Radically open DBT: Targeting emotional loneliness in Anorexia Nervosa

The loneliness factor in eating disorders: Implications for psychopathology and biological signatures

OBJECTIVES

Eating disorders (ED) are severe psychiatric conditions. While the biological consequences of EDs are well established, including an increase in inflammatory biomarkers, the influence of psychological factors, such as loneliness, has only recently gained attention in research. Loneliness has been associated with more severe psychopathology in ED patients, while its association with inflammatory biomarkers has only been explored in the general population. For these reasons, we aimed to investigate any possible associations between psychological features, trauma, and inflammatory biomarkers with loneliness in people with ED.

METHODS

This study examined the interaction between loneliness, eating psychopathology, and biological markers in people with EDs. A group of 97 female patients with various diagnoses of ED was assessed for loneliness, general and eating psychopathology, traumatic history during childhood, and clinical biomarkers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and urinary-free cortisol (UFC).

RESULTS

The results indicated that individuals with ED who reported moderate to severe loneliness also displayed greater general psychopathology (p = 0.001), weight concerns (p = 0.007), and physical neglect during childhood (p = 0.006). Furthermore, people with higher levels of loneliness also had higher inflammatory indexes (ESR p = 0.001, CRP p = 0.027) and were positively correlated with markers of stress reaction such as UFC (p < 0.05).

CONCLUSION

The findings underscore the importance of considering loneliness in the assessment of individuals with an ED. We observed notable associations between loneliness and increased psychopathology (both general and specific to eating), as well as higher levels of inflammation and childhood physical neglect. Addressing loneliness may contribute to improving overall well-being and potentially support recovery. This consideration encompasses both psychological and physical factors that interplay in the clinical presentation of individuals.

Early evaluation of a DBT-informed online intervention for people with eating disorders

OBJECTIVES

Eating disorders (EDs) have a worldwide prevalence of 7.8%, with towering mortality rates and high healthcare costs. The current recommended treatment for EDs principally works by directly targeting ED thoughts and behaviours, but recovery rates are low. A multifaceted link between difficulties with emotions and EDs is now widely established, and newer third-wave therapies that aim to address these underlying emotion difficulties are promising. The current study piloted an online emotion self-help intervention which was co-developed with clinicians and people with lived experienced of EDs. The intervention aimed to specifically address difficulties with emotion identification and regulation, as well as unhelpful beliefs about emotions, which are believed to give rise to and maintain ED thoughts and behaviours.

METHOD

We recruited 39 people with self-reported EDs to test this intervention over a one-week period. Our participants were asked to complete a series of questionnaires measuring emotion processes and psychopathology on Day 1 (T1) before being given access to the intervention. Participants were then asked to practice the newly acquired skills for seven days, before taking the same questionnaires on Day 9 (T2). We also asked participants to qualitatively report on their experience of the intervention.

RESULTS

We found significant improvements in ED psychopathology (ED-15), depression (PHQ-9), and anxiety (GAD-7) pre- to post-intervention, with medium to large effect sizes. All our emotion variables namely alexithymia (TAS-20), difficulties regulating emotions (DERS-SF), and unhelpful beliefs about emotions (EBQ) also showed significant changes post-intervention with medium to large effect sizes. Most importantly, changes in emotion regulation processes were linked to improved eating psychopathology. The qualitative analysis corroborated this finding, highlighting how the intervention helped them form new beliefs about emotions, which helped them reduce ED behaviours.

DISCUSSION

Significant improvements in emotion processing and regulations, as well as psychopathology, along with positive qualitative feedback, suggest that the intervention effectively met its aims of increasing awareness of the link between emotions and eating psychopathology, providing help to identify and regulate emotions, and normalising emotional experiences. While our results are promising, further research is required to assess its effectiveness longer term and in clinical settings.

Investigating the Theory of Clinical Perfectionism in a Transdiagnostic Eating Disorder Sample Using Network Analysis

Eating disorders are deadly psychiatric illnesses, with treatments working for less than half of individuals who seek treatment. The transdiagnostic theory of eating disorders proposes that eating disorders share similar maintaining symptoms, such as what this theory calls clinical perfectionism (i.e., high levels of concern over mistakes and personal standards). However, it has been difficult to examine the interrelationship of specific aspects of perfectionism, beyond assessing moderation effects, which have generally not found support for the theory of clinical perfectionism in eating disorders. Thus, we used network analysis to test the theory of perfectionism by testing the interrelationships between maladaptive perfectionism facets (concern over mistakes, personal standards, parental criticism, parental expectations, and personal standards) and eating disorder symptoms in 397 individuals diagnosed with an eating disorder. Concern over mistakes was a central symptom and demonstrated the strongest interrelationships with eating disorder symptoms compared to the other aspects of perfectionism, connecting to eating concerns and cognitive restraint. Objective binge eating had a strong negative connection to personal standards. We identified specific central symptoms and illness pathways of perfectionism, which partially supports the theory of clinical perfectionism. Results, if replicated, may suggest that concern over mistakes might be best reconceptualized as part of eating disorder pathology and be targeted to improve treatment outcomes for eating disorders.

Emotional reactivity and prosocial behaviour in response to witnessing social exclusion in adolescents with eating disorders and healthy controls

BACKGROUND

Prosocial behaviour can promote positive social interactions and it is a key skill in adolescence. People with emotional problems or psychiatric disorders, such as people with eating disorders might have impairments in prosocial behaviour, due to broader documented difficulties in underlying processes (e.g., mentalizing).

METHODS

The aim of this study was to examine prosocial behaviour in adolescents with eating disorders compared to healthy controls, using a computerised behavioural task. Adolescents (N = 123) including patients with eating disorders (n = 61) and healthy adolescents (n = 62) played a four-player computerised Prosocial Cyberball Game with three pre-programmed avatar players. During the task, participants witnessed the exclusion of one of the players, and subsequently had the opportunity to compensate for this by throwing the ball more often to the excluded player. Throughout the game, participants rated the level of negative emotion in themselves and in the excluded player.

RESULTS

Patients made significantly fewer ball tosses towards the excluded player during the compensation round compared to healthy controls (large effect size). Patients reported a significantly smaller increase in negative emotion after witnessing the exclusion and a significantly smaller decrease in negative emotion following the compensation round (large effect sizes). Patients also estimated a smaller decrease in negative emotion in the excluded player following the compensation round (medium effect size). There were no significant associations between these outcomes and eating disorder psychopathology in patients.

CONCLUSIONS

Compared to healthy adolescents, adolescent patients with eating disorders demonstrated less prosocial compensatory behaviour towards a computerised victim of social exclusion. In addition, they reported flatter negative emotion in themselves in response to witnessing and compensating for exclusion, and in the excluded player following compensation. If these findings are replicated, interventions to target these difficulties might contribute to improvements in social functioning in this patient group.

Perceived change mechanisms in multi-family therapy for anorexia nervosa: A qualitative follow-up study of adolescent and parent experiences

OBJECTIVE

Multi-family therapy (MFT-AN) is a promising group-based treatment for adolescent anorexia nervosa. This study aimed to explore how young people and parents perceived change to occur during MFT treatment.

METHODS

Young people (10-18 years) diagnosed with anorexia nervosa or atypical anorexia nervosa and their parents who completed MFT-AN alongside family therapy for anorexia nervosa within the preceding 2 years were eligible for this study. Semi-structured qualitative interviews were conducted. Recordings were transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

Twenty-three participants (8 young people, 10 mothers and 5 fathers) completed interviews. Five main themes were identified; (1) Powerful connection, (2) Intensity, (3) New learning and perspective shifts, (4) Comparisons, and (5) Discharge is not recovery. There was a strong sense that being with others in a similar position in an intense environment were key factors in promoting change. Comparisons were inevitable and could promote insight and foster motivation, but could also be unhelpful at times. Participants spoke about how recovery continues beyond service use and requires ongoing attention and support.

CONCLUSIONS

Through the mechanisms of connection, intensity, new learning and comparisons change is perceived to occur in MFT-AN. Some of these are considered unique to this treatment format.

Using values in cognitive and behavioral therapy: A bridge back to philosophy

Ancient therapeutic practices have influenced the development of cognitive behavioral therapy (CBT) theories such as Albert Ellis's rational emotive behavior therapy and Aaron Beck's cognitive therapy. By drawing inspiration from Socratic questioning, the importance of philosophy in evidence-based practices in human mental health can be acknowledged. Stoicism has also informed CBT, notably its emphasis on establishing psychological distance from emotions. Cognition and emotion are two aspects of mental processes, and irrational demands are processed through rational deliberation. Using mental imaging techniques and acceptance strategies (to accept oneself and the world as imperfect), avoiding catastrophic interpretations and acknowledging emotions are also included among such practices. METHODS: We will explore the use of values across CBT, acceptance and commitment therapy (ACT), and radically open dialectical behavioral therapy (RO DBT) to clarify their use of values. RESULTS: In this framework, values are conceptualized as life-orienting principles and are now widely used across CBTs, such as acceptance and commitment therapy and radically open dialectical behavioral therapy. In recent years, the development of CBT has involved a renewed relationship with philosophy through the use of values, interest in dialectics and development of self-questioning practices reminiscent of classical Socratic principles. This movement from applied clinical psychology toward philosophical skills has also encouraged the recent emergence of philosophical health considerations. The opposition between psychological and philosophical health can be questioned, and the fundamental issue of philosophical skills implemented in psychiatric treatment (and not solely as practices of enhancement for the sane) needs to be considered.

Emotion Regulation Deficits in Adolescent Girls with Major Depression, Anorexia Nervosa and Comorbid Major Depression and Anorexia Nervosa

In adolescence, both major depression (MD) and anorexia nervosa (AN) are associated with deficits in emotion regulation (ER). However, studies have yet to compare ER profiles within the disorders and the effect of comorbid MD+AN is unclear. This study examined the habitual use of ER in 229 girls, aged 12-18 years, with MD (n = 84), AN (n = 37), comorbid MD+AN (n = 25), and healthy girls (n = 83). Girls with MD, AN and MD+AN reported more maladaptive and less adaptive ER strategies than healthy girls. MD and MD+AN groups showed more frequent use of maladaptive ER compared to only AN, with no differences between only MD and MD+AN. This suggests that MD+AN is not necessarily associated with higher ER deficits, rather, an additional diagnosis of MD exacerbates impairments in AN. Identifying specific ER profiles can provide important targets in prevention and treatment for AN, MD and AN+MD.

Social support across eating disorder diagnostic groups: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III)

INTRODUCTION

Previous studies have suggested the positive influence of social support on the treatment and recovery of eating disorders (EDs). Yet, more research is needed on how objective and subjective social support differ between ED diagnostic groups using nationally representative data. Therefore, the current secondary data analysis examined associations between EDs and objective and subjective social support using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) study.

METHODS

Participants completed measures of lifetime and past year diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) and items assessing objective social support (i.e., number of close friends and close relatives) and subjective social support (i.e., perceptions of availability of support).

RESULTS

Compared to those without EDs, those with AN, BN, and BED had poorer subjective social support-or lower perceptions of social support. However, there were fewer differences regarding objective social support. Individuals with BN reported a lower number of close relatives compared to those without EDs and those with AN, but there were no differences in the number of close friends between ED groups. Those who experienced remission from EDs had higher perceptions of social support compared to those with past year EDs.

DISCUSSION

The findings show deficits in subjective social support across EDs but only lower objective social support in BN. This highlights the clinical utility of increasing perceptions of social support across EDs. The findings also show the importance of perceived social support in recovery from EDs.

The Social Safeness and Pleasure Scale (SSPS): a psychometric evaluation of the Swedish version in a non-clinical sample and two clinical samples with eating disorders or borderline personality disorder

BACKGROUND

Social safeness and pleasure refer to the extent to which people experience their world as safe, warm, and soothing. Difficulties in achieving social safeness have been identified as a transdiagnostic vulnerability factor for developing and maintaining psychopathology and for feeling less contentment and self-compassion. The study aim was to evaluate the psychometric properties of the Swedish version of the Social Safeness and Pleasure Scale (SSPS).

METHODS

The SSPS was evaluated in a non-clinical sample of 407 participants. The internal consistency and test-retest reliability of the SSPS were explored and a confirmatory factor analysis was performed. Convergent validity was studied based on the assumption of negative correlations with the personality traits detachment and mistrust, derived from the Swedish Universities Scale of Personality. Divergent validity was studied based on the assumption of no or small correlations with impulsiveness and adventure-seeking-personality traits not assumed to be related to social safeness. Validity was also investigated by comparing the SSPS results in the non-clinical sample with those in two clinical groups of patients diagnosed with either borderline personality disorder (BPD; n = 58) or eating disorders (n = 103), recruited from two psychiatric outpatient clinics.

RESULTS

Confirmatory factor analysis confirmed a one-factor structure. Cronbach's alpha was 0.95 and test-retest reliability was 0.92. Validity was supported by moderate to strong negative correlations between the SSPS and the detachment and mistrust scales and no or small correlations with the impulsiveness and adventure-seeking scales in a personality questionnaire. Finally, we found significantly lower mean values on the SSPS in the clinical groups compared with the non-clinical group, with the lowest mean in the BPD sample.

CONCLUSIONS

The results showed good to excellent psychometric properties for the Swedish version of the SSPS, supporting its use in both clinical practice and research. Future research could use the SSPS when evaluating interventions aimed at improving the ability to develop social safeness, such as compassion-focused therapy or radically open dialectical behavior therapy, interventions that may be particularly important in BPD patients.

Adolescent experience of radically open dialectical behaviour therapy: a qualitative study

BACKGROUND

Radically Open Dialectical Behaviour Therapy (RO DBT) is a novel transdiagnostic treatment that targets 'maladaptive overcontrol'; a transdiagnostic cluster of traits associated with excessive emotional and behavioural inhibitory control. Outcomes are promising for adults with a range of psychiatric disorders. No study to date has explored the adolescent experience of RO DBT.

METHODS

Of the 25 eligible adolescents who received RO DBT between March 2015 and April 2017, 15 (14-17 years) consented and completed a semi-structured interview about their experience of treatment within 1 month of discharge. Interviews were recorded and then transcribed manually. Free text responses were analysed using reflexive thematic analysis.

RESULTS

The majority (n = 13) had a primary diagnosis of anorexia nervosa, although comorbidity was the norm, with 80.0% having two or more predicted comorbid psychiatric diagnoses. All had received some prior psychological treatment. Four themes were identified from analysis of transcripts: 1) Broadening Horizons, 2) Building Connections, 3) Flexibility, 4) Information Overload. Generally, RO DBT was perceived as helpful in both content and process. The focus on social and broader well-being, rather than specific mental health symptoms, was considered beneficial by many. Adolescents appreciated the group-based format of skills classes and reported benefiting from learning and practicing skills each week. The fourth theme, Information Overload, highlighted that for some, the amount of content felt overwhelming and that it was hard to remember and digest all the information, suggesting that adaptations, or simplifications, may be required to ensure accessibility for adolescents.

CONCLUSIONS

RO DBT is perceived as a relevant and beneficial new treatment for adolescents with maladaptive overcontrol. The broad treatment focus is perceived as unique and of particular benefit. It is reported to help with general and social functioning and foster cognitive and behavioural flexibility. Nevertheless, the amount and complexity of material was felt to be very large by some and may suggest the need for modified adolescent-specific materials.

Changes of symptoms of eating disorders (ED) and their related psychological health issues during the COVID-19 pandemic: a systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic and its related social restrictions have profoundly affected people's mental health. It can be assumed that symptomatic behaviors and mental health of individuals with eating disorders (ED) deteriorated during this time. To get a thorough overview, we conducted a systematic review and meta-analysis with the following aims: First, to provide a comprehensive overview of symptoms of ED during the COVID-19-related confinement; second, to identify psychological mechanisms which impacted the emergence and maintenance of ED symptoms; third, to describe changes of daily routine and changes of access to healthcare in individuals with ED during confinement.

METHODS

We searched Embase, PubMed, and Scopus databases for observational studies published between January 1st, 2020, to July 1st, 2021, which investigated the symptomatology of ED during the COVID-19 pandemic.

RESULTS

After the screening, 13 studies with 7848 participants were included in the present systematic review and meta-analysis. The overall pooled prevalence of exacerbation of binge eating, food restriction, purging behaviors, and concerns about food intake in the pooled sample of 7848 was 59.65% (95% CI: 49.30%; 69.60%), and the overall prevalence of improved symptoms of ED in the pooled sample of 741 individuals was 9.37% (95% CI: 3.92%; 16.57%). Furthermore, COVID-19-related social restrictions negatively impacted the psychological health, daily routines, and physical activity of individuals with ED. More specifically, symptoms of anxiety and depression related to ED were increased significantly over time. However, there were also positive aspects to the COVID-19 pandemic. The main positive consequences included more emotional support from the family, less pressure to engage in social activities, and more flexible meal planning. Individuals with ED reported having difficulties getting access to healthcare centers and using telemedicine. They also found a hard time communicating via online sessions.

CONCLUSIONS

According to our interpretation, based on the data included in the systematic review and meta-analysis, the COVID-19 pandemic and its related social restrictions detrimentally impacted the mental health of majority of individuals with ED. Limited and impaired access to healthcare interventions appeared to have further exacerbated mental health issues of individuals with ED. Given this background, it seems that individuals with ED demand more attention during the COVID-19 crisis, and it is necessary to ensure that their course of treatment remains uninterrupted.

Interpersonal Affective Touch in a Virtual World: Feeling the Social Presence of Others to Overcome Loneliness

Humans are by nature social beings tuned to communicate and interact from the very beginning of their lives. The sense of touch represents the most direct and intimate channel of communication and a powerful means of connection between the self and the others. In our digital age, the development and diffusion of internet-based technologies and virtual environments offer new opportunities of communication overcoming physical distance. It however, happens that social interactions are often mediated, and the tactile aspects of communication are overlooked, thus diminishing the feeling of social presence, which may contribute to an increased sense of social disconnection and loneliness. The current manuscript aims to review the extant literature about the socio-affective dimension of touch and current advancements in interactive virtual environments in order to provide a new perspective on multisensory virtual communication. Specifically, we suggest that interpersonal affective touch might critically impact virtual social exchanges, promoting a sense of co-presence and social connection between individuals, possibly overcoming feelings of sensory loneliness. This topic of investigation will be of crucial relevance from a theoretical perspective aiming to understand how we integrate multisensory signals in processing and making sense of interpersonal exchanges, this is important in both typical and atypical populations. Moreover, it will pave the way to promising applications by exploring the possibility to use technical innovations to communicate more interactively in the case of people who suffer from social isolation and disconnection from others.

Intact neural and behavioral correlates of emotion processing and regulation in weight-recovered anorexia nervosa: a combined fMRI and EMA study

Altered emotion processing and regulation mechanisms play a key role in eating disorders. We recently reported increased fMRI responses in brain regions involved in emotion processing (amygdala, dorsolateral prefrontal cortex) in acutely underweight anorexia nervosa (AN) patients while passively viewing negatively valenced images. We also showed that patients' ability to downregulate activity elicited by positively valenced pictures in a brain region involved in reward processing (ventral striatum) was predictive of worse outcomes (increased rumination and negative affect). The current study tries to answer the question of whether these alterations are only state effects associated with undernutrition or whether they constitute a trait characteristic of the disorder that persists after recovery. Forty-one individuals that were weight-recovered from AN (recAN) and 41 age-matched healthy controls (HC) completed an established emotion regulation paradigm using negatively and positively valenced visual stimuli. We assessed behavioral (arousal) and fMRI measures (activity in the amygdala, ventral striatum, and dorsolateral prefrontal cortex) during emotion processing and regulation. Additionally, measures of disorder-relevant rumination and affect were collected several times daily for 2 weeks after scanning via ecological momentary assessment. In contrast to our previous findings in acute AN patients, recAN showed no significant alterations either on a behavioral or neural level. Further, there were no associations between fMRI responses and post-scan momentary measures of rumination and affect. Together, these results suggest that neural responses to emotionally valenced stimuli as well as relationships with everyday rumination and affect likely reflect state-related alterations in AN that improve following successful weight-recovery.

The Importance of Emotional Regulation in Mental Health

Mental health is a critical component of overall well-being and exists on a continuum much like physical health. Although many ways to assess mental health exist outside of either having a disorder or not, practitioners often rely on the presence or absence of symptomatology. The assessment and promotion of emotional regulation in patients is one way to encourage individuals to engage in mental health-promoting behaviors. Specific techniques are discussed that address emotional regulation. Overall, providing patients with the tools to regulate emotional responding will likely have a direct impact on well-being as well as reduce MH symptomology.

Higher admission and rapid readmission rates among medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa during COVID-19

The COVID-19 pandemic has had sweeping and deleterious effects on the well-being of individuals worldwide. Eating disorders (EDs) are no exception, with incidence and prevalence of EDs rising since COVID-19 onset. The current study examined inpatient census and readmission rates among youth (aged 8-18) hospitalized for medical complications of anorexia nervosa (AN) or atypical anorexia nervosa (AAN) throughout distinct periods of the COVID-19 pandemic, including pre-COVID-19 (n = 136), COVID-19 lockdown (n = 3), and post COVID-19 lockdown (n = 24). Data from the COVID-19 lockdown period was excluded from analyses due to low sample size. Youth hospitalized during post COVID-19 lockdown were over 8-times more likely to be readmitted within 30-days of discharge compared to patients hospitalized before the pandemic (p = .002). Further, the inpatient census of youth with AN/AAN was significantly higher during post COVID-19 lockdown compared to pre-COVID-19 (p = .04). One-third of patients hospitalized since the pandemic identified COVID-19 consequences as a primary correlate of their ED. Our findings, although not causal, suggest an association between COVID-19 and AN/AAN development and exacerbation in youth, thus prompting more medical admissions and rapid readmissions among this demographic. This study has important implications for understanding how AN/AAN onset and exacerbation in youth has been affected by the COVID-19 pandemic and can inform new efforts to support individuals navigating treatment during a global crisis.

Efficacy of emotion-focused therapy in the treatment of eating disorders: A systematic review

BACKGROUND

The high incidence of eating disorders (EDs) means that its treatment is approached from various perspectives, among which we find emotion-focused therapy (EFT). Therefore, the main objective of this systematic review was to know the effectiveness of EFT for eating disorders.

METHOD

A systematic review of PubMed, the Cochrane Library and the Psychology and Behavioural Sciences Collection was carried out without a time limit and in a population with an eating disorder diagnosis.

RESULTS

Eight studies fulfilled the eligibility criteria: (1) six studies treated the population with binge eating disorder (BED) five were group treatments, and four included the combined modality; (2) one with BED, bulimia nervosa (BN) and Eating Disorder No Otherwise Specified (EDNOS); and (3) one for a single case of anorexia nervosa (AN). The duration of treatments ranged from 12 weeks to 18 months, and all studies used the original EFT protocol. Specific variables of each type of eating disorder were studied, as well as comorbid symptoms.

CONCLUSIONS

It seems that the results coincide in the existence of post-treatment improvements both in eating psychopathology and in affective symptoms, although with variable data during follow-up. More research is needed to affirm the efficacy of EFT as an empirically validated treatment for EDs.

Radically open dialectical behaviour therapy adapted for adolescents: a case series

BACKGROUND

Overcontrol is a transdiagnostic cluster of traits associated with excessive psychological, behavioural and social inhibitory control. It is associated with psychiatric diagnoses of depression, restrictive eating disorders and/or obsessive-compulsive personality disorder. Radically Open Dialectical Behaviour Therapy is a transdiagnostic treatment for maladaptive overcontrol. This case series evaluates an adolescent adaption (RO-A) for a transdiagnostic group of adolescents identified as overcontrolled.

METHODS

Twenty-eight adolescents were consecutively referred for RO-A from two different National and Specialist Child and Adolescent Mental Health Services between June 2017 and February 2020. Baseline self-report measures assessed overcontrol characteristics, relationship and attachment quality and mental health symptoms of depression and eating disorders, which were repeated at discharge.

RESULTS

Adolescents in this case series reported high rates of depression (78.6%), self-harm (64.3%) and eating disorders (78.6%). Most (85.7%) had two or more mental health diagnoses and all had previous mental health treatments before starting RO-A. The mean number of RO-A sessions attended was 18 group-based skills classes and 21 individual sessions over a mean period of 34 weeks. Significant improvements with medium and large effect sizes were reported in cognitive flexibility (d = 1.63), risk aversion (d = 1.17), increased reward processing (d = .79) and reduced suppression of emotional expression (d = .72). Adolescents also reported feeling less socially withdrawn (d = .97), more connected to others (d = 1.03), as well as more confident (d = 1.10) and comfortable (d = .85) in attachment relationships. Symptoms of depression (d = .71), eating disorders (d = 1.06) and rates of self-harm (V = .39) also significantly improved. Exploratory correlation analyses suggest improvements in overcontrol are moderately to strongly correlated with improvements in symptoms of depression and eating disorders.

CONCLUSIONS

This case series provides preliminary data that RO-A may be an effective new treatment for adolescents with overcontrol and moderate to severe mental health disorders like depression and eating disorders. RO-A led to improved management of overcontrol, improved relationship quality and reduced mental health symptoms. Further evaluation is indicated by this case series, particularly for underweight young people with eating disorders. More rigorous testing of the model is required as conclusions are only tentative due to the small sample size and methodological limitations.

Formulation in eating disorder focused family therapy: why, when and how?

In the broadest sense, formulation, or case conceptualisation, is the process of collaborative sense-making. It is something all clinicians are doing constantly, whether formally and consciously or not. Most clinicians are familiar with the general principals and need to formulate as it is a core part of clinical training across most disciplines. Treatment manuals often discuss formulation, but the practical steps involved and the process of developing, building upon and revising formulations are not always provided. In clinical practice, the active use and continued development of formulation during treatment is not always prioritised, especially beyond the initial assessment. This could be due to a number of reasons, such as a potential lack of clarity, understanding or confidence in the use of formulation across treatment, a lack of dedicated time and reflective space for formulation in the context of increasingly busy clinical settings, or a perception that it may be less necessary in the context of treatment approaches that are more structured and prescriptive. This article outlines the use of formulation in family therapy for child and adolescent eating disorders, provides guidance on how to actively include formulation more throughout treatment and discusses why this might be useful.

"It is the only constant in what feels like a completely upside down and scary world": Living with an eating disorder during COVID-19 and the importance of perceived control for recovery and relapse

The COVID-19 pandemic has had a profound, negative impact on the lives and wellbeing of much of the population, and it can raise additional challenges for individuals with eating disorders (EDs). During early stages of the UK lockdown, individuals reported disruptions to many aspects of their lives, including reduced feelings of control and serious concerns over the impact of the pandemic on ED symptoms and/or recovery. This study applied a mixed methods online survey to collect responses from 58 individuals (age 16-65yrs) with lived experience of EDs. Data was collected across two time points (April 2020 and June 2020) to explore the ongoing impacts of the pandemic on this population. The results suggest that higher perceptions of general, external control may be associated with ED recovery. Quantitative results show that individuals who reported recovering from their ED since the first time point, also reported significant increases in perceived control (compared to individuals who had relapsed or whose ED status was unchanged). Thematic analysis generated two themes: ED behaviours as an 'auxiliary control mechanism', and loss of auxiliary control after lockdown. Individuals who experienced less perceived control reported a tendency to rely upon eating disorder behaviours as an auxiliary coping mechanism, i.e., diminished external control was directed inwards and replaced with controlling their own behaviour. The preliminary results suggest that perceived control may be a significant factor in ED recovery. Individuals with EDs may be at significant risk of detrimental impacts on their recovery and wellbeing because of the pandemic reducing peoples' sense of control. These preliminary findings highlight the need for further research in this area, including investigation around potential interventions based upon strengthening perceptions of control to promote ED recovery.

Radically open dialectical behavior therapy for anorexia nervosa: A multiple baseline single-case experimental design study across 13 cases

BACKGROUND AND OBJECTIVES

No treatment for adult anorexia nervosa (AN) has shown sufficient effectiveness or superiority to other treatments. Overcontrol has been suggested as a viable mechanism to target in the treatment of patients with AN. Radically open dialectical behavior therapy (RO DBT) is developed for disorders related to maladaptive overcontrol. Our objective was to evaluate the outcome of RO DBT for AN in a clinical outpatient setting.

METHODS

Thirteen adult female patients with mild to moderate AN provided written consent and entered a multiple baseline single-case experimental design study. Median age at eating disorder (ED) onset was 15 years and the median duration of the ED was 10 years. Individual changes were assessed weekly during a baseline phase (A) of four to six weeks, and during the subsequent 40-week RO DBT phase (B). Additional assessments were conducted before and after treatment, and at a six-month follow-up. Primary outcome was ED psychopathology. Secondary outcomes were psychosocial impairment, quality of life, social connectedness, and adaptive control strategies.

RESULTS

Eight patients (62%) completed treatment. All completers were in full remission after treatment, with BMI ≥18.5 kg/m² and ED psychopathology within one standard deviation of the community mean. Improvements occurred after introducing RO DBT, not during baseline.

LIMITATIONS

Participants were female with mild to moderate AN, limiting generalizability to severe AN or males.

CONCLUSIONS

The study provides preliminary support for using RO DBT in adult outpatients with AN and overcontrol. Further studies should replicate these findings.

Emotional regulation in eating disorders and gambling disorder: A transdiagnostic approach

BACKGROUND AND AIMS

Difficulties in Emotion Regulation (ER) are related to the etiology and maintenance of several psychological disorders, including Eating Disorders (ED) and Gambling Disorder (GD). This study explored the existence of latent empirical groups between both disorders, based on ER difficulties and considering a set of indicators of personality traits, the severity of the disorder, and psychopathological distress.

METHODS

The sample included 1,288 female and male participants, diagnosed with ED (n = 906) and GD (n = 382). Two-step clustering was used for the empirical classification, while analysis of variance and chi-square tests were used for the comparison between the latent groups.

RESULTS

Three empirical groups were identified, from the most disturbed ER profile (Subgroup 1) to the most functional (Subgroup 3). The ER state showed a linear relationship with the severity of each disorder and the psychopathological state. Different personality traits were found to be related to the level of emotion dysregulation.

DISCUSSION AND CONCLUSION

In this study, three distinct empirical groups based on ER were identified across ED and GD, suggesting that ER is a transdiagnostic construct. These findings may lead to the development of common treatment strategies and more tailored approaches.

Psychological Risk Factors for the Development of Restrictive and Bulimic Eating Behaviors: A Polish and Vietnamese Comparison

The aim of this paper is to identify psychological factors which are culture specific or common predictors for restrictive and bulimic behaviors towards eating for young women raised in different cultures. The study included 661 young women from Poland (n = 233) and Vietnam (n = 428). Subjects filled-in the Eating Disorders Inventory (EDI-3) and the Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS), and body measurements were collected to calculate anthropometric indices. Women form Vietnam were less satisfied with their appearance than were their Polish peers, but Vietnamese showed a lower level of preoccupation with being overweight and fear of obesity. Intercultural differences indicate that Vietnamese women show greater intensities for psychological variables, connected with restrictive and bulimic eating behaviors, verified in the research model: low self-esteem, personal alienation, interpersonal insecurity, interpersonal alienation, emotional dysregulation, interoceptive deficits, perfectionism and asceticism, and anxiety.

Sharing and connecting with others - patient experiences of radically open dialectical behavior therapy for anorexia nervosa and overcontrol: a qualitative study

BACKGROUND

Recovery rates after psychological treatments for anorexia nervosa are low to moderate, and in adults, no treatment outperforms any other. The aim of this study was to evaluate patient experiences of Radically open dialectical behavior therapy (RO DBT), a treatment developed for disorders related to maladaptive overcontrol.

METHODS

Eleven female patients with anorexia nervosa were interviewed after either treatment completion (eight patients) or drop-out (three patients) from RO DBT. Interviews were transcribed and analyzed with inductive thematic analysis.

RESULTS

The analysis yielded five main themes: 1) a comprehensive treatment, 2) the benefits of sharing and connecting with others, 3) growing trust, 4) moving toward valued goals - but some remain, and 5) doing well in treatment.

CONCLUSION

Patients appreciated what they described as a comprehensive treatment and holistic view of their problems, which helped them reduce both maladaptive overcontrol and eating disorder symptoms. Gradually sharing personal experiences both in- and outside therapy was described as essential and led to enhanced social connectedness.

TRIAL REGISTRATION

The intervention study (Isaksson M, et al. J Behav Ther Exp Psychiatry. 71, 2021) that preceded this interview study was performed by the first, second, third, and fifth author, preregistered in the ISRCTN registry (no: ISRCTN47156042 ).

Adding maintaining factors to developmental models of anorexia nervosa: An empirical examination in adolescents

OBJECTIVE

A biopsychosocial approach has been proposed to explain the pathogenesis of anorexia nervosa (AN), despite only a few of the existing etiological models having received empirical support. The aim of this study was to empirically investigate Herpertz-Dahlmann, Seitz, and Konrad (2011, https://doi.org/10.1007/s00406-011-0246-y)'s developmental model and to consider if interpersonal reactions to the illness might serve as maintaining factors following the model proposed by Treasure and Schmidt (2013, https://doi.org/10.1186/2050-2974-1-13) METHOD: One hundred adolescents and their families were participated in the study: 50 diagnosed with AN, paired by age and parents' socio-economic status with 50 adolescents without a pathology. Biological, psychological and familial variables were assessed using ten questionnaires and a blood analysis test. Additionally, structural equation modeling was conducted to assess two hypothetical models.

RESULTS

The fit of both models was good after the addition of two covariate parameters (e.g., Comparative Fit Index > 0.96 and Tucker-Lewis Index > 0.95). Premorbid traits were linked to body dissatisfaction and to the number of stressful life events; this in turn was linked to AN symptoms. Biological and familial consequences reinforced this pathology.

CONCLUSIONS

Our findings provide support for both models, suggesting that inter relationships between bio-psycho-familial variables can influence the course of AN during adolescence.

The Questionnaire on Self-Transcendence (QUEST): A Measure of Trait Self-Transcendence Informed by Contextual Cognitive Behavioral Therapies

Self-transcendence is thought to increase well-being and is implicitly promoted in contextual cognitive behavioral therapies (CCBTs). This study conceptualizes, develops, and validates the first comprehensive CCBT-informed self-transcendence questionnaire. Using a CCBT-informed theory, we propose four self-transcendence facets: distancing oneself from mental content, distinguishing an observer of mental experience that is separate from the content of experience, experiencing innate connectedness with other beings, and noticing the constantly changing nature of experience. We measured these facets with items from existing relevant questionnaires and novel, expert-informed items. Exploratory factor analyses and bifactor exploratory structural equation models supported the first three of these facets. Those factors evidenced convergent validity with decentering, defusion, experiential avoidance, and mindfulness, and criterion and incremental validity in predicting psychological well-being. Our findings support a CCBT-informed model of self-transcendence, introduce the first instrument to comprehensively measure the self-transcendence facets we identified, indicate links with well-being, and suggest future intervention targets.

Targeting maladaptive overcontrol with radically open dialectical behaviour therapy in a day programme for adolescents with restrictive eating disorders: an uncontrolled case series

BACKGROUND

Radically Open Dialectical Behaviour Therapy (RO-DBT) was developed to target maladaptive overcontrol, a proposed core difficulty of restrictive eating disorders. RO-DBT is now the main group treatment model at the Intensive day Treatment Programme (ITP), Maudsley Hospital. This ITP case series aimed to investigate whether overcontrol is associated with restrictive eating disorder symptoms in adolescents and to evaluate ITP outcomes since RO-DBT skills classes were introduced.

METHOD

Self-report measures of eating disorder symptoms and temperament, personality and social characteristics linked to overcontrol were collected at assessment and discharge from ITP for all consecutive adolescents who attended between February 2015 and January 2019 (N = 131). Weight change, global outcomes and treatment needs post-ITP were also recorded.

RESULTS

Eating disorder symptoms at assessment were significantly correlated with overcontrol factors, including social connectedness (r = -.67), reward responsivity (r = -.54), and cognitive inflexibility (r = .52). Adolescents stayed in ITP on average 13.40 weeks. 70.8% had a Good-Intermediate outcome on Morgan-Russell scale. 4.6% did not respond and were referred to inpatient treatment from ITP. Significant improvements in drive for thinness (d = .33), depressive mood (d = .41), social connectedness (d = .48), and emotional expressiveness (d = .97) were reported at discharge. No changes were observed in perfectionism or negative temperament.

CONCLUSIONS

This study offers preliminary evidence that eating disorder symptoms are associated with overcontrol factors in adolescence and that they can improve with RO-DBT informed day programme treatment. RO-DBT is a promising treatment that offers a new way of conceptualising treatment targets and recovery for adolescent restrictive eating disorders.

Eating disorders in times of the COVID-19 pandemic-Results from an online survey of patients with anorexia nervosa

OBJECTIVE

The COVID-19 pandemic and the resulting public restrictions pose a psychological burden for humans worldwide and may be particularly detrimental for individuals with mental disorders. Therefore, the current study explored effects of the COVID-19 pandemic on eating disorder (ED) symptoms and other psychological aspects in former inpatients with anorexia nervosa (AN).

METHOD

One-hundred and fifty-nine patients with AN-discharged from inpatient treatment in 2019-completed an online survey on contact history with COVID-19, changes in ED symptoms and other psychological aspects, health care utilization, and strategies patients employed to cope during the pandemic.

RESULTS

Approximately 70% of patients reported that eating, shape and weight concerns, drive for physical activity, loneliness, sadness, and inner restlessness increased during the pandemic. Access to in-person psychotherapies and visits at the general practitioner (including weight checks) decreased by 37% and 46%, respectively. Videoconference therapy was used by 26% and telephone contacts by 35% of patients. Patients experienced daily routines, day planning and enjoyable activities as the most helpful among the most used coping strategies.

DISCUSSION

The COVID-19 pandemic poses great challenges to patients with AN. ED-related thoughts and behaviors may be used as dysfunctional coping mechanisms to regain control over the current circumstances. E-mental health interventions appear to be promising for supporting AN patients during these hard times. Furthermore, interventions addressing symptoms of depression and anxiety, as well as intolerance of uncertainty might help them manage their ED symptoms.

Self-directed behaviors differentially explain associations between emotion dysregulation and eating disorder psychopathology in patients with or without objective binge-eating

BACKGROUND

Emotion dysregulation and negative self-directed behaviors are key characteristics of eating disorders (EDs), but their interaction in relation to ED psychopathology is insufficiently explored, and empirically robust and clinically relevant models are needed.

METHODS

This study examined whether the association between emotion dysregulation and ED psychopathology was mediated by different negative self-directed behaviors in 999 ED patients divided into two sub-samples based on absence or presence of objective binge-eating episodes (OBE). Several simple and extended mediation models were examined using the Difficulties in Emotion Regulation Scale (DERS) as independent variable, the Structural Analysis of Social Behavior (SASB) as mediator, and the Eating Disorder Examination Questionnaire (EDE-Q) as dependent variable.

RESULTS

An associational pathway was found where higher emotion dysregulation was associated with more negative self-directed behaviors, which in turn was associated with higher ED psychopathology. Self-directed behaviors of importance differed between patient groups. In participants without OBE, lower self-love and higher self-attack were influential, whereas in participants with OBE, lower self-affirmation and higher self-blame were influential.

CONCLUSIONS

Self-directed behaviors may help to explain the association between emotion dysregulation and ED psychopathology. Our findings have both theoretical and clinical implications that are pathology-specific. Addressing specific self-directed behaviors could be an important way of helping patients deal with their emotions in relation to ED psychopathology.

Dialectical behavioral therapy: an update and review of the existing treatment models adapted for adults with eating disorders

Despite the effectiveness of CBT in reducing shape/weight concerns and dietary restraint, research suggests that patients considered recovered may still exhibit emotional difficulties related to eating disorders (EDs). Dialectical behavior therapy (DBT) has been adapted for a variety of mental disorders characterized by emotion dysregulation and, more recently, for EDs specifically. The current review found that the majority of the research studies employed one of the following three adaptations of DBT for EDs: The Stanford Model, Radically Open-DBT (RO-DBT), or Multidiagnostic ED-DBT (MED-DBT). Therefore, this review sought to review and update the empirical research on each adaptation and (2) offer preliminary recommendations for when and which adaptation of DBT to use when treating adults with EDs. Findings from the empirical literature on DBT and EDs indicate that the Stanford Model has the most rigorous and numerous studies demonstrating efficacy and effectiveness in those diagnosed with binge eating disorder. Fewer studies have been conducted using the Stanford Model with bulimia nervosa; therefore, less strong assertions can be made about DBT with those diagnosed with bulimia. The MED-DBT model has been evaluated in several open trials within higher levels of care with promising results, but the lack of randomized clinically-controlled trials prevents a definitive statement about its efficacy. Finally, research on applying the RO-DBT model to anorexia-nervosa, restricting subtype is in its infancy, prohibiting solid conclusions or recommendations regarding its efficacy or effectiveness.

Radically Open Dialectical Behavior Therapy: Social Signaling, Transdiagnostic Utility and Current Evidence

At the core of an overcontrolled personality and coping style is a tendency to have too much self-control, exhibiting as behavioral and cognitive inflexibility, high inhibition of emotion, high detail-focused processing and perfectionism, and a lack of social connectedness. Overcontrol underlies a wide variety of psychiatric illnesses and as such, an innovative transdiagnostic therapy called Radically Open Dialectical Behavior Therapy (RO DBT) has been developed to treat disorders characterized by overcontrol. RO DBT targets maladaptive social signaling in order to help individuals "rejoin the tribe," hypothesizing that increasing social connectedness by means of targeting social signaling is the central mechanism of change in treatment. Because RO DBT is used for individuals with an overcontrolled personality style, rather than individual disordered symptoms, it can be used transdiagnostically across a range of comorbid disorders, including treatment-resistant depression and anxiety, anorexia nervosa, and personality disorders such as obsessive-compulsive personality disorder. The current article introduces this novel treatment approach and discusses its emphasis on social signaling and its transdiagnostic nature. We then provide the first review of existing literature testing the efficacy of RO DBT across clinical populations, discuss issues related to assessment of overcontrol, and speculate on future directions for this novel therapy.

Emotions in play: young people's and clinicians' experience of 'Thinking about Emotions' group

PURPOSE

Emotional difficulties in young people (YP) with anorexia nervosa (AN) are well recognised. Improved strategies are needed to support inpatients to tolerate group therapy and to help them to better identify and manage their emotions. Cognitive Remediation and Emotion Skills Training (CREST) for AN adults, aimed at improving emotional processing skills, has been found beneficial in adult AN groups. A case series of CREST was conducted in an inpatient ward for YP (CREST-YP) to evaluate its suitability for a younger population.

METHODS

A mixed-methods assessment was used. Thirty-two YP and 3 facilitators took part in qualitative interviews. YP (n = 32) also completed pre- and post-self-report questionnaires assessing emotional functioning.

RESULTS

Preliminary qualitative results showed that YP found it helpful to learn about emotion processes. More support is needed to clarify the link between emotions and AN. Quantitative results showed no significant changes in YP's self-perceived emotional functioning. Although no statistically significant changes were observed, a small increase in YP's use of both reappraisal (standardised mean changes scores, SMCC 0.22) and suppression (SMCC - 0.22) as a means to regulate their emotions was found.

CONCLUSIONS

Pilot findings suggest that CREST-YP is a suitable intervention for YP with AN. Age-appropriate adaptations are needed to improve YP's engagement in group CREST.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series.

Capturing the impact of adolescent inpatient admissions: The Social Connectedness Scale

BACKGROUND

Outcome measurement is central to health service provision. In child and adolescent mental health services (CAMHS), there are established tools used to assess symptoms and track progress. However, there is a relative dearth of assessments of subjective well-being or recovery. Social connectedness is a concept linked with well-being and risk in young people. We sought to evaluate the utility and acceptability of a measure of social connectedness in inpatient CAMHS.

METHOD

As part of routine clinical practice, we asked 92 young people (mean age 16 years old) on two inpatient CAMHS wards to complete the Social Connectedness Scale, alongside other assessments, and also comment on its acceptability. We repeated the measure on discharge from the unit.

RESULTS

The findings showed that the measure was internally consistent (α = .910) and sensitive to change in this population. Scores also correlated with another self-report measure focusing on well-being and mental distress, but not with clinician-rated measures. Ratings of relevance and ease of understanding were reasonable and young people value social connection.

CONCLUSION

The Social Connectedness Scale might offer an appropriate method of exploring this element of young peoples' experience and progress, as part of inpatient mental health admissions.

Emerging Psychological Treatments in Eating Disorders

The authors present the theoretic model, structure of treatment, and preliminary evidence for several emerging treatments that are increasingly being used and studied in eating disorders treatment, including dialectical behavior therapy, acceptance and commitment therapy, integrative cognitive-affective therapy, and neuromodulation. In addition, the article discusses treatments that address mindfulness, interpersonal factors, and habit.

Addressing Loneliness in Complex PTSD

Loneliness impacts both physical and psychological health and is associated with increases of all-cause mortality and suicidal behavior. Because loneliness may result from a variety of developmental, interpersonal, and intrapersonal factors, distinguishing its components, origins, and sustaining factors as it manifests in various psychopathological states are important steps in formulating interventions to alleviate these conditions. To date, loneliness has not been widely studied in relation to complex posttraumatic stress disorder (PTSD), which is newly delineated in the International Classification of Diseases, characterized by PTSD symptoms in the context of significant early trauma, as well as "disturbances in self-organization" marked by affective dysregulation, negative self-concept, and disturbances in relationships. In this article, illustrating with case material, we suggest that loneliness plays a major role in the development of complex PTSD and in the preservation of its symptoms. Consequently, therapies for complex PTSD should include interventions that address loneliness.

Alexithymia and Treatment Outcome in Anorexia Nervosa: A Scoping Review of the Literature

Alexithymia is of great interest as an outcome predictor of recovery from anorexia nervosa, since it may interfere with both treatment compliance and patients' ability to benefit from the adopted interventions. For this reason, in the last years new treatment approaches targeting emotion identification, expression, and regulation have been applied and tested. Using the PRISMA methodology, we performed a scoping review of the literature about treatment outcome in anorexia nervosa, in terms of changes in alexithymia as assessed by its most commonly used self-report measure, the Toronto Alexithymia Scale (TAS). The Medline and Scopus databases were searched, and articles were included if matching the following criteria: dealing with patients affected by anorexia nervosa, without limits of age; involving the application of any kind of targeted therapy or treatment; assessing alexithymia and the effect of a treatment intervention on alexithymia, using the TAS. Ten studies were eventually included; overall, according to the selected studies, alexithymia levels often remain high even after specific treatment. Further research aimed at a deeper understanding of the actual impact of alexithymia on the outcome of anorexia, as well as exploring alternative treatment strategies for alexithymia in eating disorders (EDs), are warranted.