Meal support using mobile technology in Anorexia Nervosa. Contextual differences between inpatient and outpatient settings

Every mistake is a treasure: Lessons learned from the TRIANGLE trial for anorexia nervosa

BACKGROUND

Despite several decades of treatment research for anorexia nervosa (AN), many of the same questions remain: how to boost enrollment, engage participants, prevent attrition, and meet the needs of a diverse patient population within the rigorous framework of a randomized controlled trial (RCT).

METHODS

In this research forum, we highlight some of the challenges and opportunities observed over the course of TRIANGLE, the largest RCT for severe AN treatment in the UK to date. We discuss strategies for addressing common challenges and avoiding common pitfalls and propose solutions to future researchers seeking to conduct treatment research in AN.

RESULTS

Our experience underscores the value of involving people with lived experience at every stage of intervention research. We offer additional recommendations for treatment researchers, including, (1) early qualitative research to identify patient barriers and obstacles, (2) clear, systematic collaboration with clinical sites for patient recruitment and passive data collection, (3) careful consideration of assessment metrics, including repeated measurement of quality of life, (4) adopting a flexible, patient-centered approach to clinical trial research, and (5) considering the unique needs and obstacles that might impact carer participation in research and their ability to provide support to their loved ones.

DISCUSSION

We hope that these lessons learned will prove fruitful for the next generation of researchers embarking on treatment research for AN.

PUBLIC SIGNIFICANCE

Using the TRIANGLE trial as an illustrative case study, we highlight the value of lived experience and codesign for developing and testing interventions for AN. We offer several lessons learned over the course of the trial, pertaining to trial enrollment, retention and engagement, measurement of outcomes, and research adaptations for real-world settings, and hope that these recommendations facilitate future treatment research for AN.

Visual art- and music-based interventions as adjuvants in the treatment of eating disorders: a systematic review and a theoretical model

AIM

To assess the effect of visual art- and music-based interventions in the treatment of eating disorders.

METHODS

This study was registered in PROSPERO (CRD42020161503). Six databases (CINAHL, EMBASE, Lilacs, PsycINFO, PubMed and The Cochrane Library) were consulted. The searches were performed on 19 June 2019, and updated on 18 March 2022. No restriction on language, date, or publication status was applied. Methodological quality was assessed using Joanna Briggs Institute's instruments. All steps were performed by two independent reviewers and a third participated in the event of disagreement.

RESULTS

Eight studies were included. Few statistically significant results were found. Overall, both interventions might help to reduce negative emotional states.

CONCLUSION

Visual art- and music-based interventions present limited and inconclusive scientific evidence in patients with eating disorders and therefore their effectiveness is currently unknown. A theoretical model is proposed to guide future research. Further studies are needed to clarify their clinical relevance.

Virtual food exposure with positive mood induction or social support to reduce food anxiety in anorexia nervosa: A feasibility study

OBJECTIVE

Aversive emotions toward food and the consequences of eating are at the core of anorexia nervosa. Exposure therapy is effective to reduce anxiety and avoidance toward feared stimuli. Based on the inhibitory learning framework, this study examined the feasibility to induce social support or positive mood to enhance the impact of a single session virtual food exposure on food-related anxiety in anorexia nervosa.

METHOD

One hundred and forty-five patients were randomized to: (1) virtual food exposure (i.e., baseline condition), (2) virtual food exposure plus positive mood induction (i.e., positive mood condition), or (3) virtual food exposure plus social support (i.e., social support condition). They completed self-report assessments of anxiety toward virtual foods, general anxiety, positive mood, social support, and hunger, before and after virtual food exposure. Number of eye gazes and touches toward foods were recorded during the virtual reality exposure.

RESULTS

Patients had lower levels of anxiety toward virtual foods in the positive mood condition, compared to the baseline condition [F(2,141)  = 4.36, p = .015; medium effect size]. They also touched food items more often in the baseline condition. No other significant changes were found.

DISCUSSION

Virtual food exposure enhanced by positive mood induction seems a feasible approach to strengthen the impact of food exposure in anorexia nervosa.

PUBLIC SIGNIFICANCE

This research contributes to the understanding of how patients with anorexia nervosa can be supported to overcome fear and anxiety around food. Virtual reality enables patients to expose themselves to difficult situations (e.g., kitchen with foods of various calorie contents) while experiencing positive stimuli, such as a loving and kind pet or a supportive avatar.

Feasibility, Adherence, and Effectiveness of Blended Psychotherapy for Severe Mental Illnesses: Scoping Review

BACKGROUND

Blended psychotherapy (bPT) combines face-to-face psychotherapy with digital interventions to enhance the effectiveness of mental health treatment. The feasibility and effectiveness of bPT have been demonstrated for various mental health issues, although primarily for patients with higher levels of functioning.

OBJECTIVE

This scoping review aims to investigate the feasibility, adherence, and effectiveness of bPT for the treatment of patients with severe mental illnesses (SMIs).

METHODS

Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, we conducted searches in PubMed, MEDLINE, Embase, PsycINFO, and PsycArticles for studies published until March 23, 2023.

RESULTS

Out of 587 screened papers, we incorporated 25 studies encompassing 23 bPT interventions, involving a total of 2554 patients with SMI. The intervention formats and research designs exhibited significant variation. Our findings offer preliminary evidence supporting the feasibility of bPT for SMI, although there is limited research on adherence. Nevertheless, the summarized studies indicated promising attrition rates, spanning from 0% to 37%, implying a potential beneficial impact of bPT on adherence to SMI treatment. The quantity of evidence on the effects of bPT for SMI was limited and challenging to generalize. Among the 15 controlled trials, 4 concluded that bPT interventions were effective compared with controls. However, it is noteworthy that 2 of these studies used the same study population, and the control groups exhibited significant variations.

CONCLUSIONS

Overall, our review suggests that while bPT appears promising as a treatment method, further research is necessary to establish its effectiveness for SMI. We discuss considerations for clinical implementation, directions, and future research.

Exploring Correlations of Food-Specific Disgust with Eating Disorder Psychopathology and Food Interaction: A Preliminary Study Using Virtual Reality

The emotion of disgust is thought to play a critical role in maintaining restrictive eating among individuals with anorexia nervosa. This exploratory cross-sectional study examined correlations between food-specific trait and state disgust, eating disorder psychopathology, illness severity (body mass index: BMI), and interactions with virtual foods in people with anorexia nervosa. Food-specific trait disgust and eating disorder symptoms were measured before exposure to virtual foods in one of three virtual reality (VR) kitchens to which participants were randomly allocated. Food interactions (eye gaze and reaching towards virtual foods) were measured during the VR exposure. Food-specific state disgust ratings were collected after the VR exposure. In the entire sample, eating disorder symptoms correlated positively with food-specific trait disgust (rs (68) = 0.45, p < 0.001). We also found a significant association between food-specific state disgust and eating disorder symptoms in each virtual kitchen scenario: virtual kitchen only (rs (22) = 0.40, p = 0.05), virtual kitchen plus pet (rs (22) = 0.80, p < 0.001), and virtual kitchen plus avatar (rs (20) = 0.78, p < 0.001). No significant correlation was observed for the link between food-specific disgust measures and food-related touch. Correlations between food-specific trait disgust and food-related eye gaze differed across scenarios. The current experimental paradigm needs to be improved to draw firm conclusions. Both food-specific trait and state disgust are associated with eating disorder psychopathology, and therefore, effective strategies are warranted to attenuate food-specific disgust.

Effects of Music Therapy in the Reduction of Pre-Meal Anxiety in Patients Suffering from Anorexia Nervosa

Literature reviews appear to indicate that Music Therapy (MT) may instil a sense of empowerment and generate feelings of renewed self-confidence, distracting subjects who follow this type of intervention from negative thoughts and, generally, helping patients suffering from Anorexia Nervosa (AN) to redevelop or rediscover their identity. The purpose of the study reported in this paper is to investigate whether MT proposed before an evening meal is capable of decreasing pre-meal anxiety in adolescents suffering from AN who follow the Day-hospital Treatment Programme at the San Bortolo Hospital of Vicenza (Italy). A total of 24 patients participated voluntarily in once-weekly sessions of group-based MT conducted by a qualified music therapist over a period of six months. Before evening meals on Monday, Tuesday and Wednesday, pre-meal anxiety was measured using a self-report scale, and the MT group session occurred every Wednesday before the evening meal was consumed. MT activities were both active and receptive. It has been found that with respect to Mondays and Tuesdays, pre-meal anxiety was significantly lower on Wednesdays following participation in the MT group. MT is evidently capable of reducing pre-meal anxiety and may be adopted as a supportive element in treatment plans relating to patients with AN in a day-hospital treatment programme.

Improving mealtimes for patients and staff within an eating disorder unit: the next chapter

OBJECTIVES

Mealtimes are an integral part of treatment for patients in an eating disorder inpatient unit. However, they are often distressing and anxiety provoking for both patients and staff. A consequence of patients' distress is an increase in eating disorder behaviours specific to mealtimes. This is the second paper detailing a quality improvement project following on from an initial paper outlining the first test of change. The aim of this quality improvement project was to decrease the number of eating disorder behaviours at mealtimes in the dining room through the implementation of interventions identified through diagnostic work.

METHODS/DESIGN

The Model for Improvement was used as the systematic approach for this project. Baseline assessment included observations in the dining room, gathering of qualitative feedback from staff and patients and the development of a form which identifies eating disorder behaviours completed by staff. Interventions in the form of three change ideas have so far been introduced including (1) a host role in the dining room, (2) a guide to the dining room for new staff along with competencies and (3) a dining goals group. The impact of the three interventions is assessed.

RESULTS

The introduction of the interventions has overall reduced the average number of eating disorder behaviours per patient in the dining room by 33%.

CONCLUSIONS

This paper reports the challenges and successes of continuing a QI project through the COVID-19 pandemic and the need for multiple tests of change to improve a complex problem. The results demonstrate a consistent reduction in eating disorder behaviours over a period of nearly 2 years.

Impaired Cognitive Empathy in Outpatients with Chronic Musculoskeletal Pain: A Cross-Sectional Study

Background

In recent years, a growing number of researchers showed significant interest in psychological and social interventions to manage chronic musculoskeletal (MSK) pain. Cognitive and emotional empathy is an attractive and valuable sociopsychological factor that may provide protection and resilience against chronic MSK pain. However, its effect on outpatients remains underexplored.

Objective

To compare the empathy ability between chronic MSK pain outpatients and healthy controls and explore the relationship between cognitive/emotional empathy and chronic pain.

Methods

Patients with chronic MSK pain (n = 22) and healthy controls (n = 26) completed the pain assessment and empathy ability task, utilizing a multidimensional empathy assessment tool with satisfactory reliability and validity (i.e., the Chinese version of the Multifaceted Empathy Test (MET-C)).

Results

The data indicated that the chronic MSK pain outpatients had impaired cognitive empathy (i.e., lower squared cognitive empathy accuracy: Student's t = −2.119, P = 0.040, and longer task completion time: Student's t = 3.382, P = 0.002) compared to healthy controls, and cognitive empathy was negatively correlated with pain intensity (r = −0.614, P = 0.002). Further, the impaired cognitive empathy was present in identifying positive, but not negative emotions.

Conclusion

These results indicate that chronic MSK pain is associated with impaired empathy ability. Our studies contribute to offering a potential direction for developing psychosocial interventions to treat chronic MSK pain.

Attitudes Surrounding Music of Patients With Anorexia Nervosa: A Survey-Based Mixed-Methods Analysis

Anorexia nervosa (AN) is one of the main eating disorders. It has the highest mortality of all psychiatric disorders, and the success rates of current therapies are not fully satisfactory. Thus, there is a need for novel interventions. We investigated the attitudes surrounding music of 41 patients with clinically-diagnosed AN as well as their thoughts on the potential therapeutic uses of music using a questionnaire of 50 questions. Free text responses were qualitatively analyzed for reoccurring themes with NVivo 12 software. Yes/no questions and questions of best fit were analyzed using the IBM SPSS Statistics version 25. The most prevalent theme was the positive effect of music. Most patients reported that listening to music evokes varying emotions in them (83%) which may be of positive or negative nature. Similarly, patients associated certain music with particular positive, but also with particular negative memories. A majority of patients stated that music helps to distract them (85%), helps with loneliness (59%) and helps them feel more connected to others (58%). This data indicates that people with AN make nonclinical use of music which seems to elicit positive as well as negative emotions and memories. Patients felt music is beneficial with regard to important aspects of AN, such as emotional problems, loneliness, and relationship difficulties. Most of them would also like to attend music therapy.

A pilot study investigating the influence of oxytocin on attentional bias to food images in women with bulimia nervosa or binge eating disorder

BACKGROUND

Previous research has found that exogenous oxytocin administration has the potential to modulate attentional biases in women with anorexia nervosa. Recent work has indicated that attentional biases to food may reinforce the recurrent binge eating behaviour characterising bulimia nervosa and binge eating disorder. To date, however, no study has yet investigated the effect of oxytocin on attentional biases to palatable food in women with bulimia nervosa and binge eating disorder.

METHODS

The present study employed a single-session cross-over design to test the hypothesis that a divided dose of 64 IU of intranasal oxytocin, administered as one intranasal dose of 40 IU of oxytocin followed by a top-up of 24 IU of oxytocin 80 minutes later, vs placebo administration administered in the same dosing schedule would reduce attentional biases towards food images in a dot probe task. We hypothesised that oxytocin administration would reduce vigilance towards food to a greater degree in women with bulimia nervosa or binge eating disorder vs healthy comparison women. Twenty-five women with bulimia nervosa or binge eating disorder and 27 comparison women without history of an eating disorder were recruited to take part in the study.

RESULTS

In contrast to our hypothesis, there was no main effect of diagnosis on attentional bias to food (fixed effect = 5.70, P = 0.363), nor a significant interaction between diagnosis and drug condition (fixed effect =-14.80, P = 0.645). There was a main effect of drug condition, such that oxytocin increased vigilance towards food vs neutral images in the dot probe task (fixed effect = 10.42, P = 0.044). A correlation analysis revealed that this effect was moderated by attentional bias in the placebo condition, such that greater avoidance of food stimuli in the placebo condition was associated with a greater increase in vigilance induced by oxytocin.

CONCLUSIONS

The findings of the present study add to a mixed body of literature investigating the therapeutic effects of oxytocin in women. Future research would benefit from dose-response studies investigating the optimal dose of oxytocin for modulating the attentional processing of palatable food in populations with eating disorders.

What can food-image tasks teach us about anorexia nervosa? A systematic review

A salient feature of anorexia nervosa (AN) is the persistent and severe restriction of food, such that dietary intake is inadequate to maintain a healthy body weight. Experimental tasks and paradigms have used illness-relevant stimuli, namely food images, to study the eating-specific neurocognitive mechanisms that promote food avoidance. This systematic review, completed in accordance with PRISMA guidelines, identified and critically evaluated paradigms involving images of food that have been used to study AN. There were 50 eligible studies, published before March 10th 2018, identified from Medline and PsychINFO searches, and reference screening. Studies using food image-based paradigms were categorised into three methodologic approaches: neuropsychology, neurophysiology, and functional magnetic resonance imaging (fMRI). Paradigms were reviewed with a focus on how well they address phenomena central to AN. Across tasks, differences between individuals with AN and healthy peers have been identified, with the most consistent findings in the area of reward processing. Measuring task performance alongside actual eating behaviour, and using experimental manipulations to probe causality, may advance understanding of the mechanisms of illness in AN.

Mobile Self-Help Interventions as Augmentation Therapy for Patients with Anorexia Nervosa

Background: It has been suggested that patients with anorexia nervosa (AN) who are resistant to first-line treatment would benefit from second-level interventions targeting specific features, an adaptive form of intervention. Guided self-help programs administered via mobile technology have the dual focus of instigating behavior change and managing anxiety associated with eating disorders in the moment and in users' naturalistic environments. Introduction: We evaluated the feasibility, acceptability, and preliminary augmentative effects of mobile-based, guided self-help interventions (Recovery vodcasts) after initial unsuccessful first-line treatments for patients with AN. Materials and Methods: Patients with AN who were unsuccessful in their treatments were recruited to access Recovery vodcasts as augmentation treatment for 3 weeks in Korea. Acceptability and feasibility of the intervention were evaluated, and qualitative feedback was collected. Preliminary treatment effects of adding the Recovery vodcasts were assessed, including eating disorder pathology, anxiety and depression symptoms, and body mass index. Results: The Recovery vodcasts were acceptable for patients with AN. The patients' psychopathologies of eating disorders improved with augmentation of the vodcasts in their first-line treatments. In addition, there was a tendency toward improvement of affective symptoms. The participants' feedback suggested that the intervention could be improved. Conclusions: The study demonstrated that the Recovery vodcasts were well accepted by Korean patients with AN. Moreover, augmentation of the Recovery vodcasts could facilitate improvements in psychopathology of eating disorders, anxiety, and mood symptoms for patients with AN.

Use of Tablet Devices in the Management of Agitation Among Inpatients with Dementia: An Open-Label Study

OBJECTIVE

To investigate the feasibility, safety, and utility of tablet devices as novel nonpharmacologic tools in managing older psychiatric inpatients with agitation and dementia.

METHODS

Thirty-six patients at a geriatric psychiatry inpatient unit were provided with tablets when agitated and used various apps on the tablet related to communication, games, music, web browser, and photography during their stay. Study staff documented the frequency, duration, and app usage history and rated the extent to which agitation improved after tablet use.

RESULTS

All participants, regardless of dementia severity, were able to use apps and were rated by staff to have clinical benefit. Dementia severity was negatively associated with app complexity. Age was negatively associated with frequency and duration of tablet use.

CONCLUSION

Tablet use as a nonpharmacologic intervention for agitation in older adults, including those with severe dementia, appears to be feasible, safe, and of potential utility.

The effects of intranasal oxytocin on smoothie intake, cortisol and attentional bias in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterised by severe malnutrition as well as intense fear and anxiety around food and eating with associated anomalies in information processing. Previous studies have found that the neuropeptide, oxytocin, can influence eating behaviour, lower the neurobiological stress response and anxiety among clinical populations, and alter attentional processing of food and eating related images in AN.

METHODOLOGY

Thirty adult women with AN and twenty-nine healthy comparison (HC) women took part in the current study. The study used double blind, placebo controlled, crossover design to investigate the effects of a single dose of intranasal oxytocin (40 IU) on a standard laboratory smoothie challenge, and on salivary cortisol, anxiety, and attentional bias towards food images before and after the smoothie challenge in AN and HC participants. Attentional bias was assessed using a visual probe task.

RESULTS

Relative to placebo intranasal oxytocin reduced salivary cortisol and altered anomalies in attentional bias towards food images in the AN group only. The oxytocin-induced reduction in attentional avoidance of food images correlated with oxytocin induced reduction in salivary cortisol in the AN group before the smoothie challenge. Intranasal oxytocin did not significantly alter subjective feelings of anxiety or intake during the smoothie challenge in the AN or HC groups.

CONCLUSIONS

Intranasal oxytocin may moderate the automated information processing biases in AN and reduce neurobiological stress. Further investigation of the effects of repeated administration of oxytocin on these processes as well as on eating behaviour and subjective anxiety would be of interest.

Motivational Text Message Intervention for Eating Disorders: A Single-Case Alternating Treatment Design Using Ecological Momentary Assessment

OBJECTIVE

This study tested a motivational text message treatment adjunct for individuals with eating disorders (EDs) who exhibited high dietary restraint/restriction.

METHOD

A replicated single-case alternating treatment design was used to examine (a) the feasibility of combining a brief motivational interview with subsequent text messages and (b) the influence of the text messages on eating behaviors and motivation to change in individuals with EDs (N=12). The protocol was 8weeks and the text messages were adjunctive to cognitive-behavioral therapy.

RESULTS

The intervention was well accepted (mean rating=7/10) and feasible within the context of monetary compensation (mean daily monitoring compliance =91%). Text messages did not impact behavioral outcomes: dietary restraint and kilocalorie intake. They had mixed effects on motivation to change dietary restraint, measured by the Readiness and Motivation Questionnaire (RMQ). When receiving text messages, RMQ precontemplation scores (desire to restrict) significantly increased, indicating decreased motivation; however, action scores (effort toward reducing dietary restraint) significantly increased, indicating increased motivation. These effects were moderated by weight status. Underweight individuals (n=4; body mass index [BMI]<19.0) reported increased ambivalence-that is, an increased desire to restrict and increased action toward reducing restriction-in response to the text messages. Normal weight participants (n=8; BMI>19.0) reported only increased action toward reducing restriction in response to the text messages.

DISCUSSION

These data demonstrate text messages are a potentially feasible and acceptable treatment adjunct and may be effective at increasing motivation to change for normal weight individuals, while their influence on underweight patients is more complex. These findings provide a foundation for future research in technology-based motivational interventions for EDs and offer preliminary evidence for using these methods among normal weight individuals.

E-Health Interventions for Eating Disorders: Emerging Findings, Issues, and Opportunities

This study aimed to review the emerging findings regarding E-health interventions for eating disorders and to critically discuss emerging issues as well as challenges for future research. Internet-based cognitive behavioral therapy and guided self-help have demonstrated promising results in terms of reducing eating disorder psychopathology. Emerging findings also suggest that E-health interventions reach an underserved population and improve access to care. The use of smartphone applications is becoming increasingly popular and has much potential although their clinical utility and effectiveness is presently unknown and requires investigation. Important challenges include the diagnostic process in E-health interventions, the optimization of E-health within existing health care models, and the investigation and implementation of blended care. More high-quality research is needed to bring the field forward and to determine the place for E-health in our health care service delivery systems.

Intranasal oxytocin attenuates attentional bias for eating and fat shape stimuli in patients with anorexia nervosa

We examined the impact of oxytocin on attentional processes for eating, shape, and weight stimuli in patients with anorexia nervosa (AN). A double-blind, placebo-controlled within-subject crossover design was used. Intranasal oxytocin or placebo followed by a visual probe detection task with food, weight, and shape images was administered to 64 female subjects: 31 patients with AN and 33 control students. The AN group showed significant reductions in the attentional biases toward eating-related stimuli (p=0.030, d=0.516) and toward negative shape stimuli (p=0.015, d=0.498) under the influence of intranasal oxytocin. The effect of oxytocin was correlated with autistic spectrum traits in the AN group. Oxytocin had no effect on the amount of juice consumed in either group. The results of this study suggest that oxytocin attenuates the attentional vigilance to eating and fat shape stimuli in patients with AN. Further studies using oxytocin as a form of intervention for patients with AN are needed.