Understanding outcomes in family-based treatment for adolescent anorexia nervosa: a network approach

Examination of PTSD symptom networks over the course of cognitive processing therapy

OBJECTIVES

Cognitive processing therapy (CPT) is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, little is known about how interrelationships between PTSD symptoms change over the course of treatment. The current study examined baseline, midtreatment, and posttreatment PTSD symptom networks during CPT for PTSD.

METHOD

Adults with PTSD (n = 107) received 12 sessions of CPT as part of a randomized trial. Self-reported PTSD symptoms were assessed at pretreatment, midtreatment, and posttreatment, and network analysis was used to examine the interrelationships between symptoms at these three timepoints. Linear regression was conducted to examine whether any baseline symptoms or midpoint symptoms predicted overall treatment change.

RESULTS

In the baseline PTSD network, feelings of detachment and feeling upset at reminders of the trauma were central to the symptom network. These symptoms were no longer central at midtreatment, possibly suggesting that CPT quickly reduces the importance of these symptoms. These findings were consistent with regression results that, after accounting for multiple comparisons, high baseline scores of feeling upset at trauma reminders predicted later treatment change. At the conclusion of treatment, strong negative emotions were the most central symptom and may be most important in maintaining or lowering other PTSD symptoms at the conclusion of treatment.

CONCLUSIONS

Though replication is necessary, these findings offer insights into identifying which symptoms may be most predictive of treatment outcomes and the course by which CPT reduces PTSD symptoms. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Remote family education and support program for parents of patients with adolescent and early adulthood eating disorders based on interpersonal psychotherapy: study protocol for a pilot randomized controlled trial

BACKGROUND

In cases of adolescent and early adulthood eating disorders, despite the importance of the patients' relationship with their parents, conflict and confusion frequently occur among them. Interpersonal psychotherapy (IPT) is a present-focused psychotherapy that emphasizes the interpersonal context of symptoms. We developed a remote family education and support program exclusively for parents of patients with eating disorders, based on the principle of IPT. The use of IPT is expected to reduce conflicts in the patient-parent relationship. Consequently, parents will be better able to listen to patients, and patients will be better able to express their thoughts and desires. In this study, we describe the protocol for a randomized controlled trial designed to examine the effectiveness of this program in promoting effective communication in their home based on active listening skills of parents of patients with adolescent and early adulthood eating disorders.

METHODS

Participants will be parents of patients aged 12-29 years with adolescent and early adulthood eating disorders. Individually randomized, parallel-group trial design will be employed. Seventy participants will be allocated to one of two treatment conditions: (1) remote family education and support program (four, 150 min weekly group sessions) for parents plus treatment-as-usual for patients (consultation by physicians or no treatment), or (2) waiting for the control condition (parents will wait to start the program for 8 weeks) plus treatment-as-usual for patients. The primary outcome measure will be parents' active listening ability as measured by the Active Listening Attitude Scale at 8 weeks after randomization. Additionally, perception of social support (Social Provision Scale-10 item), loneliness (UCLA Loneliness Scale), mental health status (K6), family function (Family Assessment Device), and parent-evaluated eating disorder symptoms (Anorectic Behavior Observation Scale) will be assessed. Data from the intention-to-treat sample will be analyzed 8 weeks after randomization.

DISCUSSION

This is the first study to evaluate the effectiveness of a family education and support program for parents of patients with adolescent and early adulthood eating disorders based on IPT. If this type of intervention is effective, although indirect, it could be a new support method for this patient population.

TRIAL REGISTRATION

Clinical Trials. gov ID NCT05840614.

The Maudsley model of anorexia nervosa treatment for adolescents and emerging adults: A multi-centre cohort study

OBJECTIVE

The aim of this study was examining the efficacy of the Maudsley Model of Anorexia Nervosa Treatment for Adolescents and Young Adults (MANTRa) compared to individual psychotherapy that can be considered as standard in Austria (TAU-O).

METHOD

In this cohort study, 92 patients between 13 and 21 years suffering from full-syndrome, atypical or weight-restored anorexia nervosa (AN) received either 24-34 individual MANTRa sessions (n = 45) or TAU-O (n = 47). Outcome variables were age- and sex-related BMI, eating disorder and comorbid psychopathology at 6-, 12- and 18-month post baseline as well as acceptability of treatment and therapeutic alliance.

RESULTS

Both treatments resulted in significant improvements in age- and sex related BMI and reductions in eating disorder and comorbid psychopathology over time with significant differences between groups in favour of MANTRa. The percentage of participants with fully remitted AN was significantly higher in the MANTRa group compared to TAU-O at 18-month follow-up (MANTRa: 46% vs. TAU-O: 16%, p = 0.006). Satisfaction with both treatments was high.

CONCLUSIONS

MANTRa is an effective treatment programme for adolescents and young adults with AN. Randomised controlled trials comparing MANTRa with existing treatments are necessary.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov (Identifier: NCT03535714).

Multifamily therapy for adolescent eating disorders: a study of the change in eating disorder symptoms from start of treatment to follow-up

BACKGROUND

This study aimed to evaluate multifamily therapy (MFT) for adolescents with eating disorders (EDs) in a clinical setting, by presenting the outcome of families participating in this treatment at a specialist ED service. MFT was an adjunct to treatment at local mental health services. In particular, the study aimed to present the change in eating disorder symptoms and psychological distress from before to after treatment and at a 6 months follow-up.

METHODS

Participants were 207 adolescents receiving outpatient MFT (10 or 5 months) at Oslo University Hospital in Norway between 2009 and 2022. Adolescents had heterogeneous ED presentations, with a preponderance of anorexia nervosa (AN) and atypical AN. All participants completed pre- and post-treatment questionnaires [The eating disorder examination questionnaire (EDE-Q) and the strengths and difficulties questionnaire (SDQ)]. 142 adolescents additionally completed the same questionnaires at 6 months follow-up. Weight and height were measured at all time points.

RESULTS

Linear mixed model analyses showed that from start of treatment to follow-up, there was a significant increase in BMI percentile (p < 0.001) and a significant decrease in EDE-Q global score (p < 0.001) and SDQ total score (p < 0.001).

CONCLUSIONS

The study shows that adolescents with an eating disorder who received adjunct outpatient MFT in a real world clinical setting, experienced reductions in ED symptoms comparable to that found in a randomized controlled trial.

TRIAL REGISTRATION

The data used in this study was collected as part of routine clinical procedures for quality assurance and trial registration is therefore not required.

Predictors of caregiver burden before starting family-based treatment for adolescent anorexia nervosa and associations with weight gain during treatment

PURPOSE

Caregivers play a pivotal role in the success of family-based treatment (FBT) for anorexia nervosa (AN). Caregiver burden is frequently demonstrated in eating disorders (EDs) and may impact FBT outcomes. This study examined factors associated with caregiver burden before starting FBT and whether pre-treatment caregiver burden was associated with weight gain during FBT.

METHODS

Participants included 114 adolescents with AN or atypical AN (mean age = 15.6 years, SD = 1.4) and a primary caregiver (87.6% mothers) who received FBT in the United States. Before starting treatment, participants completed self-report measures of caregiver burden (via the Eating Disorder Symptom Impact Scale), caregiver anxiety, caregiver depression, and ED symptoms. Clinical characteristics and percentage of target goal weight (%TGW) at FBT session 1 and 3 and 6 months after starting treatment were obtained via retrospective chart review. Hierarchical regressions examined predictors of caregiver burden before FBT initiation. Associations between pre-treatment caregiver burden and %TGW gain at 3 and 6 months after starting FBT were assessed with hierarchical regressions.

RESULTS

Caregiver anxiety (p < 0.001), family history of EDs (p = 0.028), adolescent mental health treatment history (p = 0.024), and ED symptoms (p = 0.042) predicted caregiver burden before starting FBT. Pre-treatment caregiver burden was not associated with %TGW gain at 3 or 6 months. Males demonstrated less %TGW gain than females at 3 months (p = 0.010) and 6 months (p = 0.012).

CONCLUSION

Proactively evaluating caregiver burden before starting FBT is suggested. Providing recommendations and/or referrals for identified caregiver vulnerabilities could indirectly impact FBT progress. Males in FBT could require longer courses of treatment and extra vigilance to this demographic is suggested.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Eating disorder psychopathology and resilience in Iranian college students: A network analysis

OBJECTIVE

Eating disorder (ED) psychopathology is common among Iranian college students. Resilience (i.e., the ability to bounce back and adapt in the face of adverse and stressful conditions) has been found to be a protective factor against ED psychopathology in the West. However, no research to date has examined resilience as a protective factor against ED psychopathology in Iran. The current study used network analysis to examine an ED and resilience network in an Iranian sample.

METHOD

Participants were Iranian college students (N = 478) who completed the Farsi-Eating Disorder Examination-Questionnaire and Farsi-Brief Resilience Scale. We estimated a network of ED symptoms and resilience processes and identified central and bridge symptoms.

RESULTS

Central ED and resilience nodes were discomfort in seeing one's own body, feeling guilty about eating due to shape/weight, and thinking about shape and weight making it difficult to concentrate. Having a hard time making it through stressful events bridged with binge eating and fear of losing control over eating.

CONCLUSION

Processes related to managing stress and binge eating appear to maintain the association between ED symptoms and resilience processes.

A network analysis in adolescent anorexia nervosa exploring the connection between both patient and carer reactions and outcome

OBJECTIVE

This paper used network analysis to test the associations between eating disorder-related psychopathology and carers' responses to anorexia nervosa symptoms in adolescents. Additionally, the prognostic value of central and bridge network nodes was explored.

METHOD

This is a secondary analysis of a three-armed randomised-controlled-trial of adolescents with anorexia nervosa (n = 149) and their primary carer (n = 149) who were allocated to either treatment as usual (TAU), or one of two versions of a carer skills intervention (ECHO) added to TAU. A network analysis was run in the full sample. The prognostic role of central and bridge nodes was tested through multiple regression analyses.

RESULTS

Carers' depression and emotional over-involvement, as well as patients' depression showed the highest strength centrality. Patients' depression and carers' accommodation exhibited the highest bridge expected influence. Across the full sample, and in the ECHO group, carers' accommodation predicted patients' higher body mass index (BMI), while patients' depression predicted worse psychosocial functioning at 1-year follow-up. In the ECHO group, higher carers' depression also predicted lower BMI.

CONCLUSIONS

Carers' accommodation and depression in both carers and patients were involved in the maintenance of psychopathology in adolescents with anorexia nervosa. Depression in both patients and carers is a potential treatment target for family interventions.

Promising effect of multi-family therapy on BMI, eating disorders and perceived family functioning in adolescent anorexia nervosa: an uncontrolled longitudinal study

This contribution reports on the results of an uncontrolled longitudinal study investigating the effects of a Multi-Family Therapy (MFT) as treatment for adolescent Anorexia Nervosa (AN) and the role played by perceived family functioning in these effects. 150 patients (144 females) and their families took part in an MFT and were assessed at the beginning, middle, end of the therapy, as well as 6 and 12 months after the end of therapy. BMI, eating disorders symptomatology (EDI-II) and perceived family functioning (FAD) all improved over the time of MFT, and these benefits remained at both times of follow-up. Ultimately, we found that the improvement of some dimensions of family functioning (i.e., roles, communication, and general family functioning) mediated the improvement of several dimensions of symptomatology (i.e., ineffectiveness, impulsivity, social insecurity, interpersonal distrust). These observations provide further support for MFT as useful for improving mental health, weight restoration, and perceived family functioning of adolescents with AN.

Psychopathology predicts mental but not physical bariatric surgery outcome at 3-year follow-up: a network analysis study

PURPOSE

This study aimed to explore the psychopathological variables that may predict bariatric surgery outcomes after 3 years.

METHODS

One hundred ninety-six candidates for bariatric surgery completed self-report questionnaires to assess eating attitudes, eating disorder (ED)-related psychopathology, affective symptoms, interpersonal and psycho-social functioning. One-hundred patients repeated this assessment 3 years after bariatric surgery. A network analysis was run including the pre-surgical measurements in the network. A composite score derived from the combination of the most central network nodes, as well as clinical and socio-demographical variables, was included in a multivariate regression analysis with weight loss, ED psychopathology and psycho-social functioning as outcomes.

RESULTS

Depression, stress, and shape concerns were the most central network nodes. The composite network score predicted higher ED psychopathology and worse psycho-social functioning at 3-year follow-up, but not weight loss. Higher age, restricting type of bariatric surgery and higher pre-operative BMI were further predictors of reduced weight loss and greater ED psychopathology.

CONCLUSIONS

Affective symptoms and shape concern play a central role in the psychopathology of candidates to bariatric surgery and predict post-surgery ED psychopathology and psycho-social functioning. These variables may allow to identify patients with higher pre-operative risk and in need of further psycho-social interventions.

LEVEL OF EVIDENCE

III, evidence obtained from well-designed cohort study.

Network analysis studies in patients with eating disorders: A systematic review and methodological quality assessment

INTRODUCTION

Network psychometrics has been enthusiastically embraced by researchers studying eating disorders (ED), but a rigorous evaluation of the methodological quality of works is still missing. This systematic review aims to assess the methodological quality of cross-sectional network analysis (NA) studies conducted on ED clinical populations.

METHODS

PRISMA and PICOS criteria were used to retrieve NA studies on ED. Methodological quality was evaluated based on five criteria: variable-selection procedure, network estimation method, stability checks, topological overlap checks, and handling of missing data.

RESULTS

Thirty-three cross-sectional NA studies were included. Most studies focused on populations that were female, white and, with an anorexia nervosa (AN) diagnosis. Depending on how many criteria were satisfied, 27.3% of studies (n = 9) were strictly adherent, 30.3% (n = 10) moderately adherent, 33.3% (n = 11) sufficiently adherent, and 9.1% (n = 3) poorly adherent. Missing topological overlap checks and not reporting missing data represented most unreported criteria, lacking, respectively, in 63.6% and 48.5% of studies.

CONCLUSIONS

Almost all reviewed cross-sectional NA studies on ED report those methodological procedures (variable-selection procedure, network estimation method, stability checks) necessary for a network study to provide reliable results. Nonetheless these minimum reporting data require further improvement. Moreover, elements closely related to the validity of an NA study (controls for topological overlap and management of missing data) are lacking in most studies. Recommendations to overcome such methodological weaknesses in future NA studies on ED are discussed together with the need to conduct NA studies with longitudinal design, to address diversity issues in study samples and heterogeneity of assessment tools.

PUBLIC SIGNIFICANCE

The present work aims to evaluate the quality of ED NA studies to support applications of this approach in ED research. Results show that most studies adopted basic procedures to produce reliable results; however, other important procedures linked to NA study validity were mostly neglected. Network methodology in ED is extremely promising, but future studies should consistently include topological overlap control procedures and provide information on missing data.

Eating disorder psychopathology and negative affect in Iranian college students: a network analysis

BACKGROUND

ED psychopathology is becoming more prevalent in Iran. Negative affect has been found to be an important risk factor in eating disorder (ED) onset in research conducted in Western countries, and is also emerging as a potential vulnerability factor to ED psychopathology in Iran. Network theory offers a novel framework to understand the association between negative affect and ED psychopathology in Iran. The primary aim of the current study was to use network analysis to identify bridge symptoms (i.e., symptoms that activate or weaken symptoms in another cluster) across a negative affect and ED psychopathology network among Iranian college students. We also aimed to identify core symptoms (i.e., nodes that demonstrate the strongest connections to other nodes).

METHOD

Participants were Iranian college students (n = 637; 60.3% women) who completed the Farsi-eating disorder examination-questionnaire and Farsi-negative affect. We estimated a network of ED symptoms and negative affective states and identified bridge and central symptoms.

RESULTS

Hostility and shame emerged as central bridge symptoms across the negative affect and ED psychopathology clusters. The most central nodes were strong desire to lose weight, definite fear of losing control over eating, and binge eating episodes.

CONCLUSION

The negative affective states of hostility and shame may increase vulnerability to ED psychopathology among Iranian college students. Findings have important implications for ED prevention programs that should be examined in future research.

Network-based methods for psychometric data of eating disorders: A systematic review

BACKGROUND

Network science represents a powerful and increasingly promising method for studying complex real-world problems. In the last decade, it has been applied to psychometric data in the attempt to explain psychopathologies as complex systems of causally interconnected symptoms. One category of mental disorders, relevant for their severity, incidence and multifaceted structure, is that of eating disorders (EDs), serious disturbances that negatively affect a person's eating behavior.

AIMS

We aimed to review the corpus of psychometric network analysis methods by scrutinizing a large sample of network-based studies that exploit psychometric data related to EDs. A particular focus is given to the description of the methodologies for network estimation, network description and network stability analysis providing also a review of the statistical software packages currently used to carry out each phase of the network estimation and analysis workflow. Moreover, we try to highlight aspects with potential clinical impact such as core symptoms, influences of external factors, comorbidities, and related changes in network structure and connectivity across both time and subpopulations.

METHODS

A systematic search was conducted (February 2022) on three different literature databases to identify 57 relevant research articles. The exclusion criteria comprehended studies not based on psychometric data, studies not using network analysis, studies with different aims or not focused on ED, and review articles.

RESULTS

Almost all the selected 57 papers employed the same analytical procedures implemented in a collection of R packages specifically designed for psychometric network analysis and are mostly based on cross-sectional data retrieved from structured psychometric questionnaires, with just few exemptions of panel data. Most of them used the same techniques for all phases of their analysis. In particular, a pervasive use of the Gaussian Graphical Model with LASSO regularization was registered for in network estimation step. Among the clinically relevant results, we can include the fact that all papers found strong symptom interconnections between specific and nonspecific ED symptoms, suggesting that both types should therefore be addressed by clinical treatment.

CONCLUSIONS

We here presented the largest and most comprehensive review to date about psychometric network analysis methods. Although these methods still need solid validation in the clinical setting, they have already been able to show many strengths and important results, as well as great potentials and perspectives, which have been analyzed here to provide suggestions on their use and their possible improvement.

Lessons learned developing and testing family-based interoceptive exposure for adolescents with low-weight eating disorders

BACKGROUND

Anorexia nervosa (AN) usually develops in early adolescence and is characterized by high rates of morbidity and mortality. Family-based therapy (FBT) is the leading evidence-based treatment for adolescents with AN, but not all patients experience sufficient improvement. The purpose of this manuscript is to describe the development and subsequent experience with a Family-Based Interoceptive Exposure (FBT-IE) for adolescents with a broader form of low-weight eating disorders.

METHODS

The novel IE-based behavioral intervention is a six-session family-based treatment module designed to directly target and modify disgust by altering the prefrontal regulation of the insula response to aversive stimuli by decreasing visceral sensitivity (e.g., bloating). Each session teaches a new skill regarding tolerating distress to visceral sensations associated with disgust and an in-vivo "IE exercise," in which the family is provided with a meal replacement shake of unknown content and caloric density.

RESULTS

In this novel treatment, the patient learns to tolerate disgust in the context of a challenging food stimulus as a way to increase consumption of restricted foods outside of session.

CONCLUSION

We discuss successes and challenges executing this treatment with patients with low-weight eating disorders and propose future directions for the intervention.