ed themselves as separated in the relationship
domain ( χ
2 (1) 0.7; P 0 . 007), but no other
signifi cant differences were found on social status.
Procedure
This study was carried out in a single 90-min
session. The SCID-I was administered at the begin-
ning of the session, followed by the questionnaires
and the dot-probe task. At the end of the session,
height and weight measures were obtained by the
experimenter.
Results
Socio-demographic and clinical variables
One hundred and twenty-three participants were ini-
tially included. Two healthy controls were excluded
from the study because they did not meet the BMI
inclusion criteria (18.5 – 25; Committee 1995); and
three recovered people were excluded because they
did not meet the inclusion criteria (menstruation
recovered for less than 12 months). The fi nal sample
( N 118) consisted of 50 HCs, 46 individuals with
a current ED and 22 people with a lifetime history
of EDs and recovered. Of those with an ED, 29 had
AN (20 with restrictive subtype and nine with binge/
purge subtype), and 17 individuals had BN. Of those
recovered from an ED, 13 people had AN in the past
and nine had BN. Five participants in the currently
Table I. Socio-demographic variables compared between groups, expressed as mean (standard deviation)
and percentage. One-way ANOVA and Bonferroni post-hoc correction adopted. Chi-square calculated
for categorical variables.
ED ( N 46) REC ( N 22) HC ( N 50) Test statistic
Age 27.3 (10.2) 29.5 (8.4) 25.3 (7.4) F (2,115) 1.8
P 0 . 16
Education 15.8 (3.4) 16.4 (5.0) 16.7 (3.0) F (2,115) 0.7
P 0 . 50
BMI 19.0 (4.0) 21.8 (2.3) 21.7 (1.9) F (2,115) 11.6
P 0 . 000
EDvsREC: P 0 . 001
EDvsHC: P 0 . 00
RECvsHC: P 1.0
Length of illness 10.5 (9.5) 8.0 (6.2) N/A t 1.1
p 0.3
Medication 45.7% 22.7% N/A X
2 (1) 3.3
P 0 . 06
Admissions 37% 27.3% N/A χ
2 (1) 0.6
P 0 . 43
Comorbidity 43.5% 27.3% N/A χ
2 (1) 1.6
P 0 . 19
Status Single: 76.1%
Relation: 17.4%
Married: 2.2%
Separated: 4.3%
Single: 59.1%
Relation: 18.2%
Married: 13.6%
Separated: 9.1%
Single: 34%
Relation: 50%
Married: 12%
Separated: 4%
χ
2 (6) 21.8
P 0 . 001
Without a partner
(single/divorced)
80.4% 68.2% 38% X
2 (2) 18.7
P 0 . 000
Shared accomodation 67.4% 72.7% 78% χ
2 (2) 1.8
P 0 . 40
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Reward and rejection sensitivity in eating disorders 5
Parental style (PBI) and adverse childhood experiences
(CECA): anorexia nervosa vs. bulimia nervosa
(currently ill and recovered groups)
When people with AN and BN were compared,
higher levels of maternal antipathy and lower
level of care were reported by the BN group. Table
IV shows the PBI and CECA ratings for these
groups.
Also, participants with BN reported less closeness
to other children.
When people recovered from AN were compared
with people recovered from BN, the latter group
reported higher levels of paternal antipathy and
higher frequency of sexual abuse.
Parental style (PBI) and adverse childhood experiences
(CECA): eating disorders vs. recovered participants vs.
healthy controls
Table III shows the PBI and CECA ratings for each
group. Participants with a lifetime diagnosis of EDs
reported higher levels of overprotection from both
parents with lower levels of care. Higher antipathy
and maternal neglect were also more commonly
reported. People with EDs reported higher levels of
early separations from their parents, and higher lev-
els of sexual abuse. Also they reported lower levels
of closeness to peers. Within the ED group, those
who had recovered from their eating disorder were
less likely to have experienced an early separation.
Table II. Clinical measures expressed as mean and standard deviation. One-way ANOVA and Post-hoc
Bonferroni correction used.
ED (44) REC (21) HC (50) Test statistic
EDE-Q Restriction 3.8 (1.5) 1.9 (5.9) 0.7 (0.8) F (2,115) 14.9
P 0 . 000
EDvsREC: P 0 . 03
EDvsHC: P 0 . 00
RECvsHC: P 0 . 26
EDE-Q Eating Concern 4.0 (3.9) 1.0 (1.9) 0.2 (0.3) F (2,115) 27.5
P 0 . 000
EDvsREC: P 0 . 00
EDvsHC: P 0 . 00
RECvsHC: P 0 . 63
EDE-Q Weight Concern 3.8 (1.4) 1.9 (3.1) 0.8 (0.7) F (2,115) 39.5
P 0 . 000
EDvsREC: P 0 . 00
EDvsHC: P
0 . 00
RECvsHC: P 0 . 04
EDE-Q Shape Concern 4.5 (1.3) 1.8 (1.7) 1.2 (1.0) F (2,115) 84.0
P 0 . 000
EDvsREC: P 0 . 00
EDvsHC: P 0 . 00
RECvsHC: P 0 . 24
EDE-Q Total 3.9 (1.2) 1.1 (1.9) 1.0 (1.7) F (2,115) 56.1
P 0 . 000
EDvsREC: P 0 . 00
EDvsHC: P 0 . 00
RECvsHC: P 1.0
DASS Stress 18.0 (8.7) 10.9 (7.1) 6.4 (5.4) F (2,115) 32.0
P 0 . 000
EDvsREC: P 0 . 001
EDvsHC: P 0 . 00
RECvsHC: P 0 . 04
DASS Depression 21.5 (12.9) 4.8 (6.0) 3.9 (4.5) F (2,115) 52.0
P 0 . 000
EDvsREC: P 0 . 00
EDvsHC: P 0 . 00
RECvsHC: 1.0
DASS Anxiety 13.0 (10.3) 5.6 (5.9) 3.3 (3.3) F (2,115) 23.1
P 0 . 000
EDvsREC: P 0 . 00
EDvsHC: P 0 . 00
RECvsHC: P 1.0
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6 V. C a r di et al.
Table III. One-way ANOVA and Post-hoc Bonferroni correction reported for the “ Parental Bonding Instrument ” and for the “ Childhood
Experience of Care and Abuse subscales ” in the three groups of participants. Chi-square statistic has been used for categorical
variables.
ED
(PBI: 44
CECA: 39)
REC
(PBI:21,CECA: 20)
HC
(PBI:50, CECA 39) Test statistic
PBI mother care 20.9 (9.1) 21.6 (10.8) 28.1 (6.8) F (2,115) 9.5
P 0 . 000
EDvsHC: P 0 . 000
EDvsREC: P 1.0
RECvsHC: P 0 . 012
PBI mother overpr 15.9 (8.8) 15.7 (9.9) 11.4 (7.2) F (2,115) 4.0
P 0 . 02
EDvsHC: P 0 . 02
EDvsREC: P 1.0
RECvsHC: P 0 . 14
PBI father care 17.6 (9.2) 21.5 (9.9) 24.0 (8.5) F (2, 115) 6.0
P 0 . 003
EDvsHC: P 0 . 002
EDvsREC: P 0 . 32
RECvsHC: P 0 . 83
PBI father overpr 14.7 (7.9) 15.0 (7.3) 9.6 (6.7) F (2,115) 7.3
P 0 . 001
EDvsHC P 0 . 003
EDvsREC: P 1.0
RECvsHC: P 0 . 01
CECA mother antipathy 20.0 (8.8) 21.1 (7.7) 13.5 (5.2) F (2,95) 10.4
P 0 . 000
EDvsHC: P 0 . 001
EDvsREC: P 1.0
RECvsHC: P 0 . 001
CECA mother neglect 15.4 (6.6) 13.9 (3.7) 11.4 (3.2) F (2,95) 6.5
P 0.02
EDvsHC: P 0 . 002
EDvsREC: P 0 . 78
RECvsHC: P 0 . 21
CECA father antipathy 21.0 (8.6) 19.6 (8.5) 15.3 (6.7) F (2,95) 5.3
P 006
EDvsHC: P 0 . 006
EDvsREC: P 1.0
RECvsHC: P 0 . 16
CECA father neglect 17.9 (7.9) 16.7 (7.2) 15.3 (5.8) F (2,95) 1.4
P 0 . 25
EDvsHC: P 0 . 29
EDvsREC: P 1.0
RECvsHC: P 1.0
CECA loss of parents 5.7% 5.6% 2.6%
χ
2 (2) 0.5
P 0 . 77
CECA early separation 35.3% 17.6% 5% χ
2 (2) 10.8
P 0 . 004
CECA closeness to adults 71.80% 70% 79.5% χ
2 (2) 1.2
P 0 . 54
CECA closeness to children 61.5% 80% 97.4% χ
2 (2) 15.5
P 0 . 000
CECA physical abuse 17.1% 16.7% 7.7% χ
2 (2) 1.7
P 0 . 42
CECA sexual abuse 30.8% 30% 5.1% χ
2 (2) 9.3
P 0 . 009
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Reward and rejection sensitivity in eating disorders 7
Table IV. “ Parental Bonding Instrument ” and “ Childhood Experience of Care and Abuse ” subscales ’ ratings expressed as mean (standard
deviation) and percentage for participants with anorexia nervosa, bulimia nervosa, recovered from anorexia nervosa and recovered from
bulimia nervosa. t -Tests and Chi-squares calculated.
AN (29) BN (17) Test statistic REC AN (13) REC BN (9) Test statistic
PBI mother care 23.0 (7.7) 17.3 (10.3) t (44) 2.1
P 0 . 04
24.5 (10.3) 17.6 (10.7) t (19) 1.5
P 0 . 1
PBI mother
overprotection
15.4 (9.2) 16.8 (8.2) t (44) 0.5
P 0 . 61
14.1 (9.0) 18 (11.2) t (19) 0.9
P 0 . 4
PBI father care 17.3 (8.8) 18.1 (10.1) t (44) 0.3
P 0 . 77
22.0 (9.0) 20.7 (11.5) t (19) 0.3
P 0 . 8
PBI father overprotection 15.4 (8.6) 13.6 (6.4) t
(44) 0.7
P 0 . 45
14.2 (7.7) 16.2 (6.8) t (19) 0.6
P 0 . 5
CECA mother antipathy 18.1 (5.9) 22.8 (11.5) t (44) 1.6
P 0 . 01
19.4 (8.7) 23.2 (6.0) t (19) 1.2
P 0 . 3
CECA mother neglect 12.7 (8.2) 19.4 (8.1) t (44) 3.5
P 0 . 001
13.3 (3.7) 14.7 (3.9) t (19) 0.8
P 0 . 4
CECA father antipathy 20.8 (8.2) 21.5 (9.6) t (44) 0.2
P 0 . 81
15.6 (6.2) 24.0 (8.9) t (19) 2.4
P 0 . 03
CECA father neglect 18.0 (6.3) 17.8 (10.2) t (44) 0.09
P 0 . 92
14 (5.0) 19.8 (8.3) t (19) 1.9
P 0 . 09
Loss of parents 5% 6.7% χ
2 (1) 0.04
P 0 . 83
11.1% 0% χ
2 (1) 1.0
P 0 . 3
Early separation from
parents
15.8% 60% χ
2 (1) 7.2
P 0 . 007
11.1% 25% χ
2 (1) 0.6
P 0 . 4
Closeness to adults 78.3% 56.3% χ
2 (1) 2.9
P 0 . 23
72.7% 66.7% χ
2 (1) 0.1
P 0 . 8
Closeness to children 73.9% 43.8% χ
2 (1) 3.6
P 0 . 05
81.8% 77.8% χ
2 (1) 0.05
P 0 . 8
Physical abuse 15% 20% χ
2 (1) 0.1
P 0 . 69
22.2% 11.1% χ
2 (1) 0.4
P 0 . 5
Sexual abuse 26% 37.5% χ
2 (1) 0.6
P 0 . 44
9.1% 55.6% χ
2 (1) 5.0
P 0 . 02
Attentional bias to social rejection and acceptance:
eating disorders vs. recovered participants vs.
healthy controls
Signifi cant differences between groups were found
on the dot-probe task (Figure 1a ,b). The interaction
between EDs, RECs, HCs groups and rejecting/
accepting faces was signifi cant ( F (2,105) 9.8;
P .001). The ITI variable (500 vs. 1250 ms) was
not signifi cant ( F (2, 105) 0.1; P 0.7). People
with an ED showed both a signifi cant attentional
bias towards the rejecting faces ( AB : Mean 16.8,
SD 50.6; lateAB : Mean 24.0, SD 62.9) and an
attentional disengagement from the accepting faces
( AB: Mean 11.7, SD 50.0; lateAB :
Mean 4.6, SD 56.4). In contrast, HCs showed
a sustained attentional bias towards accepting faces
( AB : Mean 17.9, SD 53.9; lateAB : Mean 12.3,
SD 76.4) and a sustained disengagement from
rejecting faces ( AB : Mean 12.0, SD 61.6;
lateAB : Mean 20.7, SD 67.9) ( Post-hoc Bonfer-
roni test : rejecting faces P 0.001, accepting faces
P 0.05). The current and recovered ED groups
had a similar pattern in both the early (500 ms) and
later stages (1250 ms) of attention ( Post-hoc Bonfer-
roni test : rejecting faces P 0.9, accepting faces
P 0.9) although the absolute differences were
smaller in the recovered group (Rejecting faces: AB :
Mean 11.6, SD 69.6; lateAB : Mean 7.7,
SD 67.7); Accepting faces: AB : Mean 1.0,
SD 51.5; lateAB : Mean 10.5, SD 55.0) and
were not signifi cantly different from HCs ( Post -hoc
Bonferroni Test : rejecting faces P 0.1, accepting
faces P 0.3).
There were no differences on the task between
participants who were taking medication and par-
ticipants who were not ( F (1,60)
0.7, P 0.4).
Attentional bias to social rejection and acceptance:
anorexia vs. bulimia (currently ill participants)
Table V shows the attentional bias scorings for the
currently ill and recovered anorexic and bulimic
samples. When only participants currently ill were
considered, people with AN did not differ signifi -
cantly from people with BN on attentional bias
scores (both immediate and delayed) (Group:
F (1,41) 0.7; P 0.41). However, they had a greater
immediate AB to rejecting faces and a smaller atten-
tional disengagement from accepting faces than
people with BN (Figure 2a,b).
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8 V. C a r di et al.
Figure 1. (A) Attentional bias to and disengagement from rejecting faces in participants currently ill, recovered and healthy controls. (B)
Attentional bias to and disengagement from accepting faces in participants currently ill, recovered and healthy controls.
When participants recovered from AN were com-
pared to participants recovered from BN, signifi cant
differences were not found ( F (1,17) 0.07; p 0.8).
The two groups showed the same attentional trend
as currently ill participants for the rejecting faces.
However, participants recovered from BN showed a
trend for an initial bias towards accepting faces and
for a later disengagement from them.
Attentional bias to social rejection and acceptance:
participants with a lifetime diagnosis of AN vs.
participants with a lifetime diagnosis of BN vs.
healthy controls
Signifi cant differences on the interaction between
accepting vs. rejecting faces and the groups of HCs
and of participants with a lifetime diagnosis of AN
or with a lifetime diagnosis of BN were found
( F (2,105) 9.5; P 0.000). Both people with a life-
time diagnosis of AN or BN showed a similar, imme-
diate attentional bias to rejection (lifetime AN: AB :
Mean 19.9 (SD 53.0); lifetime BN: AB :
Mean 7.4 (SD 62.5)) which was maintained at
1250s (lifetime AN: lateAB : Mean 18.7 (SD 56.0);
lifetime BN: lateAB : Mean 19.6 (SD 77.7)).
They also had an immediate and sustained atten-
tional avoidance of accepting faces (lifetime AN: AB :
Mean 10.7 (SD 56.2); lateAB : Mean 0.1
(49.6); lifetime BN: AB : Mean 4.5 (SD 39.1);
lateAB : Mean 17.4 (SD 64.3)). HCs showed
the opposite attentional pattern (accepting faces:
AB : Mean 17.9 (SD 53.9); lateAB : Mean 12.3
(SD 76.4); rejecting faces: AB : Mean 12.0
(SD 61.6); lateAB : Mean 20.7 (SD 67.9)).
Early experiences and attentional bias (AB) to
rejection and acceptance
A composite score “ early adversity “ was calculated
combining the items “ Separation from parents ” ,
“ Closeness to children ” and “ Sexual abuse ” from the
CECA questionnaire. Table VI shows the regression
model with the attentional bias to rejection and accep-
tance considered as outcome variables and “ early
adversity ” entered as predictor. “ Early adversity ” pre-
dicted vigilance to rejection ( B 0.32; t 3.2;
P 0.002; ES 0.1) but did not predict the AB to
acceptance ( B
0 . 018 , t 0 . 166 , P 0 . 869).
Clinical variables and attentional bias
The AB to rejection correlated positively with the
Anxiety subscale of the DASS ( r 0.219; P 0 . 023)
across groups and the attentional bias to accepting
faces correlated negatively with the Stress ( r 0.251;
P 0 . 009) and Anxiety ( r 0.252; P 0 . 008) sub-
scales of the DASS.
Discussion
People with an ED showed vigilance and failure to
disengage from rejecting, critical faces and avoidance
Table V. Attentional bias scores expressed as means and standard deviations for currently ill and recovered anorexic and bulimic participants.
Cohen ’ s “ d ” used to indicate effect sizes.
AN BN Recovered AN Recovered BN
AN vs. BN:
Effect sizes
Recovered AN vs.
Recovered BN:
Effect sizes
Rejection AB 23 (45.6) 5.4 (58.9) 11.9 (70.6) 11.1 (73.0) ES 0.3 ES 0.01
Late AB 23.2 (53.0) 25.7 (80.4) 7.3 (64.5) 8.3 (76.3) ES 0.03 ES 0.01
Acceptance AB 10.2 (56.2) 14.4 (37.5) 12.0 (59.0) 14.2 (37.3) ES 0.08 ES 0.05
Late AB 1.8 (51.7) 9.7 (66.0) 5.0 (45.6) -31.8 (62.6) ES 0.1 ES 0.7
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Reward and rejection sensitivity in eating disorders 9
(Waller 2008) and affective (Surguladze et al. 2004;
Bourke et al. 2010) disorders. Impaired disengage-
ment from negative social cues (e.g., angry faces) is
also associated with social anxiety (Moriya and
Tanno 2011).
Approximately 7.6% of the variance in the atten-
tional bias to rejection was related to early separation
from parents. This supports the hypothesis of a con-
tinuity in the trajectory of the quality of social rela-
tionships, with diffi culties in early relationships
associated with later problems in the interpersonal
domain (Bowlby 1982; Rutter 1996; Maier and
Lachman 2000). Furthermore, this result confi rms
the link between adverse childhood experiences and
rejection sensitivity (Downey and Feldman 1996;
Dandeneau and Baldwin 2004) and abnormal atten-
tional processes to social stimuli (Pollak 2003).
Although people with BN reported higher levels
early adverse experiences in childhood. theydid not
have signifi cant differences on attentional processes.
This fi nding suggests that childhood adversity is only
one of the variables which account for sensitivity to
social reward and rejection in EDs.
The attenuated attentional bias found in the recov-
ered sample might suggest that recovery and possibly
treatment has the potential to modulate the implicit
cognitive processing of social stimuli. However, it is
also possible that the recovered group has less of a
problem within the interpersonal domain, as attach-
ment patterns have been found to be important
prognositic indicators in EDs (Illing et al. 2010).
of accepting, compassionate faces. This was the
converse of the pattern seen in HCs. Patients who
had recovered from an ED had an intermediate
response between people currently ill and HCs. The
attentional bias to rejection was associated with anx-
iety and early adverse experiences (early separation
from parents, isolation from peers and unwanted
sexual experiences). The avoidance of accepting
faces was associated with levels of stress. No signifi -
cant differences were found between people with a
lifetime diagnosis of AN (both recovered and cur-
rently ill) and participants with a lifetime diagnosis
of BN (both recovered and currently ill).
These fi ndings are in line with experimental studies
which have found abnormal automatic processes
related to reward and threat in people with EDs, includ-
ing abnormal attentional bias to angry faces (Harrison
et al. 2010); a failure of positive facial cues to prime
attention (Cserj é si et al. 2010); the reduced implicit
reward from faces (Watson et al. 2010); reduced emo-
tional reactivity to social comedy (Davies et al. 2010).
In addition to the abnormal attention processes to
social stimuli, people with ED have also been found
to have abnormal attentional processes (Brooks et al.
2011) and brain activations (Uher et al. 2004; Brooks
et al. 2011) to food stimuli
An attentional bias towards threat and away from
reward has been found in anxiety disorders (Mogg
et al. 2000; Frewen et al. 2008), therefore this shared
intermediate phenotype adds support to the sugges-
tion that EDs might lie within the spectrum of anxiety
Figure 2. (A) Attentional bias to and disengagement from rejecting faces in people with anorexia and bulimia. (B) Attentional bias to and
disengagement from accepting faces in people with anorexia and bulimia.
Table VI. Regression model. Predictor composed of three items: early separation from parents, closeness
to children and unwanted sexual experiences. Attentional bias to rejection considered as outcome
measure.
Model
Unstandardized
coeffi cients
Standardized
coeffi cients t P
B Std. Error Beta B SE
1 (Constant) .406 6.428 0.063 0.950
Early separation
Closeness to Children
Unwanted sexual experiences
135.754 42.395 .328 3.202 0.002
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10 V. C a r di et al.
Statement of Interest
The authors report no fi nancial interests or potential
confl ict of interest.
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The results from this study may explain the high
sensitivity to rejection (Rieger et al. 2010), social
anxiety and poor quality of social relationships
reported in people with EDs (Aime et al. 2006; Bohn
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Clinical implication and future research
Treatments targeting information processing bias
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There are limitations in the power of the study
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Conclusion
Interpersonal diffi culties have been proposed as
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cognitive may be benefi cial and warrant further
investigation.
Acknowledgements
This work was in part funded by a Department of
Health NIHR Programme Grant for Applied
Research (Reference number RP-PG-0606 - 1043).
This work was also supported by the NIHR Bio-
medical Research Centre for Mental Health. The
views expressed in this publication are those of the
author(s) and not necessarily those of the NHS, the
NIHR or the Department of Health. The authors
acknowledge S. Dandeneau for the rejecting and
accepting faces used in the dot-probe. Valentina
Cardi is supported by a scholarship from the Region
Abruzzo (Progetto Speciale Multiasse “Reti per
l’Alta Formazione” – P.O. F. S. E. 2007-2013, Piano
Operativo 2009-2010-2011). Freya Corfi eld is sup-
ported by the Psychiatry Research Trust.
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