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In this study we would like to investigate whether there is an affective attentional bias in adolescent patients with Anorexia Nervosa (AN). With a free vision eye-tracking paradigm we examine if an independent measurement of attentional biases towards affective stimuli.

Abbereant processing of negative information (i.e. attention bias) is a cognitive marker of depression and has been implicated in the development and maintenance of depressive symptoms (Beck & Clark, 1997; Everaert, Koster, & Derakshan, 2012; Joormann & Tanovic, 2015; Joormann, Talbot, & Gotlib, 2007). However, empirical findings have been criticized based on the methodology of attention bias assessment, which has come under scrutiny due to potential unreliable measurement of reaction times (Rodebaugh et al., 2016). Recently, a novel attention paradigm measuring attention processing of sad faces based on eye-tracking has been developed and tested in depressed patients (Klawohn et al., 2020; Lazarov, 2018). This initial study demonstrated that depressed patients, compared to never-depressed healthy controls dwelled longer on negative stimuli (sad faces), while both groups showed a bias towards positive stimuli (happy faces). However, attentional bias scores over time and a comparison of attention bias scores of these groups (never-depressed and depressed people) with remitted depressed patients (i.e. people who have been suffering from depression but are currently symptom-free) are lacking. The first aim of this project is to evaluate the test-retest-reliability of this novel eye-tracking based paradigm. The second aim of the project is to compare the attention bias scores of healthy, non-depressed control participants, remitted depressed patients and currently depressed patients. The third aim of the study is to explore the relation between emotional bias, memory functioning and therapy related processes in the three groups.

Enhancing the engagement in adaptive behaviors is highly relevant in the treatment of mental disorders. In depression, symptoms such as low mood and diminished interest in activities, however, can impede the implementation of behavioral interventions (e.g. Behavioral Activation) in daily life. We have argued that the engagement in planned activities could be facilitated by the use of mental imagery (i.e. the mental simulation of activities based on prior experiences). Initial findings suggest that mental imagery can indeed serve as a ‘motivational amplifier’ by increasing the anticipated emotional value of activities (Renner et al., 2019). To extend this beyond self-report, we plan to assess the motivational impact of mental imagery in a more objective manner using eye tracking. We assume that motivational imagery leads to a learned association between the imagined activity and positive emotions. As positive stimuli have been shown to attract attention (Pool, Brosch, Delplanque, & Sander, 2016), positively imagined activities are expected to gain priority in the allocation of attention. The aim of the present study is, thus, to test whether motivational imagery (using brief auditory guided imagery scripts) shifts attention toward picture stimuli that were previously associated with a positive as compared to a neutral mental image during a mental imagery task.

According to behavioral models, depression is associated with a decreased engagement in potentially rewarding activities leading to reduced reward experiences and a worsening of mood (Lewinsohn, 1974). Evidence-based treatments of depression, such as Behavioural Activation (Martell, Dimidjian, & Herman-Dunn, 2010), aim to foster individuals' re-engagement in such behaviours via scheduling of potentially rewarding activities. We have argued that activity scheduling might be facilitated by positive mental imagery (Holmes, Blackwell, Burnett Heyes, Renner, & Raes, 2016; Renner, Murphy, Ji, Manly, & Holmes, 2019). Mental imagery refers to the multi-sensory phenomenon of seeing with the ‘mind’s eye’, hearing with the ‘mind’s ear’, and so on (Kosslyn, Ganis, & Thompson, 2001). Our lab has started to investigate the association between prospective mental imagery (i.e. simulations of what a future event will look, sound, and feel like) and reward, motivation, and behavior. Our initial studies, with a single-session activity scheduling plus mental imagery training, suggest that positive future imagery can indeed facilitate reward experiences and motivation to engage in planned activities (Heise, Werthmann, Tuschen-Caffier, & Renner, in prep.; Renner et al., 2019). As a next step, we aim to pilot test the feasibility, acceptability and effects of an extended 4-session activity scheduling plus imagery training (vs. an active control condition of activity scheduling plus relaxation), delivered over the internet. The study will be conducted in a non-clinical sample with volunteers from the general population reporting mild to moderate feelings of low mood and sadness based on established cut-offs.

According to behavioral models, depression is associated with a decreased engagement in potentially rewarding activities leading to reduced reward experiences and a worsening of mood (Lewinsohn, 1974). Evidence-based treatments of depression, such as Behavioural Activation (BA; Martell, Dimidjian, & Herman-Dunn, 2010), aim to foster individuals' re-engagement in such behaviours via scheduling of potentially rewarding activities. We have argued that activity scheduling might be facilitated by positive mental imagery (Holmes, Blackwell, Burnett Heyes, Renner, & Raes, 2016; Renner, Murphy, Ji, Manly, & Holmes, 2019). Mental imagery refers to the multi-sensory phenomenon of seeing with the ‘mind’s eye’, hearing with the ‘mind’s ear’, and so on (Kosslyn, Ganis, & Thompson, 2001). Our lab has started to investigate the association between prospective mental imagery (i.e. simulations of what a future event will look, sound, and feel like) and reward, motivation, and behavior. Our initial studies, with a single-session activity scheduling plus mental imagery training, suggest that positive future imagery can indeed facilitate reward experiences and motivation to engage in planned activities (Heise, Werthmann, Murphy, Tuschen-Caffier, & Renner, under review; Renner et al., 2019). As a next step, we aim to test the effects, feasibility, and acceptability of an extended 4-session activity scheduling plus imagery training (vs. a waitlist control condition), delivered over the internet. The study will be conducted with volunteers fulfilling diagnostic criteria for a major depressive episode.

Additional file 1. Participant Consent Form.

Anorexia Nervosa (AN) is a life-threatening eating disorder, characterized by persistent pathological weight loss behaviors and an intense fear of weight gain, food and eating. Whilst there is an abundance of scientific theories on the etiology and maintenance of disordered eating behavior in AN, there is a lack of empirical and experimental research testing these theoretical assumptions. The need for a theory firmly grounded in empirical evidence becomes strikingly clear when we consider the current treatment outcomes for AN: For adults with AN, recovery rates after treatment are fairly poor. For adolescents with AN, the prognosis is somewhat brighter in that family therapy seems moderately effective. However, a substantial proportion of adult and adolescent patients fails to change their behavior in the long-term. Moreover, working mechanisms of therapy programs also remain largely empirically unexplored. This calls for a paradigm shift towards more experimental research on key processes that potentially contribute to the persistence of AN. Only by manipulating presumed causal factors experimentally and measuring the effects on core symptoms of AN, we can determine whether these factors are truly involved in maintaining AN. The latter would provide us with fresh ideas for treatment innovation regarding which factors should be addressed during treatment. The goal of the current symposium is to demonstrate innovative research on key processes in AN designed to advance our understanding of the complex mechanisms contributing to AN maintenance. We will highlight how each potential maintaining mechanism is currently being addressed in day-to-day treatment of AN and how it could lead to treatment innovation.

Objective: Attention processing for food may be biased in people with Anorexia Nervosa (AN). However previous studies have had inconsistent results. This is likely to be due to indirect assessment of attention, which does not inform on the underlying attention processes, and/or the heterogeneity of participants across studies, testing either adults or adolescents with AN, i.e. people at very different developmental and illness stages. Method: Eye-tracking was employed as a direct assessment of attention during a visual probe task with food versus non-food pictures. Attention bias for food was measured in 39 adults and 34 adolescents with AN and in 53 adults and 31 adolescents without AN. Results: All participants had a direction bias for food, specifically for high-calorie food. However, adults with AN subsequently avoided maintaining attention on food versus non food cues, compared to adults without AN. Adolescents with or without AN demonstrated increased attention maintenance on food versus non-food cues, and, contrary to our hypothesis, did not differ in their attention bias for food cues. Accordingly, adults with AN differed significantly from adolescents with AN in attention maintenance for food cues: whilst adolescents with AN showed significantly increased attention maintenance on food stimuli, adults avoided maintaining attention on food cues. Discussion: Adults with AN may apply attention strategies to facilitate restrictive eating. This strategy is absent in adolescents with AN. This difference in food-related attention bias between adolescents and adults with AN suggests that attention biases develop over time as the illness progresses.