Written case formulations in the treatment of anorexia nervosa: Evidence for therapeutic benefits

Formulation in eating disorder focused family therapy: why, when and how?

In the broadest sense, formulation, or case conceptualisation, is the process of collaborative sense-making. It is something all clinicians are doing constantly, whether formally and consciously or not. Most clinicians are familiar with the general principals and need to formulate as it is a core part of clinical training across most disciplines. Treatment manuals often discuss formulation, but the practical steps involved and the process of developing, building upon and revising formulations are not always provided. In clinical practice, the active use and continued development of formulation during treatment is not always prioritised, especially beyond the initial assessment. This could be due to a number of reasons, such as a potential lack of clarity, understanding or confidence in the use of formulation across treatment, a lack of dedicated time and reflective space for formulation in the context of increasingly busy clinical settings, or a perception that it may be less necessary in the context of treatment approaches that are more structured and prescriptive. This article outlines the use of formulation in family therapy for child and adolescent eating disorders, provides guidance on how to actively include formulation more throughout treatment and discusses why this might be useful.

Therapist written goodbye letters: evidence for therapeutic benefits in the treatment of anorexia nervosa

BACKGROUND

Despite their use in clinical practice, there is little evidence to support the use of therapist written goodbye letters as therapeutic tools. However, preliminary evidence suggests that goodbye letters may have benefits in the treatment of anorexia nervosa (AN).

AIMS

This study aimed to examine whether therapist written goodbye letters were associated with improvements in body mass index (BMI) and eating disorder symptomology in patients with AN after treatment.

METHOD

Participants were adults with AN (n = 41) who received The Maudsley Model of Anorexia Treatment for Adults (MANTRA) in a clinical trial evaluating two AN out-patient treatments. As part of MANTRA, therapists wrote goodbye letters to patients. A rating scheme was developed to rate letters for structure and quality. Linear regression analyses were used to examine associations between goodbye letter scores and outcomes after treatment.

RESULTS

Higher quality letters and letters that adopted a more affirming stance were associated with greater improvements in BMI at 12 months. Neither the overall quality nor the style of goodbye letters were associated with improvements in BMI at 24 months or reductions in eating disorder symptomology at either 12 or 24 months.

CONCLUSIONS

The results highlight the potential importance of paying attention to the overall quality of therapist written goodbye letters in the treatment of AN, and adopting an affirming stance.

An illustration of collaborative care with a focus on the role of fathers in Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)

The aim of this case study is to illustrate the importance of collaborative care as part of Maudsley Anorexia Nervosa Treatment for Adults (MANTRA). Mothers are often at the foreground of providing support within the family. However, fathers have the potential to play a profound role. In this paper, we describe a patient with anorexia nervosa treated with the MANTRA. The formulation of this case included autistic spectrum traits in both the father and daughter leading to social isolation. We describe how the family members were engaged into treatment and how paternal support was used to promote social connection and an improved quality of life in the daughter. Some details of the case have been altered to maintain confidentiality.

Advances in the treatment of anorexia nervosa: a review of established and emerging interventions

BACKGROUND

Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments.

METHODS

We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials.

RESULTS

We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation.

CONCLUSIONS

Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.

Imagery rescripting and cognitive dissonance: A randomized controlled trial of two brief online interventions for women at risk of developing an eating disorder

OBJECTIVE

This pilot study compared two brief online interventions, imagery rescripting and cognitive dissonance, to an assessment-only control condition in a sample of body-dissatisfied young women at risk of developing an eating disorder. We examined the degree to which each intervention reduced disordered eating and modified risk and protective factors for eating disorders.

METHOD

Female university students (N = 107, 17-28 years of age) completed a screening questionnaire, followed by random allocation to one of the three conditions, followed by a baseline assessment, body dissatisfaction induction, and brief online intervention. Participants in the active conditions then completed online daily home practice and a postintervention questionnaire.

RESULTS

Findings provide qualified support for the imagery rescripting intervention, with participants reporting higher body image acceptance (Cohen's d = 0.49) than the cognitive dissonance condition, and higher self-compassion (d = 0.59) and lower levels of disordered eating (d = 0.59) than the control condition, at postintervention. There was no significant impact of cognitive dissonance on any factors. Change in body image acceptance and self-compassion mediated the relationship between allocated condition and change in disordered eating at postintervention.

DISCUSSION

These findings provide preliminary support for the use of online-adapted imagery-based techniques (e.g., imagery rescripting) to reduce risk for the development of an eating disorder by strengthening protective factors (i.e., body image acceptance and self-compassion) and reducing disordered eating. Further exploration of the use of imagery strategies in the prevention of disordered eating is required, including prospective tests of the mechanisms of action.

Premorbid and Illness-related Social Difficulties in Eating Disorders: An Overview of the Literature and Treatment Developments

BACKGROUND

Social difficulties in eating disorders can manifest as predisposing traits and premorbid difficulties, and/or as consequences of the illness.

OBJECTIVE

The aim of this paper is to briefly review the evidence of social problems in people with eating disorders and to consider the literature on treatments that target these features.

METHOD

A narrative review of the literature was conducted.

RESULTS

People with eating disorders often manifest traits, such as shyness, increased tendency to submissiveness and social comparison, and problems with peer relationships before illness onset. Further social difficulties occur as the illness develops, including impaired social cognition and increased threat sensitivity. All relationships with family, peers and therapists are compromised by these effects. Thus, social difficulties are both risk and maintaining factors of eating disorders and are suitable targets for interventions. Several forms of generic treatments (e.g. interpersonal psychotherapy, cognitive analytic therapy, focal psychodynamic therapy) have an interpersonal focus and show some efficacy. Guided self-management based on the cognitive interpersonal model of the illness directed to both individuals and support persons has been found to improve outcomes for all parties. Adjunctive treatments that focus on specific social difficulties, such as cognitive remediation and emotion skills training and cognitive bias modification have been shown to have a promising role.

CONCLUSION

More work is needed to establish whether these approaches can improve on the rather disappointing outcomes that are attained by currently used treatments for eating disorders.

Original opinion: the use of Bloom's Taxonomy to teach and assess the skill of the psychiatric formulation during vocational training

OBJECTIVES

This paper proposes the use of the cognitive domain of Bloom's Taxonomy, an educational classification system, to guide the critical thinking required for the composition of the psychiatric formulation during the various stages of specialist training.

CONCLUSIONS

Bloom's Taxonomy offers a hierarchical, structured approach to clinical reasoning. Use of this method can assist supervisors and trainees to understand better the concepts of and offer a developmental approach to critical reasoning. Application of the Taxonomy, using cognitive 'action words' (verbs) within each of the levels, can promote increasing sophistication in the construction of the psychiatric formulation. Examples of how the Taxonomy can be adapted to design educational resources are suggested in the article.