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Wonderlich JA, Dodd DR, Sondag C, Jorgensen M, Blumhardt C, Evanson AN, Bjoralt C, Wonderlich SA. Clinical and scientific review of severe and enduring anorexia nervosa in intensive care settings: introducing an innovative treatment paradigm. J Eat Disord 2024; 12:131. [PMID: 39227928 PMCID: PMC11373466 DOI: 10.1186/s40337-024-01079-9] [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: 05/31/2024] [Accepted: 08/06/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Anorexia nervosa is a serious and potentially lethal psychiatric disorder. Furthermore, there is significant evidence that some individuals develop a very long-standing form of the illness that requires a variety of different treatment interventions over time. OBJECTIVE The primary goal of this paper was to provide a review of treatment strategies for severe and enduring anorexia nervosa (SE-AN) with the particular focus on treatments involving hospital care. Additionally, we wish to highlight a contemporary approach to such care and provide qualitative reactions to this model from both staff and patients. METHODS A selective and strategic review of the treatment literature for SE-AN was conducted for the current paper. Emphasis was placed on clinical or scientific papers related to hospital-based care. Additionally, staff who work on a specific inpatient eating disorder unit with a substantial treatment program for SE-AN, along with a number of SE-AN patients were surveyed regarding their experiences working on, or receiving treatment on the unit. Importantly, the staff of this unit created a specific treatment protocol for individuals receiving hospital care. The results of the highlight both advantages and challenges of a hospital-based protocol oriented toward emphasizing quality of life, medical stability, and a health-promoting meal plan. DISCUSSION While there is general inconsistency with the type of treatment that is best suited to individuals with SE-AN, this is particularly true for higher levels of care that rely on inpatient hospital units or residential treatment settings. This is a highly significant clinical topic in need of further clinical and scientific examination.
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Affiliation(s)
- Joseph A Wonderlich
- Sanford Research, Center for Biobehavioral Research, Fargo, ND, USA.
- Eating Disorders Unit, Sanford Health, Fargo, ND, USA.
| | - Dorian R Dodd
- Sanford Research, Center for Biobehavioral Research, Fargo, ND, USA
- Eating Disorders Unit, Sanford Health, Fargo, ND, USA
| | - Cindy Sondag
- Eating Disorders Unit, Sanford Health, Fargo, ND, USA
| | | | | | | | - Casey Bjoralt
- Eating Disorders Unit, Sanford Health, Fargo, ND, USA
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2
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Fernández García S, Quiles Marcos Y. Effectiveness of the Maudsley Model of Anorexia Nervosa Treatment for Adults: A systematic review. EUROPEAN EATING DISORDERS REVIEW 2024. [PMID: 38961594 DOI: 10.1002/erv.3122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/04/2024] [Accepted: 06/22/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Maudsley Model of Anorexia nervosa (AN) Treatment for Adults (MANTRA) is recommended by NICE for the treatment of adults with AN. However, despite this fact, the approach remains relatively understudied. The aim of this study was to systematically update the research evidence regarding the use of the MANTRA in the treatment of Eating Disorders (ED). METHOD The databases used were Web of Science, Scopus, and PsycInfo, including studies up to 31 May 2023. PRISMA guidelines were followed, and Cochrane tools were used to assess the risk of bias. The search focused on identifying published articles that discussed the usefulness of MANTRA as a component of treatment for ED, following PICO criteria. RESULTS Nine studies spanning the period from 2011 to 2023 were included. Findings suggested that MANTRA was effective in improving body mass index (BMI), eating symptomatology and emotional state. There were generally no significant differences compared to other treatment conditions. Limitations to interpreting this systematic review include the methodological quality of included studies and the elevated risk of bias. CONCLUSIONS This review was the first to examine the effectiveness of MANTRA. The results indicate that MANTRA has shown effectiveness similar to other treatments for adults AN patients in addressing key clinical variables. It has been used in different populations (adolescents, males, inpatients) and formats (group, online) However, more research is needed to determine its effectiveness.
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Affiliation(s)
| | - Yolanda Quiles Marcos
- Department of Behavioral Sciences and Health, Miguel Hernández University, Elche, Spain
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3
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Almenara CA. 40 years of research on eating disorders in domain-specific journals: Bibliometrics, network analysis, and topic modeling. PLoS One 2022; 17:e0278981. [PMID: 36520823 PMCID: PMC9754234 DOI: 10.1371/journal.pone.0278981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 11/27/2022] [Indexed: 12/23/2022] Open
Abstract
Previous studies have used a query-based approach to search and gather scientific literature. Instead, the current study focused on domain-specific journals in the field of eating disorders. A total of 8651 documents (since 1981 to 2020), from which 7899 had an abstract, were retrieved from: International Journal of Eating Disorders (n = 4185, 48.38%), Eating and Weight Disorders (n = 1540, 17.80%), European Eating Disorders Review (n = 1461, 16.88%), Eating Disorders (n = 1072, 12.39%), and Journal of Eating Disorders (n = 393, 4.54%). To analyze these data, diverse methodologies were employed: bibliometrics (to identify top cited documents), network analysis (to identify the most representative scholars and collaboration networks), and topic modeling (to retrieve major topics using text mining, natural language processing, and machine learning algorithms). The results showed that the most cited documents were related to instruments used for the screening and evaluation of eating disorders, followed by review articles related to the epidemiology, course and outcome of eating disorders. Network analysis identified well-known scholars in the field, as well as their collaboration networks. Finally, topic modeling identified 10 major topics whereas a time series analysis of these topics identified relevant historical shifts. This study discusses the results in terms of future opportunities in the field of eating disorders.
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Affiliation(s)
- Carlos A. Almenara
- School of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Perú
- * E-mail:
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Fleming C, Byrne J, Healy K, Le Brocque R. Working with families of adults affected by eating disorders: uptake, key themes, and participant experiences of family involvement in outpatient treatment-as-usual. J Eat Disord 2022; 10:88. [PMID: 35768840 PMCID: PMC9245299 DOI: 10.1186/s40337-022-00611-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 06/15/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Eating disorders are associated with significant personal and family costs. Clinical guidelines recommend family members be involved and supported during care, but little has been reported regarding the preferences of adults around carer involvement in treatment. The necessary intensity of family work with adults is also unknown. A trial of a standardised brief family involvement method was conducted in an adult eating disorder service offering treatment-as-usual. Uptake and feasibility of implementing the approach as part of standard outpatient care and the preliminary impact on issues identified by adult patients and carers were evaluated. METHODS Eligible referrals at an adult eating disorders outpatient clinic were offered as needed family consultation to address presenting interpersonal problems identified by patients and their family members, and outcomes were evaluated 4 weeks later. Pre and post intervention surveys identified participant self-reported change in (i) problem frequency, (ii) distress and disruption caused, and (iii) confidence regarding presenting problems. Open text responses provided an overview of patient and carer goals for family involvement and revealed how the novel method impacted these areas as well as overall experience of, and feedback regarding, the brief family intervention. RESULTS Twenty-four female participants aged 18-53, and 22 carers participated in 31 consultations. Common concerns raised were eating disorder related interpersonal and communication issues. The focused sessions, offered on a one-at-a-time basis, showed preliminary effectiveness for reducing both patients and carer concerns. For example, adult patients reported that life interference from interpersonal problems was lower and confidence to deal with them was higher following family consultation. Carers also reported that frequency, level of worry, and life interference around presenting problems were lower after the structured family intervention. CONCLUSIONS Brief family consultation, with a single focus on issues identified by family members and adult patients, was a safe and feasible procedure with adults affected by eating disorders. Effective at meeting the needs of participants, the framework investigated in the current study may also be a useful direction for adult services to consider when looking to support families and meet recommendations for their routine involvement in the outpatient care. TRIAL REGISTRATION Australian Clinical Trials Register number: ACTRN12621000047897 (www.anzctr.org.au).
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Affiliation(s)
- Carmel Fleming
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Qld, 4072, Australia.
- Queensland Eating Disorder Service, Queensland Health Metro North Hospital and Health Service, Brisbane, Australia.
| | - Jacqueline Byrne
- Queensland Eating Disorder Service, Queensland Health Metro North Hospital and Health Service, Brisbane, Australia
- School of Nursing and Midwifery, Griffith University, Brisbane, Qld, 4122, Australia
| | - Karen Healy
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Qld, 4072, Australia
| | - Robyne Le Brocque
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Qld, 4072, Australia
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Fleming C, Le Brocque R, Healy K. How are families included in the treatment of adults affected by eating disorders? A scoping review. Int J Eat Disord 2021; 54:244-279. [PMID: 33345319 DOI: 10.1002/eat.23441] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The involvement of families in the treatment of adults with eating disorders is recommended as a core component of comprehensive care, yet little is known about the optimal way to implement or routinely facilitate this. This article evaluates the recent evidence on the inclusion of families in treatment programs for adults with eating disorders. METHOD A systematic literature search was conducted to identify evidence of family inclusive treatment approaches for adults with eating disorders. A scoping review framework was applied to assess and synthesize findings. RESULTS Sixty-eight studies were identified. Substantial conceptual research contributing to the theoretical basis of current practice with families of adults with eating disorders and clinical applications in current use were identified. Most research used uncontrolled studies with few experimental designs, reflecting the standing of the extant literature. Common elements of existing approaches have been distinguished and shared core components of interventions identified. DISCUSSION Results confirmed that family members of adults were willing to be involved with eating disorder treatment services and appeared to respond to interventions of varying intensity and duration. The impact on individual patients, and effect on treatment outcomes, are yet to be established. The localized settings of existing studies, the homogenous nature of interventions used, and the limited diversity in research subjects, make it difficult to generalize from the results to the wide range of adult eating disorder presentations seen in practice. Suggestions for future research and further clinical developments are discussed.
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Affiliation(s)
- Carmel Fleming
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Health Metro North Hospital and Health Service, Queensland Eating Disorder Service, Brisbane, Australia
| | - Robyne Le Brocque
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Queensland, Australia
| | - Karen Healy
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Queensland, Australia
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Wonderlich SA, Bulik CM, Schmidt U, Steiger H, Hoek HW. Severe and enduring anorexia nervosa: Update and observations about the current clinical reality. Int J Eat Disord 2020; 53:1303-1312. [PMID: 32359125 DOI: 10.1002/eat.23283] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 12/22/2022]
Abstract
Several objectives underlie the current article. First, to review historical diagnostic issues and clinical strategies for treating SE-AN. Second, to provide an overview of recent evidence informed strategies and clinical innovations for the treatment of SE-AN. Third, based on the authors' collective clinical and research experience, we offer eight observations that we believe capture the current clinical experience of patients with SE-AN. Some of these observations represent empirically testable hypotheses, but all are designed to generate a meaningful discussion about the treatment of this group of individuals with eating disorders. Finally, we hope to call clinicians, scientists, professional organizations, advocates, and policy makers to action to attend to critical issues related to the care of individuals with SE-AN. We believe that an international discussion could clarify areas of need for these patients and identify opportunities for clinical innovation that would enhance the lives of individuals with SE-AN and their families.
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Affiliation(s)
- Stephen A Wonderlich
- Sanford Research, Center for Bio-behavioral Research, Fargo, North Dakota, USA.,Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA
| | - Cynthia M Bulik
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ulrike Schmidt
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Howard Steiger
- Eating Disorder Continuum, Douglas Mental Health University Institute, Montreal, Canada.,Psychiatry Department, McGill University, Montreal, Canada
| | - Hans W Hoek
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, USA.,Parnassia Psychiatric Institute, The Hague, The Netherlands
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7
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Foroughe M, Stillar A, Goldstein L, Dolhanty J, Goodcase ET, Lafrance A. Brief Emotion Focused Family Therapy: An Intervention for Parents of Children and Adolescents with Mental Health Issues. JOURNAL OF MARITAL AND FAMILY THERAPY 2019; 45:410-430. [PMID: 30105875 DOI: 10.1111/jmft.12351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This study evaluated the 2-day intensive modality of Emotion Focused Family Therapy (EFFT). The intervention attempts to prepare parents to take a primary role in their child's recovery from a range of mental health issues. One hundred and twenty-four parents completed the intervention and provided data a week prior to intervention, post-intervention and at 4-month follow-up. Results include significantly reduced parent blocks and increased parental self-efficacy in relation to involvement in their child's recovery, as well as significant improvement in child symptomatology. The findings confirm positive results from an earlier pilot study involving eating disorders and demonstrate the potential for EFFT as an intervention for a range of clinical problems in children and youth.
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Leonidas C, Nazar BP, Munguía L, Santos MA. How do we target the factors that maintain anorexia nervosa? A behaviour change taxonomical analysis. Int Rev Psychiatry 2019; 31:403-410. [PMID: 31244361 DOI: 10.1080/09540261.2019.1624509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
All psychological treatments for anorexia nervosa appear to have equal (albeit modest) effects. This may be explained because they target similar processes. Although different psychological treatments have been developed for anorexia nervosa treatment, their taxonomical components have not been compared. This study undertook a taxonomical analysis of behaviour change techniques (BCTs), using the CALO-RE analysis tool, from the manuals of Enhanced Cognitive Behavioural Therapy (CBT-E), Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), Family Based Therapy (FBT), Specialist Supportive Clinical Management (SSCM), and Focal Psychodynamic Psychotherapy (FPT). The highest number of BCTs were found in FPT (72,5%), and the lowest were in SSCM (30%). The other interventions had a similar range of BCTs which mainly focused on goal planning (FBT (50%), CBT-E (47.5%), MANTRA (42.5%)). Modelling, shaping, and training communication, self-monitoring, and fear arousal were the less commonly used BCTs across manuals. Manualized psychological interventions for people with anorexia nervosa share a substantial number of behaviour change techniques which might explain their similar levels of effectiveness. New strategies may be needed in order to improve outcomes.
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Affiliation(s)
- Carolina Leonidas
- a Psychology Department , Federal University of the Triângulo Mineiro (UFTM) , Uberaba , Brazil
| | - Bruno P Nazar
- b Institute of Psychiatry , Federal University of Rio de Janeiro (IPUB-UFRJ) , Rio de Janeiro , Brazil
| | - Lucero Munguía
- c Clinical Sciences Department, Faculty of Medicine and Health Sciences , University of Barcelona , Barcelona , Spain
| | - Manoel A Santos
- d Psychology Department, Faculty of Philosophy, Sciences and Letters at Ribeirão Preto , University of São Paulo (FFCLRP-USP) , Ribeirão Preto , Brazil
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9
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Treasure J, Schmidt U, Kan C. An illustration of collaborative care with a focus on the role of fathers in Maudsley Anorexia Nervosa Treatment for Adults (MANTRA). J Clin Psychol 2019; 75:1403-1414. [PMID: 31038745 DOI: 10.1002/jclp.22789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Janet Treasure
- Section of Eating Disorder, Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Ulrike Schmidt
- Section of Eating Disorder, Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Carol Kan
- Section of Eating Disorder, Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
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Oldershaw A, Startup H, Lavender T. Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa. Front Psychol 2019; 10:219. [PMID: 30886593 PMCID: PMC6410927 DOI: 10.3389/fpsyg.2019.00219] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 01/22/2019] [Indexed: 12/17/2022] Open
Abstract
In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.
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Affiliation(s)
- Anna Oldershaw
- Salmons Centre for Applied Psychology, Canterbury Christ Church University, Canterbury, United Kingdom
- Kent and Medway All Age Eating Disorder Service, North East London NHS Foundation Trust, London, United Kingdom
| | - Helen Startup
- Sussex Eating Disorders Service and Research and Development Department, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Tony Lavender
- Salmons Centre for Applied Psychology, Canterbury Christ Church University, Canterbury, United Kingdom
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Mac Neil BA, Hudson CC. Patient Experience and Satisfaction With Acceptance and Commitment Therapy Delivered in a Complimentary Open Group Format for Adults With Eating Disorders. J Patient Exp 2018; 5:189-194. [PMID: 30214925 PMCID: PMC6134549 DOI: 10.1177/2374373517748640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We examined patient experiences and satisfaction with acceptance and commitment therapy (ACT) delivered in a novel weekly open-group therapy format immediately following psychiatric intake assessment into a hospital-based outpatient adult eating disorders program. Participants were 68 adults with a Diagnostic and Statistical Manual of Mental Disorders, 5th edition diagnosis of an eating disorder who reported their experiences and satisfaction with the ACT group. Participants reported that they were somewhat satisfied to very satisfied with the open ACT group and that the treatment content was helpful. Specifically, participants reported that ACT group helped them to recognize their personal values and learn strategies for behavior change. Satisfaction with ACT group was associated with engagement in the broader group therapy program. Results suggest that ACT delivered in an open group format is well liked by adults in an outpatient program for eating disorders. ACT is a promising complimentary treatment for individuals with eating disorders that can be easily integrated by clinicians into outpatient care.
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Affiliation(s)
- Brad A Mac Neil
- Adult Eating Disorders Program (AEDP), Kingston Health Sciences Centre (KHSC), Kingston, Ontario, Canada
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
| | - Chloe C Hudson
- Adult Eating Disorders Program (AEDP), Kingston Health Sciences Centre (KHSC), Kingston, Ontario, Canada
- Department of Psychology, Queen’s University, Kingston, Ontario, Canada
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Dawson L, Mullan B, Touyz S, Rhodes P. Are recovery stories helpful for women with eating disorders? A pilot study and commentary on future research. J Eat Disord 2018; 6:21. [PMID: 30128153 PMCID: PMC6092853 DOI: 10.1186/s40337-018-0206-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/04/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Anecdotally it is well known that eating disorder memoirs are popular with people with anorexia nervosa and recovery stories are readily available online. However, no research to date has empirically explored whether such stories are helpful for current sufferers. The aim of the current pilot study was to explore the efficacy of recovery narratives as a means of improving motivation and self-efficacy and to qualitatively explore patient perspectives of such stories. METHOD Fifty-seven women with anorexia nervosa and subclinical anorexia nervosa participated in this online study. Participants were randomised to either receive recovery stories or to a wait-list control group. After completing baseline measures, participants read five stories about recovery, and completed post-intervention measures two weeks later. RESULTS The quantitative results indicated that reading stories of recovery had no effect on motivation and self-efficacy over a two-week period. In contrast, the qualitative results showed that the stories generated thoughts about the possibility of recovery and the majority indicated they would recommend them to others. CONCLUSIONS This study adds to a growing body of research exploring the integration of voices of lived experience into treatment approaches. Future research should focus on 1) identifying for whom and at which stage of illness recovery stories might be helpful; 2) the mechanism via which they might operate; and 3) the most helpful way of presenting such stories.
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Affiliation(s)
- Lisa Dawson
- Eating Disorder Service, The Sydney Children's Hospital Network, Westmead Campus, Sydney, Australia.,2Centre for Family Based Mental Health Care, St Vincent's Private Hospital, Sydney, Australia
| | - Barbara Mullan
- 3School of Psychology and Speech Pathology, Curtin University, Perth, WA Australia
| | - Stephen Touyz
- 4School of Psychology, The University of Sydney, Sydney, Australia
| | - Paul Rhodes
- 4School of Psychology, The University of Sydney, Sydney, Australia
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Zeeck A, Herpertz-Dahlmann B, Friederich HC, Brockmeyer T, Resmark G, Hagenah U, Ehrlich S, Cuntz U, Zipfel S, Hartmann A. Psychotherapeutic Treatment for Anorexia Nervosa: A Systematic Review and Network Meta-Analysis. Front Psychiatry 2018; 9:158. [PMID: 29765338 PMCID: PMC5939188 DOI: 10.3389/fpsyt.2018.00158] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/09/2018] [Indexed: 12/17/2022] Open
Abstract
Background: The aim of the study was a systematic review of studies evaluating psychotherapeutic treatment approaches in anorexia nervosa and to compare their efficacy. Weight gain was chosen as the primary outcome criterion. We also aimed to compare treatment effects according to service level (inpatient vs. outpatient) and age group (adolescents vs. adults). Methods:The data bases PubMed, Cochrane Library, Web of Science, Cinahl, and PsychInfo were used for a systematic literature search (until Feb 2017). Search terms were adapted for data base, combining versions of the search terms anorexia, treat*/therap* and controlled trial. Studies were selected using pre-defined in- and exclusion criteria. Data were extracted by two independent coders using piloted forms. Network-meta-analyses were conducted on all RCTs. For a comparison of service levels and age groups, standard mean change (SMC) statistics were used and naturalistic, non-randomized studies included. Results: Eighteen RCTs (trials on adults: 622 participants; trials on adolescents: 625 participants) were included in the network meta-analysis. SMC analyses were conducted with 38 studies (1,164 participants). While family-based approaches dominate interventions for adolescents, individual psychotherapy dominates in adults. There was no superiority of a specific approach. Weight gains were more rapid in adolescents and inpatient treatment. Conclusions: Several specialized psychotherapeutic interventions have been developed and can be recommended for AN. However, adult and adolescent patients should be distinguished, as groups differ in terms of treatment approaches considered suitable as well as treatment response. Future trials should replicate previous findings and be multi-center trials with large sample sizes to allow for subgroup analyses. Patient assessment should include variables that can be considered relevant moderators of treatment outcome. It is desirable to explore adaptive treatment strategies for subgroups of patients with AN. Identifying and addressing maintaining factors in AN remains a major challenge.
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Affiliation(s)
- Almut Zeeck
- Department of Psychosomatic Medicine and Psychotherapy, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Hans-Christoph Friederich
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Timo Brockmeyer
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Gaby Resmark
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrich Hagenah
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Stefan Ehrlich
- Division of Psychological and Social Medicine and Developmental Neurosciences, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universitaet Dresden, Dresden, Germany
| | - Ulrich Cuntz
- Schön Klinik Roseneck, Prien am Chiemsee, Germany
| | - Stephan Zipfel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Armin Hartmann
- Department of Psychosomatic Medicine and Psychotherapy, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
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Drabkin A, Rothman MS, Wassenaar E, Mascolo M, Mehler PS. Assessment and clinical management of bone disease in adults with eating disorders: a review. J Eat Disord 2017; 5:42. [PMID: 29214023 PMCID: PMC5713040 DOI: 10.1186/s40337-017-0172-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/08/2017] [Indexed: 01/09/2023] Open
Abstract
AIM To review current medical literature regarding the causes and clinical management options for low bone mineral density (BMD) in adult patients with eating disorders. BACKGROUND Low bone mineral density is a common complication of eating disorders with potentially lifelong debilitating consequences. Definitive, rigorous guidelines for screening, prevention and management are lacking. This article intends to provide a review of the literature to date and current options for prevention and treatment. METHODS Current, peer-reviewed literature was reviewed, interpreted and summarized. CONCLUSION Any patient with lower than average BMD should weight restore and in premenopausal females, spontaneous menses should resume. Adequate vitamin D and calcium supplementation is important. Weight-bearing exercise should be avoided unless cautiously monitored by a treatment team in the setting of weight restoration. If a patient has a Z-score less than expected for age with a high fracture risk or likelihood of ongoing BMD loss, physiologic transdermal estrogen plus oral progesterone, bisphosphonates (alendronate or risedronate) or teriparatide could be considered. Other agents, such as denosumab and testosterone in men, have not been tested in eating-disordered populations and should only be trialed on an empiric basis if there is a high clinical concern for fractures or worsening bone mineral density. A rigorous peer-based approach to establish guidelines for evaluation and management of low bone mineral density is needed in this neglected subspecialty of eating disorders.
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Affiliation(s)
- Anne Drabkin
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
| | - Micol S. Rothman
- University of Colorado Hospital, Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO 80045 USA
| | | | - Margherita Mascolo
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
| | - Philip S. Mehler
- Denver Health and Hospital Authority, 660 Bannock MC 4000, Denver, CO 80204 USA
- Eating Recovery Center, 7351 E. Lowry Blvd. Suite 200, Denver, CO 80230 USA
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Schmidt U, Sharpe H, Bartholdy S, Bonin EM, Davies H, Easter A, Goddard E, Hibbs R, House J, Keyes A, Knightsmith P, Koskina A, Magill N, McClelland J, Micali N, Raenker S, Renwick B, Rhind C, Simic M, Sternheim L, Woerwag-Mehta S, Beecham J, Campbell IC, Eisler I, Landau S, Ringwood S, Startup H, Tchanturia K, Treasure J. Treatment of anorexia nervosa: a multimethod investigation translating experimental neuroscience into clinical practice. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BackgroundAnorexia nervosa (AN) is a severe psychiatric condition and evidence on how to best treat it is limited.ObjectivesThis programme consists of seven integrated work packages (WPs) and aims to develop and test disseminable and cost-effective treatments to optimise management for people with AN across all stages of illness.MethodsWP1a used surveys, focus groups and a pre–post trial to develop and evaluate a training programme for school staff on eating disorders (EDs). WP1b used a randomised controlled trial (RCT) [International Standard Randomised Controlled Trial Number (ISRCTN) 42594993] to evaluate a prevention programme for EDs in schools. WP2a evaluated an inpatient treatment for AN using case reports, interviews and a quasi-experimental trial. WP2b used a RCT (ISRCTN67720902) to evaluate two outpatient psychological therapies for AN. WP3 used a RCT (ISRCTN06149665) to evaluate an intervention for carers of inpatients with AN. WP4 used actimetry, self-report and endocrine assessment to examine physical activity (PA) in AN. WP5 conducted a RCT (ISRCTN18274621) of an e-mail-guided relapse prevention programme for inpatients with AN. WP6 analysed cohort data to examine the effects of maternal EDs on fertility and their children’s diet and growth. WP7a examined clinical case notes to explore how access to specialist ED services affects care pathways and user experiences. Finally, WP7b used data from this programme and the British Cohort Study (1970) to identify the costs of services used by people with AN and to estimate annual costs of AN for England.ResultsWP1a: a brief training programme improved knowledge, attitudes and confidence of school staff in managing EDs in school. WP1b: a teacher-delivered intervention was feasible and improved risk factors for EDs in adolescent girls. WP2a: both psychological therapies improved outcomes in outpatients with AN similarly, but patients preferred one of the treatments. WP2b: the inpatient treatment (Cognitive Remediation and Emotional Skills Training) was acceptable with perceived benefits by patients, but showed no benefits compared with treatment as usual (TAU). WP3: compared with TAU, the carer intervention improved a range of patient and carer outcomes, including carer burden and patient ED symptomatology. WP4: drive to exercise is tied to ED pathology and a desire to improve mood in AN patients. PA was not increased in these patients. WP5: compared with TAU, the e-mail-guided relapse prevention programme resulted in higher body mass index and lower distress in patients at 12 months after discharge. WP6: women with an ED had impaired fertility and their children had altered dietary and growth patterns compared with the children of women without an ED. WP7a: direct access to specialist ED services was associated with higher referral rates, lower admission rates, greater consistency of care and user satisfaction. WP7b: the annual costs of AN in England are estimated at between £45M and £230M for 2011.ConclusionsThis programme has produced evidence to inform future intervention development and has developed interventions that can be disseminated to improve outcomes for individuals with AN. Directions for future research include RCTs with longer-term outcomes and sufficient power to examine mediators and moderators of change.Trial registrationCurrent Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ulrike Schmidt
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Helen Sharpe
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Savani Bartholdy
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Eva-Maria Bonin
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Helen Davies
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Abigail Easter
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Institute of Child Health, University College London, London, UK
| | - Elizabeth Goddard
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rebecca Hibbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jennifer House
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Alexandra Keyes
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Pooky Knightsmith
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Antonia Koskina
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nicholas Magill
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jessica McClelland
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nadia Micali
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Institute of Child Health, University College London, London, UK
| | - Simone Raenker
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Bethany Renwick
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Charlotte Rhind
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Mima Simic
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Lot Sternheim
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Woerwag-Mehta
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jennifer Beecham
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
- Personal Social Services Research Unit, University of Kent, Canterbury, UK
| | - Iain C Campbell
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Ivan Eisler
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Child Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Landau
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | - Helen Startup
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Kate Tchanturia
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Zainal KA, Renwick B, Keyes A, Lose A, Kenyon M, DeJong H, Broadbent H, Serpell L, Richards L, Johnson-Sabine E, Boughton N, Whitehead L, Treasure J, Schmidt U. Process evaluation of the MOSAIC trial: treatment experience of two psychological therapies for out-patient treatment of Anorexia Nervosa. J Eat Disord 2016; 4:2. [PMID: 26865980 PMCID: PMC4748560 DOI: 10.1186/s40337-016-0091-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 02/01/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND This study is part of a series of process evaluations within the MOSAIC Trial (Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions). This randomised controlled trial (RCT) compared two psychological treatments, the Maudsley Model for Treatment of Adults with Anorexia Nervosa (MANTRA) and Specialist Supportive Clinical Management (SSCM) for adult outpatients with Anorexia Nervosa. The present process study integrates quantitative (treatment acceptability and credibility) and qualitative (written) feedback to evaluate patients' treatment experiences. METHOD All 142 MOSAIC participants were asked to (a) rate treatment acceptability and credibility on visual analogue scales (VAS) at six and 12 months post-randomisation, and (b) provide written feedback regarding their views on their treatment at 12 months. Transcripts were first analysed thematically and then rated according to the global valence of feedback (positive, mixed/negative). RESULTS 114/142 (80.3 %) MOSAIC participants provided VAS data and 82 (57.7 %) provided written feedback. At 12 months, MANTRA patients gave significantly higher acceptability and credibility ratings compared to SSCM patients. A significantly higher proportion of MANTRA patients provided written feedback. MANTRA patients also tended to write in more detail and to give globally more positive feedback when compared to individuals receiving SSCM. Qualitative themes suggest that patients experienced the two treatments differently in terms of characteristics and outcomes. CONCLUSIONS This study highlights the benefits of incorporating qualitative and quantitative data into RCT process evaluations. MANTRA patients were more willing to express their views on treatment and generally felt more positively about this than those receiving SSCM.
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Affiliation(s)
- Kelly Ann Zainal
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Beth Renwick
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Alexandra Keyes
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Anna Lose
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Martha Kenyon
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Hannah DeJong
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Hannah Broadbent
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Lucy Serpell
- />Hope Wing, Porters Avenue Health Centre, North East London Foundation Trust, Dagenham, Essex UK
- />Eating Disorders Research Group, Research Dept. of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Lorna Richards
- />The Phoenix Wing, St Ann’s Hospital, Barnett, Enfield and Haringey Mental Health Trust, Tottenham, London, UK
| | - Eric Johnson-Sabine
- />The Phoenix Wing, St Ann’s Hospital, Barnett, Enfield and Haringey Mental Health Trust, Tottenham, London, UK
| | - Nicky Boughton
- />Oxford Adult Eating Disorder Service, Cotswold House, Warneford Hospital, Oxford NHS Foundation Trust, Oxford, UK
| | - Linette Whitehead
- />Oxford Adult Eating Disorder Service, Cotswold House, Warneford Hospital, Oxford NHS Foundation Trust, Oxford, UK
| | - Janet Treasure
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - Ulrike Schmidt
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
| | - on behalf of the MOSAIC trial group
- />Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, PO Box 59, SE5 8AF London, UK
- />Hope Wing, Porters Avenue Health Centre, North East London Foundation Trust, Dagenham, Essex UK
- />Eating Disorders Research Group, Research Dept. of Clinical, Educational & Health Psychology, University College London, London, UK
- />The Phoenix Wing, St Ann’s Hospital, Barnett, Enfield and Haringey Mental Health Trust, Tottenham, London, UK
- />Oxford Adult Eating Disorder Service, Cotswold House, Warneford Hospital, Oxford NHS Foundation Trust, Oxford, UK
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Hay PJ, Claudino AM, Touyz S, Abd Elbaky G. Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa. Cochrane Database Syst Rev 2015; 2015:CD003909. [PMID: 26212713 PMCID: PMC6491116 DOI: 10.1002/14651858.cd003909.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Anorexia nervosa is a disorder with high morbidity and significant mortality. It is most common in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting, and a number of differing psychological therapies are presently used in treatment. This is an update of a Cochrane review which was last published in 2008. OBJECTIVES To assess the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents treated in an outpatient setting. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group Specialised Register (CCDANCTR) (16 July 2014). This register includes relevant randomised controlled trials from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We screened reference lists of all included studies and sent letters to identified, notable researchers requesting information on unpublished or ongoing studies. SELECTION CRITERIA All randomised controlled trials of one or more individual outpatient psychological therapies for adults with anorexia nervosa, as defined by DSM-5 or similar international criteria. DATA COLLECTION AND ANALYSIS We selected a range of outcome variables, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons used the mean or standardised mean difference (MD or SMD), and binary outcome comparisons used the risk ratio (RR). Two review authors (PH and AC or ST) extracted data independently. MAIN RESULTS We identified 10 trials from the search, with a total of 599 anorexia nervosa participants, and included them in the review. Seven had been identified in the previous versions of this review and we now include three new trials. We now deem one previously identified ongoing trial to be ineligible, and six ongoing trials are new for this update. Two of the 10 trials included children. Trials tested diverse psychological therapies and comparability was poor. Risks of bias were mostly evident through lack of blinded outcome assessments (in 60% of studies) and incomplete data reporting (attrition bias).The results suggest that treatment as usual (TAU) when delivered by a non-eating-disorder specialist or similar may be less efficacious than focal psychodynamic therapy. This was suggested for a primary outcome of recovery by achievement of a good or intermediate outcome on the Morgan and Russell Scale (RR 0.70, 95% confidence interval (CI) 0.51 to 0.97; 1 RCT, 40 participants; very low-quality evidence). However there were no differences between cognitive analytic therapy and TAU for this outcome (RR 0.78, 95% CI 0.61 to 1.00; 2 RCTs, 71 participants; very low-quality evidence), nor for body mass index (BMI). There were no differences in overall dropout rates between individual psychological therapies and TAU.Two trials found a non-specific specialist therapy (Specialist Supportive Clinical Management) or an Optimised TAU delivered by therapists with eating disorder expertise was similar in outcomes to cognitive behaviour therapy (BMI MD -0.00, 95% CI -0.91 to 0.91; 197 participants, low-quality evidence). When comparing individual psychological therapies with each other, no specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial (35 participants). None of the trials identified any adverse effects. Insufficient power was problematic for the majority of trials. AUTHORS' CONCLUSIONS There was a suggestion in one trial that focal psychodynamic therapy might be superior to TAU, but this is in the context of TAU performing poorly. An alternative control condition of dietary advice alone appeared to be unacceptable, but again this is based on just one trial. Owing to the risk of bias and limitations of studies, notably small sample sizes, we can draw no specific conclusions about the effects of specific individual psychological therapies for anorexia nervosa in adults or older adolescents. Larger RCTs of longer treatment duration and follow-up are needed.
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Affiliation(s)
- Phillipa J Hay
- Western Sydney UniversityCentre for Health ResearchPenrithNew South WalesAustralia2751
- James Cook UniversityTownsvilleQueenslandAustralia
| | - Angélica M Claudino
- Federal University of São Paulo (UNIFESP)Department of Psychiatry and Psychological MedicineRua Borges Lagoa 570 conj. 71São PauloSão PauloBrazil04038‐000
| | - Stephen Touyz
- University of SydneySchool of Psychology and Boden Institute School of MedicineSydneyNSWAustralia2006
| | - Ghada Abd Elbaky
- Campbelltown Hospital, South Western Sydney Local Health DistrictDepartment of PsychiatryTherry RoadCampbelltownNSWAustralia2560
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18
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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.
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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
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19
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Gutiérrez E, Carrera O. Psychotherapy in anorexia nervosa: What does the absence of evidence mean? World J Transl Med 2014; 3:150-157. [DOI: 10.5528/wjtm.v3.i3.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/01/2014] [Accepted: 10/10/2014] [Indexed: 02/05/2023] Open
Abstract
Psychological treatment in anorexia nervosa (AN) is disheartening. Psychotherapy is the “treatment of choice” for adults though this recommendation is grounded on the absence of good quality clinical studies. This paper seeks to address the question of why improvements in the psychological treatment of AN have been thwarted, and why one of the best treatments available for adult patients is specialist supportive clinical management that has entered the stage through the backdoor of nonspecific supportive treatments originally serving as a placebo treatment assigned in randomized clinical trials to control for non-specific aspects of true psychosocial treatments. The possibility that most of the psychopathological features that characterise the AN symptoms profile could be best understood as the direct consequences of emaciation would enhance the utility of research with animal models for generating new hypothesis to improve AN treatment.
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20
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Dawson L, Rhodes P, Touyz S. "Doing the impossible": the process of recovery from chronic anorexia nervosa. QUALITATIVE HEALTH RESEARCH 2014; 24:494-505. [PMID: 24594747 DOI: 10.1177/1049732314524029] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In this study, we aimed to explore the process of recovery over time from the perspective of those who had fully recovered from chronic anorexia nervosa (AN), using stringent recovery criteria. Eight women, assessed as fully recovered from chronic AN, told their story of the process of recovery. Data were analyzed using the qualitative method, narrative inquiry. Recovery was identified as a long and complex process that spanned four phases: from being unable or unready to change, to experiencing a tipping point where motivation increased and changed in quality, allowing the women to take action against the AN and finally allowing them to reflect and rehabilitate. Results provide a framework for understanding this complex process. Findings suggest that full recovery from chronic AN is possible and emphasize the importance of hope, motivation, self-efficacy, and support from others in the recovery process.
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Affiliation(s)
- Lisa Dawson
- 1The University of Sydney, Sydney, New South Wales, Australia
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21
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Waterman-Collins D, Renwick B, Lose A, Kenyon M, Serpell L, Richards L, Boughton N, Treasure J, Schmidt U. Process Evaluation of the MOSAIC Trial, Part I: Therapist Experiences of Delivering Two Psychological Therapies for Treatment of Anorexia Nervosa. EUROPEAN EATING DISORDERS REVIEW 2014; 22:122-30. [DOI: 10.1002/erv.2278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 12/09/2013] [Accepted: 12/12/2013] [Indexed: 12/16/2022]
Affiliation(s)
- Daniella Waterman-Collins
- Section of Eating Disorders, Department of Psychological Medicine; Institute of Psychiatry, King's College London; London
| | - Beth Renwick
- Section of Eating Disorders, Department of Psychological Medicine; Institute of Psychiatry, King's College London; London
| | - Anna Lose
- Section of Eating Disorders, Department of Psychological Medicine; Institute of Psychiatry, King's College London; London
| | - Martha Kenyon
- Section of Eating Disorders, Department of Psychological Medicine; Institute of Psychiatry, King's College London; London
| | - Lucy Serpell
- Hope Wing, Porters Avenue Health Centre, North East London Foundation Trust; Dagenham Essex UK
- Eating Disorders Research Group, Research Dept. of Clinical, Educational & Health Psychology; University College London; London
| | - Lorna Richards
- The Phoenix Wing, St Ann's Hospital, Barnett, Enfield and Haringey Mental Health Trust; Tottenham London
| | - Nicky Boughton
- Oxford Adult Eating Disorder Service, Cotswold House, Warneford Hospital, Oxford NHS Foundation Trust; Oxford UK
| | - Janet Treasure
- Section of Eating Disorders, Department of Psychological Medicine; Institute of Psychiatry, King's College London; London
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine; Institute of Psychiatry, King's College London; London
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Schmidt U, Wade TD, Treasure J. The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA): Development, Key Features, and Preliminary Evidence. J Cogn Psychother 2014; 28:48-71. [PMID: 32759130 DOI: 10.1891/0889-8391.28.1.48] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anorexia nervosa (AN) is a severe mental disorder that affects mainly young females. In adults with a well-established form of the illness, it is hard to treat. In 2006, we proposed a maintenance model of AN, combining intra- and interpersonal factors and we have recently refined this model. The model encompasses four main maintaining factors (a thinking style characterized by rigidity, detail focus, and a fear of making mistakes; an avoidant emotion processing and relational style; positive beliefs about the use of anorexia for the person [pro-anorexia beliefs]; and a response of close others to the illness characterized by high expressed emotion and enabling of and accommodation to the illness). In this article, we describe how the model has been translated into a novel treatment for AN and the preliminary evidence supporting this. Implications for clinical practice and research are discussed.
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Affiliation(s)
- Ulrike Schmidt
- Department of Psychological Medicine, Institute of Psychiatry, King's College London, London
| | - Tracey D Wade
- School of Psychology, Flinders University, Australia
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, King's College London, London
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Abstract
BACKGROUND Treatment resistance is an omnipresent frustration in eating disorders. Attempts to identify the features of this resistance and subsequently develop novel treatments have had modest effects. This selective review examines treatment resistant features expressed in core eating disorder psychopathology, comorbidities and biological features. Novel treatments addressing resistance are discussed. DESCRIPTION The core eating disorder psychopathology of anorexia nervosa becomes a coping mechanism likely via vulnerable neurobiological features and conditioned learning to deal with life events. Thus it is reinforcing and ego syntonic resulting in resistance to treatment. The severity of core features such as preoccupations with body image, weight, eating and exercising predicts greater resistance to treatment. Bulimia nervosa patients are less resistant to treatment with treatment failure related to greater body image concerns, impulsivity, depression, severe diet restriction and poor social adjustment. For those with binge eating disorder overweight in childhood and high emotional eating predicts treatment resistance. There is suggestive data that a diagnosis of an anxiety disorder and severe perfectionism may confer treatment resistance in anorexia nervosa and substance use disorders or personality disorders with impulse control problems may produce resistance to treatment in bulimia nervosa. Traits such as perfectionism, cognitive inflexibility and negative affect with likely genetic influences may also affect treatment resistance. Pharmacotherapy and novel therapies have been developed to address treatment resistance. Atypical antipsychotic drugs have shown some effect in treatment resistant anorexia nervosa and topiramate and high doses of SSRIs are helpful for treatment of resistant binge eating disorder patients. There are insufficient randomized controlled trials to evaluate the novel psychotherapies which are primarily based on the core psychopathological features of the eating disorders. CONCLUSION Treatment resistance in eating disorders is usually predicted by the severity of the core eating disorder psychopathology which develops from an interaction between environmental risk factors with genetic traits and a vulnerable neurobiology. Future investigations of the biological features and neurocircuitry of the core eating disorders psychopathology and behaviors may provide information for more successful treatment interventions.
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Affiliation(s)
- Katherine A Halmi
- New York Presbyterian Hospital, Westchester Division, 21 Bloomingdale Rd, Whites Plains, NY 10605, USA.
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Schmidt U, Renwick B, Lose A, Kenyon M, DeJong H, Broadbent H, Loomes R, Watson C, Ghelani S, Serpell L, Richards L, Johnson-Sabine E, Boughton N, Whitehead L, Beecham J, Treasure J, Landau S. The MOSAIC study - comparison of the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: study protocol for a randomized controlled trial. Trials 2013; 14:160. [PMID: 23721562 PMCID: PMC3679869 DOI: 10.1186/1745-6215-14-160] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 05/14/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anorexia nervosa (AN) is a biologically based serious mental disorder with high levels of mortality and disability, physical and psychological morbidity and impaired quality of life. AN is one of the leading causes of disease burden in terms of years of life lost through death or disability in young women. Psychotherapeutic interventions are the treatment of choice for AN, but the results of psychotherapy depend critically on the stage of the illness. The treatment response in adults with a chronic form of the illness is poor and drop-out from treatment is high. Despite the seriousness of the disorder the evidence-base for psychological treatment of adults with AN is extremely limited and there is no leading treatment. There is therefore an urgent need to develop more effective treatments for adults with AN. The aim of the Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC) is to evaluate the efficacy and cost effectiveness of two outpatient treatments for adults with AN, Specialist Supportive Clinical Management (SSCM) and the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA). METHODS/DESIGN 138 patients meeting the inclusion criteria are randomly assigned to one of the two treatment groups (MANTRA or SSCM). All participants receive 20 once-weekly individual therapy sessions (with 10 extra weekly sessions for those who are severely ill) and four follow-up sessions with monthly spacing thereafter. There is also optional access to a dietician and extra sessions involving a family member or a close other. Body weight, eating disorder- related symptoms, neurocognitive and psychosocial measures, and service use data are measured during the course of treatment and across a one year follow up period. The primary outcome measure is body mass index (BMI) taken at twelve months after randomization. DISCUSSION This multi-center study provides a large sample size, broad inclusion criteria and a follow-up period. However, the study has to contend with difficulties directly related to running a large multi-center randomized controlled trial and the psychopathology of AN. These issues are discussed.
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Affiliation(s)
- Ulrike Schmidt
- PO59, Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Beth Renwick
- PO59, Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Anna Lose
- PO59, Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Martha Kenyon
- PO59, Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Hannah DeJong
- PO59, Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Hannah Broadbent
- PO59, Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Rachel Loomes
- Oxford Adult Eating Disorder Service, Cotswold House, Warneford Hospital, Oxford, UK
| | | | | | - Lucy Serpell
- Hope Wing, Porters Avenue Health Centre, Dagenham, Essex, UK
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Lorna Richards
- The Phoenix Wing, St Ann’s Hospital, Tottenham, London, UK
| | | | - Nicky Boughton
- Oxford Adult Eating Disorder Service, Cotswold House, Warneford Hospital, Oxford, UK
| | - Linette Whitehead
- Oxford Adult Eating Disorder Service, Cotswold House, Warneford Hospital, Oxford, UK
| | - Jennifer Beecham
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
- Personal Social Services Research Unit, University of Kent, Canterbury, UK
| | - Janet Treasure
- PO59, Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK
| | - Sabine Landau
- Department of Biostatistics, Institute of Psychiatry, Kings College London, London, UK
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Treasure J, Schmidt U. The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. J Eat Disord 2013; 1:13. [PMID: 24999394 PMCID: PMC4081714 DOI: 10.1186/2050-2974-1-13] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 02/03/2013] [Indexed: 12/12/2022] Open
Abstract
AIM To describe the evidence base relating to the Cognitive-Interpersonal Maintenance Model for anorexia nervosa (AN). BACKGROUND A Cognitive-Interpersonal Maintenance Model maintenance model for anorexia nervosa was described in 2006. This model proposed that cognitive, socio-emotional and interpersonal elements acted together to both cause and maintain eating disorders. METHOD A review of the empirical literature relating to the key constructs of the model (cognitive, socio-emotional, interpersonal) risk and maintaining factors for anorexia nervosa was conducted. RESULTS Set shifting and weak central coherence (associated with obsessive compulsive traits) have been widely studied. There is some evidence to suggest that a strong eye for detail and weak set shifting are inherited vulnerabilities to AN. Set shifting and global integration are impaired in the ill state and contribute to weak central coherence. In addition, there are wide-ranging impairments in socio-emotional processing including: an automatic bias in attention towards critical and domineering faces and away from compassionate faces; impaired signalling of, interpretation and regulation of emotions. Difficulties in social cognition may in part be a consequence of starvation but inherited vulnerabilities may also contribute to these traits. The shared familial traits may accentuate family members' tendency to react to the frustrating and frightening symptoms of AN with high expressed emotion (criticism, hostility, overprotection), and inadvertently perpetuate the problem. CONCLUSION The cognitive interpersonal model is supported by accumulating evidence. The model is complex in that cognitive and socio-emotional factors both predispose to the illness and are exaggerated in the ill state. Furthermore, some of the traits are inherited vulnerabilities and are present in family members. The clinical formulations from the model are described as are new possibilities for targeted treatment.
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Affiliation(s)
- Janet Treasure
- Department of Psychological Medicine, King’s College London, Institute of Psychiatry, The Basement, P059, 103 Denmark Hill, London, SE5 8AF, UK
| | - Ulrike Schmidt
- Department of Psychological Medicine, King’s College London, Institute of Psychiatry, The Basement, P059, 103 Denmark Hill, London, SE5 8AF, UK
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Wildes JE, Marcus MD, Bright AC, Dapelo MM, Psychol MC. Emotion and eating disorder symptoms in patients with anorexia nervosa: an experimental study. Int J Eat Disord 2012; 45:876-82. [PMID: 22473650 PMCID: PMC3393827 DOI: 10.1002/eat.22020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the effect of negative emotion on self-reported eating disorder symptoms and objectively-measured eating behavior in patients with anorexia nervosa (AN). METHOD Twenty-eight females with AN were randomized to a negative or neutral mood induction followed by a test meal. Participants completed assessments one week before the experimental session, before (pretest) and after (posttest) the mood induction, and after the test meal. RESULTS Participants in the negative emotion condition had an increase in negative affect from pretest to posttest that was accompanied by significantly greater increases in self-reported eating disorder symptoms than were exhibited by participants in the neutral emotion condition, who had no increase in negative affect. There was no effect of emotion condition on eating behavior. DISCUSSION Results suggest that negative emotions influence the expression of cognitive eating disorder symptoms in individuals with AN, which may have implications for the identification of treatment targets.
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Affiliation(s)
- Jennifer E. Wildes
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Marsha D. Marcus
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ashley C. Bright
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Marcela Marin Dapelo
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA
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Calugi S, Dalle Grave R, Marchesini G. Longstanding underweight eating disorder: associated features and treatment outcome. Psychother Res 2012; 23:315-23. [PMID: 22921017 DOI: 10.1080/10503307.2012.717308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The clinical features and the response to inpatient cognitive-behavior treatment (I-CBT) of underweight individuals with either longstanding or more recent-onset eating disorder have rarely been compared. We compared the psychopathological profile and the response to I-CBT of 37 female patients with longstanding eating disorder (≥10 years, L-ED) and 58 with shorter disease duration. Individuals with L-ED had higher age, baseline BMI, higher frequency of self-induced vomiting, laxative and diuretic misuse, but not different personality traits at baseline and not different psychopathological changes, outcome, and dropout rates in response to I-CBT. This study provides preliminary evidence that I-CBT may be useful to treat L-ED and improve their eating disorder psychopathology.
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Affiliation(s)
- Simona Calugi
- Department of Eating Disorder and Obesity, Verona, Italy.
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