Casey M. Stern’s research while affiliated with Yeshiva University and other places

Objective Little is known about the timing of behavioral versus cognitive change in 10‐session cognitive‐behavioral therapy for non‐underweight eating disorders (CBT‐T). We aimed to: (a) evaluate the magnitude of behavioral and cognitive symptom reduction across treatment; and (b) investigate the relation between early behavioral change and subsequent cognitive change. We hypothesized: (a) large and significant reductions in behavioral and cognitive symptoms from pre‐ to mid‐treatment and from pre‐ to post‐treatment; and (b) that early behavioral change would predict subsequent cognitive change over the course of treatment. Method Patients ( N = 63) were offered CBT‐T and completed the Eating Disorder‐15 on a weekly basis. We used intent‐to‐treat analyses. For Aim 1, we conducted a series of fixed‐effect multilevel models for each outcome variable, accounting for repeated measures (pre‐, mid‐, and post‐treatment) within individuals. For Aim 2, we conducted a linear regression using early behavioral change as the predictor and subsequent cognitive change as the outcome. Results We observed large and significant reductions in most behavioral and all cognitive symptoms pre‐ to mid‐treatment and pre‐ to post‐treatment. Early changes in behavioral symptoms did not significantly predict subsequent cognitive changes. Discussion Behavioral improvements occurred rapidly and were sustained throughout treatment, whereas cognitive changes followed a more gradual trajectory. The absence of a significant predictive relationship between early behavioral change and subsequent cognitive change suggests that these domains may improve independently. Future research should investigate the mechanisms linking behavioral and cognitive changes.

Importance The neurobiology of avoidant/restrictive food intake disorder (ARFID) is poorly understood. Objective To evaluate whether individuals with ARFID exhibit disruptions in fear, appetite, and disgust brain regions compared with healthy control (HC) participants when shown images of food and objects. Design, Setting, and Participants In this case-control study conducted from July 2016 to January 2021, children, adolescents, and young adults completed structured interviews and a validated functional magnetic resonance imaging (fMRI) food cue paradigm. The study was conducted at a single academic medical center. Data analysis was conducted from April 2023 to August 2024. Exposures Presence vs absence of ARFID and its phenotypes (ARFID-fear, ARFID–lack of interest in eating, ARFID–sensory sensitivity); pictures of food vs objects during fMRI food cue paradigm. Main Outcomes and Measures Blood oxygenation level–dependent activation in regions of interest (ROIs; amygdala, hypothalamus, insula, anterior cingulate cortex [ACC]) and the whole brain. Results Participants were 110 children, adolescents, and young adults with full or subthreshold ARFID (75 participants; mean [SD] age, 16.2 [3.8] years; 41 [55%] female) and age-matched HC participants (35 participants; mean [SD] age, 17.3 [4.0] years; 27 [69%] female) recruited for studies of the neurobiology of ARFID and restrictive eating disorders. Participants with ARFID demonstrated greater activation than HC participants of the ACC (mean difference, 0.48 [95% CI, 0.19 to 0.77]; P = .009), sensory association cortex (mean difference on left side, 0.54 [95% CI, 0.29 to 0.79]; P = .005; right side, 0.52 [95% CI, 0.28 to 0.76]; P = .02), and supplementary motor cortex (mean difference, 0.81 [95% CI, 0.47 to 1.15]; P = .04). The ARFID-fear group showed greater amygdala activation vs HC (mean difference, 0.49 [95% CI, 0.16 to 0.82]; P = .04), and greater lack of interest was associated with lower hypothalamus activation in the ARFID–lack of interest group ( r = −0.38 [95% CI, −0.69 to −0.11]; P = .03). The ARFID–sensory sensitivity group did not show greater insula activation vs HC but showed greater activation of the ACC (mean difference, 0.48 [95% CI, 0.22 to 0.74]; P = .005) and somatosensory cortex (mean difference on left side, 0.60 [95% CI, 0.33-0.87]; P = .001; right side, 0.54 [95% CI, 0.29 to 0.80]; P = .03). Conclusions and Relevance Results indicate generalized hyperactivation of ACC, sensory association cortex, and supplementary motor cortex in response to visual food stimuli in children, adolescents, and young adults with ARFID, suggesting a novel neurobiological circuit associated with this disorder. Activation appears consistent with ARFID phenotypic rationales for food avoidance, with hyperactivation of fear regions in ARFID-fear and hypoactivation of appetite regions with increasing ARFID–lack of interest severity.

Background Individuals with avoidant/restrictive food intake disorder (ARFID) self‐report heightened sensitivity to taste and smell, but neither phenomenon has been systematically explored in the laboratory. We hypothesized that, compared to healthy controls (HC, n = 34), children, adolescents, and adults with full/subthreshold ARFID ( n = 100; ages 9 to 23 years) would self‐report heightened response to taste/smell stimuli and exhibit stronger bitter taste perception and heightened smell perception in performance‐based tasks, and these differences would be especially prominent in those with the ARFID‐sensory sensitivity presentation. Method We measured self‐reported sensitivity to taste/smell with the adolescent/adult sensory profile (AASP). We measured performance‐based bitter taste perception with the regional taste intensity test (RTIT) and 6‐ N ‐propylthiouracil (PROP) test, and olfactory performance with the Sniffin' Sticks test (including the odor threshold, odor detection, and odor identification subscales). Results As expected, the ARFID group self‐reported heightened response to taste/smell on the AASP, compared to HC, with an especially large effect size in the subset with the ARFID‐sensory sensitivity presentation. Contrary to hypotheses, on performance‐based measures, neither the ARFID group—nor the ARFID‐sensory sensitivity group specifically—demonstrated heightened sensitivity to bitter taste on the RTIT or PROP tests, nor heightened smell perception on the Sniffin' Sticks test. Conclusion These first laboratory findings in a clinically diagnosed sample of individuals with full/subthreshold ARFID highlight the discrepancy between perceived versus actual sensitivity to taste/smell stimuli. Future research should explore whether this discrepancy can be replicated and therapeutically leveraged to facilitate successful food exposures.

Objective Cognitive‐behavioral therapy for avoidant/restrictive food intake disorder (ARFID; CBT‐AR) shows promise in improving clinical outcomes in children/adolescents and adults. We aimed to identify predictors of outcomes in CBT‐AR. We hypothesized that younger age, non‐underweight status, and presence of the fear of aversive consequences profile of ARFID would predict greater likelihood of remission post–treatment, and that presence of the lack of interest in eating/food and sensory sensitivity profiles would predict greater likelihood of persistence post‐treatment. We included sex as an exploratory predictor. Method Individuals ( N = 94, ages 10–55 years) were offered 20–30 outpatient sessions of CBT‐AR. We collected clinical and demographic data at pre‐treatment, and remission status at post‐treatment. Results Consistent with our hypothesis, presence (versus absence) of the fear profile predicted an almost three‐fold increased likelihood of remission. Presence of the sensory profile, lack of interest profile, age, weight status, and sex were not predictors of ARFID outcome. Discussion The fear of aversive consequences profile of ARFID may be more amenable to treatment with CBT‐AR. This is the first study to identify predictors of treatment outcome following CBT‐AR. Randomized controlled trials are needed to confirm these findings and examine moderators.

Objective Despite substantial research indicating difficulties with emotion regulation across eating disorder presentations, emotion regulation has yet to be studied in adults with avoidant/restrictive food intake disorder (ARFID). We hypothesized that (1) those with ARFID would report greater overall emotion regulation difficulties than nonclinical participants, and (2) those with ARFID would not differ from those with other eating disorders on the level of emotion regulation difficulty. Methods One hundred and thirty‐seven adults (age 18–30) from an outpatient clinic with ARFID ( n = 27), with other primarily restrictive eating disorders (e.g., anorexia nervosa; n = 34), and with binge/purge eating disorders (e.g., bulimia nervosa; n = 51), as well as nonclinical participants ( n = 25) recruited via Amazon Mechanical Turk (MTurk) completed the Difficulties in Emotion Regulation Scale (DERS). We compared DERS scores across groups. Results In line with expectations, patients with ARFID scored significantly higher than nonclinical participants on the DERS Total ( p = 0.01) with a large effect size ( d = 0.87). Also as hypothesized, those with ARFID did not differ from those with other primarily restrictive ( p = 0.99) or binge/purge disorders ( p = 0.29) on DERS Total. Discussion Adults with ARFID appear to exhibit emotion regulation difficulties which are greater than nonclinical participants, and commensurate with other eating disorders. These findings highlight the possibility of emotion regulation difficulties as a maintenance mechanism for ARFID.

Background DSM-5 differentiates avoidant/restrictive food intake disorder (ARFID) from other eating disorders (EDs) by a lack of overvaluation of body weight/shape driving restrictive eating. However, clinical observations and research demonstrate ARFID and shape/weight motivations sometimes co-occur. To inform classification, we: (1) derived profiles underlying restriction motivation and examined their validity and (2) described diagnostic characterizations of individuals in each profile to explore whether findings support current diagnostic schemes. We expected, consistent with DSM-5 , that profiles would comprise individuals endorsing solely ARFID or restraint (i.e. trying to eat less to control shape/weight) motivations. Methods We applied latent profile analysis to 202 treatment-seeking individuals (ages 10–79 years [ M = 26, s.d. = 14], 76% female) with ARFID or a non-ARFID ED, using the Nine-Item ARFID Screen (Picky, Appetite, and Fear subscales) and the Eating Disorder Examination-Questionnaire Restraint subscale as indicators. Results A 5-profile solution emerged: Restraint/ARFID-Mixed ( n = 24; 8% [ n = 2] with ARFID diagnosis); ARFID-2 (with Picky/Appetite; n = 56; 82% ARFID); ARFID-3 (with Picky/Appetite/Fear; n = 40; 68% ARFID); Restraint ( n = 45; 11% ARFID); and Non-Endorsers ( n = 37; 2% ARFID). Two profiles comprised individuals endorsing solely ARFID motivations (ARFID-2, ARFID-3) and one comprising solely restraint motivations (Restraint), consistent with DSM-5 . However, Restraint/ARFID-Mixed (92% non-ARFID ED diagnoses, comprising 18% of those with non-ARFID ED diagnoses in the full sample) endorsed ARFID and restraint motivations. Conclusions The heterogeneous profiles identified suggest ARFID and restraint motivations for dietary restriction may overlap somewhat and that individuals with non-ARFID EDs can also endorse high ARFID symptoms. Future research should clarify diagnostic boundaries between ARFID and non-ARFID EDs.

Background Avoidant/restrictive food intake disorder (ARFID) and anorexia nervosa (AN) are the two primary restrictive eating disorders; however, they are driven by differing motives for inadequate dietary intake. Despite overlap in restrictive eating behaviors and subsequent malnutrition, it remains unknown if ARFID and AN also share commonalities in their cognitive profiles, with cognitive alterations being a key identifier of AN. Discounting the present value of future outcomes with increasing delay to their expected receipt represents a core cognitive process guiding human decision-making. A hallmark cognitive characteristic of individuals with AN (vs. healthy controls [HC]) is reduced discounting of future outcomes, resulting in reduced impulsivity and higher likelihood of favoring delayed gratification. Whether individuals with ARFID display a similar reduction in delay discounting as those with AN (vs. an opposing bias towards increased delay discounting or no bias) is important in informing transdiagnostic versus disorder-specific cognitive characteristics and optimizing future intervention strategies. Method To address this research question, 104 participants (ARFID: n = 57, AN: n = 28, HC: n = 19) completed a computerized Delay Discounting Task. Groups were compared by their delay discounting parameter (ln)k. Results Individuals with ARFID displayed a larger delay discounting parameter than those with AN, indicating steeper delay discounting (M ± SD = −6.10 ± 2.00 vs. −7.26 ± 1.73, p = 0.026 [age-adjusted], Hedges’ g = 0.59), with no difference from HC (p = 0.514, Hedges’ g = −0.35). Conclusion Our findings provide a first indication of distinct cognitive profiles among the two primary restrictive eating disorders. The present results, together with future research spanning additional cognitive domains and including larger and more diverse samples of individuals with ARFID (vs. AN), will contribute to identifying maintenance mechanisms that are unique to each disorder as well as contribute to the optimization and tailoring of treatment strategies across the spectrum of restrictive eating disorders.

Background Cognitive‐behavioral therapy for avoidant/restrictive food intake disorder (ARFID; CBT‐AR) theoretically targets three prototypic motivations (sensory sensitivity, lack of interest/low appetite, fear of aversive consequences), aligned with three modularized interventions. As an exploratory investigation, we: (1) evaluated change in candidate mechanisms in relationship to change in ARFID severity, and (2) tested if assignment (vs. not) to a module resulted in larger improvements in the corresponding mechanism. Method Males and females ( N = 42; 10–55 years) participated in an open trial of CBT‐AR. Results Decreases in scaled scores for each candidate mechanism had medium to large correlations with decreases in ARFID severity—sensory sensitivity: −0.7 decrease ( r = .42, p = .01); lack of interest/low appetite: −0.3 decrease ( r = .60, p < .0001); and fear of aversive consequences: −1.1 decrease ( r = .33, p = .05). Linear mixed models revealed significant weekly improvements for each candidate mechanism across the full sample ( ps < .0001). There were significant interactions for the sensory and fear of aversive consequences modules–for each, participants who received the corresponding module had significantly larger decreases in the candidate mechanism than those who did not receive the module. Discussion Sensory sensitivity and fear of aversive consequences improved more if the CBT‐AR module was received, but lack of interest/low appetite may improve regardless of receipt of the corresponding module. Future research is needed to test target engagement in CBT‐AR with adaptive treatment designs, and to identify valid and sensitive measures of candidate mechanisms. Public Significance The mechanisms through which components of CBT‐AR work have yet to be elucidated. We conducted an exploratory investigation to test if assignment (vs. not) to a CBT‐AR module resulted in larger improvements in the corresponding prototypic ARFID motivation that the module intended to target. Measures of the sensory sensitivity and the fear of aversive consequences motivations improved more in those who received the corresponding treatment module, whereas the lack of interest/low appetite measure improved regardless of if the corresponding module was received.

Background Recent research suggests that individuals with eating disorders (EDs) report elevated anhedonia, or loss of pleasure. Although individuals with avoidant/restrictive food intake disorder (ARFID) often express that they do not look forward to eating, it is unclear whether they experience lower pleasure than those without EDs. Thus, identifying whether individuals with ARFID experience anhedonia may yield important insights that inform clinical conceptualization and treatment. Methods A sample of 71 participants ages 10–23 with full and subthreshold ARFID and 33 healthy controls (HCs) completed the Pica, ARFID, and Rumination Disorder Interview, a diagnostic interview to assess ARFID profile severity (lack of interest in food, sensory sensitivity, fear of aversive consequences) and the Temporal Experience of Pleasure Scale (TEPS), a self-report measure of consummatory and anticipatory pleasure. Statistical analyses were performed using the full TEPS and also the TEPS with food-related items removed. Results The ARFID group reported significantly lower anticipatory and consummatory pleasure compared to HCs, but these differences were no longer significant after controlling for depression, nor after removing food items from the TEPS. Within the ARFID sample, greater ARFID severity was associated with lower anticipatory pleasure across analyses, and greater endorsement of the lack of interest in food profile was related to lower anticipatory pleasure. ARFID severity was also associated with lower consummatory pleasure using the full TEPS, but this relationship was no longer significant with food items removed. Conclusions These results provide initial evidence for lower pleasure before potentially pleasurable events in individuals with more severe ARFID, particularly those with the lack of interest phenotype. Our findings also suggest that depression is likely to contribute low pleasure in this population. Future research should seek to further characterize how dimensions of pleasure relate to the maintenance and treatment of ARFID symptoms.