Food review of Brownies(1200字)

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Food Review of Brownies

The moment we came into the classroom, we saw a big square plate covered with a silver paper. “What’s that?”I wondered. The air was filled with the sweet smell of chocolate, which was my favorite. We felt my stomach growling.

Then, Karen distributed a small piece of Brownie to each one of us. We rushed to the table first and took the biggest one. But Karen did not allow us to eat right away. “Oh no, it’s so terrible!”we said to ourselves. It was the most painful thing in the world that one wasn’t permitted to eat his favorite food. We had no choice but to wait, and swallowed fiercely.

Finally, fifteen minutes later, Karen allowed us to eat the Brownie. We grabbed the Brownie directly and took one big bit. Yum, the outside of the Brownie was a little bit hard, but it tasted good. We went on eating. The inside part was much softer and sweeter, quite to my taste. After putting the Brownie into my mouth, it melted quickly, thus we swallowed the whole Brownie in one breath. It was so wonderful!

After eating, I burped with satisfaction. My mouth was full of sweet Brownie smell, and we really enjoyed this feeling. We look forward to Karen’s cooking skill next time.


第二篇:systematic review and meta-analysis of cognitive bias to food stimuli 62600字

ClinicalPsychologyReview31(2011)37–51

ContentslistsavailableatScienceDirect

ClinicalPsychologyReview

Asystematicreviewandmeta-analysisofcognitivebiastofoodstimuliinpeoplewithdisorderedeatingbehaviour

SamanthaBrooksa,?,AlexisPrinceb,DanielStahlc,IainC.Campbella,JanetTreasurea,d

a

EatingDisordersUnit,InstituteofPsychiatry,King'sCollege,London,UK

NutritionalSciencesDivision,Franklin-WilkinsBuilding,LondonKing'sCollege,London,UKc

DepartmentofBiostatistics,InstituteofPsychiatry,King'sCollege,London,UKd

GuysKingsandStThomas'MedicalSchool,King'sCollegeLondon,UK

b

articleinfoabstract

Aim:Maladaptivecognitionsaboutfood,weightandshapebiasattention,memoryandjudgmentandmaybelinkedtodisorderedeatingbehaviour.Thispaperreviewsinformationprocessingoffoodstimuli(words,pictures)inpeoplewitheatingdisorders(ED).

Method:PubMed,Ovid,ScienceDirect,PsychInfo,WebofScience,CochraneLibraryandGoogleScholarweresearchedtoDecember2009.63studiesmeasuredattention,memoryandjudgmentbiastowardsfoodstimuliinwomenwithED.

Results:Strooptaskshadsuf?cientsamplesizeforameta-analysesandeffectsrangedfromsmalltomedium.Otherstudiesofattentionbiashadvariableeffects(e.g.theDot-Probetask,distractertasksandStartleEyeblinkModulation).Ameta-analysisofmemorybiasstudiesinEDandREyieldedinsigni?canteffect.Effectsizesforjudgmentbiasrangedfromnegligibletolarge.

Conclusions:PeoplewithEDhavegreaterattentionalbiastofoodstimulithanhealthycontrols(HC).EvidenceforamemoryandjudgmentbiasinEDislimited.

?2010ElsevierLtd.Allrightsreserved.

Articlehistory:

Received11March2010

Receivedinrevisedform23August2010Accepted15September2010Keywords:

AnorexianervosaBulimianervosaCognitivebiasRestrainedeatersAttentionMemoryJudgment

Contents1.2.

Introduction.............Method...............2.1.Searching...........2.2.Selection...........

2.2.1.Eligibilitycriteria...

2.3.Dataabstraction........2.4.Studycharacteristics......2.5.Quantitativedatasynthesis..Results...............3.1.Generaldemographics....Attentionalbias...........4.1.TheStrooptask........

4.1.1.AN&BNpopulations.4.1.2.Restrained(RE)versus

4.2.TheDot-Probetask......

4.2.1.AN&BNpopulations.4.2.2.Restrained(RE)versus

4.3.Distractertasks........

4.3.1.AN&BNpopulations.4.3.2.Restrained(RE)versus

.............

............................................................................................................................................................UnrestrainedEaters(uRE)..........................UnrestrainedEaters(uRE)..........................UnrestrainedEaters(uRE)

....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................3839394040404040414141414141414141414147

3.4.

?Correspondingauthor.EatingDisordersUnit,InstituteofPsychiatry,16DeCrespignyPark,DenmarkHill,LondonSE58AF,UK.Tel.:+442078480653;fax:+442078480182.E-mailaddress:Samantha.brooks@kcl.ac.uk(S.

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

Brooks).0272-7358/$–seefrontmatter?2010ElsevierLtd.Allrightsreserved.doi:

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

10.1016/j.cpr.2010.09.006

38S.Brooksetal./ClinicalPsychologyReview31(2011)37–51

Memorybias......................5.1.AN&BNpopulations..............5.2.Restrained(RE)versusUnrestrainedEaters(uRE).6.Judgmentbias.....................

6.1.Perceptualestimationtask............

6.1.1.AN&BNpopulations..........6.1.2.Restrained(RE)versusUnrestrainedEaters

6.2.Thoughtverbalisation..............

6.2.1.AN&BNpopulations..........6.2.2.Restrained(RE)versusUnrestrainedEaters

6.3.Foodcuereactivity................

6.3.1.AN&BNpopulations..........6.3.2.Restrained(RE)versusUnrestrainedEaters

7.Discussion.......................

7.1.Comparisonwithpreviousreviews........7.2.Limitations...................7.3.Sensitivityofmethods..............7.4.Clinicalimplications...............

7.4.1.Attentionalbias.............7.4.2.Memorybias..............

7.5.Implicationsofprocessingbiasesinnon-clinicalRE7.6.Conclusions...................References.........................

5.

........................(uRE)........(uRE).........(uRE)............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4747474747474747474747474748484848494949494949

1.Introduction

Dysfunctionalattitudesregardingweightshapeandeating,forexampleconcernsaboutfood,weightgain,misperceptionsregardingthebodyandobsessionsaboutthinnessarediagnosticcriteriaforeatingdisorders(ED)(AmericanPsychiatricAssociation,1994).RobustprospectiveevidenceexistsforthecontributionofweightconcerntothedevelopmentandmaintenanceofED(Goldfein,Walsh,&Midlarsky,2000;Gowers&Shore,2001;Jacobi,Paul,De,Nutzinger,&Dahme,2004).

CognitivetheoriesrelatedtoED(Fairburn,Cooper,&Shafran,2003;Vitousek&Orimoto,1993)proposethatelaborate,inaccuratecognitivestructuresormaladaptiveschemataunderpincommonconcernsaboutweight,shapeandeating.Overuseofmaladaptiveschematamaycausetheseconcernstobecomehabitualandautomatic(Williamson,Muller,Reas,&Thaw,1999),biasingattention,memoryandjudgmentregardingED-relatedstimulisuchasfood.ProcessingbiasesrelatedtofoodstimulimaycontributetothedevelopmentandmaintenanceofED(Vitousek&Orimoto,1993),andsusceptibilitytocognitivebiasesmayactasabiomarkerforEDs.

Thereissomeevidencethatbulimianervosa(BN)isaculturally-boundWesternphenomenon,whereasanorexianervosa(AN)islikelytobemorestronglylinkedtoheritablefactors(Keel&Klump,2003).Somedisorderedeatingbehaviourmaythereforebelinkedtoanabundanceoffood-relatedstimuli(e.g.advertisementsandtheavailabilityofhighlypalatablefood)inWesternsocieties.Cognitiveprocessingoffood-relatedstimulimightincreasedopaminereleaseinthebrainassociatedwithincentivesaliency–theabilityofastimulustoelicitareward-drivenresponse(Berridge,2009;Wise,2006).

Biasedinformationprocessingoffood-relatedstimuli(e.g.relatedtoattention,memoryandjudgment)maybeconcomitantwithdifferentialpsychologicalfunction(e.g.excessivecognitiverestrictionandcontrolofeatingversusimpulsivity)inthosewhoareatriskofdevelopingANorBN.Forexample,forthosewhoareatriskofdevelopingAN,acognitivebiastofoodstimulimightre?ectrigidcognitivestrategieslinkedtocognitiverestrictionofappetitiveprocesses.Conversely,thosewhohaveimpulsiveappetitivetenden-ciesandareatriskofdevelopingBNmightexperiencedisruptiontocognitiveprocessesinresponsetofoodstimuli,astheymaybelessabletomaintainattention,memoryandjudgment.VariousexperimentalparadigmsexamineinformationprocessingtofoodstimulibothinpeoplewithanEDandinpeopleathighriskbutwithoutphysiologicalcomplicationsthatmayin?uencecognitions.Forexample,restrainedeaters(RE)whoseweightisinthenormalrangebutwhorestrictfoodintake.Attentionbiasreferstohowsalientstimuliarepreferentiallyprocessedsothatthefocusofattentionin?uencesresponses(Macleod,Mathews,&Tata,1986).Othermeasuresofattentionbiasusedistractertaskstodeterminewhetherdisease-relatedstimulicandrawattentionawayfromatargetstimulus(e.g.Smeets,Roefs,Van,&Jansen,2008).

MemoryandjudgmentbiasesarethetwoothercognitivedomainsextensivelystudiedinED(Williamsonetal.,1999),butsomewhatneglectedinpreviousreviews.Informationrelatedtoanindividual'sconcernsmaybeencodedmorereadilyinmemoryandeasiertorecall.Judgmentbiasreferstotheperceptionofbody-andfood-relatedstimuliandhowperceptionisalteredinrelationtoanindividual'scurrentconcernsormaladaptiveschemata.

EarlierreviewshavereportedattentionalbiasinEDpopulationsandatrisknon-clinicalgroupsusingStrooptasks.OnequalitativereviewfoundthatinpeoplewithANinterferenceismostrobustforfood-relatedstimuli,whereasinpeoplewithBNitisstrongestforbody-relatedwordsandinpeoplewithnon-clinicalREinterferenceforfoodwordsisequivalenttowomenwithANbutforbody-relatedwordsisvirtuallynon-existent(Faunce,2002).

Ameta-analysisof28Stroopstudieswithpositiveandnegativebody-andfood-relatedstimuliinANandBNandnon-clinicalRE(Dobson&Dozois,2004)foundthatbothbody-andfood-relatedstimulicauseequivalentattentionalbiasinpeoplewithBN,butgreatereffectforbody/weightthanfoodstimuliinpeoplewithAN;attentionalbiasinREtoanystimuliwasvirtuallynon-existent.

Alatermeta-analysisexaminedStroopstudiesusingfoodandbody-relatedstimuliwithnegativeovertones(e.g.relatedtoweightconcerns)in27studies:ED,non-eatingdisorderedwomenwithconcernsabouttheirbodiesandeating,andHCwereexamined.(Johansson,Ghaderi,&Andersson,2005).Themeaninterferencescoreacrossbody-andfood-relatedstimuliinwomenwithEDwassigni?cantlylargerthaninnon-EDwomenwithbodyandshapeconcernsandnormalcontrols.

Anothermeta-analysisextendedthese?ndingswithattentionandmemorybiasesinEDandnon-clinicalgroupsusingStroop(n=27),Dot-Probe(n=4)andmemorytasks(n=6)(Lee&Shafran,2004).

S.Brooksetal./ClinicalPsychologyReview31(2011)37–5139

EDpopulationsandnon-clinicalsampleswithEDpathology(e.g.restrainedeating,highdriveforthinnessandchronicdieters)takelongertonameeating-,weight-andshape-relatedwords.Dot-Probestudiesarecomparativelysparse,butmorerobustthantheStroopatmeasuringdisorderseverity.Therewassomeindicationofmemorybiasesforeating-relatedstimuliinEDandnon-clinicalsamples.

Thisreviewextendspreviousreviewsbyconsideringparadigmsexaminingthesalienceofdisease-relatedstimuliinpeoplewithdisorderedeatingbehaviour,thatis,thedegreetowhichtherelevanceofstimuliin?uencesinformationprocessing(attention,memoryandperceptualjudgment).Otherparadigmsexaminethevalenceofdisease-relatedstimuliinpeoplewithdisorderedeatingbehaviour,thatis,whethertheirattitudeormoodtowardsthestimulusispositiveornegative.Forexample,theImplicitAssociationTest(IAT:Greenwald,1998)andtheAffectiveSimonTask(DeHouwer,2003)aretwopopularmethods.Valencyencompassesanevaluationofthemeritofastimulus,whereassaliencyinvolvesthe‘strengthofrelevance’(e.g.whetherthestimulusdisruptscognitivefunctionornot).Food-andnotbody-relatedstimuliwereincludedinthisreview,inordertosummarisetheeffectsofappetitiveprocessesoncognitivefunctionsinpeoplewithEDandthoseatrisk(e.g.RE),asopposedtoprocessesrelatedtoconcernsaboutthebody.

Thisreviewdiffersfrompreviousreviews(Dobson&Dozois,2004;Johanssonetal.,2005;Lee&Shafran,2004)on?vecounts;a)itconsiderscognitivebiastofoodstimulionly,asthereissomeevidencethatbiastowardsfoodstimuliismorerobustthanbodyimagestimuliatdetectingadifferencebetweenEDgroups(Faunce,2002);b)itexaminesabroadersampleofEDs(e.g.AN,BNandthoseatriskbutwithoutphysicalcomplications:RE);c)itsummarisesthemostwidelystudiedcognitivebiasesofsalienceinED(e.g.attention,memoryandjudgmentbias);d)itincludestwometa-analyses(forattentionandmemorybias);e)thereisextensivequantitativeinformationtoaidinterpretationofthedifferencesbetweenpatientandcontrolgroups(e.g.Cohen'sd,Con?denceIntervals,meanscoresandprobabilityvaluesforsigni?cance).

Theaimofthisreviewistosynthesizeandanalyzeinformationprocessing(attention,memoryandjudgment)towardsfoodstimuliinpeoplewithanEDandpeopleathighriskofdevelopinganED,e.g.restrainedeaters(RE).2.Method

TheQualityofReportingOfMeta-analyses,or‘QUOROMstate-ment’wasfollowed(Moheretal.,1999).Thisenablesreviewsandmeta-analysestobeconductedinastandardisedmanner,comparableacrossmultiplestudies.TheQUOROMstatementfollowstheprovisothatthereare4componentstobeaddressedbyasystematicreviewandmeta-analysis:a)thepatient,thepopulationorproblem;b)theintervention,independentvariableorexposure,c)thecomparatorsandd)thedependentvariableoroutcomesofinterest.StudyselectionfollowstheQUOROM?ow-chart(seeSupplementarymaterial).2.1.Searching

PubMed,Medline,Ovid,ScienceDirect,PsychInfo,WebofScience,CochraneLibraryandGoogleScholarweresearched,andhandsearchesthroughreferencelistsuptoDecember2008.Keywordswere;EATINGDISORDER,ANOREXIANERVOSA,,BINGEEATING,BULIMIANERVOSA,RESTRAINEDEATING,DIETING,ATTENTION,ATTENTIONALBIAS,COGNITION,COGNITIVEBIAS,DOT-PROBE,EXPLICIT,IMPLICIT,INFORMATION,JUDGEMENTBIAS,PERCEPTION,INFORMATIONPROCESSING,MEMORY,MEMORYBIAS,STROOP,STARTLE,FOOD,MEAL,CALORIE.

SixtaskswerefoundthatexaminebiastofoodstimuliinEDorREpopulations:

TheStrooptask(Stroop,1935):Inthistask,participantsareassessedonthetimetakentonametheinkcolourofcolourwords;e.g.theword‘BLUE’writteningreenink.Trialswithwordswrittenininkcoloursthataredifferenttothewordsare‘incongruenttrials’,whereastrialswithwordswritteninthesameinkcolourare‘congruenttrials’.Timelatenciesforeachtrialaremeasuredandlikelyrepresentattentionalbias,thatis,thelengthoftimetakentonamethetotalblockofinkcoloursinwhichthewordsarewritten.Duringincongruenttrials,ittakeslongertonamethetotalblockofinkcoloursthanduringcongruenttrials.The‘Modi?edStroop’taskusesdisease-salientwordsinsteadofcolourwords,becausedisease-salientwordshavethesameeffectontimelatenciesasincongruenttrials.Bothincongruentanddisease-salienttrialsincreasetimelatencies.Forincongruenttrialsthisisprobablybecausecolourperceptionandreadingutilisedifferentbrainregions.Fordisease-salientwords,thisislikelybecausesuchwordsaredeemedthreateninganddistractattentionawayfromtheinkcolour.However,one?awoftheStrooptaskisthatitisnotpossibletodeterminewhetherincreasedtimelatenciesareduetohypervigilancetowardsthestimulioravoidanceofthestimuli.TheDot-Probetask(Macleodetal.,1986):Thistaskmeasureshypervigilanceandavoidanceofstimuliinattentionalbias.Hypervigilancereferstoattentionbeingdrawntowardsthestimulus;avoidancemeansthatattentionisdrawnawayfromthestimulus.Salientandneutralwordsarepresentedseparatelyonascreenfollowedbyadot(theprobe).Theresponsetimestoprobeswithwordsarecompared.Slowerresponsetimesarethoughttoindicateavoidanceofthestimulus,whereasfasterresponsetimesindicatehypervigilancetowardsthestimulus.Distractertasks:The‘odd-one-out’taskisavisualsearchtaskwheretheparticipant?ndsatargetwordlocatedamongamatrixofdistracterwords.Thematrixisasquareofwordswithatargetwordplacedinrandomlocationsduringtrials.Thematrixeitherconsistsofdisease-relatedwordsandaneutraltargetword(distractioncondition)orneutralwordsandadisease-relatedtargetword(detectioncondition)(Smeetsetal.,2008).Inthedistractioncondition,therationaleisthatattentionwillbedrawntothedisease-relatedwordssothatitwilltakelongertolocatetheneutraltarget.Conversely,inthedetectioncondition,itissuggestedthatattentionwillbedrawntothetargetcausingaspeededdetection.Otherparadigmspresentsalientstimuliduringanunrelatedcognitivetaskandmeasuretheamountofinterfer-encetoperformanceonthecognitivetask(Dicksonetal.,2008).Interferenceismeasuredbyincreasedtimelatenciesandreducedaccuracyduringtaskperformanceandlikelyre?ectsattentionbeingdrawnawayfromthetaskandtowardthesalientstimulus.Memorytasks:Audiomemorytasksinvolvetherecallofaurally-presentedstimuli.Oneexampleisanincidentallearningtask.Thisiswheretherecallofperipheralstimuliisexamined.Forexample,awordpairispresentedandaparticipantrespondstooneofthesewords(thetargetword)withthesecondwordofthepairintheir‘periphery’ofprocessing.Aftertheinitialtrialrun,participantsareaskedtorecallasmanywordsfromtheperipheryastheycan.Freerecalltasksmeasurespontaneousrecallofpreviously-presentedstimuli.Forexample,alistofwordsisreadaloud,andtheparticipantisaskedtofreely(e.g.inanyorder)recallthewordspresentedtothem,asatestofshort-termmemory.Anextensionoffree-recalltaskscanmeasurelong-termmemory(e.g.deeper

40S.Brooksetal./ClinicalPsychologyReview31(2011)37–51

encodingofitemsthatmightrepresentmoresemanticprocessingofthewords).Theamountofwordsrecalledisnormallyrecordedduringmemorytasks,butalsothespeedinwhichthewordsarerecalledmayalsoberecordedasanindicationofthestrengthofthememorytrace.

Perceptualestimation:Measuringwhetherjudgementoffoodstimuli,e.g.size,shapeoramountisbiasedbyskewedestimations.Forexample,estimatingthenumberofcandiesinajarandwhetherpeoplewithEDarelikelytounder-orover-estimatetheamount.Themeasureisusuallyascoretorepresentthedeviationoftheestimationfromthecorrectanswer.Perceptualerrorsmayre?ectanunderlyingpathologythatmaycontributetoperceptualerrorssuchasbodydysmorphicdisorderinwomenwithED.

Thoughtverbalisation:Inthesetasks,participantsrandomlyrecordthefrequencyofthoughtsaboutfoodusingadigitalcounter.Ableeperorphonetextatrandomtimesduringthedayindicatescommencementofrecording.Writtentranscriptsofaudiorecordingsenablecategorisationoffoodthoughts,e.g.positiveandnegativestatementsaboutfood,andalsothefrequencyofthoughtsrecordedduringtheday.Thistechniqueisusefulbecauseitallowsareal-lifemeasureofthoughtsaboutfood.However,itisalsodependentontheparticipantaccuratelyrecordingthethoughtstheyarehavingaboutfood.ItislikelythatwomenwithEDmaywishtoconcealthoughtsthattheyhaveaboutfood.2.2.Selection

2.2.1.Eligibilitycriteria

Studieswereexcluded(n=20)iftheydidnotincludeaHCgroup(Carter,Bulik,Mcintosh,&Joyce,2000;Cooper&Fairburn,1993;Cooper&Fairburn,1994;Lee&Shafran,2008),ifanon-clinicalgroup(otherthanrestrainedeaters)wasstudied(Channon&Hayward,1990;Johansson,Ghaderi,&Andersson,2004;Mogg,Bradley,Hyare,&Lee,1998;Placanica,Faunce,&SoamesJob,2002;Soetens&Braet,2007),iffoodwordswerenotexclusive(Carteretal.,2000;Cooper,Anastasiades,&Fairburn,1992)andifnotEnglish(Leonard,Divac,Bichindaritz,Rouer-Saporta,&Samuel-Lajeunesse,1997;Rodriguez-Campayo&Martinez-Sanchez,2005;Urdapilleta,Mirabel-Sarron,Meunier,&Richard,2005).FourStroopstudies(Channon,Hemsley,&De,1988;Cooper&Fairburn,1992;Cooper&Todd,1997;Mendlewicz,Nef,&Simon,2001)wereexcludedasnodatawerepublishedforthefoodcondition,anditwasimpossibletocontacttheauthorstoobtainthisinformation.Supplementarymaterialisavailableonrequestfor?owdiagramofselectedandexcludedstudies.Tables1and2summariseinformationontheincludedstudies.

From63studies,43ful?lledeligibilitycriteriaandwereusedeitherforaqualitativesystematicreviewor(forattentionalbiasandmemorystudies)ameta-analysis.2.3.Dataabstraction

Meanresponsetime,standarddeviation,samplesizeforAN,BN,REandHCgroupswereextractedfromthe‘foodcondition’and‘control-foodcondition’.Meandifference(andstandarddeviationofdifference)betweentwoconditionswascalculatedtoindicatean‘informationprocessingscore’.Insomestudies,onlymeanresponsetimesforfoodwereavailable,butincluded.Insuchstudies,thecalculationdescribedabovecouldnotbecompleted(e.g.bysubtractingthecontrolconditionfromthefoodcondition).

MeandifferenceininformationprocessingscorebetweenEDandHCgroupswasstandardisedbycalculatingCohen'sd;thedifferencebetweenthetworawmeansdividedbythepooledstandarddeviation

(Rosenberg,Adams,&Gurevitch,2009).Standarderrorofeachstudy'sstandardisedeffectsizewascalculatedfromestimatedeffectsandgroupsizesofthetwogroups(i.e.ANversushealthycontrol,orBNversusHC)usingthemethodofCooper&Hedges(Cooper&Hedges,2009).

2.4.Studycharacteristics

Theincludedstudiesfollowedacross-sectionaldesignwithahealthycontrol(HC)group.StudieshadANorBNsamples,orboth.FivestudieshadundifferentiatedEDgroups(Shafran,Lee,Cooper,Palmer,&Fairburn,2007;Shafran,Lee,Cooper,Palmer,&Fairburn,2008;Smeetsetal.,2008;Stormark&Torkildsen,2004;Waller&Ruddock,1995).RE,werecomparedtouRE,fromHermanandPolivy'sRestraintScale(Herman&Polivy,1980),ortheDutchEatingBehaviourQuestionnaire(DEBQ)(VanStrien,Frijters,Bergers,&Defares,1985).OneStroopstudyreportedahistoryofdepression(Johansson,Carlbring,Ghaderi,&Andersson,2008),fourstudiesreportedahistoryofanxiety,twoStroop(Fassinoetal.,2002;Johanssonetal.,2008)andtwoDot-Probe(Shafranetal.,2007,2008).SeeSupplementarymaterialforasummaryofstudydemographics.2.5.Quantitativedatasynthesis

AnalysesweredoneinSTATA10(StataCorp,CollegeStation,TX,USA)withuser-contributedcommandsformeta-analyses:metan(Bradburn,Deeks,&Altman,1998),metabias(Steichen,1998),metainf(Tobias,2001),metatrim(Steichen,2000),andmetareg(Sharp,1998).Strooptaskscontributedtometa-analysisinAN(n=13),BN(n=9)andRE(n=9).Studiesofmemorybiascontributedtometa-analysis,poolingallparticipantgroups(n=6).Studiesusingotherparadigmsweretoosmallforfurthermeta-analyses(Dot-Probe,n=3;Distractortasks,n=4;StartleEyeblinkModulation,n=1;PerceptualEstimationTask,n=1;ThoughtVerbalisation,n=3;FoodCueReactivity,n=3):onlystudyeffectsizesarereported.Cohen'sdand95%con?denceintervals(C.I.s)arereported.Cohen'sdeffectsizesarede?nedasnegligible(≥?0.15andN0.15),small(≥0.15andN0.40),medium(≥0.40andN0.75),large(≥0.75andN1.10),verylarge(≥1.10andN1.45)andhuge(≥1.45).ApositiveCohen'sdeffectsizerepresentsagreaterscoreintheEDcomparedtoHCgrouporagreaterscoreintheREcomparedtotheuREgroup.C.I.sthatfalleithersideofzerorepresentaninsigni?canteffectsize.

Meta-analysisusingmetanforStrooptasksinAN,BNandEDversusHC,andREversusuREusedpooledstandardeffectsizesbetweengroups,usingarandom-effectsmodel,assumingthatbothwithin-groupvariabilityofscoresandmeaneffectsizesarecausedbydifferencesbetweenstudies(between-studyheterogeneity).Ran-dom-effectsmodelsincorporatebetweengroupheterogeneity,resultinginestimateswithwiderC.I.sthan?xed-effectsmodels,butmorerealisticinpsychiatricstudiesduetothevarietyofcasemixandsettingsbetweenstudies(Everitt,2003).ToformallyassesstheassumptionofhomogeneityoftrueeffectsizesweusedCochran'sQtest,andasamplesizeindependentmeasureofinconsistencyI2wascalculated[I2=(Q?df)/Q](Higgins,Thompson,Deeks,&Altman,2003).

Statisticallysigni?cantresultsaremorelikelytobepublished.Publicationbiaswasassessedbyvisualinspectionoffunnelplots[aplotofastudy'sprecision(1/standarderror)againsteffectsize]andbystatisticalsigni?cance:Begg'sadjustedranktest(Begg&Mazumdar,1994)andEgger'stest(Egger,Smith,Schneider,&Minder,1997),andtrimand?llmethod(Duvall&Tweedie,2000)usingmetabiasandmetatrim.Thetrimand?llmethodinputsvaluesestimatedtobemissingfromtheanalysisduetopublicationbiasandre-estimatestheeffectsize.Asecondimportantbiasis“poortrialqualitybias”,whichcausesexaggeratedeffectsizes.Evidenceforthis

S.Brooksetal./ClinicalPsychologyReview31(2011)37–5141

isifstudieswithsmallsamplesizesarebiasedtowardslargebene?cialeffectsandcanalsobespottedinfunnelplots.3.Results

Supplementarymaterialisavailableonrequestfora?ow-diagramofstudyselection.3.1.Generaldemographics

Supplementarymaterialisavailableforasummaryofstudydemographics.4.Attentionalbias4.1.TheStrooptask

4.1.1.AN&BNpopulations

TheStrooptaskwasmostfrequentlyused(n=16)inwomenwithED(Ben-Tovim&Morton,1989;Ben-Tovim&Walker,1991;Black,Wilson,Labouvie,&Heffernan,1997;Davidson&Wright,2002;Fassinoetal.,2002;Green,McKenna,&DeSilva,1994;Green,Wakeling,Elliman,&Rogers,1998;Johanssonetal.,2008;Jones-Chesters,Monsell,&Cooper,1998;Lokken,Marx,&Ferraro,2006;Long,Hinton,&Gillespie,1994;Lovell,Williams,&Hill,1997;Perpina,Hemsley,Treasure,&DeSilva,1993;Sackville,Schotte,Touyz,Grif?ths,&Beumont,1998;Stormark&Torkildsen,2004;Waller&Ruddock,1995)(SeeFig.1forForrestPlotofstudiesincludedinthemeta-analysis.).Fourstudieswereexcludedasrawdatawasnotavailable(Channonetal.,1988;Cooper&Fairburn,1994;Cooper&Todd,1997;Mendlewiczetal.,2001).Ameta-analysisofStroopstudiesrevealedanoverallsmallstandardisedmeandifference(SMD)effectsizeof0.34(95%C.I.:0.20,0.48);andinANasmalleffectsizeof0.26(95%C.I.:0.01,0.51);inBNamediumeffectsizeof0.43(95%C.I.:0.21–0.64)wasfound.ThreestudiesusedabroadEDconceptualiza-tionanddidnotcontributetoaseparatemeta-analysis(Perpinaetal.,1993;Stormark&Torkildsen,2004;Waller&Ruddock,1995).Onestudyshowedanextremeeffectsizeof?.99(95%C.I.:?1.65,?0.33)intheoppositedirection(Fassinoetal.,2002).Meta-analysiswithoutthisoutlierslightlyincreasedtheoveralleffectsizeto0.39(95%C.I=0.27–0.51)andto0.38(95%CI:0.20–0.56)intheANgroup.

Weusedametaregression(Sharp,1998)toassessthein?uenceofstudypopulation(ANorBN).TheanalysisshowedthatbetweenANandBNthedifferenceineffectsizesforresponsetimeswasinsigni?cant(Δd=?0.17(?0.53–0.20,p=0.35).Runningthemeta-regressionwithouttheoutlier(Fassinoetal.,2002)revealednosigni?cantdifferenceineffectsizes(difference:Δd=?0.05(?0.32?0.23,p=0.7).

WeexamineddifferentialeffectsizesbetweenStroopbasedoncomputer(n=10)versuscard-basedtasks(n=6)usingmetaregres-sion(Sharp,1998)withstandardisedmeandifferences(SMD)asthedependentvariable,andgroupandmethodasindependentvariables(usingANandBNgroupsonly).Nosigni?cantgroupdifferencesbutatrendtowardsmethoddifferences.StudiesoncomputerscoredΔd=0.31(95%C.I.=0.02,0.650)lessthancardstudies;thisgroupdifferencediminishediftheoutlierstudy(Fassinoetal.,2002)wasexcluded(difference:Δd=0.20(95%CI=0.08,0.49,p=0.15).Onestudyusedbothwordsandpictures(Stormark&Torkildsen,2004);weusedonlydatafromwordsforconsistency.Picturepresentationyieldedahugesigni?canteffectsizeof3.64inanon-differentiatedEDpopulation.SeeFig.1forForrestplotofStroopstudiesinEDpopulations.

VisualinspectionofBegg'sfunnelplotsuggestsnopublicationbias,andstatisticalanalysiswithbothBegg'sandEgger'stestsforpublicationbiaswerenon-signi?cant(p=0.6,p=0.5respectively).Thetrimand?llmethod(Steichen,2000)allowedforuncorrected

datatobegiven.SeeSupplementarymaterialforFunnelplotsofpublicationbias.

4.1.2.Restrained(RE)versusUnrestrainedEaters(uRE)

StroopTasksweremostfrequentlyused(n=9)inRE(Blacketal.,1997;Francis,Stewart,&Hounsell,1997;Green&Rogers,1993;Mahamedi&Heatherton,1993;Overduin,Jansen,&Louwerse,1995;Perpinaetal.,1993;Sackvilleetal.,1998;Stewart&Samoluk,1997;Tapper,Pothos,Fadardi,&Ziori,2008).Meta-analysisrevealedasigni?cantsmalleffectsizeofd=0.36(95%CI:0.07,0.65).SeeFig.2forForrestplot.Onestudy(Green&Rogers,1993showedanextremelylargesigni?canteffectsizeofd=1.77(95%CI:1.03,2.51).Sensitivityanalysiswasrerunwithouttheoutlier(Green&Rogers,1993)andthesmalleffectsizeremainedsigni?cantd=0.24(95%CI:0.02,0.46).Differenceineffectsizesbetweencomputer(n=5)versuscard(n=4)tasksusingametaregressionshowednosigni?cantdifference(Δdcomputer–Veral=0.41,95%CI:?0.25,1.08).NoStroopstudiesinREusedfoodpictures,allusedfoodwords.SeeFig.2foraForrestPlotofStroopstudiesinRE.

VisualinspectionofBegg'sfunnelplotsuggeststhattherewasnopublicationbias,andBegg'sandEgger'stestswerenon-signi?cant(p=0.5,p=0.4respectively).Thetrimand?llmethod(Steichen,2000)didnotestimateanyhypothesizedstudyandthereforeeffectsizeestimatedidnotchange,andsouncorrecteddataisgiven.SeeSupplementarymaterialforFunnelplotinRE.4.2.TheDot-Probetask

4.2.1.AN&BNpopulations

Twopapersbythesamegroup(Shafranetal.,2007,2008)usedfoodpicturesduringDot-Probetasksandpresentedtwoseparatestudies.Studyoneinthe2007paperwasnotincludedbecausethecomparisongrouphadEDpathology(shapeconcerns).Studytwointhe2008paperwasnotincludedasitwasalongitudinaldesignwithbeforeandaftertreatmentandnoHCgroup.Studytwointhe2007paperandstudyoneinthe2008paperappeartobethesame,althoughasacomparisonfordifferentstudies(personalcommuni-cation,DrAnneRoefs).

EDwereavoidantoffoodpictureswithasigni?cantmediumeffectsizeofd=0.50(95%C.I.:0.13,0.87).Negative,highcalorieimagescausedavoidanceinED,withalargesigni?canteffectsizeofd=0.93(95%C.I.:0.55,1.32),andhypervigilancetopositivelowcaloriefoodimages,withamediumsigni?canteffectsizeofd=?0.72(95%C.I.:?1.09,?0.34).

4.2.2.Restrained(RE)versusUnrestrainedEaters(uRE)

OnestudyexaminedattentionalbiasinREusingtheDot-Probetask,andrevealedanegligibleeffectsizeofd=0.11(95%C.I.:?0.4,0.6)andnosigni?cantdifferencebetweenREanduRE.4.3.Distractertasks

4.3.1.AN&BNpopulations

Onestudyusedsupraliminalpresentationoffoodstimuliduringworkingmemoryperformance.Targetswereindividuallettersduringtheworkingmemorytask,andfoodimageswerepresentedasdistractersduringthetask.Food-relatedimageshadaninsigni?canteffectsizeofd=0.33(95%C.I.:?0.48,1.13)(Dicksonetal.,2008).Anotherstudyusedan‘odd-one-out’visualsearchtask,wherewomenwithEDindicatedthe‘target’odd-one-out.Inthedistracterconditionhighcaloriefoodwordsyieldedahugesigni?canteffectsizeofd=1.86(95%C.I.:1.45,2.28),whereaslowcaloriefoodwordswereinsigni?cant:d=0.31(95%C.I.:?0.04,0.66).Inthetargetconditionmeasuringspeededdetectionhighandlowcaloriefoodsyieldedasmallsigni?canteffectsizeofd=?0.27(C.I.:0.62,0.08).

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

46S.Brooksetal./ClinicalPsychologyReview31(2011)37–51

Fig.1.Stroopstudiesexaminingattentionalbiastofoodstimuliineatingdisorders(ED).ForestplotforStrooptaskmeta-analysis■Computer-basedreactiontimeStroopCard-basedverbalStroop.NB.Whenanoutlierisincluded(Fassinoetal.,2002),theANstandardpooledeffectsize=0.26(0.010.51)andtheoverallstandardpooledeffectsize=0.34(0.20,0.48);C.I.=Con?denceintervals;Diamond=pooledC.I.s;Studiesorganizedinchronological

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

order.

Fig.2.Stroopstudiesexaminingattentionalbiastofoodstimuliinrestrainedeaters(RE).ForestplotforStrooptaskmeta-analysis■=Computer-basedreactiontimeStroop;=Card-basedverbalStroop;StroopwithPreload;=StroopwithAppetiser;=Stroopwithunforbiddenwords;=Stroopwithsubliminalfoodwords.NB.Whenoutlierisincluded(Green&1993),theoverallpooledeffectsize=0.36(0.07,0.65);NB.Instudieswithtwoversions,single-colouredblockrepresentstheStroopmethod(computerversuscards);Studiesorganizedinchronologicalorder.

S.Brooksetal./ClinicalPsychologyReview31(2011)37–5147

4.3.2.Restrained(RE)versusUnrestrainedEaters(uRE)

NostudieswerefoundinRE.5.Memorybias5.1.AN&BNpopulations

Threetasksmeasuredmemorybiastofoodstimuli.UsingaudiorecallinwomenwithAN(Pietrowsky,Krug,Fehm,&Born,2002),hungerandsatietywasmeasuredforeffectsonrecalloffoodwords.Hungeryieldedahugesigni?cantnegativeeffectsize:d=?2.52(95%C.I.:?3.5?,?1.5)whereassatietyyieldedahugepositiveeffect:d=3.18(95%C.I.:2.08,4.28).Speci?cally,womenwithANremem-beredsigni?cantlyfewerfoodwordswhenhungry,butsigni?cantlymorefoodwordswhensatiatedincomparisontoHC.WomenwithBN(Hunt&Cooper,2001)showedaninsigni?canteffectsizeforverbalrecallofd=0.62(95%C.I.:?0.13,1.36).Inthethirdstudy(Suslowetal.,2004),thenumberofperipheralfatteningfooddistractersrecalledinwomenwithANhadaninsigni?canteffectsizeofd=0.22(?95%C.I.:?1.06,0.62).

5.2.Restrained(RE)versusUnrestrainedEaters(uRE)

TwostudiesexaminedmemorybiastofoodwordsinRE.Inonestudy,recalloffoodwordspresentedduringaDot-Probetask(Boon,Vogelzang,&Jansen,2000)yieldedanegligibleandinsigni?canteffectsizeofd=0.02(95%C.I.:?0.49,0.53),whereasspeedofresponsestofoodwordsproducedamediumandsigni?canteffectsizeofd=0.72(95%C.I.:0.19,1.25).InanotherstudyREanduRErecallofpreviously-ratedforbiddenfoodwordsforpleasantness(Israeli&Stewart,2001)yieldedalargesigni?canteffectsizeforREofd=1.08(95%C.I.:0.56,1.59).

Meta-analysisoncombinedsamplesfrombothEDandRE(n=6)(Boonetal.,2000;Hunt&Cooper,2001;Israeli&Stewart,2001;Pietrowskyetal.,2002;Suslowetal.,2004)hadaninsigni?cantpooledeffectsize:d=0.35(95%C.I.:?0.75,1.45).SeeFig.3foraForrestplotofmemorystudies.

VisualinspectionofBegg'sfunnelplotshowednopublicationbias,andstatisticalanalysiswithbothBegg'sandEgger'stestsforpublicationbiaswerenon-signi?cant(bothwerep=0.9).Thetrimand?llmethod(Steichen,2000)enableduncorrecteddatatobegiven.SeeSupplementarymaterialforFunnelplotsofpublicationbias.

6.Judgmentbias

6.1.Perceptualestimationtask

6.1.1.AN&BNpopulations

OnestudyofwomenwithANexaminedtheestimationofcandies(actualnumber=27)inajar(Vinaietal.,2007).BothANandHCgroupsunderestimatedthenumberofcandies;ANwomenreportedmarginallyfewercandiesthanHCwomenwithasmallbutinsigni?canteffectsizeofd=?0.25(95%C.I.:?0.61,0.12).6.1.2.Restrained(RE)versusUnrestrainedEaters(uRE)

NostudieswerefoundinRE.6.2.Thoughtverbalisation

6.2.1.AN&BNpopulations

NostudieswerefoundinwomenwithANorBN.

6.2.2.Restrained(RE)versusUnrestrainedEaters(uRE)

ThreestudiesrecordedfrequencyandcategoryofthoughtsofREwhenthinkingaboutfood.Oneusedarandomthoughtsamplingtechniqueduringfastingandnon-fastingconditions(Hickford,Ward,&Bulik,1997)betweenREanduRE,withaninsigni?cantnegligibleeffectsizeofd=0.14(95%C.I.:?1.02,0.74).Twostudiesexaminedfood-relatedthoughtsduringthoughtsuppressionwithaninsigni?cantnumberoffood-relatedthoughtsinonestudy:d=?0.54(95%C.I.:?0.11,1.18)(Oliver&Huon,2001)andlargesigni?canteffectsizeofd=0.96(95%C.I.:0.44,1.48)inanother(O'Connell,Larkin,Mizes,&Fremouw,2005).6.3.Foodcuereactivity

6.3.1.AN&BNpopulations

NostudieswerefoundinwomenwithANorBN.

6.3.2.Restrained(RE)versusUnrestrainedEaters(uRE)

ThreestudiesexaminedfoodcuereactivityasameasureofincentivesaliencytowardsfoodstimuliinRE.Oneexaminedfood-relatedthoughtsandfoodconsumedbyREwithandwithoutafoodcue(Fedoroff,Polivy,&Herman,2003).REconsumedsigni?cantlymorefoodandreportedmorefood-relatedthoughtstocuesthanuRE,yieldingasmallpositivesigni?canteffectsizeofd=0.33(C.I.:

systematicreviewandmetaanalysisofcognitivebiastofoodstimuli

0.02,

Fig.3.StudiesexaminingmemorybiastofoodstimuliinANandRE.ForestplotofstudiesexaminingmemorybiastofoodstimuliinwomenwithANandREstudieswithAN;studieswithsatietycondition;C.I.Con?denceIntervals.

studieswithRE;■

48S.Brooksetal./ClinicalPsychologyReview31(2011)37–51

0.67),whereasnocueyieldedamediumbutinsigni?cantnegativeeffectsizeofd=?0.60(C.I.:?0.95,0.25)intheREgroup.Inanotherstudy,foodthoughtssigni?cantlyincreasedself-reportedcravingscoreinREcomparedtouRE,yieldingamediumsigni?canteffectsizeofd=0.48(C.I.:0.12,0.85)(Harvey,Kemps,&Tiggemann,2005).Athirdstudyallowedadlibitumeatingoffavouritefoods,recordingnegativethoughts.REatesigni?cantlymorethanuRE,andfrequencyofnegativethoughtspredictedamountconsumed,yieldingamediumsigni?canteffectsizeofd=0.66(C.I.:0.05,1.26)(Hilbert,Vogele,&Himmelmann,2007).7.Discussion

WesynthesizedstudiesofcognitivebiastofoodstimuliinpeoplewithEDandRE.43outof63werereviewedinmoredetail.Stroop(datapointsEDn=22;REn=12)andmemorytasks(datapointsED&REcombined,n=6)contributedtometa-analyses:Strooptasksshowedsigni?cantsmallandmediumpooledstandardeffectsizes(0.39:OverallED;0.38:AN;0.43:BN;0.24:RE);memorytasksyieldedaninsigni?canteffectsize(0.35)fortheEDandREgroupscombined.

Otherstudieshadinsuf?cientsamplesizesformeta-analysis.Dot-ProbetasksshowedavoidantresponsestofoodimagesinED,butaninsigni?canteffectforRE.PeoplewithEDhaveahypervigilantresponse(e.g.towards/quicker)tohighcalorie–butanavoidantresponse(e.g.awayfrom/slower)tolowcaloriefoodpictures.DistractertasksmeasuredattentionbiasinEDnotRE.HighcaloriefoodwordsdistractattentioninED,withahugeeffectsizecomparedtoasmallandinsigni?canteffectsizewithlowcaloriewords.

Inconclusion,attentionbiasisgreaterforthosewithEDthanRE,andinparticularthosewithBN.FoodstimulimightelicitgreaterincentivesaliencyinthosewithBN,promptingthedesiretoeatfood.Thiscomplimentsthe?ndingthatBNisontheincreaseinWesternsocietieswherefoodstimuliaremoreabundantthaninothercultures(Keel&Klump,2003).Itcouldbethatagreaterappetitiveresponseinthebrain(e.g.associatedwithdopaminerelease)drivesanattentionbiastofood(particularlytohighcaloriefood,andwhenhungry)inpeoplewithBN,inordertodirectattentiontoacquireandconsumefood.Similarly,inthosewhoaremoreimpulsive(e.g.thoseatriskofdevelopingBN)anincreasedappetitiveresponseinthebrainislikelytointerferewithanddistractothercognitions.Conversely,perhapsthosewithANandREutilisecognitionsthatrestrictappetitiveresponsesinthebrain,reducingthestrengthofsaliencyinfoodimagesandenablingthemtofocusrigidlyonthetaskathand.

Memorybiasstudiesrevealthathungerreduces,whereassatiationincreasesmemoryrecallinANcomparedtoHC.WomenwithBNdonotshowamemorybiasforfoodwords.InREtheeffectsizeformemorybiasincreasesfromnegligibletolargewhenrecallingforbiddencomparedtonon-forbiddenfoodwords.

Thissuggeststhatmemorybiasismoreprominentinthosewhorestricttheirfoodintake(e.g.ANandRE),whereasmemorybiasislessapparentinthosewithBN.Itislikelytherefore,thatdifferentcognitiveprocessesareconcomitantwithvaryingdisorderedeatingbehaviour(e.g.restrictionversusimpulsivity).Itmightbethecasethatmemorysystemshelptokeepcognitivestrategiesassociatedwithfoodrestriction(e.g.personalrituals,placesanditemstoeat,foodsconsidered‘safe’)engagedinthosewithAN.ThismightexplainwhythereissomeevidencethatpeoplewithANandRE,butnotthosewithBN(whomaynotbesopreoccupiedwithrigidcognitivestrategiestocontrolfoodintake)haveamemorybiasforfoodstimuli.

Perceptualjudgmentbiasreferstohowselectiveinterpretationin?uencesperceptionsandactions.Althoughthisbiasrelatesto‘choice’andthereforeresemblesvalence,itismoreconcernedwiththesalienceofbias(e.g.howmuchfoodisconsumed,howmanythoughtsaboutfoodarerecorded,ratherthanpositiveornegativeoutcomes).EffectswerefoundonlywithREinthisreview,anditwas

foundthatREhavemorethoughtsaboutfood(especiallywheninstructedtorestrain)andconsumegreaterquantitiesoffood.These?ndingsareinlinewith?ndingsthatrestrainedeatingisassociatedwithahigherfrequencyofbingeing(Herman&Polivy,1990).However,itisdif?culttointerpretthese?ndingsinrelationtoANandBNastheresearchinthisareaislimited.7.1.Comparisonwithpreviousreviews

Inlinewithpreviousreviews,wefoundthatcognitivebiastofoodstimuliisrobustforeatingdisorderedpopulations(Faunce,2002).However,unlikepreviousreviewswedidnotexaminecognitivebiasestobody-relatedstimuli.Thiswasbecausewewantedtofocusonthesaliencyofappetitiveresponsesandtheimpactoncognitiveprocesses.WeshowedthatclinicalmeasuresofEDsymptomscanbeindicativeofagreatercognitivebiastofoodstimulithanincomparisontohealthycontrols,asdidsomepreviousreviews(Johanssonetal.,2005;Lee&Shafran,2004).Forexample,wereportthathighdriveforthinnessscores,thoughtsaboutfeelingfat,highscoresontheEatingAttitudesTest(EAT),highrestrainedeatingscoresandhighanxietyscoresallincreasecognitivebiastofoodstimuliinclinicalpopulations–thepreviousreviewsreportverysimilar?ndings.Incontrasttopreviousquantitativereviewsthatincluded28studies(Dobson&Dozois,2004),27studies(Johanssonetal.,2005)and37studies(Lee&Shafran,2004)wewereabletoinclude43studiesexaminingcognitivebiasestofoodstimuli.Furthermore,unlikeanypreviousreviewweaddedathirdcategory–judgmentbias(aswellasattentionandmemorybias),whichmeasureshowsaliencyoffoodimagesforsomepeoplecanincreasetheamountoffoodconsumedandthenumberofthoughtsaboutfoodthroughouttheday.

Thisreviewhasprogressed?ndingsfrompreviousreviewsinanumberofways.Firstly,morecognitivebiasstudieshavenowbeenconductedwithfoodstimuliandincontrasttopreviousreviewsweonlyincludedbiastofoodstimulitomeasureappetitiveresponses.Evidencesuggeststhatfoodstimuliaremorerobustthanbody-relatedstimuliatdetectingcognitivebiasinEDandatriskpopulations(Faunce,2002).Furthermore,thisreviewhasincludedabroaderrangeofEDgroups(e.g.AN,BNandRE),andhascoveredabroaderrangeofcognitivebiases(e.g.attention,memoryandjudgment)thaninpreviousreviews.Inaddition,thisreviewhasincludedextensivequantitativeinformationtoaidinterpretationofthedifferencesbetweenEDandHCgroups(e.g.Cohen'sd,Con?denceIntervals,meanscoresandprobabilityvaluesforsigni?cance).Finally,thisreviewincludestwometa-analyses:oneonStroopperformance,theotheronmemorybiaseswhichhasnotbeendonebefore.7.2.Limitations

Moststudieshavesmallsamplesizes.Fewstudiesreportco-morbiditiesthatmayconfoundthemeasurementofcognitivebias;somestudieshaveaneffectsizedifferencebetweenthosesufferingfromanxietyordepression(Fassinoetal.,2002;Friederichetal.,2006;Shafranetal.,2007).MoststudiesusetheStrooptaskandsomeasurementofotherbiasesislimited.StudiesofBNarelimited;moststudiesexaminedAN,anundifferentiatedEDgrouporRE,andthesubtypesofAN(restrictingANandbinge–purgeAN)havenotbeenseparatelystudied.7.3.Sensitivityofmethods

StimuliforStrooptaskswereeitherpresentedmanuallyoncardsorelectronicallyonacomputer.Wefoundnosigni?cantdifferenceineffectsizesbetweencard-basedtasks(n=13)orcomputer-basedtasks(n=11)inEDorRE,andnoevidencethatattentionalbiastofoodwordsinwomenwithANorREhabituatesduringtheexperiment(Greenetal.,1994).Blockratherthanmixedpresentation

S.Brooksetal./ClinicalPsychologyReview31(2011)37–5149

offoodwordsintheStrooptaskaremoreeffectiveatdetectingattentionalbiasinwomenwithBN(Jones-Chestersetal.,1998).Forexample,continuousratherthanintermittentpresentationofstimulicongruentwithcurrentconcernsmayleadtosaturationofcognitiveresourcesandinstigateabiasedattentionresponse.Also,blockratherthanmixedpresentationmightpromotegreatercognitiveprocessingofthestimuliasattentionis?xedonthesametypeofstimuliforalongerperiod.

PicturescomparedtofoodwordsonStroopandDot-Probetasksproducelargereffectsizes(Shafranetal.,2007,2008;Stormark&Torkildsen,2004).Imageslikelyconveymorecontextualinformationandmeaningthanwordsalone.OneStroopstudyfoundthatfoodpicturescausedahugeeffectsizecomparedtoasmalleffectsizeforwords(Stormark&Torkildsen,2004).FoodpicturesinaDot-Probetaskidenti?edmediumandlargeeffectsizesforavoidanceofhighcaloriefoodsinadisgustcontextandhypervigilancetowardspositivelow-caloriefoodsrespectivelyinwomenwithED.TherewasnohypervigilancetogeneralfoodwordsinRE(negligibleeffectsize)(Boonetal.,2000).

TheStrooptaskwasunabletodetectpreconsciousmechanismsunderlyinginformationprocessingbiastofoodstimuliinEDorRE(Sackvilleetal.,1998).However,StartleEyeblinkModulatonhasfoundthatpeoplewithBNhaveanautomaticappetitiveresponsetofoodstimuli,whichisreducedinpeoplewithAN(e.g.Friederichetal.,2006).Despitelackofresultsusingsubliminalmeasures,itcouldbeausefullineofenquiry.Someevidencesuggeststhatsubliminalpresentationofthreatcues(e.g.ego-threats,abandonmentcuesandwordspertainingtonegativebodyimage)alterbehaviouralresponses(Waller&Barnes,2002;Waller&Barter,2005).Itislikelythatsubcorticalactivationassociatedwithnon-consciousprocessingoccursduringsubliminalpresentationofsalientstimuli(e.g.sublim-inally-presentedfoodimages),andinteractswithconsciouscognitiveprocessing(e.g.Brooks,Uher,O'Daly,Treasure,&Campbell,inpress).NeurobiologicalvulnerabilitiesunderpinningthedifferencesbetweenANandBN(Kaye,2008)inbothcorticalandsubcorticalbrainregionsmightdrivecognitivebiasesidenti?edbythestudiesuncoveredinthisreview.

7.4.Clinicalimplications

7.4.1.Attentionalbias

‘Driveforthinness’,acognitionthatformsonecriterionforED(AmericanPsychiatricAssociation,1994)increasesattentionbiastofoodwords(Perpinaetal.,1993;Placanicaetal.,2002)butnotothers(Ben-Tovim&Walker,1991).However,studieshaveimpliedthatcurrentweightconcerns(e.g.aboutfeelingandlookingfat),ratherthanthoughtsaboutwanting,andstrategiesforachievingthinnessmightbemorerobustatdetectingcognitivebiasesinED(Goldfeinetal.,2000;Gowers&Shore,2001;Jacobietal.,2004).

HighEatingAttitudesTest(EAT)scoresandscoresonbulimictraitscorrespondwithgreaterattentionbiastofoodwordsinED(DavidsonandWright,2002;Lokkenetal.,2006;Waller&Ruddock,1995).‘Restrainedeating’scores(Herman&Polivy,1990;VanStrienetal.,1985)uniteEDandnon-clinicalREpopulationsbasedongreaterattentionbiastofoodwordsontheStrooptask(Green&Rogers,1993;Longetal.,1994;Tapperetal.,2008).

Highlyanxiousnon-clinicalwomenwithshapeconcernsandwomenwithEDhavesimilarlyincreasedattentionbiastofoodwords(Fassinoetal.,2002;Shafranetal.,2007,2008).

TreatmentforEDanddiagnosedrecoveryreducesattentionbiastofoodstimuli(Greenetal.,1998;Lovelletal.,1997;Shafranetal.,2008),forexampletreatmentreducestheeffectsizefromhugeinapretreatmentgroup(d=2.65)tozero(Greenetal.,1998).Therefore,itislikelythatattentionbiastofoodstimuliisaprominentfeatureofdisorderedeatingbehaviour–however,itisnotyetclearwhetherthiscognitivebiasisacauseoraconsequenceofdisorderedeatingbehaviour.

7.4.2.Memorybias

HungerreducestheamountofwordsrecalledbywomenwithAN,butsatiationincreasestheamountofwordsrecalled(Pietrowskyetal.,2002).Starvationeffectsonthebrainmayaffectmemory-processingmorethanotherinformationprocessingregions.FoodconsumptionmayactivaterewardregionsinthebraininwomenwithANcomparedtoHC,increasingthesaliencyofassociatedfoodwordsinwomenwithANandstrengtheningmemorysystems.7.5.Implicationsofprocessingbiasesinnon-clinicalRE

FoodwordscausegreaterattentionbiasinREthaninuREduringtheStrooptask(Francisetal.,1997),andafoodpreloaddoesnotalterthis(Mahamedi&Heatherton,1993),neitherdoesanappetizer(Overduinetal.,1995).Therefore,thissuggeststhatattentionbiasinREisunrelatedtofoodconsumption,andmightbeanindicationthatdysfunctionalcognitionsoccurbeforedisorderedeatingbehaviourbegins.Interestingly,fastingandfooddeprivationincreasesatten-tionalbias,especiallytowardhighcaloriefoodwords,inRE,particularlythosewithhighscoresontheDriveforThinnessandBodyDissatisfactionsubscalesoftheEDI-2(Placanicaetal.,2002).Thiscouldre?ectastarvationeffect,asperipherally-secretedhormonessuchasghrelinalertthebrainthatenergyreservesarelowandattentionisdirectedto?ndandconsumefood.

REremembermorefoodwordsthatarecategorizedas‘forbidden’(Fairburn&Harrison,2003;Vitousek&Hollon,1990;Vitousek&Orimoto,1993),whichmayre?ectincreasedsaliencetowardsfoodsdeemedhighlypalatable.Disorderedeatingpathology(e.g.suppres-sionofthoughtsaboutfood,thinkingaboutself-categorisedforbiddenfoods)inREincreasethefrequencyofthoughtsaboutfood(O'Connelletal.,2005;Oliver&Huon,2001).ThinkingaboutfoodincreasestheexperienceofcravinginRE(Harveyetal.,2005).Therefore,maladaptiveschematalikelyunderpinthedesiretorestrictfoodintake,butparadoxicallythisincreasesfoodconsumptioninnon-clinicalRE.7.6.Conclusions

TheStrooptaskcontinuestobethemostwidelyusedmeasureofattentionalbiasinED.Meta-analysesrevealthatattentionbiastofoodstimuliiscomparableinpeoplewithANandREbutgreatestinthosewithBN.MemorybiasstudiessuggestthatstarvationhasadetrimentaleffectonmemoryinED,buttheevidenceformemorybiasinEDislimited.InpeoplewithRE,attemptstosuppressthoughtsaboutfoodincreasesfood-cuereactivityandfoodconsumption,whichmightre?ectthatsensitivitytorewarddrivesarestraintmechanisminsomepeoplewithdisorderedeatingbehaviour.Somebiasesaresensitiveto?uctuationsinEDpathologywithinandwithoutthecontextoftreatment,andcouldbebiomarkersforthedisorders.Attentionandjudgmentbiases,andde?citsinmemorytofoodstimulimayre?ectthemaladaptiveschematathatunderpindisorderedeatingbehaviour;furtherstudiesshouldclarifythisinEDandat-riskgroups.

Supplementarymaterialsrelatedtothisarticlecanbefoundonlineatdoi:10.1016/j.cpr.2010.09.006.

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