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

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Back to the future: Progressing memory research in eating disorders

OBJECTIVE

Human behaviors, thoughts, and emotions are guided by memories of the past. Thus, there can be little doubt that memory plays a fundamental role in the behaviors (e.g., binging), thoughts (e.g., body-image concerns), and emotions (e.g., guilt) that characterize eating disorders (EDs). Although a growing body of research has begun to investigate the role of memory in EDs, this literature is limited in numerous ways and has yet to be integrated into an overarching framework.

METHODS

In the present article, we provide an operational framework for characterizing different domains of memory, briefly review existing ED memory research within this framework, and highlight crucial gaps in the literature.

RESULTS

We distinguish between three domains of memory-episodic, procedural, and working-which differ based on functional attributes and underlying neural systems. Most recent ED memory research has focused on procedural memory broadly defined (e.g., reinforcement learning), and findings within all three memory domains are highly mixed. Further, few studies have attempted to assess these different domains simultaneously, though most behavior is achieved through coordination and competition between memory systems. We, therefore, offer recommendations for how to move ED research forward within each domain of memory and how to study the interactions between memory systems, using illustrative examples from other areas of basic and clinical research.

DISCUSSION

A stronger and more integrated understanding of the mechanisms that connect memory of past experiences to present ED behavior may yield more comprehensive theoretical models of EDs that guide novel treatment approaches.

PUBLIC SIGNIFICANCE

Memories of previous eating-related experiences may contribute to the onset and maintenance of eating disorders (EDs). However, research on the role of memory in EDs is limited, and distinct domains of ED memory research are rarely connected. We, therefore, offer a framework for organizing, progressing, and integrating ED memory research, to provide a better foundation for improving ED treatment and intervention going forward.

Linguistic embodiment in typical and atypical anorexia nervosa: Evidence from an image-word matching task

OBJECTIVE

The integration of sensory, motor, and cognitive systems is embodied cognition, according to which mind and body are not separate and distinct, and our body (and our brain, as part of the body) contributes to determining our mental and cognitive processes. In spite of limited data available, Anorexia nervosa (AN) appears as a condition in which embodied cognition is altered, in particular, if we consider bodily sensations and visuospatial information processing. We aimed to evaluate the ability to correctly identify body parts and actions in both full (AN) and atypical AN (AAN), looking at the role of the underweight status.

METHOD

A group of 143 females (AN = 45, AAN = 43, unaffected women = 55) was enrolled. All participants performed a linguistic embodied task to evaluate the association between a picture-showing a bodily action-and a written verb. Additionally, a subsample of 24 AN participants performed a retest after stable weight recovery.

RESULTS

Both AN and AAN demonstrated an abnormal ability to evaluate the picture-written verb associations, especially if the involved bodily effectors were the same in both stimuli (i.e., pictorial and verbal) and needed a longer response time.

CONCLUSIONS

Specific embodied cognition linked to body schema seems to be impaired in persons with AN. The longitudinal analysis showed a difference between AN and AAN only in the underweight condition, suggesting the presence of an abnormal linguistic embodiment. More attention should be devoted to embodiment during AN treatment to improve bodily cognition, which might, in turn, diminish body misperception.

Novel treatments for anorexia nervosa: Insights from neuroplasticity research

OBJECTIVE

Treatment for anorexia nervosa (AN) remains challenging; there are no approved psychopharmacological interventions and psychotherapeutic strategies have variable efficacy. The investigation of evidence-based treatments has so far been compounded by an underdeveloped understanding into the neurobiological changes associated with the acute stages of AN. There is converging evidence of deficiencies in neuroplasticity in AN.

METHOD

This paper provides an overview of neuroimaging, neuropsychological, molecular and qualitative findings relating to neuroplasticity in AN, translating these findings to the identification of novel biological and psychotherapeutic strategies.

RESULTS

Novel psychopharmacological approaches that may ameliorate deficiencies in neuroplasticity include medications such as ketamine, psilocybin and human recombinant leptin. Anti-inflammatory medications and brain-derived neurotrophic factor mimetics may emerge as potential treatments following further research. Psychotherapeutic strategies that may target neuroplastic deficiencies, as well as having wider effects on identity, include imagery rescripting, memory specificity training, cognitive remediation therapy, exposure therapies, narrative therapies, cultural interventions (e.g. music and arts therapies) and yoga/mindfulness-based interventions.

CONCLUSIONS

Treatments specifically targeted towards mitigating the neurobiological sequalae of AN are warranted, and emerging neurobiological and neuropsychological research utilising longitudinal designs and large sample sizes, as well as initial feasibility studies, are necessitated to bolster translational efforts.

Project Body Neutrality: Piloting a digital single-session intervention for adolescent body image and depression

OBJECTIVE

Eating disorders and depression impact youth at alarming rates, yet most adolescents do not access support. Single-session interventions (SSIs) can reach youth in need. This pilot examines the acceptability and utility of a SSI designed to help adolescents improve functionality appreciation (a component of body neutrality) by focusing on valuing one's body based on the functions it performs, regardless of appearance satisfaction.

METHOD

Pre- to post-intervention data were collected, and within-group effect sizes and 95% confidence intervals were computed, to evaluate the immediate effects of the SSI on hopelessness, functionality appreciation, and body dissatisfaction. Patterns of use, demographics, program feedback, and responses from within the SSI were collected.

RESULTS

The SSI and all questionnaires were completed by 75 adolescents (ages: 13-17 years, 74.70% White/Caucasian, 48.00% woman/girl) who reported elevated body image and mood problems. Analyses detected significant pre-post improvements in hopelessness (dav  = 0.60, 95% CI: 0.35-0.84; dz  = 0.77, 95% CI: 0.51-1.02), functionality appreciation (dav  = 0.72, 95% CI: 0.46-0.97; dz  = 0.94, 95% CI: 0.67-1.21), and body dissatisfaction (dav  = 0.61, 95% CI: 0.36-0.86; dz  = 0.76, 95% CI: 0.50-1.02). The SSI was rated as highly acceptable, with a mean overall score of 4.34/5 (SD = 0.54). Qualitative feedback suggested adolescents' endorsement of body neutrality concepts, including functionality appreciation, as personally-relevant, helpful targets for intervention.

DISCUSSION

This evaluation supports the acceptability and preliminary effectiveness of the Project Body Neutrality SSI for adolescents with body image and mood concerns.

PUBLIC SIGNIFICANCE

Results suggest the acceptability and utility of a digital, self-guided, single-session intervention-Project Body Neutrality-for adolescents experiencing co-occurring depressive symptoms and body image disturbances. Given the intervention's low cost and inherent scalability, it may be positioned to provide support to youth with limited access to traditional care.

Realizing the untapped promise of single-session interventions for eating disorders

OBJECTIVE

Multilevel treatment barriers prevent up to 80% of individuals experiencing eating disorders (EDs) from accessing care. This treatment gap creates a critical need to identify interventions that are accessible, easily completable, and optimized for effectiveness by targeting core mechanisms linked to ED onset and maintenance. We propose single-session interventions (SSIs) as a promising path toward catalyzing innovation in the development of accessible, effective ED interventions. SSIs are structured programs that intentionally involve one encounter with a program or provider; they may serve as stand-alone or adjunctive clinical supports. All SSIs are built to acknowledge that any session might be someone's last-and that any single session can nonetheless yield meaningful clinical benefit.

METHOD

We define SSIs, summarize research supporting their utility for ED symptoms and other mental health problems, and recommend future directions for work in this domain.

RESULTS

Single-session interventions may hold promise to reduce some ED symptoms and risk factors, including restrictive eating and negative body image. Steps toward realizing this promise include (1) testing whether existing evidence-based SSIs (e.g., for depression) can also reduce EDs, risk factors, and symptoms; (2) developing novel SSIs that target modifiable ED risk factors and symptoms largely unaddressed by SSIs, such as purging and binge eating; (3) studying diverse implementation pathways; (4) capitalizing on SSIs' transdiagnostic utility to broaden funding opportunities; and (5) educating ED researchers and clinicians about SSIs.

DISCUSSION

Understanding the strengths and limits of mechanism-targeted SSIs for ED-related problems could be a low-risk, high-reward avenue toward reducing EDs at scale.

PUBLIC SIGNIFICANCE

Most individuals experiencing EDs never access any form of treatment, creating an urgent need to identify ED interventions built to overcome barriers to engaging with care. This Forum article introduces SSIs as a promising path to rapidly developing and testing accessible, evidence-based ED supports; supplementing existing ED treatment models; and reducing the individual, familial, and societal burdens of EDs at scale.

Prevention and early intervention in eating disorders: findings from a rapid review

BACKGROUND

Eating disorders (EDs) are complex psychological disorders, with low rates of detection and early intervention. They can lead to significant mental and physical health complications, especially if intervention is delayed. Given high rates of morbidity and mortality, low treatment uptake, and significant rates of relapse, it is important to examine prevention, early intervention, and early recognition initiatives. The aim of this review is to identify and evaluate literature on preventative and early intervention programs in EDs.

METHODS

This paper is one of a series of Rapid Reviews, designed to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded, and released by the Australian Government. To provide a current and rigorous review, peer-reviewed articles between 2009 and 2021 published in English were searched across three databases: ScienceDirect, PubMed and Ovid/Medline. Priority was given to high-level evidence including meta-analyses, systematic reviews, Randomised Control Trials, and large population studies. Findings from selected studies pertaining to prevention and early intervention in EDs were evaluated and are presented in this review.

RESULTS

In total, 130 studies were identified in the current review, 72% relating to prevention and 28% to early intervention. Most programs were theory-driven and targeted one or more ED risk factors such as thin-ideal internalisation and/or body dissatisfaction. There is reasonable evidence to support prevention programs reducing risk factors, particularly as part of school or university-based programs, with established feasibility and relatively high acceptance among students. There is increasing evidence around the use of technology (to increase dissemination potential) and for use of mindfulness approaches (targeting emotional resilience). Few longitudinal studies assessing incident cases following participation in a prevention program exist.

CONCLUSIONS

Although several prevention and early intervention programs have been shown to significantly reduce risk factors, promote symptom recognition, and encourage help-seeking behaviour, most of these studies have been conducted in older adolescent and university aged students, past the age of peak ED onset. One of the most targeted risk factors, body dissatisfaction, is found in girls as young as 6 years old, indicating a need for further research implementing prevention initiatives at younger ages. Follow-up research is limited; thus, the long-term efficacy and effectiveness of studied programs is unknown. Greater attention should be paid to the implementation of prevention and early intervention programs in identified high-risk cohorts or diverse groups, where a more targeted approach may be necessary.

The effect of imagery rescripting on core beliefs and eating disorder symptoms in a subclinical population

BACKGROUND AND OBJECTIVES

This study compared the effect of imagery rescripting focusing on self-compassion, imagery rescripting focusing on mastery, and a positive memory control condition on (1) emotional responses towards the memory (one day after), (2) changes in the believability of negative core beliefs, and dysfunctional eating behaviors (one week after) in individual at risk for developing an eating disorder.

METHODS

Female participants (N = 69) were allocated to one of three conditions: ImRs focusing on self-compassion (N = 24), ImRs focusing on self-mastery (N = 23), and positive memory control condition (N = 22). Participants in the ImRs conditions received a 20-min self-guided ImRs intervention, whereas participants in the control condition received a 20-min self-guided task focusing on an unrelated positive memory.

RESULTS

The experimental manipulation successfully induced the use of self-compassion and mastery strategies in the respective imagery rescripting condition. However, our data show that a single 20-min session of self-guided imagery rescripting focusing on compassion and/or mastery has no effect on the emotional response towards the aversive memory or in the change of core beliefs and eating behaviors at follow up.

LIMITATIONS

We discuss potential reasons for the null findings, including the use of a single imagery rescripting session, the sample size and the measurement of manipulation checks.

CONCLUSION

Future studies are needed to rule out methodological explanations for the null results. These findings may be of value for the development of future experimental lab paradigms which aim to evaluate the causal effects and working mechanisms of imagery rescripting.

The body satisfaction and psychological well-being of retired women athletes: A long-term qualitative analysis of bodies in motion

We conducted a qualitative evaluation of Bodies in Motion (BIM), a dissonance, mindful self-compassion-based program that addresses the unique experiences and needs of female athletes with respect to their bodies and their well-being. Using semi-structured interviews, 12 collegiate female athletes (retired 2 - 6 years) reflected and provided feedback on the enduring impact of BIM on their body image, relationship to food and exercise, and overall psychological well-being. Through thematic analysis, we found that these retired athletes, extending from their initial program learning, reported increased awareness of sport and societal messages and their impact on body image, shifted perspectives in their view of themselves and their bodies, and used learned skills to manage body image in their lives. Further, with the passage of time, athletes emphasized how what they had learned in BIM remained essential as they navigated challenging life transitions, such as their retirement from collegiate sports. Our findings indicate that the benefits female athletes report accruing in the immediate aftermath of BIM remain with them, even growing and becoming more salient as they continue to reflect on the program and its impact on their body awareness and how they navigate their lives as women and former athletes.

Compassionate Technology: A Systematic Scoping Review of Compassion as Foundation for Blended and Digital Mental Health Interventions (Preprint)

BACKGROUND

An essential value in mental health care is compassion: awareness of suffering, tolerating difficult feelings in the face of suffering, and acting or being motivated to alleviate suffering. Currently, technologies for mental health care are on the rise and could offer several advantages, such as more options for self-management by clients and more accessible and economically viable care. However, digital mental health interventions (DMHIs) have not been widely implemented in daily practice. Developing and evaluating DMHIs around important mental health care values, such as compassion, could be key for a better integration of technology in the mental health care context.

OBJECTIVE

This systematic scoping review explored the literature for previous instances where technology for mental health care has been linked to compassion or empathy to investigate how DMHIs can support compassion in mental health care.

METHODS

Searches were conducted in the PsycINFO, PubMed, Scopus, and Web of Science databases, and screening by 2 reviewers resulted in 33 included articles. From these articles, we extracted the following data: technology types, goals, target groups, and roles of the technologies in the intervention; study designs; outcome measures; and the extent to which the technologies met a 5-step proposed definition of compassion.

RESULTS

We found 3 main ways in which technology can contribute to compassion in mental health care: by showing compassion to people, by enhancing self-compassion in people, or by facilitating compassion between people. However, none of the included technologies met all 5 elements of compassion nor were they evaluated in terms of compassion.

CONCLUSIONS

We discuss the potential of compassionate technology, its challenges, and the need to evaluate technology for mental health care on compassion. Our findings could contribute to the development of compassionate technology, in which elements of compassion are explicitly embedded in its design, use, and evaluation.

Virtual prevention of eating disorders in children, adolescents, and emerging adults: a scoping review

BACKGROUND

During the COVID-19 pandemic, there was a necessity for eating disorder (ED) outpatient treatment to be delivered virtually. Given this transition, and the surge in new ED cases, there was an urgent need to investigate virtually delivered ED prevention programs. This review aimed to identify the available evidence on virtual ED prevention programs for children, adolescents, and emerging adults.

METHOD

Using scoping review methodology, seven databases were searched for studies published from January 2000 to April 2021 reporting on virtually delivered ED prevention interventions for children and adolescents (< 18 years) and emerging adults (18-25 years). Studies were excluded if they contained adults (> 25 years) and individuals with clinical ED diagnoses. Abstracts and full-text papers were reviewed independently by two reviewers. Data was extracted on study type, methodology, age, sample size, virtual intervention, outcomes, and results. In April 2022, we used a forward citation chaining process to identify any relevant articles from April 2021 to April 2022.

RESULTS

Of 5129 unique studies identified, 67 met eligibility criteria, which included asynchronous (n = 35) and synchronous (n = 18) internet-based programs, other e-technology including mobile apps (n = 3) and text messaging interventions (n = 1), computer-based programs (n = 6), and online caregiver interventions focused on child outcomes (n = 4). Few studies mainly included children and adolescents (n = 18), whereas the vast majority included emerging adults (n = 49). For children and adolescents, the most widely researched programs were Student Bodies and its adapted versions (n = 4), eBody Project (n = 2), and Parents Act Now (n = 2). For emerging adults, the most widely researched programs were Student Bodies and its adapted versions (n = 16), eBody Project (n = 6) and Expand Your Horizon (n = 4). These interventions were effective at reducing various symptoms and ED risk. Some studies demonstrated that virtual prevention intervention efficacy resembled in-person delivery.

CONCLUSION

Virtual prevention interventions for EDs can be effective, however more research is needed studying their impact on children and adolescents and on improving access for vulnerable groups. Additional efficacy studies are required, such as for text messaging and mobile app ED prevention interventions. Evidence-based recommendations for virtual ED prevention for children, adolescents, and emerging adults at-risk for EDs should be prioritized.

Imagery Rescripting for Reducing Body Image Dissatisfaction: A Randomized Controlled Trial

Background

Brief, innovative, mechanistically-driven psychological treatments for body dissatisfaction are needed. We aimed to explore the occurrence of body-related mental images among females reporting a subjective sense of body dissatisfaction (study 1), and to investigate the potential efficacy of a single session of imagery rescripting (ImRS) to reduce body dissatisfaction (Study 2: pilot; Study 3 randomized controlled trial).

Methods and Results

In study 1 (n = 31), participants reported occurrence of both positive and negative body-related mental imagery. Frequency of body-related mental imagery and negative valence of such images were significantly related to body dissatisfaction. The pilot trial (n = 63) indicated feasibility, whereby ImRS of a distressing body-related mental image significantly reduced the believability, vividness, negative affect and distress of the image within-session and one-week post-session versus an active placebo condition (Expressive writing about body related thoughts and emotions). However, ImRS did not result in significant changes in body dissatisfaction. Study 3 was a randomized controlled trial (n = 113) with 3 conditions—ImRS, Expressive writing, and wait-list control. ImRS resulted in a significant reduction of vividness, controllability and negative affect caused by the image compared to Expressive writing condition, after the intervention. However, there were no significant reductions in body dissatisfaction from baseline to 1-week assessment, nor in post-hoc analyses at the 1-month follow-up. Findings suggest that a single session of imagery rescripting seems to alleviate the negative properties of the image (i.e., has proximal effects as hypothesized in our mechanistic account), but does not bring about a significant change in body dissatisfaction (i.e., transfer downstream to more distal effects).

Conclusions

Given some promising effects of ImRS on negative body-related emotions, but lack of a downstream effect on body dissatisfaction itself, further investigation of the format, dose and focus of ImRS in this context is warranted.

New developments in cognitive-behavioural therapy for eating disorders (CBT-ED)

PURPOSE OF REVIEW

This review summarizes recent developments in cognitive-behavioural therapy for eating disorders (CBT-ED). More specifically, the past five years were covered, with the latest UK and Dutch guidelines for eating disorders as a starting benchmark, and with special consideration of the past 18 months.

RECENT FINDINGS

The new research can be divided into findings that have: (1) reinforced our existing understanding of CBT-ED's models and impact; (2) advanced our understanding and the utility of CBT-ED, including its application for the 'new' disorder Avoidant/Restrictive Food Intake Disorder (ARFID); (3) suggested new directions, which require further exploration in clinical and research terms. These include learning from the circumstances of the COVID-19 pandemic.

SUMMARY

CBT-ED has developed substantially in the past 5 years, with consolidation of its existing evidence base, further support for real-life implementation, extension of methods used, and the development of new approaches for working with younger people - particularly in the form of treatments for ARFID. Over the past 18 months, even more promising changes in delivery occurred in response to the COVID19 pandemic, showing that we can adapt our methods in order to work effectively via remote means. Challenges remain regarding poor outcomes for anorexia nervosa.

Open science practices for eating disorders research

This editorial seeks to encourage the increased application of three open science practices in eating disorders research: Preregistration, Registered Reports, and the sharing of materials, data, and code. For each of these practices, we introduce updated International Journal of Eating Disorders author and reviewer guidance. Updates include the introduction of open science badges; specific instructions about how to improve transparency; and the introduction of Registered Reports of systematic or meta-analytical reviews. The editorial also seeks to encourage the study of open science practices. Open science practices pose considerable time and other resource burdens. Therefore, research is needed to help determine the value of these added burdens and to identify efficient strategies for implementing open science practices.

Ascertaining an efficient eligibility cut-off for extended Medicare items for eating disorders

OBJECTIVE

Currently eligibility for expanded Medicare items for eating disorders (excluding anorexia nervosa) require a score ⩾ 3 on the 22-item Eating Disorder Examination-Questionnaire (EDE-Q). We compared these EDE-Q "cases" with continuous scores on a validated 7-item version of the EDE-Q (EDE-Q7) to identify an EDE-Q7 cut-off commensurate to 3 on the EDE-Q.

METHODS

We utilised EDE-Q scores of female university students (N = 337) at risk of developing an eating disorder. We used a receiver operating characteristic (ROC) curve to assess the relationship between the true-positive rate (sensitivity) and the false-positive rate (1-specificity) of cases ⩾ 3.

RESULTS

The area under the curve showed outstanding discrimination of 0.94 (95% CI: .92-.97). We examined two specific cut-off points on the EDE-Q7, which included 100% and 87% of true cases, respectively.

CONCLUSION

Given the EDE-Q cut-off for Medicare is used in conjunction with other criteria, we suggest using the more permissive EDE-Q7 cut-off (⩾2.5) to replace use of the EDE-Q cut-off (⩾3) in eligibility assessments.

Imagery Rescripting of Autobiographical Memories Versus Intrusive Images in Individuals with Disordered Eating

Background

This study compared the effect of imagery rescripting (ImRs) of early autobiographical memories to ImRs of intrusive images and a no task control condition on eating disorder (ED) related core beliefs and ED symptoms in individuals at risk of developing an eating disorder. We qualitatively explored the content of ImRs scripts.

Method

Participants (N = 66, 87.8% females) were allocated to one of three conditions: ImRs of autobiographical memories, ImRs of intrusive images, or a no task control condition. Participants in the ImRs conditions received a 9-min self-guided ImRs intervention in the lab and practiced ImRs daily for the next 6 days online. Participants in the no task control condition took a 9-min break and did not do any further tasks. All participants attended a follow-up testing 1 week after the lab session.

Results

Both ImRs manipulations resulted in greater reductions in negative core beliefs and ED symptoms compared to the no task control group. However, there were no differences among the two ImRs groups. The most widely used rescripting strategy was self-compassion, followed by unhealthy, ED-confirming strategies. No significant associations were found between the ImRs strategies and any of the outcome measures.

Conclusion

ImRs may be a promising intervention for individuals with disordered eating and both early memories as well as intrusive images may be useful targets.

Body image flexibility and its correlates: A meta-analysis

Body image flexibility refers to the ability to openly experience thoughts or feelings about the body without acting on them or trying to change them. Accumulating evidence has demonstrated that body image flexibility is connected to numerous adaptive processes, and that it is sensitive to change during psychological interventions. However, a quantitative synthesis of empirical research on body image flexibility is lacking. We conducted the first meta-analysis on body image flexibility and its correlates. Sixty-two studies were included. Random effects meta-analyses were conducted on 19 psychological correlates, divided into three clusters: eating and body image disturbances, positive body-related and general psychological constructs, and general psychopathology. Meta-analyses showed inverse correlations between body image flexibility and each construct within the eating and body image disturbances cluster (rs= -.45 to -.67), and the general psychopathology cluster (rs= -.37 to -.58). Body image flexibility was positively associated with each positive psychology construct (rs = .23 - .58). Men reported higher levels of body image flexibility than women (d = 0.32). Psychological interventions were more effective than control groups at enhancing body image flexibility in randomized controlled trials (d = 0.42). Findings confirm that body image flexibility is consistently connected to indices of mental health, and that it can be enhanced during psychological interventions.

Online imagery rescripting among young women at risk of developing an eating disorder: A randomized controlled trial

OBJECTIVE

This study compared the effectiveness of two approaches to imagery rescripting (body versus general) among young women with an elevated risk of developing an eating disorder.

METHOD

University students (N = 130 females) were randomly assigned to one of the four conditions: body or general imagery rescripting, psychoeducation, control. After initial brief laboratory training delivered online, participants in the imagery rescripting conditions were asked to practice imagery rescripting for 5 min each day for a week. Primary (global eating psychopathology, eating disorder behaviors, and body image acceptance) and secondary outcomes (self-compassion, fear of self-compassion, and dysfunctional attitudes) were measured at baseline and one-week follow up.

RESULTS

Completer analyses showed both imagery rescripting conditions and psychoeducation had significant impact on global eating psychopathology and body acceptance (d = 0.60-0.78). Psychoeducation did not impact secondary variables, whereas body imagery rescripting improved self-compassion and fear of self-compassion (d = 0.61-0.80) and general imagery rescripting improved dysfunctional attitudes (d = 0.82) compared to control. Intent to treat analyses had similar but slightly less robust results.

DISCUSSION

While three active groups had significant impact on the primary variables, imagery rescripting approaches had impact on other variables that maintain disordered eating. Future research should investigate the impact of combining psychoeducation and imagery rescripting in terms of impact on disordered eating.

Imagine food, weight and shape: mental imagery in women with eating disorders compared with healthy controls

BACKGROUND

Research into mental disorders has found mental imagery to be a maintaining factor for psychological distress. However, studies investigating mental imagery in eating disorders are scarce.

AIM

The aim of the present study was to compare spontaneous mental imagery related to eating, weight and/or appearance and intrusive prospective imagery in women with an eating disorder with female healthy controls.

METHODS

Spontaneous mental imagery and intrusive prospective imagery were assessed in adult women with an eating disorder (n = 29) and in female healthy controls (n = 32) using a semi-structured interview and the Impact of Future Events Scale, respectively.

RESULTS

In comparison with healthy controls, the spontaneous mental images in individuals with an eating disorder involved more sensory modalities (U = 156.50, p < .001, r = -.51), were more vivid (t (52) = 2.04, p = .047, d = .55), negative (U = 103.00, p < .001, r = -.62), and anxiety provoking (U = 158.50, p < .001, r = -.49), and were experienced with a lower sense of control (U = 215.00, p = .009, r = -.36). The emotional impact of intrusive prospective imagery (U = 105.00, p < .001, r = -.66) was also higher in individuals with an eating disorder, as was the number of negative prospective images (U = 283.00, p = .016, r = -.31).

CONCLUSIONS

Our findings are consistent with previous research on mental imagery in other psychiatric disorders, and provide possibilities for incorporating imagery-based techniques in treatment interventions.

Efficacy and acceptability of a pilot dietary intervention focusing on self-compassion, goal-setting and self-monitoring

OBJECTIVE

Overweight and obesity are universal health challenges. Recent evidence emphasises the potential benefits of addressing psychological factors associated with obesity in dietary programmes. This pilot study investigated the efficacy and acceptability of a combined online and face-to-face dietary intervention that used self-compassion, goal-setting and self-monitoring to improve dietary behaviour, as well as psychological factors associated with dietary behaviour.

DESIGN

Embedded mixed methods including a 4-week before-after trial and a one-on-one interview. Quantitative outcomes of the study were the levels of self-compassion; eating pathology; depression, anxiety and stress; and dietary intake. Qualitative outcomes were participants' perceptions about the acceptability of the intervention.

SETTING

UNSW Kensington campus.

PARTICIPANTS

Fourteen participants with overweight and obesity aged between 18 and 55 years old.

RESULTS

Results showed that the intervention significantly improved self-compassion and some aspects of dietary intake (e.g. decrease in energy intake) at Week Four compared with Week Zero. Some aspects of eating pathology also significantly decreased (e.g. Eating Concern). However, changes in self-compassion over the 4 weeks did not significantly predict Week Four study outcomes, except for level of stress. Most participants found self-compassion, goal-setting and self-monitoring to be essential for dietary behaviour change. However, participants also indicated that an online programme needed to be efficient, simple and interactive.

CONCLUSIONS

In conclusion, the current study provides preliminary but promising findings of an effective and acceptable combined online and face-to-face intervention that used self-compassion, goal-setting and self-monitoring to improve dietary habits. However, the results need to be examined in future long-term randomised controlled trials.

Community-Based Prevention Programs for Disordered Eating and Obesity: Updates and Current Limitations

PURPOSE OF REVIEW

To review the status of community-based disordered eating and obesity prevention programs from 2014 to 2019.

RECENT FINDINGS

In the last 5 years, prevention programs have found success in intervening with children and parental figures in wellness centers, physical activity centers, childcare centers, workplaces, online, and over-the-phone through directly reducing disordered eating and obesity or by targeting risk factors of disordered eating and obesity. Community-based prevention programs for disordered eating and programs targeting both disordered eating and obesity were scarce, highlighting the critical need for the development of these programs. Qualities of the most effective programs were those in which parents and children were educated on physical activity and nutrition via multiple group-based sessions. Limitations of current prevention programs include few programs targeting high-risk populations, a dearth of trained community members serving as facilitators, inconsistent reporting of adherence rates, and few direct measurements of disordered eating and obesity, as well as few long-term follow-ups, precluding the evaluation of sustained effectiveness.

Rescripting experimental trauma: Effects of imagery and writing as a way to reduce the development of intrusive memories

BACKGROUND AND OBJECTIVES

Imagery rescripting is an effective treatment strategy for trauma related disorders, but its underlying mechanisms are still largely unknown. The aim of the present study was to test whether a) imagery (versus writing) is essential in the process of rescripting, and b) rescripting affects emotional memories on an implicit level.

METHODS

Healthy participants were subjected to an experimental trauma ('trauma film'), and randomly allocated to four conditions: recall of film + Imagery Rescripting (ImRs), recall of film + Writing Rescripting (WRs), recall only (ImRE), or no recall + no manipulation (NM). Next, participants recorded intrusion frequency and distress during one week, after which they executed a visual interference task (VIT) including neutral and trauma film stills, to access implicit emotional memory.

RESULTS

Main findings were that ImRs and WRs resulted in fewer intrusions than NM, with no differences between both rescripting conditions. We did not find an effect on intrusion distress and the VIT.

LIMITATIONS

Stills in the VIT were distracted from all four film scenes, whereas rescripting was done on one scene only, possibly obscuring the effect. Also, an analogue sample was used, which may limit generalizability to clinical samples.

CONCLUSIONS

We replicated previous effects of ImRs on intrusion development. Furthermore, no superior effect of imagery as key modality for rescripting was found; writing seems a viable alternative. Measures for implicit emotional memory such as the VIT may have to be applied relatively soon after the experimental session (e.g., same day as the experimental session).

Short Imagery Rescripting Intervention to Treat Emotionally Dysregulated Behavior in Borderline Personality Disorder: An Exploratory Study

BACKGROUND

Current research on borderline personality disorder report an association between emotionally dysregulated behaviors and intrusive mental imagery depicting similar scenes. Imagery rescripting techniques have proven effective in reducing intrusive mental imagery in numerous contexts. We developed a two session-short intervention in which intrusive mental images are identified, analyzed, and modified for daily rehearsal at home. This study aimed to reduce the negative emotions and cognitions associated with self-injurious behaviors by replacing unhealthy imagery with more adaptive content.

METHODS

Seven females diagnosed with borderline personality disorder who reported intrusive mental imagery of dysregulated behaviors were recruited for participation. Each participant engaged in two individualized treatment sessions and daily homework requiring the rehearsal of modified imagery. Emotion regulation strategies, borderline symptom severity, and depressiveness were assessed before and after treatment.

RESULTS

Acceptance was positive, as no patient dropped out from treatment. Symptom exacerbation was not observed. Borderline symptom reduction was noted and indicia of emotional dysregulation and negative affect declined.

LIMITATIONS

The generalizability of results is limited by the small sample size and the absence of a control group. Conclusions: This new two-session short intervention was shown to decrease the emotionally dysregulated behaviors that accompany negative feelings in females with borderline personality disorder.

Meta-analytic review of dissonance-based eating disorder prevention programs: Intervention, participant, and facilitator features that predict larger effects

Many trials have provided support for dissonance-based eating disorder prevention programs. This meta-analytic review characterized the average intervention effects and tested whether various intervention, participant, and facilitator features correlated with larger effects to guide implementation of optimally effective versions of this program. We identified 56 trials that evaluated 68 dissonance-based eating disorder prevention programs (7808 participants). Average intervention effect sizes (d) relative to minimal intervention control conditions and credible alternative interventions (respectively) were 0.57 and 0.31 for thin-ideal internalization, 0.42 and 0.18 for body dissatisfaction, 0.37 and 0.17 for dieting, 0.29 and 0.21 for negative affect, and 0.31 and 0.13 for eating disorder symptoms. As hypothesized, effects were larger for interventions with more dissonance-inducing activities, more group sessions, and larger group sizes, as well as when delivered in-person versus on-line, sessions were recorded, participation was voluntary, body dissatisfaction was required, participants were mid-adolescents or adults (versus older adolescence), there were more ethnic minority participants, groups were led by clinicians versus researchers and at least two facilitators, and when facilitators received more training and supervision. Unexpectedly from a dissonance-induction perspective, effects were larger when participants were compensated. Results offer directions for maximizing the benefits of implementation efforts with dissonance-based eating disorder prevention programs, and may hold lessons for preventing other public health problems with dissonance-based interventions.

Recent Research on Bulimia Nervosa

Estimates of lifetime bulimia nervosa (BN) range from 4% to 6.7% across studies. There has been a decrease in the presentation of BN in primary care but an increase in disordered eating not meeting full diagnostic criteria. Regardless of diagnostic status, disordered eating is associated with long-term significant impairment to both physical and mental quality of life, and BN is associated with a significantly higher likelihood of self-harm, suicide, and death. Assessment should adopt a motivationally enhancing stance given the high level of ambivalence associated with BN. Cognitive behavior therapy specific to eating disorders outperforms other active psychological comparisons.

Prevention of eating disorders: 2018 in review

This article reviews the 10 prevention-related publications in Eating Disorders: The Journal of Treatment & Prevention during 2018. Two models frame this analysis. This first is the Mental Health Intervention Spectrum from health promotion → types of prevention → case identification and referral → treatment (recovery). The second parses the phases of prevention into rationale, theory, and methodology → clarification of risk factors, including very high risk, shading into warning signs → implications for specific preventive interventions → design innovation and feasibility (pilot) research → efficacy and effectiveness research → program dissemination. Collectively, the articles illustrate how complex and demanding the field of prevention is, with respect to, for example, phases of program development, the multidimensional ecology of interventions, and methodological requirements for demonstrating that a program deserves to be designated "evidence-based." A subset of the articles also illustrates how far the increasingly broad and dynamic field of prevention has advanced. Examples include models of eating disorder development in high-risk populations such as people with type 1 diabetes; prevention programming for young children; and after-school preventive interventions that combine dissonance-based lessons with empowering participation in community advocacy and activism.