Received: 15 January 2018 | Revised: 5 April 2018 | Accepted: 5 April 2018

DOI: 10.1002/eat.22871

ORIGINAL ARTICLE

Core psychopathology in anorexia nervosa and bulimia nervosa:

A network analysis

Lauren N. Forrest MA1 | Payton J. Jones BS2 | Shelby N. Ortiz BA1 |

April R. Smith PhD1

1
Department of Psychology, Miami
University, Oxford, Ohio
Abstract
2
Department of Psychology, Harvard Objective: The cognitive–behavioral theory of eating disorders (EDs) proposes that shape and
University, Cambridge, Massachusetts
weight overvaluation are the core ED psychopathology. Core symptoms can be statistically identi-
Correspondence fied using network analysis. Existing ED network studies support that shape and weight
Lauren Forrest, Department of Psychology, overvaluation are the core ED psychopathology, yet no studies have estimated AN core psychopa-
Miami University, Oxford, OH. thology and concerns exist about the replicability of network analysis findings. The current study
Email: forresln@miamioh.edu
estimated ED symptom networks among people with anorexia nervosa (AN) and bulimia nervosa
(BN) and among a combined group of people with AN and BN.

Method: Participants were girls and women with AN (n 5 604) and BN (n 5 477) seeking residen-
tial ED treatment. ED symptoms were assessed with the Eating Disorder Examination-
Questionnaire (EDE-Q); 27 of the EDE-Q items were included as nodes in symptom networks.
Core symptoms were determined by expected influence and strength values.

Results: In all networks, desiring weight loss, restraint, shape and weight preoccupation, and shape
overvaluation emerged as the most important symptoms. In addition, in the AN and combined net-
works, fearing weight gain emerged as an important symptom. In the BN network, weight
overvaluation emerged as another important symptom.

Discussion: Findings support the cognitive–behavioral premise that shape and weight overvalua-
tion are at the core of AN psychopathology. Our BN and combined network findings provide a
high degree of replication of previous findings. Clinically, findings highlight the importance of con-
sidering shape and weight overvaluation as a severity specifier and primary treatment target for
people with EDs.

KEYWORDS
anorexia nervosa, bulimia nervosa, core psychopathology, eating disorder, network analysis

1 | INTRODUCTION ED behaviors. Engaging in ED behaviors further reinforces shape and

The transdiagnostic, cognitive–behavioral theory (CBT-E) of eating dis-
orders (EDs) conceptualizes ED symptoms as being stacked like a house
of cards (Fairburn, 2008). That is, CBT-E predicts that ED symptoms
reinforce one another and that, of all ED symptoms, overvaluation of
body shape, weight, and their control (hereafter referred to as shape
and weight overvaluation) most strongly reinforce and maintain other
symptoms. Specifically, shape and weight overvaluation are proposed
to lead to engagement in dietary restraint, which then leads to other
weight overvaluation, which thereby creates cognitive and behavioral
ED cycles (Fairburn, 2008). Thus, CBT-E conceptualizes shape and
weight overvaluation as the core psychopathology for anorexia nervosa
(AN) and bulimia nervosa (BN; Fairburn, 2008; Fairburn, Cooper, & Sha-
fran, 2003).
CBT-E parallels with the network theory of psychopathology
(Borsboom & Cramer, 2013), which posits that causal relationships
among symptoms explain the emergence and maintenance of mental
disorders. This network model contrasts the traditional medical model,

Int J Eat Disord. 2018;1–12. wileyonlinelibrary.com/journal/eat V

C 2018 Wiley Periodicals, Inc. | 1
2 |
in which underlying disease entities are viewed as causing all mental
disorder symptoms. In other words, the medical model recommends a
search for a common cause of mental disorders whereas the network
model “recommends a search for mechanisms. . .causing specific ele-
ments” (Hofmann, Curtiss, & McNally, 2016, p. 100) of mental disor-
ders (e.g., shape and weight overvaluation in EDs; for a review, see
Borsboom & Cramer, 2013; Hofmann et al., 2016). Among other goals,
network theorists aim to (1) elucidate relationships among mental dis-
order symptoms, (2) understand which symptoms (if any) are most
important in the maintenance of psychopathology, and (3) use this
information to guide scientific and clinical decision making. So far, great
progress has been made on the first point, some progress has been
made on the second, and attempts at the third are just beginning to
emerge (for a review, see Fried & Cramer, 2017). In the EDs field spe-
cifically, several challenges exist to moving these goals forward.
For instance, only three ED network analyses have been published
to date. Levinson and colleagues (2017) estimated a graphical least
absolute shrinkage and selection operator (i.e., regularized partial corre-
lation; graphical LASSO) network of ED symptoms among a treatment-
seeking sample of adults with BN (N 5 196). ED symptoms were
assessed with the eating disorder examination (EDE; Fairburn &
Cooper, 1993) and the Short Evaluation of Eating Disorders (Bauer,
Winn, Schmidt, & Kordy, 2005). Indicators of weight overvaluation had
the highest centrality, meaning that these variables had the strongest
associations to other variables in the network. Forbush, Siew, and Vite-
vitch (2016) estimated an association (i.e., zero-order correlation) net-
work of ED symptoms among a community sample of adults with
mixed EDs (N 5 143). ED symptoms were assessed with the Eating
Pathology Symptom Inventory (EPSI; Forbush et al., 2013). An indicator
of body checking, which is closely related to shape and weight overval-
uation (e.g., Lavender et al., 2013) had the highest centrality. DuBois
and colleagues (2017) estimated a graphical LASSO network of ED
symptoms among a treatment-seeking sample of adolescents and
adults with mixed EDs (N 5 194). ED symptoms were assessed using
the EPSI and select Eating Disorder Examination-Questionnaire (EDE-
Q; Fairburn & Beglin, 1994) items. Shape and weight overvaluation
emerged as the most central symptoms. Taken together, despite meth-
odological differences—including network estimation techniques, sam-
ples, and ED symptom measures—shape and weight overvaluation or
closely-related constructs have emerged consistently as the most cen-
tral symptoms in ED networks.
While these results are encouraging, additional studies are needed.
For example, no studies have reliably estimated an AN network.
DuBois and colleagues (2017) included the largest AN sample (n 5 51),
yet the sample size was below the recommended minimum for network
analysis (Scott, 2012). Without investigating the symptom structure of
AN specifically, we do not have definitive evidence that shape and
weight overvaluation are the transdiagnostic core ED psychopathology,
as CBT-E hypothesizes (Fairburn, 2008). Moreover, concerns have
recently been raised that network analyses have limited replicability
(Forbes, Wright, Markon, & Kreuger, 2017; though see Borsboom
et al., 2017; Epskamp, Borsboom, & Fried, 2017). In fact, two research
groups concluded that current network estimation methods produce
FORREST ET AL.
unreliable results with “poor and absent replicability” (Forbes et al.,
2017, p. 981; Steinley, Hoffman, Brusco, & Sher, 2017). These critiques
highlight the need for high-quality ED network replication studies, as
unique characteristics about published ED networks raise replicability
concerns. For instance, existing ED network studies have estimated dif-
ferent types of networks, examined relatively distinct populations, and
assessed ED symptoms with different measures. Further, only one
study estimated a BN network with an adequate sample size (Levinson
et al., 2017) and only two studies estimated mixed ED networks
(DuBois et al., 2017; Forbush, Siew, & Vitevitch, 2016). Testing
whether previous BN and mixed ED network results replicate in studies
that include similar estimation techniques, samples, and assessments
would provide clarification regarding previously reported results.
Accordingly, the current study estimated three ED symptom net-
works: individual networks for people with AN (n 5 604) and BN (n 5
477) and a combined network among people with AN and BN (N 5
1,081). We hypothesized that shape and weight overvaluation would
emerge as the core psychopathology across networks. This study adds
to existing ED network findings by, for the first time, reliably estimating
an AN network. Moreover, the study extends existing ED network
findings by providing a high-quality replication of previous BN (Levin-
son et al., 2017) and mixed ED networks (DuBois et al., 2017), given
the similarity in network estimation techniques (i.e., graphical LASSO),
sample types (i.e., treatment-seeking), and assessments of core ED
symptoms (i.e., EDE and EDE-Q).
2 | METHOD
2.1 | Participants
This is a secondary analysis from a sample of girls and women with EDs
seeking residential ED treatment. The treatment facility’s research coor-
dinator recruited and obtained consent for all participants, within a week
of admission. Participants were compensated financially. All research
activities were approved by the relevant Institutional Review Boards.
Participant age ranged from 13 to 69 years (mean 5 25.4,
SD 5 10.9). Approximately 80% of participants were age 18 years or
older and most identified as Caucasian (84.9%). The treatment center’s
psychiatrist administered a semistructured interview to assign ED diag-
noses. Height and weight were measured at intake to calculate body
mass index. Demographic characteristics and descriptive statistics are
shown in Table 1.
2.2 | Measures
ED symptoms were assessed with the EDE-Q version 6.0 (Fairburn &
Beglin, 2008). The EDE-Q includes 28 items assessing ED symptoms
experienced over the past 28 days. Twenty-two items are rated on a
0–6 scale, where higher scores reflect greater symptom severity. Five
items assess qualities of binge eating and compensatory behaviors: the
frequency of eating a large amount of food (binge criterion A); experi-
encing loss of control over eating when eating a large amount of food
(binge criterion B); and engaging in self-induced vomiting, laxative
FORREST ET AL. | 3

T AB LE 1 Demographic characteristics and descriptive statistics

AN (n 5 604; %) BN (n 5 477; %) v2 p

Adolescent vs. adult 10.4 .001

Adolescent (< age 18) 153 (25.3) 82 (17.2)
Adult ( age 18) 451 (74.7) 395 (82.8)

Race/ethnicity 18.3 .01

European American 523 (86.6) 374 (78.4)
African American 4 (0.7) 13 (2.7)
Asian or Pacific Islander 16 (2.6) 11 (2.3)
Hispanic 23 (3.8) 30 (6.3)
Native American 1 (0.2) 3 (0.6)
Multiracial 15 (2.5) 19 (4.0)
Other 10 (1.7) 14 (2.9)

Education 11.6 .02

High school graduate or less 215 (36.5) 132 (27.7)
Technical training 6 (1.0) 7 (1.5)
Some college or Associate’s degree 212 (35.1) 199 (41.7)
Bachelor’s degree 99 (16.4) 95 (19.9)
Graduate school 65 (10.8) 42 (8.8)

Shape or weight overvaluation items 9.6 <.01

Shape or weight overvaluation < 4 111 (18.4) 55 (11.5)
Shape or weight overvaluation  4 493 (81.6) 422 (88.5)

M (SD) M (SD) t p

Age
Adolescent 15.5 (1.1) 16.1 (1.0) 4.1 <.001
Adult 28.7 (11.7) 26.3 (8.8) 23.3 .001

Body mass index

Adolescent 17.3 (2.1) 24.4 (5.7) 10.8 <.001
Adult 17.6 (2.3) 25.2 (6.9) 20.6 <.001

Note. AN 5 anorexia nervosa; BN 5 bulimia nervosa.

Two participants with BN had missing education data.

abuse, and over-exercise. The 22 items assessing ED symptoms and
the five items assessing ED behavior frequencies were included as indi-
vidual nodes (i.e., symptoms). EDE-Q item 15 was not included because
it combines the information that EDE-Q items 13 (binge criterion A)
and 14 (binge criterion B) capture.
Most participants (AN 5 81.6%, BN 5 88.5%; see Table 1) reported
clinically significant shape or weight overvaluation, as indicated by
responses 4 on either EDE-Q item 22 (weight overvaluation) or item
23 (shape overvaluation; e.g., Giannini et al., 2017). This clinical cutoff
was not used as an inclusion criterion, as diagnostic interviews were
conducted separately from EDE-Q completion.
2.3 | Data analysis
The percentage and pattern of missing data were inspected in SPSS
version 23 (IBM Corporation, 2015). For the AN group, the frequency
of using laxatives (EDE-Q item 17) had the highest percentage of miss-
ing data (0.7%). For the BN group, the weight dissatisfaction item
(EDE-Q item 25) had the highest percentage of missing data (0.8%).
Missing data were consistent with a pattern of missing completely at
random (AN v2 [121] 5 95.19, p 5 .96; BN v2 [156] 5 177.90, p 5 .11).
Within the AN and BN groups, missing data were handled via multiple
imputation in SPSS, using fully conditional specification (m 5 40).
Imputation procedures included bounds, such that imputed data could
not take on values that were impossible in the dataset. Because pooled
results were unavailable, imputed data were aggregated to estimate
networks. We inspected the accuracy of imputation procedures by ran-
domly selecting 10 of the 40 imputed datasets and re-conducting
results with each of the imputed datasets (Azur, Stuart, Frangakis, &
Leaf, 2011). Results were highly similar across all individual imputation
datasets.
2.3.1 | Network estimation
ED symptom networks were estimated in R version 3.4 using the
qgraph package (Epskamp, Cramer, Waldorp, Schmittmann, & Bors-
boom, 2012). Specifically, regularized partial correlation networks were
estimated using a graphical LASSO (Friedman, Hastie, & Tibshirani,
2014). This means that each edge (i.e., line) reflects the regularized par-
tial correlation between two nodes (i.e., symptoms). In the figures
below, thicker edges indicate larger partial correlations (i.e., stronger
associations). The graphical LASSO reduces small or unstable correla-
tions to 0 in an effort for the network to reflect only the edges that are
most robust and most likely to represent genuine associations.
We also estimated separate networks among people with both AN
subtypes: restricting (n 5 360) and binge-eating/purging (n 5 244).
4 | FORREST ET AL.

FIGURE 1 Bootstrapped strength stability for the anorexia nervosa (panel A), bulimia nervosa (panel B), and combined eating disorder (panel C)
graphical least absolute shrinkage and selection operator networks. Note. Figures indicate the accuracy (i.e., stability) of the estimated networks.
Specifically, the figures depict the maximum proportion of the original sample that can be dropped (X axis) while confidently retaining a strength
correlation above 0.7 with the original sample (Y axis). The solid line indicates the strength correlation and the shaded area indicates the 95%
confidence interval for the strength correlation. Strength correlations above 0.7 indicate that strength was estimated similarly in the full sample
and in smaller subsets of the original sample. These figures indicate that, for all networks presented, strength was estimated with high accuracy.
Accurate network estimation means that the networks can be meaningfully interpreted. [Color figure can be viewed at wileyonlinelibrary.com]

Networks were similar across subtypes. Thus, we present here the
overall AN symptom network and include in the Supporting Informa-
tion the AN subtype networks. In addition, we include in the Support-
ing Information the R code used for all analyses.
2.3.2 | Stability
Before interpreting networks, network stability must be inspected. If
networks have low stability, their estimates are prone to error and can-
not be meaningfully interpreted. Stability of three centrality indices
was indexed using R’s bootnet package (Epskamp, Borsboom, & Fried,
2017). Specifically, bootnet completed 2000 bootstraps of symptom
betweenness, closeness, and strength (see below) with progressively
smaller, random subsets of the sample. For each subset’s centrality, a
correlation-stability coefficient is computed with the original sample’s
centrality, and the coefficient’s 95% confidence intervals are calculated.
This coefficient and its confidence intervals indicate the maximum pro-
portion of the original sample that can be dropped while confidently
retaining a centrality correlation above 0.7 with the original sample.
Correlation-stability coefficients below 0.25 are unstable and error-
prone while correlation-stability coefficients >0.5 are relatively stable
and are less error-prone (Epskamp, Borsboom, & Fried, 2017).
2.3.3 | Centrality and influence
When estimating node strength, failure to differentiate positive
versus negative edge weights can obscure the degree to which a symp-
tom coheres with other symptoms in the network (Robinaugh, Millner,
& McNally, 2016). Given this limitation, Robinaugh and colleagues
(2016) developed expected influence to identify node importance.
Expected influence is similar to strength, meaning that it identifies the
strength of the relationships a given node has with other nodes. How-
ever, unlike strength, expected influence accounts for the direction of
associations. If a node has only positive associations with other nodes,
the node’s expected influence and strength will be equal. If a node has
negative and positive relations with other nodes, the node’s expected
influence will be less than the node’s strength. Expected influence val-
ues were calculated with the networktools R package (Jones, 2017).
2.3.4 | Strength differences
The bootnet R package was used to determine significant differences
in symptom strength. Specifically, bootnet calculated 2000 nonpara-
metric bootstraps of the differences between all symptoms’ strength
values, which produced a bootstrapped strength difference confidence
interval. Significant strength differences are indicated if the boot-
strapped strength difference confidence interval does not span 0.
Symptoms with significantly greater strength have high importance in

Betweenness, closeness, strength, and expected influence were calcu- the network structure (Epskamp, Borsboom, & Fried, 2017). R packages

lated for each node. For each metric, nodes with the highest centrality or to bootstrap the stability of, and differences between, expected influ-

influence are interpreted as the most core nodes in the network. Betwe- ence values are not available currently.

enness indicates the number of times a node falls within the shortest
path connecting other nodes. Closeness indicates how closely located in
space a node is to other nodes. Strength is the sum of the absolute value
of the edges connecting a node to other nodes, meaning that positive
and negative edges are not distinguished from one another.
3 | RESULTS
Strength was highly stable in all networks (Figure 1). Across networks,
the strength correlation-stability coefficient was 0.81 (AN 5 0.81,
FORREST ET AL. | 5

FIGURE 2 Anorexia nervosa graphical least absolute shrinkage and selection operator network and standardized expected influence and
strength values. Note. Expected influence and strength values are standardized. Higher standardized values (i.e., symptoms with values located
farther to the right of the figure) indicate greater influence or strength. In addition, when all edges emerging from a node are positive, expected
influence values will be exactly equal to strength values. However, when at least one edge emerging from a node is negative; expected
influence values will be less than strength values. Weight overval 5 weight overvaluation; vomit 5 vomiting to control shape or weight; social
eat 5 avoiding social eating; shape overval 5 shape overvaluation; rx weighing 5 reaction to prescribed weighing; restrict 5 restrictive eating;
restraint 5 dietary restraint; preocc shpwt 5 shape or weight preoccupation; preocc food 5 food preoccupation; over-exercise 5 over-
exercising to control shape or weight; laxatives 5 using laxatives to control shape or weight; guilt eat 5 guilt about eating; flat stomach 5 desire
to have a flat stomach; feel fat 5 feelings of fatness; fear wtgain 5 fearing weight gain; fear loc 5 fear of losing control over eating; exclude
food 5 excluding food; empty stomach 5 desire to have empty stomach; eat secret 5 eating in secret; diss weight 5 dissatisfaction with weight;
diss shape 5 dissatisfaction with shape; discomf body 5 discomfort seeing body; diet rules 5 dietary rules; desire wtloss 5 desiring weight loss;
binge loc 5 binge criterion B (losing control over eating when eating a definitely large amount of food); binge_a 5 binge criterion A (eating a def-
initely large amount of food); avoid exposure 5 avoiding body exposure. [Color figure can be viewed at wileyonlinelibrary.com]

BN 5 0.81, combined 5 0.90), indicating that at least of 81% of the
original samples can be dropped to retain a strength correlation
above 0.7 with the full samples. Betweenness was not stable in any
networks, meaning that betweenness values were highly error-prone
(betweenness correlation-stability coefficients < 0.14). The closeness
correlation-stability coefficient was 0.71 in the AN and BN networks
and 0.81 in the combined network. Given that strength was more sta-
ble compared to betweenness and closeness (which is often observed
in psychometric networks [Epskamp, Borsboom, & Fried, 2017; Forbes
et al., 2017)], and considering that the interpretation of betweenness
and closeness in psychometric networks is somewhat unclear (Forbes
et al., 2017), we removed betweenness and closeness from
interpretation. Instead, we include these results in the Supporting Infor-
mation and focus our interpretation on expected influence and
strength, which, respectively, have the benefits of accounting for edge
directionality and indexing stability and differences among symptoms.
The AN network, expected influence values, and strength values are
presented in Figure 2. Desiring weight loss (desire wtloss), restraint
(restraint), shape and weight preoccupation (preocc shpwt), shape overval-
uation (shape overval), and fearing weight gain (fear wtgain) had the high-
est expected influence and strength. Strength difference results are shown
in Figure 3. When comparing strength values, desiring weight loss,
restraint, and shape overvaluation did not significantly differ from one
another but were significantly higher than at least half of other symptoms.
6 | FORREST ET AL.

FIGURE 3 Anorexia nervosa bootstrapped strength difference results. Note. Symptoms are presented in descending order of strength
values. Values on the diagonal indicate the unstandardized strength values for each symptom. Black boxes indicate significant strength
differences, meaning that the bootstrapped strength difference confidence interval does not span 0. Gray boxes indicate nonsignificant
strength differences, meaning that the bootstrapped strength difference confidence interval spans 0

The BN network, expected influence values, and strength values
are presented in Figure 4. Desiring weight loss (desire wtloss), restraint
(restraint), shape and weight preoccupation (preocc shpwt), shape over-
valuation (shape overval), and weight overvaluation (weight overval)
had the highest expected influence and strength. Strength difference
results are shown in Figure 5. When comparing strength values, desir-
ing weight loss was significantly higher than all other symptoms. The
strength of shape overvaluation was also significantly higher than
nearly half of other symptoms.
The combined ED network, expected influence values, and
strength values are presented in Figure 6. Desiring weight loss (desire
wtloss), restraint (restraint), shape and weight preoccupation (preocc
shpwt), shape overvaluation (shape overval), fearing weight gain (fear
wtgain), and shape dissatisfaction (diss shape) had the highest expected
influence and strength. Strength difference results are shown in Figure
7. When comparing strength values, desiring weight loss, restraint,
shape overvaluation, and preoccupation with shape and weight did not
significantly differ from one another but were significantly higher than
at least half of other symptoms.
4 | DISCUSSION
This study used network analysis to examine a key hypothesis of CBT-
E: whether shape and weight overvaluation represent the core psycho-
pathology for AN and BN. We estimated individual AN and BN
symptom networks and a combined ED network. In all networks, shape
and weight overvaluation and additional indicators of shape and weight
concerns emerged as the most important symptoms. Results converge
with existing ED network analysis findings (DuBois et al., 2017; For-
bush et al., 2016; Levinson et al., 2017), which consistently support the
hypothesis that shape and weight overvaluation are the core ED
psychopathology.
In line with hypotheses and previous findings (DuBois et al., 2017;
Levinson et al., 2017), in all networks shape overvaluation and two indi-
cators of shape and weight concerns (desiring weight loss and shape
and weight preoccupation; Fairburn & Beglin, 1994) emerged as the
symptoms with the strongest importance. Restraint also had high
importance in the networks. The only point of divergence among the
networks was that fearing weight gain had high importance in the AN
and the combined networks but medium-to-high importance in the BN
network, whereas weight overvaluation had high importance in the BN
network but medium-to-high importance in the AN and combined
networks.
Multiple studies support that shape and weight overvaluation
maintain engagement in ED behaviors, and that ED behaviors further
reinforce shape and weight overvaluation. For instance, Tabri and col-
leagues (2015) found that among women with AN and BN, shape and
weight overvaluation in one week predicted greater engagement in
restrictive eating and over-exercise the following week. Similarly,
engagement in restrictive eating and over-exercise in one week
FORREST ET AL. | 7

FIGURE 4 Bulimia nervosa graphical least absolute shrinkage and selection operator network and standardized expected influence and
strength values. Note. Expected influence and strength values are standardized. Higher standardized values (i.e., symptoms with values
located farther to the right of the figure) indicate greater influence or strength. In addition, when all edges emerging from a node are
positive, expected influence values will be exactly equal to strength values. However, when at least one edge emerging from a node is
negative, expected influence values will be less than strength values. Weight overval 5 weight overvaluation; vomit 5 vomiting to control
shape or weight; social eat 5 avoiding social eating; shape overval 5 shape overvaluation; rx weighing 5 reaction to prescribed weighing;
restrict 5 restrictive eating; restraint 5 dietary restraint; preocc shpwt 5 shape or weight preoccupation; preocc food 5 food preoccupation;
over-exercise 5 over-exercising to control shape or weight; laxatives 5 using laxatives to control shape or weight; guilt eat 5 guilt about eat-
ing; flat stomach 5 desire to have a flat stomach; feel fat 5 feelings of fatness; fear wtgain 5 fearing weight gain; fear loc 5 fear of losing
control over eating; exclude food 5 excluding food; empty stomach 5 desire to have empty stomach; eat secret 5 eating in secret; diss
weight 5 dissatisfaction with weight; diss shape 5 dissatisfaction with shape; discomf body 5 discomfort seeing body; diet rules 5 dietary
rules; desire wtloss 5 desiring weight loss; binge loc 5 binge criterion B (losing control over eating when eating a definitely large amount of
food); binge_a 5 binge criterion A (eating a definitely large amount of food); avoid exposure 5 avoiding body exposure. [Color figure can be
viewed at wileyonlinelibrary.com]

positively predicted overvaluation the following week (Tabri et al.,
2015). In another longitudinal study, shape and weight overvaluation
among women with BN predicted persistence of binge eating over a
five-year period, and restraint moderated the association between
shape and weight overvaluation and binge eating (Fairburn, Stice,
Cooper, Doll, Norman, & O’Connor, 2003).
4.1 | Extension and replication of previous ED
network analyses
Our findings provide an opportunity for extension, comparison, and
contrast of previous ED network studies. To our knowledge, this study
is the first report of AN symptom structure that can be meaningfully
interpreted. Desiring weight loss, restraint, shape and weight preoccu-
pation, shape overvaluation, and fearing weight gain had the highest
centrality in our overall AN network and subtype networks. These
data-driven findings map onto many of the cognitive criteria for AN
(American Psychiatric Association, 2013), and demonstrate the useful-
ness of network analysis to further the field’s understanding of ED
classification.
Our BN network and combined network results are well suited to
examine the replicability of Levinson and colleagues’ (2017) and
DuBois and colleagues’ (2017) findings, respectively, given the similar-
ity in network estimation techniques (i.e., graphical LASSO networks),
samples (i.e., treatment-seeking samples of people with BN and mixed
EDs), and core ED symptom measures (i.e., EDE and EDE-Q). The
8 | FORREST ET AL.

FIGURE 5 Bulimia nervosa bootstrapped strength difference results. Note. Symptoms are presented in descending order of strength
values. Values on the diagonal indicate the unstandardized strength values for each symptom. Black boxes indicate significant strength
differences, meaning that the bootstrapped strength difference confidence interval does not span 0. Gray boxes indicate nonsignificant
strength differences, meaning that the bootstrapped strength difference confidence interval spans 0

current findings provide a high degree of replication of Levinson and
colleagues’ (2017) results, as desiring weight loss, shape and weight
preoccupation, and weight overvaluation emerged in both studies as
highly central symptoms. However, two differences emerged: in our
study shape overvaluation was also among the highest centrality symp-
toms and fearing weight gain had moderate-to-high centrality, whereas
in Levinson and colleagues’ study (2017), shape overvaluation was not
a highly central symptom but fearing weight gain had high centrality. In
addition, our combined ED network results provide a high degree of
replication to DuBois and colleagues’ (2017) findings. DuBois et al.
(2017) identified a composite of shape and weight overvaluation as the
most central symptom, and restraint was another highly central symp-
tom. Although we did not use a composite of shape and weight over-
valuation, in our combined network shape overvaluation and restraint
emerged as two of the highest centrality items. In a mixed ED commu-
nity sample, Forbush et al. (2016) identified an indicator of body check-
ing as the most central symptom. As our combined network did not
include a measure of body checking, our results cannot provide evi-
dence for or against these results.
Borsboom and colleagues (2017) detail that methodological and
analytic differences greatly affect network analysis results. Indeed, cur-
rent ED network studies have included several key differences, such as
constructing association versus graphical LASSO networks, assessing
symptoms with different measures, constructing networks from indi-
vidual items versus subscales, and using different indicators of
centrality or influence. Despite the differences among ED network
studies, we find it notable that indicators of shape and weight overval-
uation have emerged consistently as the most important symptoms
across studies. We also find it notable that when the samples and
measures were similar, centrality results were highly replicable.
4.2 | Limitations and future directions
Several limitations are worth noting. First, ED diagnoses were made
using a semistructured interview that is specific to the residential treat-
ment facility where data were collected. Second, we estimated a net-
work comprised only of ED symptoms as defined by the EDE-Q and as
emphasized in the focused form of CBT-E, which is limited to tradi-
tional mental disorder symptoms (Jones, Heeren, & McNally, 2017).
We did not include other potentially important risk or maintenance fac-
tors, such as emotion-related variables (e.g., Heatherton & Baumeister,
1991; Herman & Polivy, 1984), neurobiological variables (e.g., Kaye,
Fudge, & Paulus, 2009), personality characteristics (e.g., Cassin & von
Ranson, 2005), any ED-related experiences that occurred prior to the
past 28 days (e.g., highest lifetime weight), or any non-ED experiences
or symptoms (see review in Jacobi, Hayward, de Zwaan, Kraemer, &
Agras, 2004). Psychopathology networks cannot reveal anything about
variables that were not included in analyses; thus, future research
would benefit from examining the structure of ED psychopathology
when including potentially causal nodes that span multiple units of
FORREST ET AL. | 9

FIGURE 6 Combined eating disorder graphical least absolute shrinkage and selection operator network and standardized expected
influence and strength values. Note. Expected influence and strength values are standardized. Higher standardized values (i.e., symptoms
with values located farther to the right of the figure) indicate greater influence or strength. In addition, when all edges emerging from a
node are positive, expected influence values will be exactly equal to strength values. However, when at least one edge emerging from a
node is negative, expected influence values will be less than strength values. Weight overval 5 weight overvaluation; vomit 5 vomiting to
control shape or weight; social eat 5 avoiding social eating; shape overval 5 shape overvaluation; rx weighing 5 reaction to prescribed
weighing; restrict 5 restrictive eating; restraint 5 dietary restraint; preocc shpwt 5 shape or weight preoccupation; preocc food 5 food
preoccupation; over-exercise 5 over-exercising to control shape or weight; laxatives 5 using laxatives to control shape or weight; guilt
eat 5 guilt about eating; flat stomach 5 desire to have a flat stomach; feel fat 5 feelings of fatness; fear wtgain 5 fearing weight gain; fear
loc 5 fear of losing control over eating; exclude food 5 excluding food; empty stomach 5 desire to have empty stomach; eat secret 5 eating
in secret; diss weight 5 dissatisfaction with weight; diss shape 5 dissatisfaction with shape; discomf body 5 discomfort seeing body; diet
rules 5 dietary rules; desire wtloss 5 desiring weight loss; binge loc 5 binge criterion B (losing control over eating when eating a definitely
large amount of food); binge_a 5 binge criterion A (eating a definitely large amount of food); avoid exposure 5 avoiding body exposure.
[Color figure can be viewed at wileyonlinelibrary.com]

analysis and multiple forms of psychopathology (e.g., anxiety, depres-
sion; Jones et al., 2017; Levinson et al., 2017).
Third, we modeled cross-sectional associations, which cannot iden-
tify causality (e.g., see Forbes et al., 2017). Prospective and experimen-
tal work is needed to identify whether shape and weight overvaluation
have causal effects on ED etiology and on the emergence of other ED
symptoms. Fourth, while the individual items assessing shape and
weight overvaluation emerged as highly central symptoms, additional
highly central symptoms included other indicators of shape and weight
concerns. Shape and weight overvaluation and other indicators of
shape and weight concerns share some conceptual similarities and are
included in the shape concerns and weight concerns subfactor totals
on the EDE and EDE-Q (Fairburn & Cooper, 1993; Fairburn & Beglin,
1994). However, as shown in this and other ED network studies, shape
and weight overvaluation and other indicators of shape and weight
concerns—fearing weight gain (Levinson et al., 2017) and desiring
weight loss (current study)—stood out as highly central symptoms. This
point yields at least three directions for future research. First, it is pos-
sible that shape and weight overvaluation and other highly central
shape and weight concerns indicators assess the same latent construct.
In this case, future network research could model shape and weight
overvaluation as a latent variable, indicated by highly central items (e.g.,
shape overvaluation, weight overvaluation, desiring weight loss;
Epskamp, Rhemtulla, & Borsboom, 2017). At the same time, certain
10 | FORREST ET AL.

FIGURE 7 Combined eating disorder bootstrapped strength difference results. Note. Symptoms are presented in descending order of
strength values. Values on the diagonal indicate the unstandardized strength values for each symptom. Black boxes indicate significant
strength differences, meaning that the bootstrapped strength difference confidence interval does not span 0. Gray boxes indicate
nonsignificant strength differences, meaning that the bootstrapped strength difference confidence interval spans 0

indicators of shape and weight concerns are differentially associated
with ED and comorbid symptoms (Lydecker, White, & Grilo, 2017).
Thus, a second future direction is that time-series data could be used
to construct intraindividual networks (e.g., Epskamp, van Borkulo, van
der Veen, Servaas, Isvoranu, Riese, & Cramer, accepted pending revi-
sion), with shape and weight overvaluation and other shape and weight
concerns indicators modeled as observed variables. So doing could
have important implications in determining individual differences in
core ED psychopathology. A third future direction is to obtain a more
nuanced understanding of shape and weight concerns in people with
AN and BN. For instance, shape and weight overvaluation, fearing
weight gain, and desiring weight loss may have unique relations with
other ED symptoms (c.f., Lydecker et al., 2017). In addition, factor ana-
lytic studies of the EDE and EDE-Q do not often replicate the pro-
posed four-factor structure (e.g., Byrne, Allen, Lampard, Dove, &
Fursland, 2010; Peterson et al., 2007). Additional studies could investi-
gate whether shape and weight concerns are multifactorial constructs,
and whether shape and weight overvaluation load onto different fac-
tors than fearing weight gain or desiring weight loss.
Finally, results have limited generalizability. Specifically, no males
were recruited for the study. Further, approximately 20% of people with
AN and roughly 10% of people with BN did not report clinically signifi-
cant shape or weight overvaluation. The core psychopathology of
nonfat-phobic ED presentations—especially those with full or partial
threshold AN and BN—remains to be uncovered (e.g., Murray, Coniglio,
Becker, Eddy, & Thomas, 2017). In addition, the sample was comprised
of people seeking ED treatment. Additional ED network studies with
community-recruited samples are needed (c.f. Forrest, Smith, & Swan-
son, 2017). Last, individuals with binge-eating disorder (BED) were not
included in analyses. While CBT-E proposes that shape and weight over-
valuation are the core BED psychopathology, to date, ED network analy-
ses have not included adequate BED sample sizes to test this hypothesis.
4.3 | Clinical applications
As described above, one goal of constructing psychopathology networks
is to identify the symptoms that are most strongly associated with other
symptoms in a network, as these symptoms are theoretically posited to
play a large role in maintenance of psychopathology. Identifying core
symptoms can inform targeted interventions that may strongly disrupt
the symptom network and decrease ED symptoms. The current findings
point to the importance of considering shape and weight overvaluation
as a primary ED treatment target, which is a key component of many
cognitive–behavioral ED treatments (e.g., Fairburn, 2008; National Insti-
tute for Health and Care Excellence, 2017). Mitigating shape and weight
overvaluation may be accomplished through a combination of techni-
ques, such as cognitive reframing (e.g., identifying evidence supporting
and negating beliefs about one’s body), behavioral experiments (e.g.,
comparing one’s body shape or weight to every fifth person who appears
to be a similar age and gender), and exposures to situations that violate
FORREST ET AL.
expectancies (e.g., open weighing where patients can observe objective
trends; Fairburn, 2008; Reilly, Anderson, Gorrell, Schaumberg, & Ander-
son, 2017). Examining whether shape and weight overvaluation inter-
ventions decrease network connectivity and lead to reduced ED
symptoms is an important endeavor for the ED field and a key test of the
network theory of psychopathology (Borsboom & Cramer, 2013).
In addition to intervention applications, the centrality of shape and
weight overvaluation across networks suggests that shape and weight
overvaluation may be an informative transdiagnostic ED severity speci-
fier. While the current study did not assess BED core psychopathology,
many argue that shape and weight overvaluation should be included as a
BED severity specifier (e.g., Grilo, 2013). Currently, the hallmark behav-
iors for ED types are used to indicate illness severity: restrictive eating
leading to a significantly low weight for AN, compensatory behavior fre-
quencies for BN, and binge-eating frequencies for BED (American Psy-
chiatric Association, 2013). As Giannini and colleagues (2017) describe,
ideal indicators of illness severity would index “the intensity of defining
psychopathological features of the illness” (p. 914)—a goal that closely
aligns with those of network analysis. Interestingly, ED behaviors did not
play a principal role in comprising the ED psychopathology structures,
which may suggest that current severity specifiers do not fully capture
defining ED features. Indeed, Giannini and colleagues (2017) examined
the utility of current ED severity specifiers versus shape and weight
overvaluation in differentiating people with AN, BN, and BED based on
ED symptoms, comorbid symptoms, and multiple indices of impairment.
While each ED-specific specifier differentiated severities of AN, BN, and
BED on some outcomes, shape and weight overvaluation strongly differ-
entiated AN, BN, and BED severities on nearly all outcomes. The current
findings support further examining the utility of shape and weight over-
valuation as a transdiagnostic ED severity specifier.
In summary, we estimated ED symptom networks among
treatment-seeking girls and women with AN and BN. Consistent with
CBT-E, shape and weight overvaluation and indicators of shape and
weight concerns emerged as the most important symptoms in the net-
works. The current results are the first to reliably estimate AN symp-
tom structure. Moreover, findings provide a high degree of replication
to previous BN and mixed ED networks. This study supports that shape
and weight overvaluation—rather than ED behaviors—may represent
the defining features of EDs.
AC KNOW LE DGME NT
The authors would like to thank The Renfrew Center for the use of
these data.
OR CID
Lauren N. Forrest http://orcid.org/0000-0003-1481-5078
April Smith http://orcid.org/0000-0003-0832-0028
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How to cite this article: Forrest LN, Jones PJ, Ortiz SN, Smith
AR. Core psychopathology in anorexia nervosa and bulimia
nervosa: A network analysis. Int J Eat Disord. 2018;00:1–12.
https://doi.org/10.1002/eat.22871