Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Perspective
  • Published:

A network approach can improve eating disorder conceptualization and treatment

Nature Reviews Psychology volume 1, pages 419–430 (2022)Cite this article

Subjects

Abstract

Eating disorders are severe mental illnesses with the second-highest mortality rate of all psychiatric illnesses. Eating disorders are exceedingly deadly because of their complexity. Specifically, eating disorders are highly comorbid with other psychiatric illnesses (up to 95% of individuals with an eating disorder have at least one additional psychiatric illness) and have extremely heterogeneous presentations, and individuals often migrate from one specific eating disorder diagnosis to another. In this Perspective, we propose that understanding eating disorder comorbidity and heterogeneity via a network theory approach offers substantial benefits for both conceptualization and treatment. Such a conceptualization, strongly based on theory, can identify specific pathways that maintain psychiatric comorbidity, how diagnoses vary across individuals, and how specific symptoms and comorbidities can maintain illness in one individual, thereby paving the way for personalized treatment.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Latent and network models of bulimia nervosa.
Fig. 2: A network of eating disorder and social anxiety disorder symptoms.
Fig. 3: Cognitive behaviour and network models of eating disorders.
Fig. 4: Example idiographic networks of an eating disorder and comorbid symptoms.

Similar content being viewed by others

References

  1. Arcelus, J., Mitchell, A. J., Wales, J. & Nielsen, S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Arch. Gen. Psychiat. 68, 724–731 (2011).

    PubMed  Google Scholar 

  2. Smink, F. R. E., van Hoeken, D. & Hoek, H. W. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr. Psychiat. Rep. 14, 406–414 (2012).

    Google Scholar 

  3. Fichter, M. M., Quadflieg, N. & Hedlund, S. Long-term course of binge eating disorder and bulimia nervosa: relevance for nosology and diagnostic criteria. Int. J. Eat. Disord. 41, 577–586 (2008).

    PubMed  Google Scholar 

  4. Suokas, J. T. et al. Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995–2010. Psychiat. Res. 210, 1101–1106 (2013).

    Google Scholar 

  5. Roberts, M. E., Tchanturia, K., Stahl, D., Southgate, L. & Treasure, J. A systematic review and meta-analysis of set-shifting ability in eating disorders. Psychol. Med. 37, 1075–1084 (2007).

    PubMed  Google Scholar 

  6. Rosval, L. et al. Impulsivity in women with eating disorders: problem of response inhibition, planning, or attention? Int. J. Eat. Disord. 39, 590–593 (2006).

    PubMed  Google Scholar 

  7. Tchanturia, K. et al. An investigation of decision making in anorexia nervosa using the Iowa Gambling Task and skin conductance measurements. J. Int. Neuropsychol. Soc. 13, 635–641 (2007).

    PubMed  Google Scholar 

  8. Keel, P. K., Mitchell, J. E., Miller, K. B., Davis, T. L. & Crow, S. J. Social adjustment over 10 years following diagnosis with bulimia nervosa. Int. J. Eat. Disord. 27, 21–28 (2000).

    PubMed  Google Scholar 

  9. de la Rie, S., Noordenbos, G., Donker, M. & van Furth, E. The patient’s view on quality of life and eating disorders. Int. J. Eat. Disord. 40, 13–20 (2007).

    PubMed  Google Scholar 

  10. Klump, K. L., Bulik, C. M., Kaye, W. H., Treasure, J. & Tyson, E. Academy for eating disorders position paper: eating disorders are serious mental illnesses. Int. J. Eat. Disord. 42, 97–103 (2009).

    PubMed  Google Scholar 

  11. Tyler, I., Wiseman, M. C., Crawford, R. I. & Birmingham, C. L. Cutaneous manifestations of eating disorders. J. Cutan. Med. Surg. 6, 345–353 (2002).

    PubMed  Google Scholar 

  12. Lifante-Oliva, C., López-Jornet, P., Camacho-Alonso, F. & Esteve-Salinas, J. Study of oral changes in patients with eating disorders. Int. J. Dent. Hyg. 6, 119–122 (2008).

    PubMed  Google Scholar 

  13. Powers, P. S. Osteoporosis and eating disorders. J. Pediatr. Adolesc. Gynecol. 12, 51–57 (1999).

    PubMed  Google Scholar 

  14. Awazu, M., Matsuoka, S., Kamimaki, T., Watanabe, H. & Matsuo, N. Absent circadian variation of blood pressure in patients with anorexia nervosa. J. Pediatr. 136, 524–527 (2000).

    PubMed  Google Scholar 

  15. Muuss, R. E. Adolescent eating disorder: anorexia nervosa. Adolescence 20, 525–536 (1985).

    PubMed  Google Scholar 

  16. Braude, M. R. et al. Acute medical stabilisation of adults with anorexia nervosa: experience of a defined interdisciplinary model of care. Intern. Med. J. 50, 77–85 (2020).

    PubMed  Google Scholar 

  17. Mitchell, J. E., Pomeroy, C. & Huber, M. A clinician’s guide to the eating disorders medicine cabinet. Int. J. Eat. Disord. 7, 211–223 (1988).

    Google Scholar 

  18. Swenne, I. Poor catch-up growth in late adolescent boys with eating disorders, weight loss and stunting of growth. Eur. Eat. Disord. Rev. 21, 395–398 (2013).

    PubMed  Google Scholar 

  19. Tith, R. M. et al. Association of bulimia nervosa with long-term risk of cardiovascular disease and mortality among women. JAMA Psychiat. 77, 44–51 (2020).

    Google Scholar 

  20. Tabler, J., Utz, R. L., Smith, K. R., Hanson, H. A. & Geist, C. Variation in reproductive outcomes of women with histories of bulimia nervosa, anorexia nervosa, or eating disorder not otherwise specified relative to the general population and closest-aged sisters. Int. J. Eat. Disord. 51, 102–111 (2018).

    PubMed  PubMed Central  Google Scholar 

  21. Porcelli, P., Leandro, G. & De Carne, M. Functional gastrointestinal disorders and eating disorders: relevance of the association in clinical management. Scand. J. Gastroenterol. 33, 577–582 (1998).

    PubMed  Google Scholar 

  22. Coffino, J. A., Udo, T. & Grilo, C. M. Rates of help-seeking in US adults with lifetime DSM-5 eating disorders: prevalence across diagnoses and differences by sex and ethnicity/race. Mayo Clin. Proc. 94, 1415–1426 (2019).

    PubMed  Google Scholar 

  23. van den Berg, E. et al. Meta-analysis on the efficacy of psychological treatments for anorexia nervosa. Eur. Eat. Disord. Rev. 27, 331–351 (2019).

    PubMed  Google Scholar 

  24. McFarlane, T., Olmsted, M. P. & Trottier, K. Timing and prediction of relapse in a transdiagnostic eating disorder sample. Int. J. Eat. Disord. 41, 587–593 (2008).

    PubMed  Google Scholar 

  25. Streatfeild, J. et al. Social and economic cost of eating disorders in the United States: evidence to inform policy action. Int. J. Eat. Disord. 54, 851–868 (2021).

    PubMed  Google Scholar 

  26. Fried, E. I. Lack of theory building and testing impedes progress in the factor and network literature. Psychol. Inq. 31, 271–288 (2020).

    Google Scholar 

  27. Hudson, J. I., Hiripi, E., Pope, H. G. & Kessler, R. C. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biol. Psychiat. 61, 348–358 (2007).

    PubMed  Google Scholar 

  28. Godart, N. T., Flament, M. F., Perdereau, F. & Jeammet, P. Comorbidity between eating disorders and anxiety disorders: a review. Int. J. Eat. Disord. 32, 253–270 (2002).

    PubMed  Google Scholar 

  29. Kaye, W. H., Bulik, C. M., Thornton, L., Barbarich, N. & Masters, K. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am. J. Psychiat. 161, 2215–2221 (2004).

    PubMed  Google Scholar 

  30. Kerr-Gaffney, J., Harrison, A. & Tchanturia, K. Social anxiety in the eating disorders: a systematic review and meta-analysis. Psychol. Med. 48, 2477–2491 (2018).

    PubMed  Google Scholar 

  31. Mandelli, L., Draghetti, S., Albert, U., De Ronchi, D. & Atti, A.-R. Rates of comorbid obsessive-compulsive disorder in eating disorders: a meta-analysis of the literature. J. Affect. Disord. 277, 927–939 (2020).

    PubMed  Google Scholar 

  32. Ruffolo, J. S., Phillips, K. A., Menard, W., Fay, C. & Weisberg, R. B. Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance. Int. J. Eat. Disord. 39, 11–19 (2006).

    PubMed  Google Scholar 

  33. Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D. & Smith, B. N. Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication study. Int. J. Eat. Disord. 45, 307–315 (2012).

    PubMed  Google Scholar 

  34. DeSocio, J. E. Challenges in diagnosis and treatment of comorbid eating disorders and mood disorders. Perspect. Psychiat. Care 55, 494–500 (2019).

    Google Scholar 

  35. McElroy, S. L., Kotwal, R., Keck, P. E. & Akiskal, H. S. Comorbidity of bipolar and eating disorders: distinct or related disorders with shared dysregulations? J. Affect. Disord. 86, 107–127 (2005).

    PubMed  Google Scholar 

  36. McElroy, S. L. et al. Prevalence and correlates of eating disorders in 875 patients with bipolar disorder. J. Affect. Disord. 128, 191–198 (2011).

    PubMed  Google Scholar 

  37. Bleck, J. R., DeBate, R. D. & Olivardia, R. The comorbidity of ADHD and eating disorders in a nationally representative sample. J. Behav. Health Serv. Res. 42, 437–451 (2015).

    PubMed  Google Scholar 

  38. Brewerton, T. D. & Duncan, A. E. Associations between attention deficit hyperactivity disorder and eating disorders by gender: results from the National Comorbidity Survey Replication. Eur. Eat. Disord. Rev. 24, 536–540 (2016).

    PubMed  Google Scholar 

  39. Bahji, A. et al. Prevalence of substance use disorder comorbidity among individuals with eating disorders: a systematic review and meta-analysis. Psychiat. Res. 273, 58–66 (2019).

    Google Scholar 

  40. Cassin, S. & Vonranson, K. Personality and eating disorders: a decade in review. Clin. Psychol. Rev. 25, 895–916 (2005).

    PubMed  Google Scholar 

  41. Sansone, R. A., Levitt, J. L. & Sansone, L. A. The prevalence of personality disorders among those with eating disorders. Eat. Disord. 13, 7–21 (2004).

    Google Scholar 

  42. O’Brien, K. M. & Vincent, N. K. Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships. Clin. Psychol. Rev. 23, 57–74 (2003).

    PubMed  Google Scholar 

  43. Fairburn, C. G., Cooper, Z. & Shafran, R. Cognitive behaviour therapy for eating disorders: a ‘transdiagnostic’ theory and treatment. Behav. Res. Ther. 41, 509–528 (2003).

    PubMed  Google Scholar 

  44. Lock, J. & le Grange, D. Family-based treatment of eating disorders. Int. J. Eat. Disord. 37, S64–S67 (2005).

    PubMed  Google Scholar 

  45. Herzog, D. B., Nussbaum, K. M. & Marmor, A. K. Comorbidity and outcome in eating disorders. Psychiat. Clin. North. Am. 19, 843–859 (1996).

    Google Scholar 

  46. Carr, M. M. & Grilo, C. M. Examining heterogeneity of binge-eating disorder using latent class analysis. J. Psychiat. Res. 130, 194–200 (2020).

    PubMed  Google Scholar 

  47. Riesco, N. et al. Other specified feeding or eating disorders (OSFED): clinical heterogeneity and cognitive-behavioral therapy outcome. Eur. Psychiat. 54, 109–116 (2018).

    Google Scholar 

  48. Sysko, R., Hildebrandt, T., Wilson, G. T., Wilfley, D. E. & Agras, W. S. Heterogeneity moderates treatment response among patients with binge eating disorder. J. Consult. Clin. Psychol. 78, 681–690 (2010).

    PubMed  PubMed Central  Google Scholar 

  49. Fairweather-Schmidt, A. K. & Wade, T. D. DSM-5 eating disorders and other specified eating and feeding disorders: is there a meaningful differentiation? Int. J. Eat. Disord. 47, 524–533 (2014).

    PubMed  Google Scholar 

  50. Thomas, J. J., Vartanian, L. R. & Brownell, K. D. The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM. Psychol. Bull. 135, 407–433 (2009).

    PubMed  PubMed Central  Google Scholar 

  51. Galmiche, M., Déchelotte, P., Lambert, G. & Tavolacci, M. P. Prevalence of eating disorders over the 2000–2018 period: a systematic literature review. Am. J. Clin. Nutr. 109, 1402–1413 (2019).

    PubMed  Google Scholar 

  52. Fairburn, C. G. & Cooper, Z. Eating disorders, DSM-5 and clinical reality. Br. J. Psychiat. 198, 8–10 (2011).

    Google Scholar 

  53. Keel, P. K., Brown, T. A., Holm-Denoma, J. & Bodell, L. P. Comparison of DSM-IV versus proposed DSM-5 diagnostic criteria for eating disorders: reduction of eating disorder not otherwise specified and validity. Int. J. Eat. Disord. 44, 553–560 (2011).

    PubMed  Google Scholar 

  54. Frank, G. K. W., Shott, M. E. & DeGuzman, M. C. The neurobiology of eating disorders. Child. Adolesc. Psychiat. Clin. N. Am. 28, 629–640 (2019).

    Google Scholar 

  55. Brooks, S. J., Rask-Andersen, M., Benedict, C. & Schiöth, H. B. A debate on current eating disorder diagnoses in light of neurobiological findings: is it time for a spectrum model? BMC Psychiat. 12, 76 (2012).

    Google Scholar 

  56. Forbush, K. T. et al. Understanding eating disorders within internalizing psychopathology: a novel transdiagnostic, hierarchical-dimensional model. Compr. Psychiat. 79, 40–52 (2017).

    PubMed  Google Scholar 

  57. Levinson, C. A., Vanzhula, I. & Brosof, L. C. Longitudinal and personalized networks of eating disorder cognitions and behaviors: targets for precision intervention a proof of concept study. Int. J. Eat. Disord. 51, 1233–1243 (2018).

    PubMed  Google Scholar 

  58. Wilson, G. T., Grilo, C. M. & Vitousek, K. M. Psychological treatment of eating disorders. Am. Psychol. 62, 199–216 (2007).

    PubMed  Google Scholar 

  59. Keel, P. K. & Mitchell, J. E. Outcome in bulimia nervosa. Am. J. Psychiat. 154, 313–321 (1997).

    PubMed  Google Scholar 

  60. Keel, P. K., Dorer, D. J., Franko, D. L., Jackson, S. C. & Herzog, D. B. Postremission predictors of relapse in women with eating disorders. Am. J. Psychiat. 162, 2263–2268 (2005).

    PubMed  Google Scholar 

  61. Carter, J. C. et al. A prospective study of predictors of relapse in anorexia nervosa: implications for relapse prevention. Psychiat. Res. 200, 518–523 (2012).

    Google Scholar 

  62. Eddy, K. T. et al. Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. Am. J. Psychiat. 165, 245–250 (2008).

    PubMed  Google Scholar 

  63. Plessow, F. & Eddy, K. T. in Encyclopedia of Feeding and Eating Disorders (ed. Wade, T.) (Springer, 2016).

  64. Castellini, G. et al. Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study. Psychosom. Med. 73, 270–279 (2011).

    PubMed  Google Scholar 

  65. Tozzi, F. et al. Symptom fluctuation in eating disorders: correlates of diagnostic crossover. Am. J. Psychiat. 162, 732–740 (2005).

    PubMed  Google Scholar 

  66. Stice, E., Marti, C. N., Shaw, H. & Jaconis, M. An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. J. Abnorm. Psychol. 118, 587–597 (2009).

    PubMed  PubMed Central  Google Scholar 

  67. Bulik, C. M., Sullivan, P. F., Fear, J. & Pickering, A. Predictors of the development of bulimia nervosa in women with anorexia nervosa. J. Nerv. Ment. Dis. 185, 704–707 (1997).

    PubMed  Google Scholar 

  68. Strober, M., Freeman, R. & Morrell, W. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10–15 years in a prospective study. Int. J. Eat. Disord. 22, 339–360 (1997).

    PubMed  Google Scholar 

  69. Forbush, K. T. et al. A new approach to eating-disorder classification: using empirical methods to delineate diagnostic dimensions and inform care. Int. J. Eat. Disord. 51, 710–721 (2018).

    PubMed  Google Scholar 

  70. Milos, G., Spindler, A., Schnyder, U. & Fairburn, C. G. Instability of eating disorder diagnoses: prospective study. Br. J. Psychiat. 187, 573–578 (2005).

    Google Scholar 

  71. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th edn (American Psychiatric Association, 2013).

  72. Borsboom, D. & Cramer, A. O. J. Network analysis: an integrative approach to the structure of psychopathology. Annu. Rev. Clin. Psychol. 9, 91–121 (2013).

    PubMed  Google Scholar 

  73. Bringmann, L. F. & Eronen, M. I. Don’t blame the model: reconsidering the network approach to psychopathology. Psychol. Rev. 125, 606–615 (2018).

    PubMed  Google Scholar 

  74. Borsboom, D. A network theory of mental disorders. World Psychiat. 16, 5–13 (2017).

    Google Scholar 

  75. Jones, P. J. & Robinaugh, D. R. An answer to “so what?” implications of network theory for research and practice. FOCUS 19, 204–210 (2021).

    PubMed  Google Scholar 

  76. Epskamp, S., Borsboom, D. & Fried, E. I. Estimating psychological networks and their accuracy: a tutorial paper. Behav. Res. Methods 50, 195–212 (2018).

    PubMed  Google Scholar 

  77. Guyon, H., Falissard, B. & Kop, J.-L. Modeling psychological attributes in psychology — an epistemological discussion: network analysis vs. latent variables. Front. Psychol. 8, 798 (2017).

    PubMed  PubMed Central  Google Scholar 

  78. Costantini, G. et al. State of the aRt personality research: a tutorial on network analysis of personality data in R. J. Res. Personal. 54, 13–29 (2015).

    Google Scholar 

  79. Cramer, A. O. J. et al. Dimensions of normal personality as networks in search of equilibrium: you can’t like parties if you don’t like people. Eur. J. Personal. 26, 414–431 (2012).

    Google Scholar 

  80. van Bork, R. et al. Latent variable models and networks: statistical equivalence and testability. Multivar. Behav. Res. 56, 175–198 (2021).

    Google Scholar 

  81. Burger, J. et al. Bridging the gap between complexity science and clinical practice by formalizing idiographic theories: a computational model of functional analysis. BMC Med. 18, 99 (2020).

    PubMed  PubMed Central  Google Scholar 

  82. Levinson, C. A., Vanzhula, I. A., Brosof, L. C. & Forbush, K. Network analysis as an alternative approach to conceptualizing eating disorders: implications for research and treatment. Curr. Psychiat. Rep. 20, 67 (2018).

    Google Scholar 

  83. Cramer, A. O. J., Waldorp, L. J., van der Maas, H. L. J. & Borsboom, D. Comorbidity: a network perspective. Behav. Brain Sci. 33, 137–150 (2010).

    PubMed  Google Scholar 

  84. Keel, P. K. & Brown, T. A. Update on course and outcome in eating disorders. Int. J. Eat. Disord. 43, 195–204 (2010).

    PubMed  Google Scholar 

  85. Roy-Byrne, P. P. et al. Lifetime panic–depression comorbidity in the National Comorbidity Survey: association with symptoms, impairment, course and help-seeking. Br. J. Psychiat. 176, 229–235 (2000).

    Google Scholar 

  86. Nock, M. K., Hwang, I., Sampson, N. A. & Kessler, R. C. Mental disorders, comorbidity and suicidal behavior: results from the national comorbidity survey replication. Mol. Psychiat. 15, 868–876 (2010).

    Google Scholar 

  87. Kessler, R. C. et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch. Gen. Psychiat. 62, 593–602 (2005).

    PubMed  Google Scholar 

  88. Jones, P. J., Ma, R. & McNally, R. J. Bridge centrality: a network approach to understanding comorbidity. Multivar. Behav. Res. 56, 353–367 (2021).

    Google Scholar 

  89. Plana-Ripoll, O. et al. Exploring comorbidity within mental disorders among a Danish national population. JAMA Psychiat. 76, 259–270 (2019).

    Google Scholar 

  90. van Loo, H. M., Romeijn, J.-W., de Jonge, P. & Schoevers, R. A. Psychiatric comorbidity and causal disease models. Prev. Med. 57, 748–752 (2013).

    PubMed  Google Scholar 

  91. Lilienfeld, S. O. The Research Domain Criteria (RDoC): an analysis of methodological and conceptual challenges. Behav. Res. Ther. 62, 129–139 (2014).

    PubMed  Google Scholar 

  92. Pallister, E. & Waller, G. Anxiety in the eating disorders: understanding the overlap. Clin. Psychol. Rev. 28, 366–386 (2008).

    PubMed  Google Scholar 

  93. Bulik, C. M., Sullivan, P. F., Fear, J. L. & Joyce, P. R. Eating disorders and antecedent anxiety disorders: a controlled study. Acta Psychiatr. Scand. 96, 101–107 (1997).

    PubMed  Google Scholar 

  94. Levinson, C. A. & Rodebaugh, T. L. Social anxiety and eating disorder comorbidity: the role of negative social evaluation fears. Eat. Behav. 13, 27–35 (2012).

    PubMed  Google Scholar 

  95. Konstantellou, A., Campbell, M., Eisler, I., Simic, M. & Treasure, J. Testing a cognitive model of generalized anxiety disorder in the eating disorders. J. Anxiety Disord. 25, 864–869 (2011).

    PubMed  Google Scholar 

  96. Vanzhula, I. A., Calebs, B., Fewell, L. & Levinson, C. A. Illness pathways between eating disorder and post-traumatic stress disorder symptoms: understanding comorbidity with network analysis. Eur. Eat. Disord. Rev. 27, 147–160 (2019).

    PubMed  Google Scholar 

  97. Levinson, C. A. et al. Social anxiety and eating disorder comorbidity and underlying vulnerabilities: using network analysis to conceptualize comorbidity. Int. J. Eat. Disord. 51, 693–709 (2018).

    PubMed  Google Scholar 

  98. Meier, M. et al. Obsessive–compulsive symptoms in eating disorders: a network investigation. Int. J. Eat. Disord. 53, 362–371 (2020).

    PubMed  Google Scholar 

  99. Vanzhula, I. A., Kinkel-Ram, S. S. & Levinson, C. A. Perfectionism and difficulty controlling thoughts bridge eating disorder and obsessive-compulsive disorder symptoms: a network analysis. J. Affect. Disord. 283, 302–309 (2021).

    PubMed  Google Scholar 

  100. Forrest, L. N., Sarfan, L. D., Ortiz, S. N., Brown, T. A. & Smith, A. R. Bridging eating disorder symptoms and trait anxiety in patients with eating disorders: a network approach. Int. J. Eat. Disord. 52, 701–711 (2019).

    PubMed  Google Scholar 

  101. Levinson, C. A. et al. The core symptoms of bulimia nervosa, anxiety, and depression: a network analysis. J. Abnorm. Psychol. 126, 340–354 (2017).

    PubMed  PubMed Central  Google Scholar 

  102. Ralph-Nearman, C., Williams, B. M., Ortiz, A. M. L., Smith, A. R. & Levinson, C. A. Pinpointing core and pathway symptoms among sleep disturbance, anxiety, worry, and eating disorder symptoms in anorexia nervosa and atypical anorexia nervosa. J. Affect. Disord. 294, 24–32 (2021).

    PubMed  Google Scholar 

  103. Sahlan, R. N. et al. Disordered eating, self-esteem, and depression symptoms in Iranian adolescents and young adults: a network analysis. Int. J. Eat. Disord. 54, 132–147 (2021).

    PubMed  Google Scholar 

  104. Cusack, C. E., Christian, C., Drake, J. E. & Levinson, C. A. A network analysis of eating disorder symptoms and co-occurring alcohol misuse among heterosexual and sexual minority college women. Addict. Behav. 118, 106867 (2021).

    PubMed  Google Scholar 

  105. Levinson, C. A. et al. Eating disorder symptoms and core eating disorder fears decrease during online imaginal exposure therapy for eating disorders. J. Affect. Disord. 276, 585–591 (2020).

    PubMed  Google Scholar 

  106. Beltz, A. M., Moser, J. S., Zhu, D. C., Burt, S. A. & Klump, K. L. Using person-specific neural networks to characterize heterogeneity in eating disorders: illustrative links between emotional eating and ovarian hormones. Int. J. Eat. Disord. 51, 730–740 (2018).

    PubMed  PubMed Central  Google Scholar 

  107. Levinson, C. A., Vanzhula, I. A., Smith, T. W. & Stice, E. Group and longitudinal intra-individual networks of eating disorder symptoms in adolescents and young adults at-risk for an eating disorder. Behav. Res. Ther. 135, 103731 (2020).

    PubMed  PubMed Central  Google Scholar 

  108. Fichter, M. M. & Quadflieg, N. How precisely can psychotherapists predict the long-term outcome of anorexia nervosa and bulimia nervosa at the end of inpatient treatment? Int. J. Eat. Disord. 54, 535–544 (2021).

    PubMed  Google Scholar 

  109. Nakash, O. & Saguy, T. Social identities of clients and therapists during the mental health intake predict diagnostic accuracy. Soc. Psychol. Personal. Sci. 6, 710–717 (2015).

    Google Scholar 

  110. Featherston, R., Downie, L. E., Vogel, A. P. & Galvin, K. L. Decision making biases in the allied health professions: a systematic scoping review. PLoS ONE 15, e0240716 (2020).

    PubMed  PubMed Central  Google Scholar 

  111. Molenaar, P. C. M. A manifesto on psychology as idiographic science: bringing the person back into scientific psychology, this time forever. Meas. Interdiscip. Res. Perspect. 2, 201–218 (2004).

    Google Scholar 

  112. Fried, E. I. & Cramer, A. O. J. Moving forward: challenges and directions for psychopathological network theory and methodology. Perspect. Psychol. Sci. 12, 999–1020 (2017).

    PubMed  Google Scholar 

  113. Epskamp, S. et al. Personalized network modeling in psychopathology: the importance of contemporaneous and temporal connections. Clin. Psychol. Sci. 6, 416–427 (2018).

    PubMed  PubMed Central  Google Scholar 

  114. Epskamp, S., Waldorp, L. J., Mõttus, R. & Borsboom, D. The Gaussian graphical model in cross-sectional and time-series data. Multivar. Behav. Res. 53, 453–480 (2018).

    Google Scholar 

  115. Fisher, A. J. et al. Exploring the idiographic dynamics of mood and anxiety via network analysis. J. Abnorm. Psychol. 126, 1044–1056 (2017).

    PubMed  Google Scholar 

  116. Bringmann, L. F. et al. A network approach to psychopathology: new insights into clinical longitudinal data. PLoS ONE 8, e60188 (2013).

    PubMed  PubMed Central  Google Scholar 

  117. Piccirillo, M. L. & Rodebaugh, T. L. Foundations of idiographic methods in psychology and applications for psychotherapy. Clin. Psychol. Rev. 71, 90–100 (2019).

    PubMed  Google Scholar 

  118. Piccirillo, M. L., Beck, E. D. & Rodebaugh, T. L. A clinician’s primer for idiographic research: considerations and recommendations. Behav. Ther. 50, 938–951 (2019).

    PubMed  Google Scholar 

  119. Bringmann, L. F. Person-specific networks in psychopathology: past, present, and future. Curr. Opin. Psychol. 41, 59–64 (2021).

    PubMed  Google Scholar 

  120. Robinaugh, D. J., Hoekstra, R. H. A., Toner, E. R. & Borsboom, D. The network approach to psychopathology: a review of the literature 2008–2018 and an agenda for future research. Psychol. Med. 50, 353–366 (2020).

    PubMed  Google Scholar 

  121. Burger, J. et al. A clinical PREMISE for personalized models: towards a formal integration of case formulations and statistical networks. Preprint at PsyArXiv https://doi.org/10.31234/osf.io/bdrs7 (2021).

    Article  Google Scholar 

  122. Beck, A. T. Cognitive therapy: past, present, and future. J. Consult. Clin. Psychol. 61, 194–198 (1993).

    PubMed  Google Scholar 

  123. Linehan, M. M. in Cognitive-Behavioral Treatment Of Borderline Personality Disorder 558 (Guilford, 1993).

  124. Hayes, S. C., Strosahl, K. D., Bunting, K., Twohig, M. & Wilson, K. G. What is acceptance and commitment therapy? In A Practical Guide to Acceptance and Commitment Therapy (eds Hayes, S. C. & Strosahl, K. D.) 3–29 (Springer, 2004).

  125. Wright, J. H. Cognitive behavior therapy: basic principles and recent advances. Focus 4, 173–178 (2006).

    Google Scholar 

  126. Beck, J. S. & Beck, J. S. Cognitive Behavior Therapy: Basics and Beyond (Guilford, 2011).

  127. Wenzel, A. Modification of core beliefs in cognitive therapy. In Standard and Innovative Strategies in Cognitive Behavior Therapy (ed. de Oliveira, I. R.) 17–34 (InTech, 2012).

  128. Beck, A. T. The current state of cognitive therapy: a 40-year retrospective. Arch. Gen. Psychiat. 62, 953–959 (2005).

    PubMed  Google Scholar 

  129. Hopko, D. R., Lejuez, C. W., Ruggiero, K. J. & Eifert, G. H. Contemporary behavioral activation treatments for depression: procedures, principles, and progress. Clin. Psychol. Rev. 23, 699–717 (2003).

    PubMed  Google Scholar 

  130. Fried, E. I. et al. Mental disorders as networks of problems: a review of recent insights. Soc. Psychiat. Psychiatr. Epidemiol. 52, 1–10 (2017).

    Google Scholar 

  131. Halmi, K. A. Salient components of a comprehensive service for eating disorders. World Psychiatr. Assoc. 8, 150–155 (2009).

    Google Scholar 

  132. Anderson, L. K. et al. Treating eating disorders at higher levels of care: overview and challenges. Curr. Psychiat. Rep. 19, 48 (2017).

    Google Scholar 

  133. Walfish, S., McAlister, B., O’Donnell, P. & Lambert, M. J. An investigation of self-assessment bias in mental health providers. Psychol. Rep. 110, 639–644 (2012).

    PubMed  Google Scholar 

  134. Fernandez, K. C., Fisher, A. J. & Chi, C. Development and initial implementation of the Dynamic Assessment Treatment Algorithm (DATA). PLoS ONE 12, e0178806 (2017).

    PubMed  PubMed Central  Google Scholar 

  135. Garb, H. N. Clinical judgment and decision making. Annu. Rev. Clin. Psychol. 1, 67–89 (2005).

    PubMed  Google Scholar 

  136. Dawes, R. M., Faust, D. & Meehl, P. E. Clinical versus actuarial judgment. Science 243, 1668–1674 (1989).

    PubMed  Google Scholar 

  137. Kraus, D. R. et al. Predicting therapist effectiveness from their own practice-based evidence. J. Consult. Clin. Psychol. 84, 473–483 (2016).

    PubMed  Google Scholar 

  138. Constantino, M. J., Boswell, J. F., Coyne, A. E., Swales, T. P. & Kraus, D. R. Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes: a randomized clinical trial. JAMA Psychiat. 78, 960–969 (2021).

    Google Scholar 

  139. Bulik, C. M., Berkman, N. D., Brownley, K. A., Sedway, J. A. & Lohr, K. N. Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int. J. Eat. Disord. 40, 310–320 (2007).

    PubMed  Google Scholar 

  140. Kaye, W. H. & Bulik, C. M. Treatment of patients with anorexia nervosa in the US — a crisis in care. JAMA Psychiat. 78, 591 (2021).

    Google Scholar 

  141. Fairburn, C. G. Evidence-based treatment of anorexia nervosa. Int. J. Eat. Disord. 37, S26–S30 (2005).

    PubMed  Google Scholar 

  142. Levinson, C. A. et al. Using individual networks to identify treatment targets for eating disorder treatment: a proof-of-concept study and initial data. J. Eat. Disord. 9, 147 (2021).

    PubMed  PubMed Central  Google Scholar 

  143. Frumkin, M. R., Piccirillo, M. L., Beck, E. D., Grossman, J. T. & Rodebaugh, T. L. Feasibility and utility of idiographic models in the clinic: a pilot study. Psychother. Res. J. Soc. Psychother. Res. 31, 520–534 (2021).

    Google Scholar 

  144. Galatzer-Levy, I. R. & Bryant, R. A. 636,120 ways to have posttraumatic stress disorder. Perspect. Psychol. Sci. 8, 651–662 (2013).

    PubMed  Google Scholar 

  145. Kotov, R. et al. The Hierarchical Taxonomy of Psychopathology (HiTOP): a dimensional alternative to traditional nosologies. J. Abnorm. Psychol. 126, 454–477 (2017).

    PubMed  Google Scholar 

  146. Conway, C. C. & Krueger, R. F. Rethinking the diagnosis of mental disorders: data-driven psychological dimensions, not categories, as a framework for mental-health research, treatment, and training. Curr. Dir. Psychol. Sci. 30, 151–158 (2021).

    Google Scholar 

  147. Rubel, J. A., Fisher, A. J., Husen, K. & Lutz, W. Translating person-specific network models into personalized treatments: development and demonstration of the dynamic assessment treatment algorithm for individual networks (DATA-IN). Psychother. Psychosom. 87, 249–251 (2018).

    PubMed  Google Scholar 

  148. Bringmann, L. F. et al. What do centrality measures measure in psychological networks? J. Abnorm. Psychol. 128, 892–903 (2019).

    PubMed  Google Scholar 

  149. Levinson, C. A. et al. Longitudinal group and individual networks of eating disorder symptoms in individuals diagnosed with an eating disorder. J. Psychopathol. Clin. Sci. 131, 58–72 (2022).

    PubMed  Google Scholar 

  150. Spiller, T. R. et al. On the validity of the centrality hypothesis in cross-sectional between-subject networks of psychopathology. BMC Med. 18, 297 (2020).

    PubMed  PubMed Central  Google Scholar 

  151. Levinson, C. A. et al. Personalized networks of eating disorder symptoms predicting eating disorder outcomes and remission. Int. J. Eat. Disord. 53, 2086–2094 (2020).

    PubMed  PubMed Central  Google Scholar 

  152. Klintwall, L., Bellander, M. & Cervin, M. Perceived causal problem networks: reliability, central problems, and clinical utility for depression. Assessment https://doi.org/10.1177/10731911211039281 (2021).

  153. Lunansky, G. et al. Intervening on psychopathology networks: evaluating intervention targets through simulations. Methods https://doi.org/10.1016/j.ymeth.2021.11.006 (2021).

  154. Mansueto, A. C., Wiers, R. W., van Weert, J. C. M., Schouten, B. C. & Epskamp, S. Investigating the feasibility of idiographic network models. Psychol. Methods https://doi.org/10.1037/met0000466 (2022).

    Article  PubMed  Google Scholar 

  155. Quax, R., Apolloni, A. & Sloot, P. M. A. The diminishing role of hubs in dynamical processes on complex networks. J. R. Soc. Interface 10, 20130568 (2013).

    PubMed  PubMed Central  Google Scholar 

  156. Wright, A. G. C. et al. The hierarchical structure of DSM-5 pathological personality traits. J. Abnorm. Psychol. 121, 951–957 (2012).

    PubMed  PubMed Central  Google Scholar 

  157. Godart, N. T. et al. Anxiety disorders in subjects seeking treatment for eating disorders: a DSM-IV controlled study. Psychiat. Res. 117, 245–258 (2003).

    Google Scholar 

  158. Godart, N. T., Flament, M. F., Lecrubier, Y. & Jeammet, P. Anxiety disorders in anorexia nervosa and bulimia nervosa: co-morbidity and chronology of appearance. Eur. Psychiat. J. Assoc. Eur. Psychiat. 15, 38–45 (2000).

    Google Scholar 

  159. Swinbourne, J. M. & Touyz, S. W. The co-morbidity of eating disorders and anxiety disorders: a review. Eur. Eat. Disord. Rev. 15, 253–274 (2007).

    PubMed  Google Scholar 

  160. Shah, R. & Zanarini, M. C. Comorbidity of borderline personality disorder. Psychiat. Clin. North. Am. 41, 583–593 (2018).

    Google Scholar 

  161. McNally, R. J. Can network analysis transform psychopathology? Behav. Res. Ther. 86, 95–104 (2016).

    PubMed  Google Scholar 

  162. Contreras, A., Nieto, I., Valiente, C., Espinosa, R. & Vazquez, C. The study of psychopathology from the network analysis perspective: a systematic review. Psychother. Psychosom. 88, 71–83 (2019).

    PubMed  Google Scholar 

  163. von Klipstein, L., Borsboom, D. & Arntz, A. The exploratory value of cross-sectional partial correlation networks: predicting relationships between change trajectories in borderline personality disorder. PLoS ONE 16, e0254496 (2021).

    Google Scholar 

  164. Boschloo, L., van Borkulo, C. D., Borsboom, D. & Schoevers, R. A. A prospective study on how symptoms in a network predict the onset of depression. Psychother. Psychosom. 85, 183–184 (2016).

    PubMed  Google Scholar 

  165. van Borkulo, C. et al. Association of symptom network structure with the course of depression. JAMA Psychiat. 72, 1219–1226 (2015).

    Google Scholar 

  166. Fried, E. I. Moving forward: how depression heterogeneity hinders progress in treatment and research. Expert Rev. Neurother. 17, 423–425 (2017).

    PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank all of our participants and patients who have helped us formulate these ideas. The authors also thank the EAT lab for providing support, collaboration and an environment focused on positive change.

Author information

Authors and Affiliations

  1. Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY, USA

    Cheri A. Levinson, Claire Cusack & Mackenzie L. Brown

  2. Department of Psychology, Auburn University, Auburn, AL, USA

    April R. Smith

Authors
  1. Cheri A. Levinson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Claire Cusack
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mackenzie L. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. April R. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

C.A.L. researched data for the article. C.A.L., C.C. and M.L.B. wrote the article. All authors reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Cheri A. Levinson.

Ethics declarations

Competing interests

The authors declare no competing interests.

Peer review

Peer review information

Nature Reviews Psychology thanks the anonymous reviewers for their contribution to the peer review of this work.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Levinson, C.A., Cusack, C., Brown, M.L. et al. A network approach can improve eating disorder conceptualization and treatment. Nat Rev Psychol 1, 419–430 (2022). https://doi.org/10.1038/s44159-022-00062-y

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s44159-022-00062-y

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing