1
|
Croci MS, Brañas MJAA, Javaras KN, Dechant E, Jurist J, Steigerwald G, Choi-Kain LW. General Psychiatric Management for Adolescents With Borderline Personality Disorder and Eating Disorders. Am J Psychother 2024:appipsychotherapy20230045. [PMID: 39083007 DOI: 10.1176/appi.psychotherapy.20230045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024]
Abstract
Borderline personality disorder and eating disorders frequently co-occur among youths. These disorders emerge in adolescence, during the critical developmental period of building an independent sense of self and the capacity to relate to one's community. Because of core differences in the development and psychopathology of borderline personality disorder and eating disorders, adjustments are required when treating these disorders when they co-occur. Few established treatment approaches can address these disorders simultaneously. Evidence-based psychotherapies for borderline personality disorder, such as dialectical behavior therapy and mentalization-based treatment, have been adapted to accommodate the shared vulnerabilities and features of the two disorders. However, these approaches are specialized, intensive, and lengthy and are therefore poorly suited to implementation in general psychiatric or primary health care, where most frontline mental health care is provided. Generalist approaches can fill this public health gap, guiding nonspecialists in structuring informed clinical management for these impairing and sometimes fatal disorders. In this overview, the authors describe the adjustment of good (or general) psychiatric management (GPM) for adolescents with borderline personality disorder to incorporate the prevailing best practices for eating disorder treatment. The adjusted treatment relies on interventions most clinicians already use (diagnostic disclosure, psychoeducation, focusing on life outside treatment, managing patients' self-destructive behaviors, and conservative psychopharmacology with active management of comorbid conditions). Limitations of the adjusted treatment, as well as guidelines for referring patients to specialized and general medical treatments and for returning them to primary generalist psychiatric care, are discussed.
Collapse
Affiliation(s)
- Marcos S Croci
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, and National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil (Croci, Brañas); Division of Women's Mental Health (Javaras), Klarman Eating Disorders Center (Dechant), and Gunderson Personality Disorders Institute (Jurist, Steigerwald, Choi-Kain), McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston (Javaras, Dechant, Choi-Kain); Department of Psychology, Harvard University, Cambridge, Massachusetts (Steigerwald)
| | - Marcelo J A A Brañas
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, and National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil (Croci, Brañas); Division of Women's Mental Health (Javaras), Klarman Eating Disorders Center (Dechant), and Gunderson Personality Disorders Institute (Jurist, Steigerwald, Choi-Kain), McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston (Javaras, Dechant, Choi-Kain); Department of Psychology, Harvard University, Cambridge, Massachusetts (Steigerwald)
| | - Kristin N Javaras
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, and National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil (Croci, Brañas); Division of Women's Mental Health (Javaras), Klarman Eating Disorders Center (Dechant), and Gunderson Personality Disorders Institute (Jurist, Steigerwald, Choi-Kain), McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston (Javaras, Dechant, Choi-Kain); Department of Psychology, Harvard University, Cambridge, Massachusetts (Steigerwald)
| | - Esther Dechant
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, and National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil (Croci, Brañas); Division of Women's Mental Health (Javaras), Klarman Eating Disorders Center (Dechant), and Gunderson Personality Disorders Institute (Jurist, Steigerwald, Choi-Kain), McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston (Javaras, Dechant, Choi-Kain); Department of Psychology, Harvard University, Cambridge, Massachusetts (Steigerwald)
| | - Julia Jurist
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, and National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil (Croci, Brañas); Division of Women's Mental Health (Javaras), Klarman Eating Disorders Center (Dechant), and Gunderson Personality Disorders Institute (Jurist, Steigerwald, Choi-Kain), McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston (Javaras, Dechant, Choi-Kain); Department of Psychology, Harvard University, Cambridge, Massachusetts (Steigerwald)
| | - Georgia Steigerwald
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, and National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil (Croci, Brañas); Division of Women's Mental Health (Javaras), Klarman Eating Disorders Center (Dechant), and Gunderson Personality Disorders Institute (Jurist, Steigerwald, Choi-Kain), McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston (Javaras, Dechant, Choi-Kain); Department of Psychology, Harvard University, Cambridge, Massachusetts (Steigerwald)
| | - Lois W Choi-Kain
- Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo, and National Institute of Developmental Psychiatry for Children and Adolescents, São Paulo, Brazil (Croci, Brañas); Division of Women's Mental Health (Javaras), Klarman Eating Disorders Center (Dechant), and Gunderson Personality Disorders Institute (Jurist, Steigerwald, Choi-Kain), McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston (Javaras, Dechant, Choi-Kain); Department of Psychology, Harvard University, Cambridge, Massachusetts (Steigerwald)
| |
Collapse
|
2
|
Cogodi E, Ranieri J, Martelli A, Di Giacomo D. Emotional Dysregulation in Anorexia Nervosa: Scoping Review of Psychological Treatments. Healthcare (Basel) 2024; 12:1388. [PMID: 39057531 PMCID: PMC11276072 DOI: 10.3390/healthcare12141388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Eating disorders are complex psychiatric disorders characterized by compensatory and restrictive behavior and a preoccupation with one's body. Eating and purging behaviors are considered dysfunctional emotional regulation strategies. Therefore, psychological treatment is essential. The most common psychological interventions are dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), family therapy (FBT), multi-family group therapy (MFTG) and mentalization-based treatment (MBT). The aim of this study was to summarize the current evidence on the impact of psychological treatments on emotional regulation difficulties and psychological symptoms in patients with eating disorders, especially anorexia nervosa. A search was conducted on PubMed and Web of Science using the terms "anorexia nervosa" and "emotion dysregulation". Of the 278 initial articles, we included 15 publications. The results indicate that the acquisition of coping strategies, through DBT, leads to an improvement in anxiety and alexithymia. DBT, CBT and MBT lead to a reduction in the use of dysfunctional emotional regulation strategies too. Eating disorders involve both physical and mental health; therefore, it is desirable for future research to focus on the mutual synergy between the mental and physical components by evaluating various factors, such as biomarkers and the most appropriate therapeutic approach, with respect to the treatment setting.
Collapse
Affiliation(s)
- Enrica Cogodi
- Postgraduate in Clinical Psychology, University of L’Aquila, 67100 L’Aquila, Italy; (E.C.); (J.R.)
| | - Jessica Ranieri
- Postgraduate in Clinical Psychology, University of L’Aquila, 67100 L’Aquila, Italy; (E.C.); (J.R.)
- Life, Health and Environmental Sciences Department, University of L’Aquila, 67100 L’Aquila, Italy
| | - Alessandra Martelli
- Faculty of Biosciences and Agri-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy;
| | - Dina Di Giacomo
- Life, Health and Environmental Sciences Department, University of L’Aquila, 67100 L’Aquila, Italy
| |
Collapse
|
3
|
Elwyn R, Adams M, Sharpe SL, Silverstein S, LaMarre A, Downs J, Burnette CB. Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality. J Eat Disord 2024; 12:70. [PMID: 38831456 PMCID: PMC11145809 DOI: 10.1186/s40337-024-01016-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.
Collapse
Affiliation(s)
- Rosiel Elwyn
- Neuroscience and psychiatry, Thompson Institute, Birtinya, QLD, Australia
- University of the Sunshine Coast, Birtinya, QLD, Australia
| | | | - Sam L Sharpe
- Fighting Eating Disorders in Underrepresented Populations (FEDUP, Collective), West Palm Beach, FL, USA
| | | | | | | | - C Blair Burnette
- Department of Psychology, Michigan State University, Lansing, MI, USA.
| |
Collapse
|
4
|
van den Berg E, Pellemans K, Planting C, Daansen P, van Beers E, de Jonge M, Christ C, Dekker J. Treatment of patients with anorexia nervosa and comorbid post-traumatic stress disorder; where do we stand? A systematic scoping review. Front Psychiatry 2024; 15:1365715. [PMID: 38469034 PMCID: PMC10925640 DOI: 10.3389/fpsyt.2024.1365715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/12/2024] [Indexed: 03/13/2024] Open
Abstract
Objective Comorbid post-traumatic stress disorder in patients with anorexia nervosa may negatively affect the course of anorexia nervosa treatment, which is already challenging. There are currently no guidelines or recommendations on concurrent treatment approaches for both anorexia nervosa and post-traumatic stress disorder. This systematic scoping review aims to explore the feasibility, acceptability and effectiveness of psychological trauma-focused treatment concurrently offered to underweight patients receiving anorexia nervosa treatment. Method A multi-step literature search, according to an a priori protocol was performed. Databases PubMed, Embase, APA PsycINFO, Web of Science, Scopus and Cochrane Central were searched up to September 19th 2022, and the search was rerun June 19th 2023. For quality assessment, Risk of Bias in Non-randomised Studies-of Interventions tool was used. Results The extensive search yielded 1769 reports, out of which only three observational pilot studies, both English and German, published between 2004 and 2022, could be included. The included studies reported on a total of 13 female participants between 16 and 58 years old, with anorexia nervosa or otherwise specified feeding or eating disorder, baseline BMI ranging between 14.6 and 16.5, who received concurrent anorexia and post-traumatic stress disorder treatment. In all participants, the emotional and cognitive functioning was sufficient to process the offered trauma-focused interventions, despite their significantly low body weight. Discussion The findings of this review identify a dearth of treatment research on knowledge of concurrent trauma-focused treatments for patients with anorexia nervosa. Refraining patients with anorexia nervosa from trauma-focused treatment may not be warranted.
Collapse
Affiliation(s)
- Elske van den Berg
- Novarum Center for Eating Disorders, Amstelveen, Netherlands
- Arkin Mental Health Institute, Amsterdam, Netherlands
| | | | - Caroline Planting
- GGZ Ingeest VU University Medical Center Mental Health Institute, Amsterdam, Netherlands
| | - Peter Daansen
- PsyQ Mental Health Institute, Beverwijk, Netherlands
| | - Ella van Beers
- Novarum Center for Eating Disorders, Amstelveen, Netherlands
- Department of Clinical Psychology, Leiden University, Leiden, Netherlands
| | - Margo de Jonge
- Novarum Center for Eating Disorders, Amstelveen, Netherlands
| | - Carolien Christ
- Arkin Mental Health Institute, Amsterdam, Netherlands
- GGZ Ingeest VU University Medical Center Mental Health Institute, Amsterdam, Netherlands
| | - Jack Dekker
- Arkin Mental Health Institute, Amsterdam, Netherlands
- Department of Clinical Psychology, VU University, Amsterdam, Netherlands
| |
Collapse
|
5
|
Booij L, Israël M, Ferrari M, St-Hilaire A, Paquin-Hodge C, Allard M, Blaquière A, Dornik J, Freiwald S, Long SA, Monarque M, Pelletier WD, Thaler L, Yaffe M, Steiger H. Development of a transdiagnostic digital interactive application for eating disorders: psychometric properties, satisfaction, and perceptions on implementation in clinical practice. J Eat Disord 2023; 11:146. [PMID: 37644511 PMCID: PMC10466831 DOI: 10.1186/s40337-023-00871-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Given limited availability of informed treatments for people affected by eating disorders (EDs), there has been increasing interest in developing self-administered, technology-based ED interventions. However, many available interventions are limited to a specific ED diagnosis or assume that participants are ready to change. We developed a digital self-help application (called ASTrA) that was explicitly designed to be transdiagnostic and to help increase motivation for change. The aim of the present study was to describe the development and examine the psychometric properties, user satisfaction and rated potentials for practical use of our application. METHODS The content of our application was based on concepts derived from self-determination theory, the transtheoretical model of change, and cognitive theory. The application was developed by a multidisciplinary team of clinicians, researchers, staff members and individuals with lived ED experience, each being involved in all steps of the application's development. We tested validity, reliability, satisfaction and perceived feasibility for clinical implementation in an independent sample of 15 patients with an ED and 13 clinicians specialized in ED treatment. Psychometric properties were evaluated using descriptive statistics, correlations, content validity indices and intraclass coefficients. Differences in satisfaction ratings and perceived potential for clinical implementation of the application between clinicians and patients were examined using Mann-Whitney U tests. RESULTS The digital application showed excellent validity (mean i-CVI: .93, range: .86-.96) and internal reliability (all Cronbach alpha's > .88). Patients and clinicians both considered the application acceptable, appropriate, and feasible for use in clinical practice. CONCLUSIONS Findings suggest that our transdiagnostic interactive application has excellent psychometric properties. Furthermore, patients and clinicians alike were positive about the possible use of the application in clinical practice. The next step will be to investigate the application's effectiveness as an intervention to promote autonomous motivation and to facilitate remission in people on the waitlist for specialized ED treatment.
Collapse
Affiliation(s)
- Linda Booij
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada.
- Department of Psychiatry, McGill University, Montreal, Canada.
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada.
| | - Mimi Israël
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Manuela Ferrari
- Department of Psychiatry, McGill University, Montreal, Canada
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Annie St-Hilaire
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Chloé Paquin-Hodge
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Melissa Allard
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
| | - Amélie Blaquière
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
| | - Julia Dornik
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
| | - Shiri Freiwald
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
| | - Shawna A Long
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
| | - Marika Monarque
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - William D Pelletier
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
| | - Lea Thaler
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada
| | - Miriam Yaffe
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada
| | - Howard Steiger
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal West Island Integrated University Health and Social Service Centre, 6603-05 LaSalle Blvd, Montreal, QC, H4H 1R3, Canada.
- Department of Psychiatry, McGill University, Montreal, Canada.
- Research Centre, Douglas Mental Health University Institute, Montreal, Canada.
| |
Collapse
|
6
|
Brewerton TD. The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines. Front Psychiatry 2023; 14:1149433. [PMID: 37252137 PMCID: PMC10213703 DOI: 10.3389/fpsyt.2023.1149433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/18/2023] [Indexed: 05/31/2023] Open
Abstract
Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.
Collapse
|
7
|
Brewerton TD, Gavidia I, Suro G, Perlman MM. Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results. J Eat Disord 2023; 11:48. [PMID: 36973828 PMCID: PMC10044735 DOI: 10.1186/s40337-023-00773-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION We studied whether provisional posttraumatic stress disorder (PTSD) moderated discharge (DC) and 6-month follow-up (FU) outcomes of multi-modal, integrated eating disorder (ED) residential treatment (RT) based upon principles of cognitive processing therapy (CPT). METHODS ED patients [N = 609; 96% female; mean age (± SD) = 26.0 ± 8.8 years; 22% LGBTQ +] with and without PTSD completed validated assessments at admission (ADM), DC and 6-month FU to measure severity of ED, PTSD, major depressive disorder (MDD), state-trait anxiety (STA) symptoms, and eating disorder quality of life (EDQOL). We tested whether PTSD moderated the course of symptom change using mixed models analyses and if ED diagnosis, ADM BMI, age of ED onset and LGBTQ + orientation were significant covariates of change. Number of days between ADM and FU was used as a weighting measure. RESULTS Despite sustained improvements with RT in the total group, the PTSD group had significantly higher scores on all measures at all time points (p ≤ .001). Patients with (n = 261) and without PTSD (n = 348) showed similar symptom improvements from ADM to DC and outcomes remained statistically improved at 6-month FU compared to ADM. The only significant worsening observed between DC and FU was with MDD symptoms, yet all measures remained significantly lower than ADM at FU (p ≤ .001). There were no significant PTSD by time interactions for any of the measures. Age of ED onset was a significant covariate in the EDI-2, PHQ-9, STAI-T, and EDQOL models such that an earlier age of ED onset was associated with a worse outcome. ADM BMI was also a significant covariate in the EDE-Q, EDI-2, and EDQOL models, such that higher ADM BMI was associated with a worse ED and quality of life outcome. CONCLUSIONS Integrated treatment approaches that address PTSD comorbidity can be successfully delivered in RT and are associated with sustained improvements at FU. Improving strategies to prevent post-DC recurrence of MDD symptoms is an important and challenging area of future work.
Collapse
Affiliation(s)
- Timothy D Brewerton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
- Timothy D. Brewerton, MD, LLC, Mount Pleasant, SC, USA.
- Monte Nido and Affiliates, Miami, FL, USA.
| | | | | | - Molly M Perlman
- Monte Nido and Affiliates, Miami, FL, USA
- Department of Psychiatry and Behavioral Health, Florida International University College of Medicine, Miami, FL, USA
| |
Collapse
|
8
|
Tan MYL, McConnell B, Barlas J. Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: study protocol for a scoping review. BMJ Open 2022; 12:e058565. [PMID: 36167385 PMCID: PMC9516170 DOI: 10.1136/bmjopen-2021-058565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Dialectical behaviour therapy (DBT) is a well-known intervention for treating borderline personality disorder, and has been increasingly adapted for other disorders. Standard DBT consists of four treatment modes, delivered over a year. Adaptations to DBT include changes to modes of delivery, treatment length, and skills modules taught to clients, or incorporating interventions from other evidence-based therapies. There is a need to synthesise existing evidence on DBT so that stakeholders-clinicians, researchers and policymakers-can understand how it has been provided for various psychiatric conditions, and whether it has been effective. METHODS AND ANALYSIS This study proposes a scoping review conducted according to Arksey and O'Malley's (2005) procedures, to map and summarise the literature on DBT interventions for treating a range of psychiatric concerns. Electronic databases (ie, the Cochrane Central Register of Controlled Trials, PubMed, PsycINFO, SCOPUS, EBSCOhost and ProQuest Dissertations and Theses), conference proceedings and the US National Institutes of Health Ongoing Trial Register will be searched for intervention studies that involve a control or comparison group, and that report quantitative data on pre/post-measures for psychiatric symptom severity. The initial search was conducted on 18 September 2020, and data charting has not commenced. An update will be performed in September 2022, pending this protocol's publication. Data charting will collect individual studies' characteristics, methodology and reported findings. Outcomes will be reported by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews. ETHICS AND DISSEMINATION No ethical approval is required for this study. The goal of dissemination is to keep DBT stakeholders abreast on latest updates in clinical applications of DBT. Findings from this research are intended to inform a more specific topic of study (eg, a meta-analysis), to further aid in the development of DBT interventions for psychiatric populations. REGISTRATION DETAILS The study protocol was pre-registered with the Open Science Framework on 24 August 2021 (https://osf.io/vx6gw).
Collapse
Affiliation(s)
- Michelle Yan Ling Tan
- Psychology, Institute of Mental Health, Singapore
- Department of Psychology, James Cook University, Singapore
| | | | - Joanna Barlas
- Department of Psychology, James Cook University, Singapore
| |
Collapse
|
9
|
Flatt RE, Miller AJ, Foreman T, Shannon J. Considerations for Athletes with Eating Disorders Based on Levels of Care. Curr Sports Med Rep 2022; 21:92-99. [PMID: 35245244 DOI: 10.1249/jsr.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT This article provides an overview of levels of care for eating disorders (EDs) and considerations that are specific to elite athletes. We discuss the following levels of care in terms of ED pathology and treatment aspects that may be unique to athletes: 1) inpatient and residential care, 2) intensive outpatient and partial hospitalization treatment, and 3) outpatient. Illustrative case studies also are presented to highlight distinctions between levels of care and athlete-specific nuances to treatment approaches and health care teams. Finally, we review aspects of return to play plans for elite athletes with EDs.
Collapse
Affiliation(s)
| | - Alexandra J Miller
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tonya Foreman
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jeni Shannon
- Department of Sports Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
10
|
Edwards ER, Kober H, Rinne GR, Griffin SA, Axelrod S, Cooney EB. Skills-homework completion and phone coaching as predictors of therapeutic change and outcomes in completers of a DBT intensive outpatient programme. Psychol Psychother 2021; 94:504-522. [PMID: 33774902 DOI: 10.1111/papt.12325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 01/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Dialectical behaviour therapy (DBT) emphasizes generalization of skills to the patient's real-world context as a primary mechanism of change in treatment. To promote generalization, DBT includes weekly skills-focused homework assignments and as-needed phone coaching. Despite this central function of generalization in DBT, research on these treatment components is limited. The current study addresses this research gap by assessing the association of homework and phone coaching to DBT treatment outcomes. DESIGN A longitudinal study design explored the extent to which (a) completion of skills homework and (b) frequency of phone coaching were associated with therapeutic changes and treatment outcomes in a DBT intensive outpatient programme (DBT-IOP). METHOD Medical records and diary cards of 56 patients who had completed a four-month treatment cycle of DBT-IOP were reviewed and coded for proportion of skills homework completed, frequency of phone coaching calls, and reported urges for and engagement in suicide, non-suicidal self-injury, illicit or non-prescribed substance use, and alcohol use behaviours. RESULTS Completion of skills homework and frequency of phone coaching were significantly associated with (a) reduced urges for suicide, non-suicidal self-injury, illicit or non-prescribed substance use, and alcohol use from the beginning to end of treatment and (b) a lower likelihood of engaging in any of these behaviours during the final month of treatment. CONCLUSIONS Results suggest that within a DBT programme modified for an intensive outpatient setting, skills homework and phone coaching may enhance therapeutic change and outcomes in target behaviours. These generalization methods appear to be important ingredients of DBT effectiveness. PRACTITIONER POINTS In dialectical behaviour therapy (DBT), therapeutic skills homework and phone coaching are specifically designed to promote generalization of skills from the therapeutic context to the patient's real-world contexts. In a DBT intensive outpatient programme, patient engagement with therapeutic homework and phone coaching were associated with favourable therapeutic change and outcomes in target urges and behaviours. Clinicians may consider a patient's lack of homework completion and/or phone coaching to be early warning signs of poor therapeutic progress within dialectical behaviour therapy.
Collapse
Affiliation(s)
- Emily R Edwards
- Yale University School of Medicine, New Haven, Connecticut, USA.,James J. Peters VA Medical Center, VISN 2 MIRECC, Bronx, New York, USA
| | - Hedy Kober
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gabrielle R Rinne
- Yale University School of Medicine, New Haven, Connecticut, USA.,Yale University, New Haven, Connecticut, USA
| | | | - Seth Axelrod
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emily B Cooney
- Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
11
|
Cost Borne by the Counselor: Comparing Burnout Between Dialectical Behavior Therapy (DBT) Counselors and Non‐DBT Counselors. JOURNAL OF COUNSELING AND DEVELOPMENT 2021. [DOI: 10.1002/jcad.12376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
12
|
Mochrie KD, Lothes Ii J, Guender E, St John J. DBT-informed treatment in a partial hospital and intensive outpatient program: the role of step-down care. ACTA ACUST UNITED AC 2020; 23:461. [PMID: 33024726 PMCID: PMC7513610 DOI: 10.4081/ripppo.2020.461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/21/2020] [Indexed: 11/22/2022]
Abstract
Few studies to date have examined Partial Hospital (PH) and Intensive Outpatient (IOP) programs that utilize a Dialectical Behavior Therapy (DBT)-informed model. Preliminary findings suggest that DBT-informed PH programs are effective in reducing clinical symptoms; however, less is known about IOP programs as well as step-down care models. The present study utilized clinically relevant outcome indices and included a heterogeneous clinical sample. Specifically, the present study assessed pre-post data to examine changes in symptoms of depression, anxiety, hopelessness, and overall degree of suffering from intake to discharge in DBT-informed PH and IOP programs as well as a step-down condition (PH to IOP). Participants included 205 adults (ages M = 35.28, SD = 12.49). The sample was predominantly female (N = 139, 67.8%) and Caucasian (N = 181, 88.3%). The sample was divided into three distinct groups: PH program patients, PH to IOP program step-down patients, and IOP patients. Findings indicated significant symptom reduction from intake to discharge for all three conditions. There were no significant differences in mean change scores in symptom reduction between the three groups. Severity of depression symptoms at intake predicted program placement. However, type of program did not predict significant changes in symptoms from intake to discharge. This DBT-informed PH and IOP program was successful at reducing various psychiatric symptoms in the sample. Clinicians might consider the advantages of placing patients with higher symptoms of depression into PH programs with the intention of transitioning to step-down care through IOP programs that utilize DBT.
Collapse
|
13
|
Marino J, Hardin R, Gasbarro A, Dansereau VA, Fischer S. Outpatient treatment for adults with complex eating disorders and co-morbid conditions: a decision making model and case example. Eat Disord 2020; 28:171-183. [PMID: 32129726 DOI: 10.1080/10640266.2020.1723372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although Cognitive Behavioral Therapy (CBT-E) for eating disorders has the most empirical support for the outpatient treatment of adult eating disorders (EDs), this model does not include a focus on intense emotion dysregulation, suicidality, and non-suicidal self-injury (NSSI). Furthermore, a subset of patients do not achieve sustained remission with CBT-E. Given that Dialectical Behavior Therapy (DBT) was designed for treatment refractory, complex patients, clinicians must be able to use assessment information to determine which type of treatment to use. The aims of this manuscript are to 1) describe a DBT-based and research-informed conceptual model for treatment decision making for an outpatient non-academic setting, 2) present a case example of a client with significant ED symptoms and complex medical and psychiatric comorbidities, using this decision making model and 3) present descriptive data from a private practice setting in which patients are referred to DBT vs. CBT-E according to this decision making model.
Collapse
Affiliation(s)
- Joanna Marino
- Private practice, Potomac Behavioral Solutions, Arlington, VA, USA
| | - Rebecca Hardin
- Private practice, Potomac Behavioral Solutions, Arlington, VA, USA
| | | | | | - Sarah Fischer
- Department of Psychology, George Mason University, Fairfax, Virginia, USA
| |
Collapse
|
14
|
Pennell A, Webb C, Agar P, Federici A, Couturier J. Implementation of Dialectical Behavior Therapy in a Day Hospital Setting for Adolescents with Eating Disorders. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2019; 28:21-29. [PMID: 31001348 PMCID: PMC6457442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 11/22/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE This article discusses the implementation and preliminary outcomes of a Dialectical Behaviour Therapy (DBT) informed program integrated with Family Based Therapy (FBT) for adolescents with eating disorders within a day hospital program (DHP). METHOD A retrospective analysis of hospital records between 2013-2015 provided descriptive characteristics of patients. Weight and percentage ideal body weight at admission and discharge, frequency of binge and purge episodes at discharge and readmissions were analysed. RESULTS Analysis of patient characteristics indicated a broad range of eating disorder and comorbid psychiatric diagnoses among patients. Preliminary outcomes revealed increased weight and percentage of ideal body weight, decreased binge-purge status and few readmissions to the program over the two-year period studied. CONCLUSIONS The implementation of a DBT informed DHP with integration of FBT is associated with improved patient outcomes. Ongoing challenges with respect to the implementation of DBT include modifying DBT to address varying developmental levels, ages and diagnoses and promoting adherence to the program by patients and families. Limitations include small sample size, uncontrolled chart review and the nature of DHP, which include a variety of components that may influence outcomes. This research will help to inform future implementation of treatment programs for adolescents with eating disorders.
Collapse
Affiliation(s)
- Alexandra Pennell
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Cheryl Webb
- Department of Psychiatry & Behavioral Neurosciences, McMaster University, Hamilton, Ontario
| | - Paul Agar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
- Department of Psychiatry & Behavioral Neurosciences, McMaster University, Hamilton, Ontario
| | - Anita Federici
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
- Department of Psychiatry & Behavioral Neurosciences, McMaster University, Hamilton, Ontario
| | - Jennifer Couturier
- Department of Psychiatry & Behavioral Neurosciences, McMaster University, Hamilton, Ontario
| |
Collapse
|
15
|
Lewis YD, Gilon Mann T, Enoch‐Levy A, Dubnov‐Raz G, Gothelf D, Weizman A, Stein D. Obsessive–compulsive symptomatology in female adolescent inpatients with restrictive compared with binge–purge eating disorders. EUROPEAN EATING DISORDERS REVIEW 2018; 27:224-235. [DOI: 10.1002/erv.2638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 07/05/2018] [Accepted: 08/08/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Yael Doreen Lewis
- Hanotrim Eating Disorders UnitShalvata Mental Health Center Hod Hasharon Israel
- Sackler Faculty of MedicineTel Aviv University Tel Aviv Israel
| | - Tal Gilon Mann
- Pediatric Psychosomatic DepartmentSafra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
| | - Adi Enoch‐Levy
- Sackler Faculty of MedicineTel Aviv University Tel Aviv Israel
- Pediatric Psychosomatic DepartmentSafra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
| | - Gal Dubnov‐Raz
- Sackler Faculty of MedicineTel Aviv University Tel Aviv Israel
- Pediatric Psychosomatic DepartmentSafra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
| | - Doron Gothelf
- Sackler Faculty of MedicineTel Aviv University Tel Aviv Israel
- The Child Psychiatry DivisionSafra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
- Sagol School of NeuroscienceTel Aviv University Tel Aviv Israel
| | - Abraham Weizman
- Sackler Faculty of MedicineTel Aviv University Tel Aviv Israel
- Felsenstein Medical Research Center and Geha Mental Health Center Petah Tikva Israel
| | - Daniel Stein
- Sackler Faculty of MedicineTel Aviv University Tel Aviv Israel
- Pediatric Psychosomatic DepartmentSafra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
| |
Collapse
|
16
|
Sensation seeking, binge-type eating disorders, victimization, and PTSD in the National Women's Study. Eat Behav 2018; 30:120-124. [PMID: 30012278 DOI: 10.1016/j.eatbeh.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Higher degrees of sensation seeking (SS) are reported in community and clinical samples of individuals with eating disorders with binge-type features (BTEDs), but no reports exist in representative probability samples of adult women. Additionally, SS has been linked to victimization and PTSD, also associated with BTEDs, yet interrelationships between these variables are unexplored. METHODS A national, probability sample of 3006 adult women (≥18 y/o) completed structured telephone interviews including assessments for victimization, PTSD, bulimia nervosa (BN) and binge eating disorder (BED). The survey included the 6 items of the Disinhibition-Intentions for the Future (DIF) subscale of Zuckerman's Sensation Seeking Scale-VI, which asks how likely participants would be to engage in given activities. Total SS score (TSSS-DIFS) was the sum of the 6 items' scores. Differences among the 3 groups (BN, BED, non-BN/BED) were compared using ANOVA covaried by age and post-hoc t-tests. Multiple regression tested the effects of age, number of victimization experiences (NVE), lifetime PTSD, and BTEDs on TSSS-DIFS. RESULTS There were significant differences in TSSS-DIFS across BTED diagnoses (p ≤ .001). Participants with BN (p ≤ .002) and those with BED (p ≤ .01) had significantly higher scores than those without BTEDs. These findings persisted in both groups after correcting for NVE and lifetime PTSD. TSSS-DIFS was significantly higher in participants with BTED with PTSD versus those without (p ≤ .025). DISCUSSION SS traits related to disinhibition occur more commonly in U.S. adult women with BN and BED, even after controlling for NVE and PTSD, which were also associated with higher TSSS-DIFS.
Collapse
|
17
|
Anderson NL, Smith KE, Mason TB, Crowther JH. Testing an Integrative Model of Affect Regulation and Avoidance in Non-Suicidal Self-Injury and Disordered Eating. Arch Suicide Res 2018; 22:295-310. [PMID: 28644927 PMCID: PMC5917567 DOI: 10.1080/13811118.2017.1340854] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This research tested a model that integrates risk factors among non-suicidal self-injury (NSSI) and eating disorder (ED) behaviors with the aim of elucidating possible shared and unique mechanisms underlying both behaviors. Emotional distress, limited access to emotion regulation (ER) strategies, experiential avoidance, and NSSI/ED frequency were examined in a sample of 230 female undergraduates. Structural equation modeling indicated that limited access to ER strategies and avoidance mediated relationship between emotional distress and avoidance, which in turn was associated with NSSI and ED behaviors. Results suggest NSSI and ED behaviors may serve similar emotion regulation functions, and specifically highlight the role of experiential avoidance in these behaviors.
Collapse
|
18
|
Navarro-Haro MV, Botella C, Guillen V, Moliner R, Marco H, Jorquera M, Baños R, Garcia-Palacios A. Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder and Eating Disorders Comorbidity: A Pilot Study in a Naturalistic Setting. COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9906-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
19
|
Wisniewski L, Hernandez Hernandez ME, Waller G. Therapists' self-reported drift from dialectical behavior therapy techniques for eating disorders. Eat Behav 2018; 28:20-24. [PMID: 29247895 DOI: 10.1016/j.eatbeh.2017.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 11/21/2017] [Accepted: 12/06/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Research has shown that clinicians underuse or omit techniques that constitute an essential part of evidence-based therapies. However, it is not known whether this is the case in DBT for eating disorders. The aims of this study were; 1) exploring the extent to which DBT techniques were used by self-identified DBT clinicians treating eating disorders; 2) determining whether therapists fell into distinct groups, based on their usage of DBT techniques; and 3) examining whether clinician characteristics were related to the use of such techniques. METHOD Seventy-three clinicians offering DBT for eating disorders completed an online survey about their use of specific DBT techniques. They also completed measures of personality and intolerance of uncertainty. RESULTS In relation to the first aim, the pattern of use of DBT techniques showed a bimodal distribution - most were used either a lot or a little. Considering the second aim, clinicians fell into two groups according to the techniques that they delivered - one characterized by a higher use of DBT techniques and the other by a higher use of techniques that were specific to the treatment of eating disorders, rather than DBT methods. Finally, more experienced clinicians were more likely to be in the 'DBT technique-focused' group. DISCUSSION DBT clinicians are encouraged to implement both sets of techniques (DBT techniques and standard techniques for the treatment of eating disorders) in an integrated way. Training, supervision and the use of manuals are recommended to decrease therapist drift in DBT.
Collapse
Affiliation(s)
- Lucene Wisniewski
- DBT Ohio, 19910 Malvern Rd., Rm. 220, Shaker Heights, OH 44122, United States.
| | - Maria Elena Hernandez Hernandez
- Department of Psychology, University of Sheffield, 1 Vicar Lane, Cathedral Court, Floor E., Sheffield S1 2LT, United Kingdom.
| | - Glenn Waller
- Department of Psychology, University of Sheffield, 1 Vicar Lane, Cathedral Court, Floor D, Sheffield S1 2LT, United Kingdom.
| |
Collapse
|
20
|
Kolar DR, Hammerle F, Jenetzky E, Huss M. Smartphone-Enhanced Low-Threshold Intervention for adolescents with Anorexia Nervosa (SELTIAN) waiting for outpatient psychotherapy: study protocol of a randomised controlled trial. BMJ Open 2017; 7:e018049. [PMID: 29061627 PMCID: PMC5665307 DOI: 10.1136/bmjopen-2017-018049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION As smartphones are widely distributed nowadays, mental health apps seem to be a promising treatment tool. First self-help apps for eating disorders have been developed recently. However, studies assessing the efficacy of such apps are scarce. A smartphone app could prevent further weight reduction and increase commitment during waiting time for outpatient treatment, especially for adolescents with anorexia nervosa (AN). In this study protocol, a randomised controlled trial to assess the efficacy of a smartphone-enhanced low-threshold intervention for AN during waiting time is described. METHODS AND ANALYSIS 30 adolescents with AN aged 12-19 years will be recruited at three child and adolescent psychiatry centres in Germany. All participants will be randomised to consultations only or consultations and the use of the Jourvie Research app. The app will be installed either on their own smartphone or on a research device. The participants will receive biweekly to monthly consultations for 3 months to review meal plans and weight management with a clinician. In addition, the Jourvie Research app for meal, behaviour and emotion protocolling will be provided to the intervention group. The protocols will be discussed with a clinician during the consultations. Dialectical behaviour therapy-informed skills for tension regulation to increase compliance with the meal plan will be taught in the intervention group and the app will remind the participant of a skill in a moment of need. The primary outcome is the age-adjusted and height-adjusted weight gain in standard deviation score after 3 months. ETHICS AND DISSEMINATION Results will be disseminated at conferences and through peer-reviewed publications. The trial was approved by the ethics review board of the local medical association, Mainz, Germany, under the reference number 837.338.15. TRIAL REGISTRATION NUMBER German clinical trials register, reference number DRKS00008946.
Collapse
Affiliation(s)
- David R Kolar
- Department of Child and Adolescent Psychiatry, University Medicine Mainz, Mainz, Germany
| | - Florian Hammerle
- Department of Child and Adolescent Psychiatry, University Medicine Mainz, Mainz, Germany
| | - Ekkehart Jenetzky
- Department of Child and Adolescent Psychiatry, University Medicine Mainz, Mainz, Germany
| | - Michael Huss
- Department of Child and Adolescent Psychiatry, University Medicine Mainz, Mainz, Germany
| |
Collapse
|
21
|
Chen EY, Cacioppo J, Fettich K, Gallop R, McCloskey MS, Olino T, Zeffiro TA. An adaptive randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating. Psychol Med 2017; 47:703-717. [PMID: 27852348 PMCID: PMC7418949 DOI: 10.1017/s0033291716002543] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early weak treatment response is one of the few trans-diagnostic, treatment-agnostic predictors of poor outcome following a full treatment course. We sought to improve the outcome of clients with weak initial response to guided self-help cognitive behavior therapy (GSH). METHOD One hundred and nine women with binge-eating disorder (BED) or bulimia nervosa (BN) (DSM-IV-TR) received 4 weeks of GSH. Based on their response, they were grouped into: (1) early strong responders who continued GSH (cGSH), and early weak responders randomized to (2) dialectical behavior therapy (DBT), or (3) individual and additional group cognitive behavior therapy (CBT+). RESULTS Baseline objective binge-eating-day (OBD) frequency was similar between DBT, CBT+ and cGSH. During treatment, OBD frequency reduction was significantly slower in DBT and CBT+ relative to cGSH. Relative to cGSH, OBD frequency was significantly greater at the end of DBT (d = 0.27) and CBT+ (d = 0.31) although these effects were small and within-treatment effects from baseline were large (d = 1.41, 0.95, 1.11, respectively). OBD improvements significantly diminished in all groups during 12 months follow-up but were significantly better sustained in DBT relative to cGSH (d = -0.43). At 6- and 12-month follow-up assessments, DBT, CBT and cGSH did not differ in OBD. CONCLUSIONS Early weak response to GSH may be overcome by additional intensive treatment. Evidence was insufficient to support superiority of either DBT or CBT+ for early weak responders relative to early strong responders in cGSH; both were helpful. Future studies using adaptive designs are needed to assess the use of early response to efficiently deliver care to large heterogeneous client groups.
Collapse
Affiliation(s)
- E. Y. Chen
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | - J. Cacioppo
- Department of Psychology, The University of Chicago, Chicago, IL, USA
| | - K. Fettich
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | - R. Gallop
- Department of Mathematics, West Chester University, West Chester, PA, USA
- Department of Psychiatry, Center for Psychotherapy Research, Perelman School of Medicine, University of Pennsylvania, USA
| | - M. S. McCloskey
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | - T. Olino
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | | |
Collapse
|
22
|
Kelly AC, Wisniewski L, Martin-Wagar C, Hoffman E. Group-Based Compassion-Focused Therapy as an Adjunct to Outpatient Treatment for Eating Disorders: A Pilot Randomized Controlled Trial. Clin Psychol Psychother 2016; 24:475-487. [DOI: 10.1002/cpp.2018] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 04/05/2016] [Accepted: 04/08/2016] [Indexed: 11/06/2022]
|
23
|
Kolar DR, Hammerle F, Jenetzky E, Huss M, Bürger A. Aversive tension in female adolescents with Anorexia Nervosa: a controlled ecological momentary assessment using smartphones. BMC Psychiatry 2016; 16:97. [PMID: 27068217 PMCID: PMC4828844 DOI: 10.1186/s12888-016-0807-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 04/06/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Current models of Anorexia Nervosa (AN) emphasize the role of emotion regulation. Aversive tension, described as a state of intense arousal and negative valence, is considered to be a link between emotional events and disordered eating. Recent research focused only on adult patients, and mainly general emotion regulation traits were studied. However, the momentary occurrence of aversive tension, particularly in adolescents with AN, has not been previously studied. METHOD 20 female adolescents with AN in outpatient treatment and 20 healthy adolescents aged 12 to 19 years participated in an ecological momentary assessment using their smartphones. Current states of aversive tension and events were assessed hourly for two consecutive weekdays. Mean and maximum values of aversive tension were compared. Multilevel analyses were computed to test the influence of time and reported events on aversive tension. The effect of reported events on subsequent changes of aversive tension in patients with AN were additionally tested in a multilevel model. RESULTS AN patients showed higher mean and maximum levels of aversive tension. In a multilevel model, reported food intake was associated with higher levels of aversive tension in the AN group, whereas reported school or sport-related events were not linked to specific states of aversive tension. After food intake, subsequent increases of aversive tension were diminished and decreases of aversive tension were induced in adolescents with AN. CONCLUSIONS Aversive tension may play a substantial role in the psychopathology of AN, particular in relation with food intake. Therefore, treatment should consider aversive tension as a possible intervening variable during refeeding. Our findings encourage further research on aversive tension and its link to disordered eating. TRIAL REGISTRATION German register of clinical trials (DRKS): DRKS00005228 (Date of registration: September 2, 2013).
Collapse
Affiliation(s)
- David R. Kolar
- Department for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Florian Hammerle
- Department for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ekkehart Jenetzky
- Department for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University, Mainz, Germany ,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Michael Huss
- Department for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Arne Bürger
- Department for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University, Mainz, Germany ,Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| |
Collapse
|
24
|
Waller G, Mountford VA. Weighing patients within cognitive-behavioural therapy for eating disorders: How, when and why. Behav Res Ther 2015; 70:1-10. [PMID: 25938186 DOI: 10.1016/j.brat.2015.04.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 11/17/2022]
Abstract
While weight, beliefs about weight and weight changes are key issues in the pathology and treatment of eating disorders, there is substantial variation in whether and how psychological therapists weigh their patients. This review considers the reasons for that variability, highlighting the differences that exist in clinical protocols between therapies, as well as levels of reluctance on the part of some therapists and patients. It is noted that there have been substantial changes over time in the recommendations made within therapies, including cognitive-behavioural therapy (CBT). The review then makes the case for all CBT therapists needing to weigh their patients in session and for the patient to be aware of their weight, in order to give the best chance of cognitive, emotional and behavioural progress. Specific guidance is given as to how to weigh, stressing the importance of preparation of the patient and presentation, timing and execution of the task. Consideration is given to reasons that clinicians commonly report for not weighing patients routinely, and counter-arguments and solutions are presented. Finally, there is consideration of procedures to follow with some special groups of patients.
Collapse
Affiliation(s)
- Glenn Waller
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK.
| | - Victoria A Mountford
- South London and Maudsley Eating Disorder Service, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
25
|
Chen EY, Segal K, Weissman J, Zeffiro TA, Gallop R, Linehan MM, Bohus M, Lynch TR. Adapting dialectical behavior therapy for outpatient adult anorexia nervosa--a pilot study. Int J Eat Disord 2015; 48:123-32. [PMID: 25346237 PMCID: PMC5670741 DOI: 10.1002/eat.22360] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Anorexia Nervosa (AN) is associated with excessive self-control. This iterative case series describes the augmentation of Dialectical Behavior Therapy (DBT) for outpatient adult AN with skills addressing emotional and behavioral overcontrol. An overly controlled style is theorized to develop from the transaction between an individual with heightened threat sensitivity and reduced reward sensitivity, interacting with an environment reinforcing overcontrol and punishing imperfection. METHOD Case Series 1 utilized standard DBT, resulting in retention of 5/6 patients and a body mass index (BMI) effect size increase of d = -0.5 from pre- to post-treatment. Case series 2, using standard DBT augmented with skills addressing overcontrol, resulted in retention of 8/9 patients with an effect size increase in BMI at post-treatment that was maintained at 6- and 12-months follow-up (d = -1.12, d = -0.87, and d = -1.12). DISCUSSION Findings suggest that skills training targeting rigidity and increasing openness and social connectedness warrant further study of this model and treatment for AN.
Collapse
Affiliation(s)
- Eunice Y. Chen
- Department of Psychology, Temple Eating Disorders Program, Temple University, Philadelphia, Pennsylvania,Correspondence to: Eunice Chen, TED - Temple Eating Disorders Program, Department of Psychology, Temple University, 1701 N 13th Street Philadelphia, PA.
| | - Kay Segal
- The Center for Mindfulness and Behavior Therapy, Segal Behavioral Health, Deerfield, Illinois
| | | | | | - Robert Gallop
- Department of Mathematics, Westchester University, Westchester, Pennsylvania
| | - Marsha M. Linehan
- Behavioral Research and Therapy Clinics, Department of Psychology, University of Washington, Seattle, Washington State
| | - Martin Bohus
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Mannheim, Heidelberg University, Germany
| | - Thomas R. Lynch
- Department of Psychology, Emotion and Personality Bio-Behavioural Laboratory, University of Southampton, Southampton, United Kingdom
| |
Collapse
|
26
|
McFarlane T, MacDonald DE, Trottier K, Olmsted MP. The effectiveness of an individualized form of day hospital treatment. Eat Disord 2015; 23:191-205. [PMID: 25411716 DOI: 10.1080/10640266.2014.981430] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The traditional group format of day hospital treatment for eating disorders restricts individual tailoring of treatment, which is challenging when complex cases are referred. In 2007 we introduced a new program that included individual sessions. Patients referred to this program were older, had longer illness duration, and more pre-treatment symptoms than the original group program. These clients also had more psychopathology, and were more likely to have a diagnosis of anorexia nervosa binge/purge subtype. Weight gain and abstinence from symptoms were less likely for patients in this new program. However, premature discharge, rapid response, symptom frequencies, and relapse rates did not differ.
Collapse
Affiliation(s)
- Traci McFarlane
- a Eating Disorder Program , University Health Network , Toronto , Ontario , Canada
| | | | | | | |
Collapse
|
27
|
Turner BJ, Austin SB, Chapman AL. Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:576-85. [PMID: 25565473 PMCID: PMC4244876 DOI: 10.1177/070674371405901103] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/01/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Nonsuicidal self-injury (NSSI), the deliberate, self-inflicted damage of bodily tissue without the intent to die, is associated with various negative outcomes. Although basic and epidemiologic research on NSSI has increased during the last 2 decades, literature on effective interventions targeting NSSI is still emerging. Here, we present a comprehensive, systematic review of existing psychological and pharmacological treatments designed specifically for NSSI, or including outcome assessments examining change in NSSI. METHOD We conducted a systematic search of PsycINFO, MEDLINE, and ERIC databases to retrieve relevant articles that met inclusion criteria; specifically, uncontrolled and controlled trials that 1) presented quantitative outcome data on NSSI, and 2) clearly differentiated NSSI from suicidal self-injury (SSI). Consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, definition of NSSI, we excluded studies examining populations with developmental or intellectual disabilities, or with psychotic disorders. RESULTS Several interventions appear to hold promise for reducing NSSI, including dialectical behaviour therapy, emotion regulation group therapy, manual-assisted cognitive therapy, dynamic deconstructive psychotherapy, atypical antipsychotics (aripiprazole), naltrexone, and selective serotonin reuptake inhibitors (with or without cognitive-behavioural therapy). Nevertheless, there remains a paucity of well-controlled studies investigating treatment efficacy for NSSI. CONCLUSIONS Structured psychotherapeutic approaches focusing on collaborative therapeutic relationships, motivation for change, and directly addressing NSSI behaviours seem to be most effective in reducing NSSI. Medications targeting the serotonergic, dopaminergic and opioid systems also have demonstrated some benefits. Future studies employing controlled designs as well as a clear delineation of NSSI and SSI will improve knowledge regarding treatment effects.
Collapse
Affiliation(s)
- Brianna J Turner
- Graduate Student, Simon Fraser University, Burnaby, British Columbia
| | - Sara B Austin
- Graduate Student, Simon Fraser University, Burnaby, British Columbia
| | | |
Collapse
|
28
|
Juarascio AS, Manasse SM, Goldstein SP, Forman EM, Butryn ML. Review of smartphone applications for the treatment of eating disorders. EUROPEAN EATING DISORDERS REVIEW 2014; 23:1-11. [PMID: 25303148 DOI: 10.1002/erv.2327] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
mHealth tools may be a feasible modality for delivering evidence-based treatments and principles (EBPs), and may enhance treatment for eating disorders (EDs). However, research on the efficacy of mHealth tools for EDs and the extent to which they include EBPs is lacking. The current study sought to (i) review existing apps for EDs, (ii) determine the extent to which available treatment apps utilize EBPs, and (iii) assess the degree to which existing smartphone apps utilize recent advances in smartphone technology. Overall, existing ED intervention apps contained minimal EBPs and failed to incorporate smartphone capabilities. For smartphone apps to be a feasible and effective ED treatment modality, it may be useful for creators to begin taking utilizing the abilities that set smartphones apart from in-person treatment while incorporating EBPs. Before mHealth tools are incorporated into treatments for EDs, it is necessary that the feasibility, acceptability, and efficacy be evaluated.
Collapse
|
29
|
Kolar DR, Bürger A, Hammerle F, Jenetzky E. Aversive tension of adolescents with anorexia nervosa in daily course: a case-controlled and smartphone-based ambulatory monitoring trial. BMJ Open 2014; 4:e004703. [PMID: 24760350 PMCID: PMC4010818 DOI: 10.1136/bmjopen-2013-004703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Monitoring and reduction of aversive tension is a core issue in dialectical behaviour therapy of patients. It has been shown that aversive tension is increased in adult borderline personality disorder and is linked to low emotion labelling ability. However, until now there is no documented evidence that patients with anorexia nervosa suffer from aversive tension as well. Furthermore the usability of a smartphone application for ambulatory monitoring purposes has not been sufficiently explored. METHODS AND ANALYSIS We compare the mean and maximum self-reported aversive tension in 20 female adolescents (12-19 years) with anorexia nervosa in outpatient treatment with 20 healthy controls. They are required to answer hourly, over a 2-day period, that is, about 30 times, four short questions on their smartphone, which ensures prompt documentation without any recall bias. At the close out, the participants give a structured usability feedback on the application and the procedure. ETHICS AND DISSEMINATION The achieved result of this trial has direct relevance for efficient therapy strategies and is a prerequisite for trials regarding dialectical behaviour therapy in anorexia nervosa. The results will be disseminated through peer-review publications. The ethics committee of the regional medical association in Mainz, Germany approved the study protocol under the reference number 837.177.13. TRIAL REGISTRATION NUMBER The trial is registered at the German clinical trials registration under the reference number DRKS00005228.
Collapse
Affiliation(s)
- David Raphael Kolar
- Department for Child and Adolescent Psychiatry and Psychotherapy, Johannes-Gutenberg-University Mainz, Mainz, Germany
| | - Arne Bürger
- Department for Child and Adolescent Psychiatry and Psychotherapy, Johannes-Gutenberg-University Mainz, Mainz, Germany
| | - Florian Hammerle
- Department for Child and Adolescent Psychiatry and Psychotherapy, Johannes-Gutenberg-University Mainz, Mainz, Germany
| | - Ekkehart Jenetzky
- Department for Child and Adolescent Psychiatry and Psychotherapy, Johannes-Gutenberg-University Mainz, Mainz, Germany
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| |
Collapse
|
30
|
Harris J, Steele AM. Have we lost our minds? The siren song of reductionism in eating disorder research and theory. Eat Disord 2014; 22:87-95. [PMID: 24365532 DOI: 10.1080/10640266.2014.857532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Jim Harris
- a Department of Psychology , Southern Methodist University , Dallas , Texas , USA
| | | |
Collapse
|