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A network investigation of core symptoms and pathways across duration of illness using a comprehensive cognitive–behavioral model of eating-disorder symptoms

  • Caroline Christian (a1), Brenna M. Williams (a1), Rowan A. Hunt (a1), Valerie Z. Wong (a2), Sarah E. Ernst (a1), Samantha P. Spoor (a1), Irina A. Vanzhula (a1), Jenna P. Tregarthen (a3), Kelsie T. Forbush (a4) and Cheri A. Levinson (a1)...



In the past decade, network analysis (NA) has been applied to psychopathology to quantify complex symptom relationships. This statistical technique has demonstrated much promise, as it provides researchers the ability to identify relationships across many symptoms in one model and can identify central symptoms that may predict important clinical outcomes. However, network models are highly influenced by node selection, which could limit the generalizability of findings. The current study (N = 6850) tests a comprehensive, cognitive–behavioral model of eating-disorder symptoms using items from two, widely used measures (Eating Disorder Examination Questionnaire and Eating Pathology Symptoms Inventory).


We used NA to identify central symptoms and compared networks across the duration of illness (DOI), as chronicity is one of the only known predictors of poor outcome in eating disorders (EDs).


Our results suggest that eating when not hungry and feeling fat were the most central symptoms across groups. There were no significant differences in network structure across DOI, meaning the connections between symptoms remained relatively consistent. However, differences emerged in central symptoms, such that cognitive symptoms related to overvaluation of weight/shape were central in individuals with shorter DOI, and behavioral central symptoms emerged more in medium and long DOI.


Our results have important implications for the treatment of individuals with enduring EDs, as they may have a different core, maintaining symptoms. Additionally, our findings highlight the importance of using comprehensive, theoretically- or empirically-derived models for NA.


Corresponding author

Author for correspondence: Cheri A. Levinson, E-mail:


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Aardoom, J. J., Dingemans, A. E., Op't Landt, M. C. S., & Van Furth, E. F. (2012). Norms and discriminative validity of the Eating Disorder Examination Questionnaire (EDE-Q). Eating Behaviors, 13, 305309.
Berg, K. C., Peterson, C. B., Frazier, P., & Crow, S. J. (2012). Psychometric evaluation of the eating disorder examination and eating disorder examination-questionnaire: A systematic review of the literature. International Journal of Eating Disorders, 45, 428438.
Berkman, N. D., Lohr, K. N., & Bulik, C. M. (2007). Outcomes of eating disorders: A systematic review of the literature. International Journal of Eating Disorders, 40, 293309.
Borsboom, D., & Cramer, A. O. (2013). Network analysis: An integrative approach to the structure of psychopathology. Annual Review of Clinical Psychology, 9, 91121.
Boswell, J. F., Anderson, L. M., & Anderson, D. A. (2015). Integration of interoceptive exposure in eating disorder treatment. Clinical Psychology: Science and Practice, 22, 194210.
Bringmann, L. F., Elmer, T., Epskamp, S., Krause, R. W., Schoch, D., Wichers, M., … Snippe, E. (2019). What do centrality measures measure in psychological networks? The Journal of Abnormal Psychology, 128, 892903.
Bringmann, L. F., & Eronen, M. I. (2018). Don't blame the model: Reconsidering the network approach to psychopathology. Psychological Review, 125, 606615.
Carter, J. C., Blackmore, E., Sutandar-Pinnock, K., & Woodside, D. B. (2004). Relapse in anorexia nervosa: A survival analysis. Psychological Medicine, 34, 671679.
Carter, J. C., Stewart, D. A., & Fairburn, C. G. (2001). Eating disorder examination questionnaire: Norms for young adolescent girls. Behaviour Research and Therapy, 39, 625632.
Christian, C., Perko, V. L., Vanzhula, I. A., Tregarthen, J. P., Forbush, K. T., & Levinson, C. A. (2019). Using network analysis to examine differences in eating disorder symptom structure and interconnectedness across developmental stages. Journal of Abnormal Psychology. Advance online publication.
Cooper, Z., & Fairburn, C. (1987). The eating disorder examination: A semi-structured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders, 6, 18.
Cramer, A. O., Waldorp, L. J., Van Der Maas, H. L., & Borsboom, D. (2010). Comorbidity: A network perspective. Behavioral and Brain Sciences, 33, 137150.
DuBois, R. H., Rodgers, R. F., Franko, D. L., Eddy, K. T., & Thomas, J. J. (2017). A network analysis investigation of the cognitive-behavioral theory of eating disorders. Behaviour Research and Therapy, 97, 213221.
Eckert, E. D., Halmi, K. A., Marchi, P., Grove, W., & Crosby, R. (1995). Ten-year follow-up of anorexia nervosa: Clinical course and outcome. Psychological Medicine, 25, 143156.
Elliott, H., Jones, P. J., & Schmidt, U. (2019). Central symptoms predict post-treatment outcomes and clinical impairment in anorexia nervosa: A network analysis in a randomized-controlled trial. Clinical Psychological Science. Advance online publication.
Epskamp, S., Cramer, A. O., Waldorp, L. J., Schmittmann, V. D., & Borsboom, D. (2012). Qgraph: Network visualizations of relationships in psychometric data. Journal of Statistical Software, 48, 118.
Epskamp, S., Maris, G. K., Waldorp, L. J., & Borsboom, D. (2016). Network psychometrics. In Irwing, P., Hughes, D., & Booth, T. (Eds.), Handbook of Psychometrics. New York: Wiley.
Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York, NY: Guilford Press.
Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16, 363370.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A ‘transdiagnostic’ theory and treatment. Behaviour Research and Therapy, 41, 509528.
Forbush, K. T., Siew, C. S. Q., & Vitevitch, M. S. (2016). Application of network analysis to identify interactive systems of eating disorder psychopathology. Psychological Medicine, 46, 26672677.
Forbush, K. T., Wildes, J. E., & Hunt, T. K. (2014). Gender norms, psychometric properties and validity for the Eating Pathology Symptoms Inventory. International Journal of Eating Disorders, 47, 8591.
Forbush, K. T., Wildes, J. E., Pollack, L. O., Dunbar, D., Luo, J., Patterson, K., … Bright, A. (2013). Development and validation of the Eating Pathology Symptoms Inventory (EPSI). Psychological Assessment 25, 859878.
Forrest, L. N., Jones, P. J., Ortiz, S. N., & Smith, A. R. (2018). Core psychopathology in anorexia nervosa and bulimia nervosa: A network analysis. International Journal of Eating Disorders, 51, 668679.
Goldschmidt, A. B., Crosby, R. D., Cao, L., Moessner, M., Forbush, K. T., Accurso, E. C., & Le Grange, D. (2018). Network analysis of pediatric eating disorder symptoms in a treatment-seeking, transdiagnostic sample. Journal of Abnormal Psychology, 127, 251264.
Hallquist, M., Wright, A. G., & Molenaar, P. C. (2019). Problems with centrality measures in psychopathology symptom networks: Why network psychometrics cannot escape psychometric theory. Multivariate Behavioral Research, 12, 125.
Hay, P., & Touyz, S. (2015). Treatment of patients with severe and enduring eating disorders. Current Opinion in Psychiatry, 28, 473477.
Herzog, D. B., Sacks, N. R., Keller, M. B., Lavori, P. W., Von Ranson, K. B., & Gray, H. M. (1993). Patterns and predictors of recovery in anorexia nervosa and bulimia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 835842.
Jones, P. J. (2017). networktools: Tools for identifying important nodes in networks. R package, version 1.2. Retrieved from
Keel, P. K., & Brown, T. A. (2010). Update on course and outcome in eating disorders. International Journal of Eating Disorders, 43, 195204.
Klump, K. L., Bulik, C. M., Kaye, W. H., Treasure, J., & Tyson, E. (2009). Academy for eating disorders position paper: Eating disorders are serious mental illnesses. International Journal of Eating Disorders, 42, 97103.
Kristeller, J., Wolever, R. Q., & Sheets, V. (2014). Mindfulness-based eating awareness training (MB-EAT) for binge eating: A randomized clinical trial. Mindfulness, 5, 282297.
Levinson, C. A., Brosof, L. C., Vanzhula, I. A., Christian, C., Jones, P., Rodebaugh, T. L., … Menatti, A. (2018). Social anxiety and eating disorder comorbidity and underlying vulnerabilities: Using network analysis to conceptualize comorbidity. International Journal of Eating Disorders 51, 693709.
Levinson, C. A., Zerwas, S., Calebs, B., Forbush, K. T., Kordy, H., Watson, H., … Runfola, C. D. (2017). The core symptoms of bulimia nervosa, anxiety and depression: A network analysis. Journal of Abnormal Psychology 126, 340354.
Linardon, J., Phillipou, A., Castle, D., Newton, R., Harrison, P., Cistullo, L. L., … Brennan, L. (2018). Feeling fat in eating disorders: Testing the unique relationships between feeling fat and measures of disordered eating in anorexia nervosa and bulimia nervosa. Body Image 25, 163167.
Luce, K. H., & Crowther, J. H. (1999). The reliability of the eating disorder examination – self-report questionnaire version (EDE-Q). International Journal of Eating Disorders, 25, 349351.
Major, L. (2016). The experience of feeling fat for women with an anorexia nervosa diagnosis: An interpretative phenomenological analysis. Doctoral dissertation, University of Hertfordshire, Hatfield, England. Retrieved from
McNally, R. J. (2016). Can network analysis transform psychopathology? Behaviour Research and Therapy, 86, 95104.
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Beumont, P. J. V. (2004). Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behaviour Research and Therapy, 42, 551567.
Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2010). Cognitive behavioral therapy for eating disorders. Psychiatric Clinics, 33, 611627.
Norring, C. E. A., & Sohlberg, S. S. (1993). Outcome, recovery, relapse and mortality across six years in patients with clinical eating disorders. Acta Psychiatrica Scandinavica, 87, 437444.
Olatunji, B. O., Levinson, C. A., & Calebs, B. (2018). A network analysis of eating disorder symptoms and characteristics in an inpatient sample. Psychiatry Research, 262, 270281.
Pallister, E., & Waller, G. (2008). Anxiety in the eating disorders: Understanding the overlap. Clinical Psychology Review, 28, 366386.
Pe, M. L., Kircanski, K., Thompson, R. J., Bringmann, L. F., Tuerlinckx, F., Mestdagh, M., … Kuppens, P. (2015). Emotion-network density in major depressive disorder. Clinical Psychological Science 3, 292300.
Pearson, C. M., Wonderlich, S. A., & Smith, G. T. (2015). A risk and maintenance model for bulimia nervosa: From impulsive action to compulsive behavior. Psychological Review, 122, 516.
Perko, V. L., Forbush, K. T., Siew, C. S. Q., & Tregarthen, J. P. (2019). Application of network analysis to investigate sex differences in interactive systems of eating-disorder psychopathology. International Journal of Eating Disorders, 52, 13431352.
Robinson, P (2009) Severe and enduring eating disorder (SEED): Management of complex presentations of anorexia and bulimia nervosa. Chichester, UK; Malden, MA: Wiley-Blackwell.
Robinson, P. (2014). Severe and enduring eating disorders: Recognition and management. Advances in Psychiatric Treatment, 20, 392401.
Rodebaugh, T. L., Tonge, N. A., Piccirillo, M. L., Fried, E., Horenstein, A., Morrison, A. S., … Blanco, C. (2018). Does centrality in a cross-sectional network suggest intervention targets for social anxiety disorder? Journal of Consulting and Clinical Psychology 86, 831844.
Simlett, M. (2004). Relationship between feeling fat and inhibited emotional expression in women. Doctoral dissertation, University of British Columbia, Vancouver, Canada. Retrieved from
Smith, K. E., Crosby, R. D., Wonderlich, S. A., Forbush, K. T., Mason, T. B., & Moessner, M. (2018). Network analysis: An innovative framework for understanding eating disorder psychopathology. International Journal of Eating Disorders, 51, 214222.
Stice, E., & Shaw, H. E. (2002). Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research, 53, 985993.
Strober, M., Freeman, R., & Morrell, W. (1997). 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. International Journal of Eating Disorders, 22, 339360.
Treasure, J., Cardi, V., Leppanen, J., & Turton, R. (2015). New treatment approaches for severe and enduring eating disorders. Physiology and Behavior, 152, 456465.
Tregarthen, J. P., Lock, J., & Darcy, A. M. (2015). Development of a smartphone application for eating disorder self-monitoring. International Journal of Eating Disorders, 48, 972982.
van Borkulo, C., Boschloo, L., Borsboom, D., Penninx, B. W., Waldorp, L. J., & Schoevers, R. A. (2015). Association of symptom network structure with the course of depression. JAMA Psychiatry, 72, 12191226.
Vanzhula, I. A., Calebs, B., Fewell, L., & Levinson, C. A. (2019). Illness pathways between eating disorder and post-traumatic stress disorder symptoms: Understanding comorbidity with network analysis. European Eating Disorders Review, 27, 147160.
Vanzhula, I. A., Christian, C., Brosof, L. C., Jones, P., Levinson, C. A., Forbush, K. T., … Tregarthen, J. (under review). Replicability of eating disorder psychological networks in five samples: Conceptual and methodological considerations. Manuscript submitted for publication.
Walsh, B. T. (2013). The enigmatic persistence of anorexia nervosa. American Journal of Psychiatry, 170, 477484.
Wang, S. B., Jones, P. J., Dreier, M., Elliott, H., & Grilo, C. M. (2018). Core psychopathology of treatment-seeking patients with binge-eating disorder: A network analysis investigation. Psychological Medicine, 49, 19231928.
Zipfel, S., Löwe, B., Reas, D. L., Deter, H. C., & Herzog, W. (2000). Long-term prognosis in anorexia nervosa: Lessons from a 21-year follow-up study. The Lancet, 355, 721722.


A network investigation of core symptoms and pathways across duration of illness using a comprehensive cognitive–behavioral model of eating-disorder symptoms

  • Caroline Christian (a1), Brenna M. Williams (a1), Rowan A. Hunt (a1), Valerie Z. Wong (a2), Sarah E. Ernst (a1), Samantha P. Spoor (a1), Irina A. Vanzhula (a1), Jenna P. Tregarthen (a3), Kelsie T. Forbush (a4) and Cheri A. Levinson (a1)...


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