Experiential acceptance, motivation for recovery, and treatment outcome in eating disorders

A systematic review and meta-analysis of intensive treatment options for adults with eating disorders

Eating disorders (EDs) are complex conditions with one of the highest mortality rates among psychiatric illnesses. While outpatient evidence-based treatments for EDs in adults exist, there is often utilisation of more intensive interventions as part of treatment. However, a comprehensive analysis of the impacts of intensive treatment (inpatient, residential and day program) on physical and psychosocial outcomes is lacking. Thus, the current systematic review and meta-analysis aimed to investigate the effectiveness of intensive treatments in adults with EDs for the outcomes of body mass index (BMI), disordered eating, depression, and quality of life, as well as a moderation analysis investigating a range of clinical characteristics. Overall, 62 studies were included in the meta-analysis. The results revealed that intensive treatment in adults yielded significant improvements in BMI (for underweight patients), disordered eating, depression, and quality of life. Treatment setting, length of stay and geographical region of the study all served as moderators for disordered eating and depression. Nevertheless, given the high heterogeneity in the meta- and moderation analyses, these results should be interpreted with caution. Future high-quality research is needed to determine the most beneficial elements of intensive treatment (compared to outpatient) in adults with EDs.

Musicokinetic and exercise therapies decrease the depression level of elderly patients undergoing post-stroke rehabilitation: The moderating effect of health regulatory focus

This study aims to investigate the impact of musicokinetic and exercise therapies on the depression level of elderly patients undergoing post-stroke rehabilitation and its possible moderators, the promotion focus (i.e., achieve gains) and prevention focus (i.e., avoid losses or non-gains), which are the two motivational orientations of health regulatory focus. An eight-week randomized controlled trial was employed. Sixty-five elderly patients undergoing post-stroke rehabilitation in a hospital in Shanghai, China. Patients were randomly assigned to the musicokinetic (n = 32) therapy group or the exercise (n = 33) therapy group. The Mini-mental State Examination Scale measuring the patients’ cognitive functions was used to screen participants. The Hamilton Depression Rating Scale and the Health Regulatory Focus Scale were applied to assess their levels of depression and health regulatory focus on weeks 0, 4, and 8, respectively. The musicokinetic therapy had a significantly better effect than the exercise therapy for individuals who had a lower level of prevention focus, whereas the exercise therapy had a significantly better effect than the musicokinetic therapy for individuals who had a higher level of prevention focus. Musicokinetic therapy and exercise therapy were both effective in decreasing post-stroke depression for elderly patients. But it is important to choose an appropriate type of therapy per the health regulatory focus of elderly patients with post-stroke rehabilitation.

Does Training Motivation Influence Resilience Training Outcome on Chronic Stress? Results from an Interventional Study

Resilience is understood as an acquired skill which aids in coping with acute and chronic stress. Accordingly, the present study aimed to determine the effect of resilience training on mental health problems during chronic stress. To this end, we conducted a quasi-experimental study with 127 male cadets (mean age: 21 years) of the Swiss Armed Forces officers' school. Whereas the intervention group (IG) received resilience training in addition to the standard officer's education program, the control group (CG) completed the officers' school as usual. Data assessment included pre- and post- measurement of chronic stress, symptoms of depression, and vital exhaustion in both groups. Motivation for training was collected before the first training session. Those who received the resilience training reported no change in chronic stress, whereas participants in the CG showed a significant increase in chronic stress over time (η_p² = 0.025). Furthermore, significant differences between IG and CG were only found for symptoms of depression: Participants in the IG reported significantly decreased symptoms of depression, while this was not the case for participants in the CG. Within the IG, participants' training motivation strongly influenced the effectiveness of the resilience training. More specifically, motivated individuals were more likely to benefit from the resilience training than unmotivated ones. Outcome data suggest that resilience training appeared to favorably affect chronic stress and related mental health symptoms; however, the motivation for the training seemed to be an essential prerequisite.

Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis

OBJECTIVE

Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders.

METHOD

A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns.

RESULTS

41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN.

CONCLUSIONS

Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.

COVID-19 and eating disorder and mental health concerns in patients with eating disorders

BACKGROUND

The Coronavirus (COVID-19) pandemic dramatically transformed daily life for adolescents and young adults, altering social and physical environments. Previous research has shown such shifts in daily life to be especially challenging for people living with eating disorders (ED). However, the extent of this environmental change on ED symptoms and mental health (MH) has been relatively unexplored in patients with EDs. This study examines how young people with EDs feel the COVID-19 pandemic has affected their living environments as well as their ED and MH symptoms and motivation for ED recovery.

METHODS

Participants were enrollees in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) who responded to an additional survey (n = 89) in July 2020 to assess their perceptions of the impact of the COVID-19 pandemic. Participants reported on concerns of their ED worsening due to increased time living in a "triggering environment" due to the pandemic as well as perceived COVID-related changes in intrusive ED thoughts, depression, anxiety, isolation, and motivation to recover. Logistic regression models, adjusted for age and ED diagnosis, examined the association of triggering environment with ED and MH symptoms.

RESULTS

The majority of respondents reported concern for worsening of their ED due to a "triggering environment" (63%). Most reported an increase in ED thoughts (74%), feelings of anxiety (77%), depression (73%), and isolation (80%) they perceived to be related to the pandemic. Nearly one-third reported decrease in motivation to recover (29%) they perceived to be related to the pandemic. After adjusting for age and ED diagnosis, participants who reported concern for worsening of their ED due to a triggering environment had nearly 18 times the odds of decreased motivation to recover (OR 18.1; 95% CI 3.37-97.4, p = 0.003) and nearly 24 times the odds of increased ED thoughts (OR 23.8; 95% CI 4.31-131.6, p < 0.001) compared to those who did not report concern for worsening of their ED due to a triggering environment.

CONCLUSIONS

Our findings demonstrate the perceived negative impact the COVID-19 pandemic has had on the self-reported ED and MH symptoms in patients with EDs, particularly in those who report concern for a negative environmental change. These results underscore the need for heightened monitoring of patients with EDs during the pandemic.

Motivation to recover for adolescent and adult eating disorder patients in residential treatment

OBJECTIVE

This study aimed to assess how baseline motivation to recover impacts eating disorder (ED) and comorbid symptoms at end-of-treatment (EOT) for adolescents and adults in inpatient/residential treatment.

METHOD

Two hundred and three adolescent (M = 15.90) and 395 adult (M = 25.45) patients with a Diagnostic Statistical Manual, 5th edition ED diagnosis completed the Decisional Balance Scale (DBS) at baseline, and psychosocial measures (ED symptoms, anxiety, depression, obsessive-compulsive disorder symptoms), and %body mass index (kg/m² ; BMI) or median %BMI (for adolescents) at baseline and EOT.

RESULTS

The DBS Avoidance Coping and Burdens subscales at baseline were significantly lower for adolescents than adults (p < 0.001), whereas the DBS Benefits subscale at baseline did not significantly differ between subsamples (p = 0.06). Motivation to recover via DBS subscales was a more reliable predictor of EOT outcomes for both ED and comorbid psychopathology in adults (significant predictor in 19 of 54 total analyses, and 4 significant associations post-Bonferroni correction) than adolescents (significant predictor in 5 of 54 total analyses, and 1 significant association post-Bonferroni correction).

CONCLUSIONS

Baseline motivation to recover may be an important predictor of outcome for adult patients in inpatient/residential treatment but does not appear associated with outcomes for adolescent patients.

Pretreatment motivation and therapy outcomes in eating disorders: A systematic review and meta-analysis

OBJECTIVE

Identifying modifiable predictors of outcomes following treatment for eating disorders may help to tailor interventions to patients' individual needs, improve treatment efficacy, and develop new interventions. The goal of this meta-analysis was to quantify the association between pretreatment motivation and posttreatment changes in eating disorder symptomology.

METHOD

We reviewed 196 longitudinal studies reporting on change on indices of overall eating-disorder symptomatology, weight gain, binge-eating, vomiting, anxiety/depression, and treatment adherence. Meta-analyses were performed using two complementary approaches: (a) combined probability analysis using the added Z's method; (b) effect size analyses. Using random-effect models, effect sizes were pooled when there were at least three studies with the same type of statistical design and reporting statistics on the same outcome. Heterogeneity in study outcome was evaluated using Q and I² statistics. Studies were reviewed qualitatively when the number of studies or reported data were insufficient to perform a meta-analysis.

RESULTS

Forty-two articles were included. Although samples and treatments differed substantially across studies, results across studies were remarkably consistent. Both combined-probability and effect-size analyses indicated positive effects of pretreatment motivation on improvement in general eating-disorder symptoms (Cohen's r = .17), and an absence of effects on anxiety/depression symptoms. Remaining outcome indices were subject to selective reporting and/or small sample size bias.

DISCUSSION

Our findings underscore the importance of incorporating treatment engagement approaches in the treatment of eating disorders. Optimal reporting of study findings and improving study quality would improve future efforts to obtain an in-depth understanding of the relationship between motivation and eating disorder symptoms.

Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research

Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.

Avoidance coping during mealtimes predicts higher eating disorder symptoms

OBJECTIVE

Eating disorders (EDs) are characterized by significant anxiety during mealtime that contributes to food avoidance and weight loss. Individuals with EDs commonly use avoidance coping (e.g., distraction) to tolerate meals and comply with meal plans. Although this strategy may be effective short term, a large body of anxiety literature suggests that avoidance can lead to worsening of psychological symptoms long term.

METHOD

The current study (N = 66 individuals diagnosed with ED) used ecological momentary assessment (EMA) to examine the short-term and long-term associations of avoidance coping on ED symptoms.

RESULTS

Distraction during meals predicted a reduction in anxiety in the short term, and both distraction and avoidance of emotions predicted increases in excessive exercise in the short term. Distraction and avoidance of emotions predicted increases in bulimic symptoms 1 month after completion of EMA.

DISCUSSION

These results are consistent with prior literature on avoidance and suggest that avoidance coping during meals may contribute to the increase of ED behaviors in the long term. Coping strategies that encourage approach and tolerance of difficult thoughts and emotions (e.g., acceptance-based strategies) rather that avoidance coping may promote longer-term symptom reduction.

A systematic review of outcomes following residential treatment for eating disorders

OBJECTIVE

Residential centres for the treatment of eating disorders are becoming increasingly common, yet data following residential care are scarce. We reviewed outcomes of residential treatment for eating disorders across all diagnoses, age groups and genders. A secondary goal was to identify treatment elements and patient characteristics that predicted a greater response to treatment.

METHOD

Peer-reviewed studies published in the last 20 years were identified through a systematic search of the electronic databases PubMed and Cochrane Library.

RESULTS

Nineteen open-label studies reporting changes between admission and discharge were included in this review. Most took an eclectic approach to treatment, integrating elements from several different techniques without a unifying theoretical framework. All studies reported improvements in most outcomes at discharge, including changes in eating disorders psychopathology, weight, depression, anxiety and quality of life. Eight studies reported outcomes at some interval after discharge, with largely positive outcomes.

CONCLUSIONS

While residential care was associated with consistently positive outcomes, the variability in program characteristics and poor quality of research designs prevent firm conclusions from being drawn about their efficacy. Future research should include controlled studies that evaluate specific theoretical approaches and program elements, include long-term follow-up, and compare residential care to other treatment settings.

Acceptance and commitment therapy to reduce eating disorder symptoms and body image problems in patients with residual eating disorder symptoms: A randomized controlled trial

Body image problems are central aspects of eating disorders (ED), and risk factors both for the development of and relapse into an ED. Acceptance and commitment therapy (ACT) aims at helping patients accept uncomfortable internal experiences while committing to behaviors in accordance with life values. The aim of the present study was to compare the effectiveness of a group intervention, consisting of 12 sessions, based on ACT to treatment as usual (TAU) for patients with residual ED symptoms and body image problems. The study was a randomized controlled superiority trial. Patients with residual ED symptoms and body image problems were recruited from a specialized ED clinic in Sweden. The final sample consisted of 99 women, randomized to ACT or TAU. At the two-year follow-up, patients who received ACT showed a significant greater reduction in ED symptoms and body image problems and received less specialized ED care than patients in TAU. In conclusion, ACT was superior in reducing ED symptoms and body image problems.

Dysfunctional eating behaviors, anxiety, and depression in Italian boys and girls: the role of mass media

Objective:

Extensive research has implicated identification with characters in mass media in the emergence of disordered eating behavior in adolescents. We explored the possible influence of the models offered by television (TV) on adolescents’ body image, body uneasiness, eating-disordered behavior, depression, and anxiety.

Methods:

Three hundred and one adolescents (aged 14-19) from southern Italy participated. They completed a questionnaire on media exposure and body dissatisfaction, the Eating Disorder Inventory-2, the Body Uneasiness Test, the Beck Depression Inventory, and the State-Trait Anxiety Inventory – Form Y.

Results:

The main factors contributing to females’ eating-disordered behaviors were their own desires to be similar to TV characters, the amount of reality and entertainment TV they watched, and the discrepancy between their perceptions of their bodies and those of TV characters. Friends’ desire to be similar to TV characters contributed most to depression, anxiety, body uneasiness, and eating disorders for both males and females.

Conclusion:

Our data confirm that extensive watching of reality and entertainment TV correlates with eating-disordered behavior among females. Moreover, the well-known negative effects of the media on adolescents’ eating-disordered behaviors may also be indirectly transmitted by friends who share identification with TV characters.

Nourishing the Spirit: Exploratory Research on Ayahuasca Experiences along the Continuum of Recovery from Eating Disorders

Eating disorders (EDs) are serious health conditions that are among the most difficult to treat. Innovative treatments are needed and modalities from across cultures must be considered. Ayahuasca is a psychoactive plant-based tea originally used by Amazonian indigenous groups. A growing body of research points to its promise in the healing of various mental health issues. This study explored the potential therapeutic value of ayahuasca in the context of EDs, including the perceived impact of the preparatory diet and the ayahuasca purge. Sixteen individuals previously diagnosed with an ED participated in a semi-structured interview relating to their experiences with ceremonial ayahuasca drinking. Interviews were analyzed using thematic analysis. Themes presented relate to the reduction or cessation of ED and mental health symptoms, shifts in body perception, and the importance of a ceremonial setting and after-care. For some, the preparatory diet resulted in familiar patterns of concern; however, none felt triggered by the purge in ayahuasca. Ceremonial ayahuasca drinking shows promise in the healing of EDs and warrants further research.

Depression, worry, and psychosocial functioning predict eating disorder treatment outcomes in a residential and partial hospitalization setting

This retrospective study explores depression, worry, psychosocial functioning, and change in body mass index (BMI) as predictors of eating disorder (ED) symptomatology and BMI at discharge and 1-year follow-up from a residential and partial hospitalization ED treatment center. Participants were 423 male and female patients receiving treatment at an ED treatment center. Results indicate significant improvement in ED symptomatology, psychological impairment, and change in BMI (in patients with anorexia nervosa) at treatment discharge and follow-up compared to treatment admission (ps < 0.001). Depression and worry predicted ED symptomatology and psychological impairment at discharge (ps < 0.05). Depression, worry, and psychosocial functioning predicted ED symptomatology and psychological impairment at 1-year follow-up (ps < 0.001). Change in BMI was not a significant predictor of outcome. Depression, worry, and psychosocial functioning each play a role in treatment outcomes and may help clarify who might benefit from treatment. Clinicians in ED treatment centers should consider these as areas of focus for improved outcomes.

The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives

BACKGROUND

Evidence-based practice in eating disorders incorporates three essential components: research evidence, clinical expertise, and patient values, preferences, and characteristics. Conceptualized as a 'three-legged stool' by Sackett et al. in 1996 (BMJ), all of these components of evidence-based practice are considered essential for providing optimal care in the treatment of eating disorders. However, the extent to which these individual aspects of evidence-based practice are valued among clinicians and researchers is variable, with each of these stool 'legs' being neglected at times. As a result, empirical support and patient preferences for treatment are not consistently considered in the selection and implementation of eating disorder treatment. In addition, clinicians may not have access to training to provide treatments supported by research and preferred by patients. Despite these challenges, integrating these three components of evidence-based practice is critical for the effective treatment of eating disorders.

DISCUSSION

Current research supports the use of several types of psychotherapies, including cognitive-behavioral, interpersonal, and family-based therapies, as well as certain types of medications for the treatment of eating disorders. However, limitations in current research, including sample heterogeneity, inconsistent efficacy, a paucity of data, the need for tailored approaches, and the use of staging models highlight the need for clinical expertise. Although preliminary data also support the importance of patient preferences, values, and perspectives for optimizing treatment, enhancing treatment outcome, and minimizing attrition among patients with eating disorders, the extent to which patient preference is consistently predictive of outcome is less clear and requires further investigation. All three components of evidence-based practice are integral for the optimal treatment of eating disorders. Integrating clinical expertise and patient perspective may also facilitate the dissemination of empirically-supported and emerging treatments as well as prevention programs. Further research is imperative to identify ways in which this three-legged approach to eating disorder treatment could be most effectively implemented.

A qualitative analysis of participants' reflections on body image during participation in a randomized controlled trial of acceptance and commitment therapy

BACKGROUND

Negative body image is a risk factor for development and relapse in eating disorders (ED). Many patients continue to be dissatisfied with their body shape or weight after treatment. This study presents a qualitative analysis of written reflections on body image from patients with an ED and a negative body image before and after an Acceptance and Commitment Therapy group treatment at a specialized ED-unit.

METHOD

Before and after the treatment participants (n = 47) answered a questionnaire with open ended questions on their thoughts on body image. Data were analyzed through conventional content analysis.

RESULTS

Body image meant different things for different participants. For some it had to do with how you evaluate your body, whereas others focused on whether their body image was realistic or not. Some emphasized their relationship with their body, while some described body image as strongly related to global self-esteem. These different views on the concept of body image affected the participants' descriptions of their own body image, and how they wanted it to change. Body image was considered a state that fluctuated from day to day. After treatment the participants described changes in their body image, for instance perceiving oneself as less judgmental towards one's body, and a shift in focus to the important things in life.

CONCLUSIONS

The participants had different views on body image and how they wished it to change. Thus treatment interventions targeting negative body image needs to address various aspects of this complex construct.

TRIAL REGISTRATION

This study is part of an RCT registered 02/06/2014 in Clinical Trials, registration number: NCT02058121.

Factors impacting treatment and recovery in Anorexia Nervosa: qualitative findings from an online questionnaire

BACKGROUND

Anorexia nervosa (AN) is characterised by restriction of energy intake, fear of gaining weight and severe disturbances in weight or shape. Recovery from AN is a complicated and often multifaceted experience that can take many years to achieve. Qualitative research has found that support, being understood, hope, desire for recovery, positive experiences in treatment, self-efficacy, motivation and relationships are important in recovery from AN. The experience of treatment for patients with an eating disorder is an important aspect of recovery with the potential to enhance recovery or hinder it. The aim of the questionnaire was to better understand factors impacting the care experiences during treatment and or recovery from self-reported Anorexia Nervosa (AN).

METHOD

An online questionnaire was developed and administered to past or current sufferers of Anorexia Nervosa, ≥18 years of age. Participants were recruited through eating disorder organisations both in Australia and the United Kingdom. The questionnaire was a mixture of quantitative and qualitative questions. The quantitative data was analysed using descriptive statistics and the qualitative data was analysed using conventional content analysis (CCA).

RESULTS

Of those who responded, most currently experienced self-reported AN. The quantitative results identified that most participants had trust and confidence in their health care provider and felt listened to and supported yet on the subject of the suitability of treatment this had varied opinions. Being understood, hope (life after AN) and self-acceptance were considered the top three important factors in the treatment and recovery from Anorexia Nervosa. The qualitative results revealed the factors hindering or benefiting treatment and recovery, and individuals' needs during the four phases of recovery.

CONCLUSION

Factors were identified that could either hinder or benefit treatment and recovery and these included whether treatment supported the individual to cope with change, whether the individual found the treatment to be appropriate for their personal needs and whether treatment addressed underlying factors. Individuals' needs differed during the four phases of recovery. The findings of the study may help treatment providers address key factors involved in recovery at the right stage of treatment however by the nature of the qualitative methodology conclusions are putative and further definitive research is indicated.