A Cognitive-Behavioral Mindfulness Group Therapy Intervention for the Treatment of Binge Eating in Bariatric Surgery Patients

Mindfulness-Based Interventions for Surgical Patients and Impact on Postoperative Outcomes, Patient Wellbeing, and Satisfaction

Several psychosocial factors can impact surgical outcomes and overall patient wellbeing following surgery. Although advances in surgical interventions and pain management protocols can reduce surgical trauma and enhance recovery from surgery, additional intervention is warranted to optimize surgical outcomes and patient quality of life (QoL) in the short- and long-term. Research on mindfulness techniques suggests that mindfulness-based interventions (MBI) effectively promote health behaviors, reduce pain, and improve psychological wellbeing and QoL. Thus, there has been an increase in research evaluating the use of MBIs to improve postoperative outcomes and wellbeing in surgical patients. The authors provide a brief overview of psychosocial outcomes of surgery and MBIs and review the literature on the impact of MBIs on postoperative outcomes. The extant literature indicates that MBIs are feasible and acceptable for use in surgical patient populations and provides preliminary evidence of the benefits of mindfulness across a range of surgical patient populations. However, more research is needed to assess the long-term efficacy of MBIs delivered online and in-person across the perioperative continuum.

The effects of an 8-week mindful eating intervention on anticipatory reward responses in striatum and midbrain

Introduction

Accumulating evidence suggests that increased neural responses during the anticipation of high-calorie food play an important role in the tendency to overeat. A promising method for counteracting enhanced food anticipation in overeating might be mindfulness-based interventions (MBIs). However, the neural mechanisms by which MBIs can affect food reward anticipation are unclear. In this randomized, actively controlled study, the primary objective was to investigate the effect of an 8-week mindful eating intervention on reward anticipation. We hypothesized that mindful eating would decrease striatal reward anticipation responses. Additionally, responses in the midbrain-from which the reward pathways originate-were explored.

Methods

Using functional magnetic resonance imaging (fMRI), we tested 58 healthy participants with a wide body mass index range (BMI: 19-35 kg/m2), motivated to change their eating behavior. During scanning they performed an incentive delay task, measuring neural reward anticipation responses to caloric and monetary cues before and after 8 weeks of mindful eating or educational cooking (active control).

Results

Compared with the educational cooking intervention, mindful eating affected neural reward anticipation responses, with reduced caloric relative to monetary reward responses. This effect was, however, not seen in the striatum, but only in the midbrain. The secondary objective was to assess temporary and long-lasting (1 year follow-up) intervention effects on self-reported eating behavior and anthropometric measures [BMI, waist circumference, waist-to-hip-ratio (WHR)]. We did not observe effects of the mindful eating intervention on eating behavior. Instead, the control intervention showed temporary beneficial effects on BMI, waist circumference, and diet quality, but not on WHR or self-reported eating behavior, as well as long-lasting increases in knowledge about healthy eating.

Discussion

These results suggest that an 8-week mindful eating intervention may have decreased the relative salience of food cues by affecting midbrain but not striatal reward responses, without necessarily affecting regular eating behavior. However, these exploratory results should be verified in confirmatory research.The primary and secondary objectives of the study were registered in the Dutch Trial Register (NTR): NL4923 (NTR5025).

Proof of Concept for a Mindfulness-Informed Intervention for Eating Disorder Symptoms, Self-Efficacy, and Emotion Regulation among Bariatric Surgery Candidates

Up to 64% of patients seeking bariatric (weight-loss) surgery report eating disorder (ED) symptoms (addictive-like eating, binge eating, emotional eating, grazing) that can interfere with post-surgical weight loss. This prospective proof-of-concept study aimed to evaluate the impact of a pre-surgical mindfulness-informed intervention (MII) on ED symptoms and potential mechanisms-of-action to inform optimization of the intervention. Surgery-seeking adults attended four, 2-hour, MII sessions held weekly. Participants completed validated questionnaires assessing ED symptoms, eating self-efficacy, emotion regulation, and mindful eating pre-MII, post-MII, and at a 12-week follow-up. The MII consisted of mindfulness training, with cognitive, behavioral, and psychoeducational components. Fifty-six patients (M = 47.41 years old, 89.3% female) participated. Improvements in addictive-like eating, binge eating, emotional eating, and grazing were observed from pre- to post-MII. ED symptom treatment gains were either maintained or improved further at 12-week follow-up. Eating self-efficacy and emotion regulation improved from pre-MII to follow-up. Scores on the mindful eating questionnaire deteriorated from pre-MII to follow-up. In mediation analyses, there was a combined indirect effect of emotion regulation, eating self-efficacy, and mindful eating on grazing and binge eating, and an indirect effect of emotion regulation on emotional eating and addictive-like eating. Participation in the MII was associated with improvements in ED symptoms and some mechanisms-of-action, establishing proof-of-concept for the intervention. Future work to establish the MII's efficacy in a randomized controlled trial is warranted.

Fostering emotional self-regulation in female teachers at the public teaching network: A mindfulness-based intervention improving psychological measures and inflammatory biomarkers

OBJECTIVE

To examine the effect of a mindfulness-based program specifically designed for teachers in reducing perceived stress and improving the quality of experienced emotion in female active working teachers. A second outcome evaluated is the associated change in cellular inflammatory activity, measured by peripheral blood levels of cytokines.

METHOD

Eighty-eight female active teachers from public schools from São Paulo Municipality were recruited, and randomly allocated to an eight-week Mindfulness-Based Health Program for Educators (MBHP-Educa) or to Neuroscience for Education Program (Neuro-Educa: active control group). The venue of both programs were several public school facilities, where many of the teachers actually worked. Both groups received activities during eight weeks in a 2 ​h/week regimen, totalizing 16 ​h. Sixty-five participants completed the program and pre- and post-interventions measures were taken from the following scales: Interpersonal Multidimensional Reactivity Scale (IRI), Positive-and-Negative Affects Scale (PANAS), Perceived Stress Scale (PSS), Connor-Davidson Resilience Scale (CD-RISC), and a primary outcome in Ryff's Psychological Well-Being Scale (PBWS). At pre-and post-intervention, blood samples were collected for the measurement of several important inflammatory biomarkers, Tumor Necrosis Factor - α (TNF-α), Interleukin 1β (IL-1β), Interleukin 6 (IL-6), Interleukin 8 (IL-8), Interleukin 10 (IL-10) and Interleukin 12p70 (IL-12P70) through flow cytometry assay. Intervention effects were analyzed via Generalized mixed models (GLMM).

RESULTS

According to the GLMM, MBHP-Educa significantly reduced the scores of perceived stress (p ​< ​0.0001), and negative affect (p ​< ​0.0001) compared to active control group (Neuro-Educa). Conversely, an increase was observed on Psychological Well Being Scale in dimensions of Self-acceptance (p ​< ​0.0001), and Autonomy (p ​= ​0.001), as well as improvements in Resilience (p ​< ​0.0001), and Positive Affect (p ​< ​0.0001). MBHP-Educa also promoted a reduction in the levels of IL-6 (p ​= ​0.003), IL-8 (p ​= ​0.036), and increase in the levels of IL-10 (p ​< ​0.0001) and IL-12p70 (p ​< ​0.044). TNF-α, IL-1β, and IL-10p70 showed results below theoretical limit of detection accepted for CBA kit.

CONCLUSIONS

Our data suggest that mindfulness-based interventions introduced as a strategy for reducing stress, promoting well-being and improve immune function can be a useful asset in promoting psychological health among teachers in Basic Education.

The Effects of Mindfulness-Based Interventions on Suicide Outcomes: A Meta-Analysis

Although mindfulness-based interventions (MBIs) have been shown to be effective in treating several psychological difficulties, to date, no review has systematically examined their effectiveness in treating or preventing suicide. The goals of the present study were to (1) evaluate the effectiveness of MBIs in treating suicide and (2) understand how individual characteristics and characteristics of MBIs influence treatment outcomes through a systematic meta-analysis. A search of PubMed, MEDLINE, PsychINFO, and ProQuest Dissertations and Theses was conducted in February 2019. A total of 12 publications (13 studies, n = 627) were included. MBIs demonstrated significant moderate effects on suicidal ideation in pre-post studies and small effects in controlled studies. In addition, MBIs demonstrated significant moderate effects in both samples of individuals with histories of depression and histories of suicidal ideation or attempts. Moreover, MBIs led to clinically significant reductions in suicidal ideation and depression. Female participants, older samples, and longer treatments showed greater treatment effects, although these relationships were weak. Results suggest that MBIs may be promising treatments for suicidal ideation; however, more research is needed to establish the effects of these treatments as well as the mechanisms through which MBIs reduce suicide.

Dialectical Behavior Therapy for Emotional and Mindless Eating After Bariatric Surgery: a Prospective Exploratory Cohort Study

PURPOSE

To assess the effect of dialectical behavior therapy (DBT) on emotional and mindless eating and, consequently, body mass index (BMI) loss, in patients who have undergone bariatric surgery.

MATERIALS AND METHODS

A prospective exploratory cohort study was conducted with two groups of patients who had undergone bariatric surgery: the DBT group received DBT group skills training sessions, while the control group received no intervention. Outcome measurements included BMI and scores of the Emotional Eating Scale (EES) and Mindful Eating Questionnaire (MEQ).

RESULTS

The study included 36 women: 18 in each group. In the DBT group, the interval from surgery was 11.17 ± 7.12 months, and in the control group 10.89 ± 5.74. Laparoscopic sleeve gastrectomy was done in 88.9% and 83.3% of patients in the DBT and control groups respectively. The rest underwent Roux-en-Y gastric bypass. The DBT group showed significant changes in overall and subscale scores of the EES and MEQ and BMI in kg/m² after 6 months of follow-up. BMI in kg/m² changed from mean ± SD 35.45 ± 6.17 to 28.47 ± 4.28 in the DBT group, in control 35.88 ± 5.07 to 31.56 ± 3.71. The excess weight loss percentage (EWL%) in the DBT was mean ± SD 75.3 ± 17.9 and in the control was 63.6 ± 14.5. In the DBT group, the EES score and MEQ score changed from mean ± SD 45.06 ± 20.19 to 20.50 ± 13.40 and 11.52 ± 2.02 to 15.87 ± 1.92, respectively. The control group showed no significant change in scores.

CONCLUSIONS

DBT skills training can reduce emotional eating, increase mindful eating, and facilitate weight loss after bariatric surgery.

Patient perspectives on psychological care after bariatric surgery: A qualitative study

Psychological interventions may be effective in improving adherence after bariatric surgery; however, there is limited research on patients' willingness to engage with psychological aftercare. This study aimed to qualitatively explore patient perspectives on psychological services in the bariatric setting. Participants reported believing that psychological care is essential for treatment success and indicated that they wanted support with adjusting to changes in lifestyle, self-identity, and relationships after surgery. Participants suggested that psychological aftercare should be recommended by their medical team and incorporated into standard management after bariatric surgery. These findings can be used to inform the design of services for bariatric surgery patients.

Psychological predictors of poor weight loss following LSG: relevance of general psychopathology and impulsivity

PURPOSE

After bariatric surgery (BS) a significant minority of patients do not reach successful weight loss or tend to regain weight. In recent years, interest for the psychological factors that predict post-surgical weight loss has increased with the objective of developing interventions aimed to ameliorate post-surgical outcomes. In the present study, predictive models of successful or poor weight loss 12 months after BS were investigated considering pre-surgery level of psychopathological symptoms, dysfunctional eating behaviors and trait impulsivity at baseline (pre-surgery).

METHODS

Sixty-nine patients with morbid obesity canditates for laparoscopic sleeve gastrectomy were assessed regarding metabolic and psychological dimensions. Successful post-surgery weight loss was defined as losing at least 50% of excess body weight (%EWL).

RESULTS

Logistic models adjusted for patient sex, age and presence of metabolic diseases showed that the baseline presence of intense psychopathological symptoms and low attentional impulsivity predict poor %EWL (< 50%), as assessed 12-month post-surgery.

CONCLUSIONS

The present findings suggest that intensity of general psychopathology and impulsivity, among other psychological factors, might affect post-surgery %EWL. Conducting adequate psychological assessment at baseline of patients candidates for BS seems to be crucial to orient specific therapeutic interventions.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

The effectiveness of psychosocial interventions to support psychological well-being in post-operative bariatric patients: A systematic review of evidence

BACKGROUND

Bariatric surgery is considered an effective obesity management intervention for individuals with a BMI greater than 40, or 35 with co-morbidities. However, research documents that psychological difficulties prevalent amongst individuals seeking surgery may persist post-operatively. This systematic review aims to assess the evidence to show which psychosocial interventions support psychological well-being post-operatively.

METHODS

The review is registered with Prospero (CRD42018100280), complying with PRISMA guidelines. The research protocol included grey literature and database searches of psychosocial interventions for post-operative bariatric patients, between November 2017 and September 2019. The primary outcome was psychological well-being; secondary outcomes included weight loss maintenance and quality of life (QoL). The primary reviewer screened titles and extracted data. Study quality was assessed independently by two reviewers, using the Effective Public Health Practice Project criteria. Due to heterogeneity across studies, narrative synthesis was considered suitable for data analysis.

RESULTS

Ten studies met inclusion criteria. Psychosocial intervention content was delivered in a variety of ways (e.g., clinic, internet-based). Overall, participants (N = 382, Mage = 46.4) receiving psychosocial interventions post bariatric surgery, demonstrated improvements in psychological well-being and weight loss maintenance, compared to baseline measures and/or controls. The strength of evidence is currently limited by the small number of studies found and study quality, limiting the power to detect clinically meaningful changes; findings should therefore be considered preliminary.

CONCLUSION

Preliminary findings suggest that interdisciplinary interventions including acceptance-based approaches, psychoeducation, nutrition and lifestyle modification, delivered 1-year post-operative, are promising. Further scientific enquiry is warranted with well-designed studies and long-term follow-ups.

Mindfulness and eating disorder psychopathology: A meta-analysis

OBJECTIVE

Mindfulness is implicated in eating disorder (ED) psychopathology. However, this literature has not been synthesized to date. The current meta-analysis examined the associations between mindfulness and ED psychopathology.

METHODS

A total of 74 independent samples (effects = 576) were included. We used a multilevel random-effects model to estimate summary study-level effect sizes, and multilevel mixed-effects models to examine moderator effects.

RESULTS

Mindfulness was negatively associated with ED psychopathology (r = -.25, p < .001), both concurrently (r = -.25, p < .001) and prospectively (rs = -.22 to -.24, ps < .001). Associations were strongest for binge eating, emotional/external eating, and body dissatisfaction as well as the acting with awareness and nonjudging facets.

DISCUSSION

Mindfulness may be an important process in ED psychopathology. Future research should prospectively and experimentally examine the relation between mindfulness and ED psychopathology.

Psychiatric Management of Bariatric Surgery Patients: A Review of Psychopharmacological and Psychological Treatments and Their Impact on Postoperative Mental Health and Weight Outcomes

BACKGROUND

Bariatric surgery is an effective treatment for severe obesity; however, high rates of psychiatric comorbidity complicate bariatric surgery care. As a result, importance has been placed on the need for ongoing psychiatric support in patients undergoing bariatric surgery. Given the lack of conclusive presurgery psychosocial predictors of postoperative mental health outcomes, studies have now shifted their focus to understand the long-term psychosocial sequalae that arise after surgery. Increasing evidence has demonstrated the potential for psychiatric care to stabilize psychiatric symptoms and minimize patient distress.

OBJECTIVE

To review psychopharmacological and psychological interventions for patients undergoing bariatric surgery and their impact on mental health and weight outcomes after surgery.

METHODS

We performed a comprehensive literature search in Ovid MEDLINE for studies examining the impact of psychopharmacological and psychological treatments on bariatric patients' postoperative mental health and weight outcomes.

RESULTS

Overall, 37 studies were included in the review. Preliminary evidence suggests that psychiatric medications do not negatively impact weight loss or health-related quality of life in the short term; however, more rigorous research designs are needed. There are insufficient data on specific psychiatric medications and long-term impact on weight loss and psychosocial outcomes. Postoperative psychological interventions have evidence for improving eating psychopathology, anxiety, and depressive symptoms; however, effects on weight loss remain unclear.

CONCLUSION

Evidence for psychopharmacological and psychological treatments remains preliminary. Consideration should be given to integrated, stepped-care models to provide personalized psychiatric interventions after surgery. Future research on expanding current psychiatric interventions, timing of delivery, and predictors of response is needed.

Preoperative and post-operative psychosocial interventions for bariatric surgery patients: A systematic review

Psychosocial interventions are increasingly being utilized to help patients prepare for, and adjust to changes following, bariatric surgery in order to optimize psychosocial adjustment and weight loss. The current systematic review examined the impact of preoperative and post-operative psychosocial interventions with a behavioural and/or cognitive focus on weight, dietary behaviours, eating pathology, lifestyle behaviours, and psychological functioning. A PsycINFO and Medline search of publications was conducted in March 2019. Two authors assessed retrieved titles and abstracts to determine topic relevance and rated the quality of included studies using a validated checklist. Forty-four articles (representing 36 studies) met the study inclusion criteria. The current evidence is strongest for the impact of psychosocial interventions, particularly cognitive behavioural therapy, on eating behaviours (eg, binge eating and emotional eating) and psychological functioning (eg, quality of life, depression, and anxiety). The evidence for the impact of psychosocial interventions on weight loss, dietary behaviours (eg, dietary intake), and lifestyle behaviours (eg, physical activity) is relatively weak and mixed. Psychosocial interventions can improve eating pathology and psychosocial functioning among bariatric patients, and the optimal time to initiate treatment appears to be early in the post-operative period before significant problematic eating behaviours and weight regain occur.

Pre-operative Restraint and Post-operative Hunger, Disinhibition and Emotional Eating Predict Weight Loss at 2 Years Post-laparoscopic Adjustable Gastric Banding

INTRODUCTION

A principal mechanism of action in bariatric surgery is reduction in calorie consumption due to decreased hunger and increased satiety. Patients' ability to perceive post-operative changes to their hunger is therefore central to optimal results. This study examined factors that may impact how patients perceive post-operative hunger and how perception of hunger impacts eating and subsequent weight loss after laparoscopic adjustable gastric banding (LAGB).

METHODS

Patients undertaking LAGB (n = 147) provided pre-surgery and 2-year weight loss data and pre-surgery and 12-month psychological data (perception of hunger, disinhibition related to eating, emotional eating).

RESULTS

Path analysis demonstrated that patients with lower levels of pre-surgery cognitive restraint over eating experienced significantly greater reduction in perception of hunger at 12 months post-surgery. Perceived reduction in hunger was significantly associated with lower levels of both emotional eating and disinhibited eating. Finally, reduced emotional eating at 12 months significantly predicted 9% of the variance in percentage of total weight loss (%TWL) at 2 years after surgery.

CONCLUSION

These initial findings suggest that preparation for bariatric surgery may be enhanced by psychoeducation regarding cognitive restraint over eating and its effect on hunger perception. In addition, psychological treatment that focuses on identifying and responding to changes in hunger may contribute to improved outcomes for those who have difficulty adjusting to post-operative eating behaviours.

Review of Mindfulness-Related Interventions to Modify Eating Behaviors in Adolescents

There are few well-established treatments for adolescent eating disorders, and for those that do exist, remission rates are reported to be between 30 and 40%. There is a need for the development and implementation of novel treatment approaches. Mindfulness approaches have shown improvements in eating disorder-related psychopathology in adults and have been suggested for adolescents. The present review identifies and summarizes studies that have used mindfulness approaches to modify eating behaviors and to treat eating disorders in adolescents. Focused searches were conducted in Embase, Medline, and PsycINFO, and identified articles were checked for relevance. A small number of studies (n = 15) were designated as appropriate for inclusion in the review. These studies were divided into those that focused on the promotion of healthy eating/the prevention of disordered eating (n = 5), those that concentrated on targeted prevention among high risk adolescents (n = 5), and those that focused on clinical eating disordered adolescents (n = 5). Thirteen of the 15 studies reviewed reported at least one positive association between mindfulness treatment techniques and reduced weight/shape concerns, dietary restraint, decreased body mass index (BMI), eating in the absence of hunger (EAH), binge eating, increased willingness to eat novel healthy foods, and reduced eating disorder psychopathology. In summary, incorporating mindfulness to modify eating behaviors in adolescent non-clinical and clinical samples is still in the early stages, with a lack of data showing clear evidence of acceptability and efficacy. Further studies and preferably controlled conditions are warranted.

Eating expectancies before bariatric surgery: assessment and associations with weight loss trajectories

BACKGROUND

While presurgical eating behaviors have demonstrated limited prognostic value, cognitions regarding the effects of eating may serve as important predictors of weight loss outcomes after bariatric surgery. The Eating Expectancies Inventory (EEI) is a commonly used, self-report measure of expected consequences of eating; however, its psychometric and predictive properties have not yet been evaluated among bariatric surgery patients.

OBJECTIVES

This study sought to examine the factor structure and internal consistency of the EEI among bariatric surgery candidates, to examine relationships between EEI factors and measures of eating psychopathology, and to explore the effects of eating expectancies on postsurgical weight loss.

SETTING

Data originated from an interdisciplinary bariatric surgery center in the Midwest United States.

METHODS

Two hundred sixty-two women completed self-report questionnaires before bariatric surgery. Presurgical data and available postsurgical weights (at 6, 12, and 18 mo) were obtained from medical records.

RESULTS

Analyses indicated that the original 5-factor model was a good-to-excellent fit for the EEI data. All EEI factors demonstrated good reliability and were significantly associated with eating disorder symptoms and behaviors at baseline. Higher scores on EEI Factor 1 (negative affect) and Factor 5 (alleviates boredom) predicted poorer weight loss at 18 months postsurgery (n = 132).

CONCLUSIONS

Findings support the reliability and validity of the EEI among female bariatric candidates. Presurgical eating expectancies were linked to pathologic eating patterns and also predicted postsurgical weight loss trajectories, suggesting that eating expectancies may have prognostic value as predictors of bariatric surgery outcomes.

[Emotional therapies for overweight or obesity]

Obesity has become a public health problem. But care, mainly diets, is often ineffective over the long term. Emotional therapies seem to be an interesting track especially for emotional eating. After defining two key concepts of emotional eating and acceptance, the theoretical frameworks of the different emotional therapies used in the treatment of overweight or obesity will be presented: Mindfulness-Based for Eating Disorder (MB-EAT), Acceptance and Commitment Therapy, and Acceptance-Based Behavioral Treatment for Weight Loss (ABT). The goal is to understand their usefulness in the treatment of overweight or obesity and perhaps avoid using contradictory techniques such as dieting with mindfulness. If current results are promising, the effectiveness of these therapies needs to be confirmed by new studies. Finally, the article points to the emergence of new "integrative" therapies that resemble the others presented and are related but are in fact the exact opposite. Control and acceptance are indeed antithetical.

Why WAIT? Preliminary evaluation of the weight assistance and intervention techniques (WAIT) group

Individuals who attempt to lose weight may struggle because they lack skills to address problematic eating behaviors. There are multiple programs that have taught patients some of these behavioral strategies; however, it is not clear which strategies patients find to be the most useful. The purpose of this study was to examine preliminary outcomes after completion of a six-week integrative group for weight management. Retrospective chart reviews were conducted of 51 patients who completed an integrative, psychological weight management group. Patients were mailed surveys 1-2 years after completion of the group assessing for current problematic eating behaviors (i.e. emotional eating and food addiction), satisfaction with treatment, and skills they continue to use. The majority of patients lost weight, were satisfied with the group, found the group to be helpful, and felt confident they could maintain behavior changes. The strategies patients most commonly continued to use post-group included mindful eating, keeping a food diary, carrying out an exercise plan, regular weigh-ins, and planning for social eating. The number of food addiction symptoms decreased from pre- to post-group. An integrative psychological weight management group may provide patients with skills and confidence to assist with managing problematic eating behaviors and weight loss.

Application of Mindfulness in a Tier 3 Obesity Service Improves Eating Behavior and Facilitates Successful Weight Loss

CONTEXT

Mindfulness strategies may facilitate healthier eating behavior but have not previously been studied in a United Kingdom-based tier 3 obesity service.

OBJECTIVE

To demonstrate the clinical effectiveness of mindfulness as part of newly created group sessions within a tier 3 obesity service.

METHODS

Recruitment of participants (n = 53, including n = 33 completers) from patients attending a tier 3-based obesity service at University Hospitals Coventry and Warwickshire. Each participant attended four group sessions, at which mindfulness-based eating behavior strategies were taught. Self-reported eating behavior and body weight were assessed at baseline and following completion of attendance at the group sessions. Paired-sample t tests were performed. P < 0.05 was considered significant. Data are reported for the 33 completers. Weight difference was assessed in a retrospective control group of 33 patients who did not attend the group sessions but received the standard multidisciplinary input.

RESULTS

There were statistically significant improvements (P = 0.009) in self-reported eating behavior [driven by improvements in "fast-foodism" (P = 0.031)] and reduction in body weight [3.06 kg (SD 5.2 kg), P = 0.002] at 6 months following completion of the group sessions. This was statistically more (P = 0.036) than 6-month weight loss in the control group (0.21 kg). Participants reported improved self-esteem and confidence in self-management of body weight.

CONCLUSION

Application of mindfulness-based eating behavior strategies, taught at group sessions within a tier 3 obesity service, resulted in significant improvement in eating behavior, and facilitated subsequent weight loss over 6 months. Such a strategy has potential for scalability to the wider obese population.

Psychosocial Concerns Following Bariatric Surgery: Current Status

PURPOSE OF REVIEW

The purpose of this paper is to review the current status of research on psychosocial concerns following bariatric surgery.

RECENT FINDINGS

Bariatric surgery has a positive overall impact on weight and obesity-related comorbidities, as well as a positive short-term impact on mental health and psychosocial functioning. Nonetheless, research has documented a number of different psychosocial concerns that may emerge following surgery including maladaptive eating, substance use disorders, suicide, lack of social support, and excess skin. Moreover, special populations of patients may have distinctive psychosocial concerns based on sociodemographic factors such as age or severity of obesity. Available studies suggest that psychosocial interventions have a positive impact on post-surgery outcomes, particularly maladaptive eating. However, research is limited, and long-term data are lacking. Monitoring patients after bariatric surgery for negative psychosocial outcomes is warranted. Research is needed to develop and evaluate personalized approaches to optimize long-term weight loss and psychosocial adjustment.

Mindfulness-based interventions and their effects on emotional clarity: A systematic review and meta-analysis

BACKGROUND

An inability to identify or describe internal emotional experience has been linked to a range of affective disorders. Despite burgeoning research on mindfulness-based interventions and their possible effects on emotion regulation, the effects of such interventions on emotional clarity is unclear. This review examines the evidence for the effect of mindfulness-based interventions on self-reported emotional clarity.

METHOD

Published studies indexed by PsycINFO, PubMed and Scopus, as available in April 2017, were systematically reviewed. Interventions that included mindfulness practice or philosophy, and reported a suitable measure of emotional clarity at pre- and post-intervention were selected. A random-effects meta-analysis was performed. Subgroup comparisons were also conducted to test for differences between clinical and non-clinical samples, between specific and approximate measures of emotional clarity, and between controlled and uncontrolled trials.

RESULTS

Seventeen studies met the criteria for inclusion. The overall estimated effect size for pre- to post-intervention was small to moderate, Hedges' g = 0.42, 95% CI [0.25, 0.59] and for between groups results was small to large, Hedges' g = 0.52, 95% CI [0.15, 0.90].

LIMITATIONS

Studies varied substantially in design quality and study characteristics. Furthermore, while interventions in the reviewed studies all had mindfulness components, many had other components in addition to mindfulness. Consequently, this review is limited by the heterogeneity of studies and results should be interpreted with caution.

CONCLUSIONS

There is preliminary evidence to suggest that mindfulness-based interventions may increase emotional clarity. However, more homogenous and targeted experiments are required to confirm these initial findings.

Greater mindful eating practice is associated with better reversal learning

Mindfulness-based interventions are thought to reduce compulsive behavior such as overeating by promoting behavioral flexibility. Here the main aim was to provide support for mindfulness-mediated improvements in reversal learning, a direct measure of behavioral flexibility. We investigated whether an 8-week mindful eating intervention improved outcome-based reversal learning relative to an educational cooking (i.e., active control) intervention in a non-clinical population. Sixty-five healthy participants with a wide BMI range (19–35 kg/m²), who were motivated to change their eating habits, performed a deterministic reversal learning task that enabled the investigation of reward- and punishment-based reversal learning at baseline and following the intervention. No group differences in reversal learning were observed. However, time invested in the mindful eating, but not the educational cooking intervention correlated positively with changes in reversal learning, in a manner independent of outcome valence. These findings suggest that greater amount of mindfulness practice can lead to increased behavioral flexibility, which, in turn, might help overcome compulsive eating in clinical populations.

Project HELP: a Remotely Delivered Behavioral Intervention for Weight Regain after Bariatric Surgery

BACKGROUND

Weight regain following bariatric surgery is common and potentially compromises the health benefits initially attained after surgery. Poor compliance to dietary and physical activity prescriptions is believed to be largely responsible for weight regain. Patients may benefit from developing specialized psychological skills necessary to engage in positive health behaviors over the long term. Unfortunately, patients often face challenges to physically returning to the bariatric surgery program for support in developing and maintaining these behaviors. Remotely delivered interventions, in contrast, can be conveniently delivered to the patient and have been found efficacious for a number of health problems, including obesity. To date, they have received little attention with bariatric surgery patients. The study aimed to evaluate a newly developed, remote acceptance-based behavioral intervention for postoperative weight regain.

METHODS

Patients at least 1.5 years out from surgery who experienced postoperative weight regain were recruited to receive the 10-week intervention. Participants were assessed at baseline, mid-treatment, post-treatment, and at 3-month follow-up.

RESULTS

Support for the intervention's feasibility and acceptability was achieved, with 70 % retention among those who started the program and a high mean rating (4.7 out of 5.0) of program satisfaction among study completers. On average, weight regain was reversed with a mean weight loss of 5.1 ± 5.5 % throughout the intervention. This weight loss was maintained at 3-month follow-up. Significant improvements in eating-related and acceptance-based variables also were observed.

CONCLUSIONS

This pilot study provides initial support for the feasibility, acceptability, and preliminary efficacy of a remotely delivered acceptance-based behavioral intervention for postoperative weight regain.

A Pilot Study of an Acceptance-Based Behavioral Intervention for Weight Regain After Bariatric Surgery

BACKGROUND

Tens of thousands of bariatric surgery patients each year experience sub-optimal weight loss, significant regain, or both. Weight regain can contribute to a worsening of weight-related co-morbidities, and for some, leads to secondary surgical procedures. Poor weight outcomes have been associated with decreased compliance to the recommended postoperative diet. Decreased compliance may be partially due to a lack of psychological skills necessary to engage in healthy eating behaviors over the long term, especially as the effects of surgery (on appetite, hunger, and desire for food) decrease. Many behavioral interventions do not sufficiently address these challenges and often have limited effectiveness. The study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness of a novel 10-week acceptance-based behavioral intervention to stop postoperative weight regain.

METHODS

A sample of bariatric surgery patients (n = 11) who regained at least 10 % of their maximum lost postoperative weight was recruited. All participants received the intervention, which emphasized psychological skills thought to be integral to successful weight control post-surgery.

RESULTS

The intervention was shown to be feasible and acceptable, with 72 % retention and high mean rating (4.25 out of 5.00) of program satisfaction among completers. Weight regain was stopped, and even reversed, with a mean total body weight loss of 3.58 ± 3.02 % throughout the 10-week intervention. There were also significant improvements in eating-related and acceptance-related variables.

CONCLUSIONS

These findings provide initial support for the use of a psychological acceptance-based intervention for weight regain in bariatric surgery patients.

A Randomised Controlled Comparison of Second-Level Treatment Approaches for Treatment-Resistant Adults with Bulimia Nervosa and Binge Eating Disorder: Assessing the Benefits of Virtual Reality Cue Exposure Therapy

A question that arises from the literature on therapy is whether second-level treatment is effective for patients with recurrent binge eating who fail first-level treatment. It has been shown that subjects who do not stop binge eating after an initial structured cognitive-behavioural treatment (CBT) programme benefit from additional CBT (A-CBT) sessions; however, it has been suggested that these resistant patients would benefit even more from cue exposure therapy (CET) targeting features associated with poor response (e.g. urge to binge in response to a cue and anxiety experienced in the presence of binge-related cues). We assessed the effectiveness of virtual reality-CET as a second-level treatment strategy for 64 patients with bulimia nervosa and binge eating disorder who had been treated with limited results after using a structured CBT programme, in comparison with A-CBT. The significant differences observed between the two groups at post-treatment in dimensional (behavioural and attitudinal features, anxiety, food craving) and categorical (abstinence rates) outcomes highlighted the superiority of virtual reality-CET over A-CBT. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

A structured literature review on the role of mindfulness, mindful eating and intuitive eating in changing eating behaviours: effectiveness and associated potential mechanisms

The role of mindfulness, mindful eating and a newer concept of intuitive eating in modulating eating habits is an area of increasing interest. In this structured literature review, a summary of the current evidence is presented, together with details of interventions undertaken and the tools to measure outcomes. It is broad in scope given the emerging evidence base in this area. The review yielded sixty-eight publications: twenty-three interventions in obese/overweight populations; twenty-nine interventions in normal-weight populations; sixteen observational studies, three of which were carried out in overweight/obese populations. Mindfulness-based approaches appear most effective in addressing binge eating, emotional eating and eating in response to external cues. There is a lack of compelling evidence for the effectiveness of mindfulness and mindful eating in weight management. Mindfulness-based approaches may prevent weight gain. Reduced food intake was seen in some of the studies in overweight and obese populations, but this was less apparent in the studies in normal-weight populations. The evidence base for intuitive eating is limited to date and further research is needed to examine its potential in altering eating behaviours. Mindfulness appears to work by an increased awareness of internal, rather than external, cues to eat. Mindfulness and mindful eating have the potential to address problematic eating behaviours and the challenges many face with controlling their food intake. Encouraging a mindful eating approach would seem to be a positive message to be included in general weight management advice to the public.

Mindfulness-based interventions for adults who are overweight or obese: a meta-analysis of physical and psychological health outcomes

OBJECTIVE

The aim of this study was to evaluate the impact of mindfulness-based interventions on psychological and physical health outcomes in adults who are overweight or obese.

METHODS

We searched 14 electronic databases for randomized controlled trials and prospective cohort studies that met eligibility criteria. Comprehensive Meta-analysis software was used to compute the effect size estimate Hedge's g.

RESULTS

Fifteen studies measuring post-treatment outcomes of mindfulness-based interventions in 560 individuals were identified. The average weight loss was 4.2 kg. Overall effects were large for improving eating behaviours (g = 1.08), medium for depression (g = 0.64), anxiety (g = 0.62) and eating attitudes (g = 0.57) and small for body mass index (BMI; g = 0.47) and metacognition (g = 0.38) outcomes. Therapeutic effects for BMI (g = 0.43), anxiety (g = 0.53), eating attitudes (g = 0.48) and eating behaviours (g = 0.53) remained significant when examining results from higher quality randomized control trials alone. There was no efficacy advantage for studies exceeding the median dose of 12 h of face-to-face intervention. Studies utilizing an Acceptance and Commitment Therapy approach provided the only significant effect for improving BMI (g = 0.66), while mindfulness approaches produced great variation from small to large (g = 0.30-1.68) effects across a range of psychological health and eating-related constructs. Finally, the limited longitudinal data suggested maintenance of BMI (g = 0.85) and eating attitudes (g = 0.75) gains at follow-up were only detectable in lower quality prospective cohort studies.

CONCLUSIONS

Mindfulness-based interventions may be both physically and psychologically beneficial for adults who are overweight or obese, but further high-quality research examining the mechanisms of action are encouraged.

An exploratory study of Mindfulness Based Stress Reduction for emotional eating

Emotional eating is an important predictor of weight loss and weight regain after weight loss. This two part study's primary aim was to explore changes in emotional eating in a general population of individuals taking the Mindfulness Based Stress Reduction (MBSR) program, with a secondary aim to explore whether changes in mindfulness predicted changes in emotional eating. Self-reported survey data exploring these questions were collected before and after the intervention for two sequential studies (Study 1 and Study 2). While there were no control groups for either study, in both studies emotional eating scores following the MBSR were significantly lower than scores prior to taking the MBSR (p < 0.001; p < 0.001) In Study 2, changes in mindfulness were correlated with changes in emotional eating (r = 0.317, p = 0.004). These results suggest that MBSR may be an effective intervention for emotional eating, and that further research is warranted to examine effects on weight loss and maintenance.

A mindfulness-based intervention to control weight after bariatric surgery: Preliminary results from a randomized controlled pilot trial

OBJECTIVE

This study aimed to develop and test a novel mindfulness-based intervention (MBI) designed to control weight after bariatric surgery.

DESIGN

Randomized, controlled pilot trial.

SETTING

Beth Israel Deaconess Medical Center, Boston, MA, USA.

INTERVENTIONS

Bariatric patients 1-5 years post-surgery (n=18) were randomized to receive a 10-week MBI or a standard intervention.

MAIN OUTCOME MEASURES

Primary outcomes were feasibility and acceptability of the MBI. Secondary outcomes included changes in weight, eating behaviors, psychosocial outcomes, and metabolic and inflammatory biomarkers. Qualitative exit interviews were conducted post-intervention. Major themes were coded and extracted.

RESULTS

Attendance was excellent (6 of 9 patients attended ≥7 of 10 classes). Patients reported high satisfaction and overall benefit of the MBI. The intervention was effective in reducing emotional eating at 6 months (-4.9±13.7 in mindfulness vs. 6.2±28.4 in standard, p for between-group difference=0.03) but not weight. We also observed a significant increase in HbA1C (0.34±0.38 vs. -0.06±0.31, p=0.03). Objective measures suggested trends of an increase in perceived stress and symptoms of depression, although patients reported reduced stress reactivity, improved eating behaviors, and a desire for continued mindfulness-based support in qualitative interviews.

CONCLUSIONS

This novel mindfulness-based approach is highly acceptable to bariatric patients post-surgery and may be effective for reducing emotional eating, although it did not improve weight or glycemic control in the short term. Longer-term studies of mindfulness-based approaches may be warranted in this population.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02603601.

APOLO-Bari, an internet-based program for longitudinal support of bariatric surgery patients: study protocol for a randomized controlled trial

Background

Despite evidence of successful weight loss for bariatric surgery patients, some patients experience considerable weight regain over the long term. Given the strong association between post-surgery health behaviors and outcomes, aftercare intervention to address key behaviors appears to be a reasonable relapse-prevention strategy. As the burden of obesity rates increases in healthcare centers, an internet-based program appears to be a reasonable strategy for supporting bariatric surgery patients in the long term. The primary purpose of the current project is to develop and test the efficacy and perceived utility of APOLO-Bari.

Methods/design

This study is a randomized control trial, which will be conducted in two hospital centers in the North of Portugal; it includes a control group receiving treatment as usual and an intervention group receiving the APOLO-Bari program for one year in addition to treatment as usual. A total of 180 male and female participants who underwent bariatric surgery (gastric sleeve or gastric bypass surgery) for 12 to 20 months will be recruited. Both groups will complete a similar set of questionnaires at baseline, every 4 months until the end of the intervention, and at 6 and 12 months follow-up. Assessment includes anthropometric variables and psychological self-report measures. The primary outcome measure will be weight regain measured at the end of treatment, and at 6 and 12 months follow-up. The secondary aims are to test the cost-effectiveness of the intervention and to investigate psychological predictors and trajectories of weight regain. APOLO-Bari was developed to address the weight regain problem in the bariatric population by offering additional guidance to bariatric patients during the postoperative period. The program includes: (a) a psychoeducational cognitive-behavioral-based self-help manual, (b) a weekly feedback messaging system that sends a feedback statement related to information reported by the participant, and (c) interactive chat sessions scheduled with a trained psychologist in the field.

Discussion

APOLO-Bari may play an important role in broadening therapeutic reach to bariatric patients who would not otherwise have continuous support, with important implications for public health treatment.

Trial registration

Current Controlled Trials: ISRCTN37668662.

Food cue reactivity and craving predict eating and weight gain: a meta-analytic review

According to learning-based models of behavior, food cue reactivity and craving are conditioned responses that lead to increased eating and subsequent weight gain. However, evidence supporting this relationship has been mixed. We conducted a quantitative meta-analysis to assess the predictive effects of food cue reactivity and craving on eating and weight-related outcomes. Across 69 reported statistics from 45 published reports representing 3,292 participants, we found an overall medium effect of food cue reactivity and craving on outcomes (r = 0.33, p < 0.001; approximately 11% of variance), suggesting that cue exposure and the experience of craving significantly influence and contribute to eating behavior and weight gain. Follow-up tests revealed a medium effect size for the effect of both tonic and cue-induced craving on eating behavior (r = 0.33). We did not find significant differences in effect sizes based on body mass index, age, or dietary restraint. However, we did find that visual food cues (e.g. pictures and videos) were associated with a similar effect size to real food exposure and a stronger effect size than olfactory cues. Overall, the present findings suggest that food cue reactivity, cue-induced craving and tonic craving systematically and prospectively predict food-related outcomes. These results have theoretical, methodological, public health and clinical implications.

Impact of a CBT psychotherapy group on post-operative bariatric patients

Psychological difficulties for patients seeking bariatric surgery are greater and in the post-operative phase, a significant minority go on to experience significant psychosocial difficulties, increasing their risk of poorer post-operative adjustment and associated weight regain. 17 post-operative patients participated in an eight-week cognitive behavioral therapy (CBT) based psychotherapy group at the Ottawa Hospital. A pre-post design with a 3-month follow-up investigated the impact of the group on emotional eating, general as well as obesity-specific adjustment, psychological distress, and attachment. There were significant and meaningful improvements in patients’ level of psychological distress, perceived difficulties in their lives, and weight-related adjustment that were maintained at a 3-month follow-up period. Although statistical change was not significant, there were also meaningful improvements in emotional overeating and relationship anxiety and avoidance. The intervention also appeared to be acceptable to patients in that attendance and satisfaction were good. Findings suggest that a short-term CBT psychotherapy group led to significant and meaningful benefits in psychological wellbeing for post-surgical bariatric patients.

Stop regain: a pilot psychological intervention for bariatric patients experiencing weight regain

BACKGROUND

A subset of bariatric patients fails to achieve or maintain long-term successful weight loss. Psychological and behavioral factors contributing to poor long-term outcomes include decreased adherence to surgical eating guidelines, life stressors that derail weight maintenance, unhealthy eating patterns, and substance use.

OBJECTIVES

A 6-week pilot group behavioral intervention utilizing techniques of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) was developed to treat bariatric patients experiencing weight regain.

SETTING

Patients were treated at a large Midwestern academic medical center.

METHODS

Twenty-eight patients (93% female, 100% Caucasian) with a mean age of 53 and a mean BMI of 35.6 had regained an average of 17 kg or 37% of the weight lost after initially successful Roux-en-Y gastric bypass (RYGB). All patients completed the Structured Clinical Interview for DSM-IV-TR (SCID I) modules assessing mood and substance dependence, and completed a series of questionnaires before and after group treatment, with weekly assessment of depressive symptoms, binge eating, and alcohol use. Results were analyzed utilizing repeated measures ANOVA.

RESULTS

Weight decreased during the intervention by an average of 1.6 ± 2.38 kg (p ≤ 0.01). Level of depressive symptoms improved for treatment completers (p ≤ 0.01). Food records indicated that grazing patterns decreased (p ≤ 0.01) and subjective binge eating episodes decreased (p ≤ 0.03).

CONCLUSIONS

A 6-week pilot group behavioral intervention demonstrated an ability to help patients reverse their pattern of weight regain. Tailored behavioral interventions may be a useful treatment to enhance maintenance of long-term weight loss.

Measurement of disordered eating following bariatric surgery: a systematic review of the literature

Disordered eating is elevated in bariatric surgery patients and is a risk factor for poor surgical outcomes. A systematic review evaluated the definitions and measurement methods used to identify and assess disordered eating in patients following bariatric surgery. One hundred articles were identified featuring 35 questionnaires and 23 interviews. There were numerous variations to diagnostic criteria and amendments to measures to account for the post-surgical eating context. Only 20% of questionnaires and 4% of interviews had reported psychometric evaluation in post-surgery samples. Results highlight the need for a consistent definition of disordered eating and for current assessment measures to be (a) adapted to account for the altered gastrointestinal system in patients following surgery and (b) psychometrically evaluated in bariatric surgery patients.

Quasi-prospective, real-life monitoring of food craving post-bariatric surgery: comparison with overweight and normal weight women

Food cravings are common post-bariatric surgery, suggested as predictors of relapse and weight regain, but relatively unstudied, especially in the longer term. The present study investigated the frequency and nature of food craving experiences after gastric surgery in comparison with non-surgical control participants. Participants were 21 women, 4-38 months post-surgery (mean age = 44 years, 9 following gastric banding, 12 after Roux-en-Y gastric bypass), and two comparison samples of 39 overweight dieters and 33 normal weight non-dieters. They completed a food craving record after every food craving, a daily mood assessment and a food diary over a 7-day period. Over the 299 craving episodes, savoury foods were the most commonly craved (40% of craving events), followed by chocolate (31%). Post-bariatric patients reported more and stronger cravings than normal weight non-dieters but at a similar frequency and strength to overweight dieters. Neither hunger nor negative mood distinguished the food cravings of post-bariatric patients from those of comparison participants, nor did the proportion that led to eating (58%). Food cravings should be anticipated post-bariatric surgery but no more so at 12 months post-surgery than by other overweight or obese individuals. Food cravings are not the product of extreme hunger nor do they have the connection with negative mood seen in disordered eating. In addition, the ability to fulfil cravings by eating the craved food is reduced by the surgery itself, although the duration of surgical restraint is uncertain.

Mindfulness-based interventions for obesity-related eating behaviours: a literature review

Mindfulness-based interventions (MBIs) targeting eating behaviours have gained popularity in recent years. A literature review was conducted to determine the effectiveness of MBIs for treating obesity-related eating behaviours, such as binge eating, emotional eating and external eating. A search protocol was conducted using the online databases Google Scholar, PubMed, PsycINFO and Ovid Healthstar. Papers were required to meet the following criteria to be included in this review: (i) describe a MBI or the use of mindfulness exercises as part of an intervention; (ii) include at least one obesity-related eating behaviour as an outcome; (iii) include quantitative outcomes; and (iv) be published in English in a peer-reviewed journal. A total of N = 21 papers were included in this review. Interventions used a variety of approaches to implement mindfulness training, including combined mindfulness and cognitive behavioural therapies, mindfulness-based stress reduction, acceptance-based therapies, mindful eating programmes, and combinations of mindfulness exercises. Targeted eating behaviour outcomes included binge eating, emotional eating, external eating and dietary intake. Eighteen (86%) of the reviewed studies reported improvements in the targeted eating behaviours. Overall, the results of this first review on the topic support the efficacy of MBIs for changing obesity-related eating behaviours, specifically binge eating, emotional eating and external eating.

Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: a systematic review

Mindfulness-based approaches are growing in popularity as interventions for disordered eating and weight loss. Initial research suggests that mindfulness meditation may be an effective intervention for binge eating; however, no systematic review has examined interventions where mindfulness meditation was the primary intervention and no review has examined its effect on subclinical disordered eating or weight. Using the PRISMA method for systematic reviews, we reviewed 14 studies that investigated mindfulness meditation as the primary intervention and assessed binge eating, emotional eating, and/or weight change. Results suggest that mindfulness meditation effectively decreases binge eating and emotional eating in populations engaging in this behavior; evidence for its effect on weight is mixed. Additional research is warranted to determine comparative effectiveness and long-term effects of mindfulness training.

Which facets of mindfulness are related to problematic eating among patients seeking bariatric surgery?

There has been growing research indicating the potential positive benefits of mindfulness-based interventions for obesity, but few studies have examined the relationship of mindfulness processes to obesity-related behaviors, particularly among clinical populations such as bariatric surgery candidates. The current study examined the relationship of specific mindfulness facets to a variety of problematic eating behaviors assessed through diagnostic interviews in a clinical sample of 820 patients seeking bariatric surgery. Results indicated that greater mindfulness on specific facets, particularly acting with awareness, was related to less binge and emotional eating. Greater mindfulness was also related, though less consistently, to less habitual overeating and grazing. The observing facet was generally unrelated to problematic eating, but in a few cases being more observant related to having greater eating problems. The results of the study and future directions are discussed in relation to research on problematic eating in obesity and mindfulness-based interventions.

Emerging psychological treatments in the field of eating disorders

Few treatments for eating disorders have established a base of empirical support, and those that have are still limited by high dropout rates and low abstinence rates. Thus, there is a critical need for innovative eating disorder treatments to fill this gap. The past decade has seen a surge in the development of novel treatments that address eating pathology. This review provides an overview of the emerging psychological treatments for eating disorders, including descriptions of the therapeutic rationales, treatment techniques, and research support. The review will cover face-to-face interventions that are provided in the context of individual or group psychotherapy. Treatments included in this review were organized into the following six categories based on their underlying therapeutic rationales: (1) cognition-focused approaches, (2) emotion regulation approaches, (3) exposure-based approaches, (4) motivational enhancement, (5) integrative approaches, and (6) family- and couple-based interventions.