Identifying fundamental criteria for eating disorder recovery: a systematic review and qualitative meta-analysis

Effectiveness and predictors of psychotherapy in eating disorders: state-of-the-art and future directions

PURPOSE OF REVIEW

Psychotherapy is the cornerstone of the multidisciplinary treatment approach for eating disorders. This review examines recent evidence regarding effectiveness, predictors, and mechanisms of change of psychotherapy in eating disorders, providing a road map for clinicians and researchers.

RECENT FINDINGS

Family-based treatments (FBT) are effective in adolescents with anorexia nervosa and bulimia nervosa. Evidence-based psychotherapies for anorexia nervosa have no evidence of superiority compared with treatment as usual (TAU) in adults with anorexia nervosa. Cognitive-behavioural therapy (CBT) is the first-choice psychotherapy recommended for adults with bulimia nervosa and binge-eating disorder (BED). Self-help interventions have some evidence of effectiveness in nonunderweight individuals with eating disorders. Early symptom improvement and adolescent age predict more favourable outcomes.

SUMMARY

Evidence-based psychotherapies can be suggested for eating disorders, although follow-up data are needed. Beyond anorexia nervosa, bulimia nervosa, and BED, there is no evidence of psychotherapy effectiveness in other eating disorders. The effectiveness of novel (e.g. 'third-wave') psychotherapies, treatment delivery modality (e.g. internet-delivered), and adjunctive interventions (e.g. virtual reality) needs to be further explored. A broader definition of recovery is recommended, including behavioural, physical, and psychological criteria. Predictors and mechanisms of changes have not been studied enough: quantitative and qualitative studies are needed to promote more tailored and individualized psychotherapy interventions.

Lived experience of hypertensive disorders of pregnancy: a systematic review and meta-synthesis

BACKGROUND

Hypertensive disorders are major causes of maternal and neonatal morbidity and mortality, affecting ∼10% pregnancies worldwide.

OBJECTIVE

Understanding the lived experience of women with hypertensive disorders during pregnancy is important to inform best practice and provide holistic care.

STUDY DESIGN

This is a systematic review and meta-synthesis of studies containing qualitative components relating to direct lived experience of hypertensive disorders of pregnancy. Medline via Ovid, Embase via Ovid, CINAHL via Ebsco, PsycINFO via Ebsco, Scopus, Web of Science Core Collection, and ASSIA via ProQuest were searched between database inception and June 2024. Quality assessment was performed using the Critical Appraisal Skills Programme checklist for qualitative research. Themes were labeled and organized into a framework using NVivo software.

RESULTS

Eighteen studies were included in the meta-synthesis. Anxiety, stress, fear and panic emerged as the most common emotional experiences during hypertensive disorders of pregnancy. Loss of control was also mentioned frequently and consistently across studies (frequency effect size 38.9% and intensity effect size 15.3%). Emotional responses to physical symptoms or lack thereof, and feelings about the impact of the complicated pregnancy on family and community also emerged as central themes associated with hypertensive disorders of pregnancy.

CONCLUSION

A range of emotional experiences was captured across the studies included in our meta-synthesis, some of which were observed across global settings whereas others were context-dependent. Interventions and care pathways for pregnancies affected by hypertensive disorders should aim to support women through complex emotional experiences as well as reducing morbidity and mortality.

Experiences of intensive treatment for people with eating disorders: a systematic review and thematic synthesis

BACKGROUND

Eating disorders are complex difficulties that impact the individual, their supporters and society. Increasing numbers are being admitted to intensive treatment settings (e.g., for inpatient treatment, day-patient treatment or acute medical treatment). The lived experience perspectives of what helps and hinders eating disorder recovery during intensive treatment is an emerging area of interest. This review aims to explore patients' perspectives of what helps and hinders recovery in these contexts.

METHODS

A systematic review was conducted to identify studies using qualitative methods to explore patients' experiences of intensive treatment for an eating disorder. Article quality was assessed using the Critical Appraisal Skill Programme (CASP) checklist and thematic synthesis was used to analyse the primary research and develop overarching analytical themes.

RESULTS

Thirty articles met inclusion criteria and were included in this review. The methodological quality was mostly good. Thematic synthesis generated six main themes; collaborative care supports recovery; a safe and terrifying environment; negotiating identity; supporting mind and body; the need for specialist support; and the value of close others. The included articles focused predominantly on specialist inpatient care and were from eight different countries. One clear limitation was that ethnicity data were not reported in 22 out of the 30 studies. When ethnicity data were reported, participants predominantly identified as white.

CONCLUSIONS

This review identifies that a person-centred, biopsychosocial approach is necessary throughout all stages of eating disorder treatment, with support from a sufficiently resourced and adequately trained multidisciplinary team. Improving physical health remains fundamental to eating disorder recovery, though psychological support is also essential to understand what causes and maintains the eating disorder and to facilitate a shift away from an eating disorder dominated identity. Carers and peers who instil hope and offer empathy and validation are valuable additional sources of support. Future research should explore what works best for whom and why, evaluating patient and carer focused psychological interventions and dietetic support during intensive treatment. Future research should also explore the long-term effects of, at times, coercive and distressing treatment practices and determine how to mitigate against potential iatrogenic harm.

A peer mentoring program for eating disorders: improved symptomatology and reduced hospital admissions, three years and a pandemic on

BACKGROUND

Peer support involves people (mentors) using their own experiences to assist others (mentees). The impetus to include peer support in eating disorder recovery is high, however research on implementation of peer roles in eating disorder management is limited. A previous pilot study found positive but preliminary results for a Peer Mentor Program (PMP) for eating disorders. The PMP has since developed over time, including broadening its eligibility criteria and shifting to predominantly online delivery during COVID-19. This study aimed to evaluate the updated version of the PMP, on a larger and more diverse group of mentees.

METHODS

Previously collected PMP service data from July 2020 to April 2022 (during COVID-19 lockdowns) was evaluated for fifty-one mentees using mixed methods. Data from program start (baseline), mid-point (3-months) and end (6-months) for measures of eating disorder symptoms as measured by the Eating Disorder Examination Questionnaire (EDE-Q) and psychological wellbeing as measured by the Depression, Anxiety and Stress Scale (DASS) was evaluated. Frequency of eating disorder-related hospital admissions during PMP participation versus the 6 months prior, direct program costs and qualitative mentee feedback were also analysed. One way ANOVA's with post hoc tests were used to evaluate symptom change and thematic analysis was conducted on qualitative data.

RESULTS

Program attendance averaged 12.12 (SD ± 1.57) of a possible 13 sessions. Statistically significant and clinically meaningful improvements were demonstrated across all subscales of the eating disorder and psychological wellbeing symptom measures. EDE-Q Global score and DASS scores decreased significantly by program end. Fewer eating disorder-related hospital admissions were reported during PMP than the 6-months prior. Qualitative findings were positive and themed around the unique benefits of lived experience connection, a new kind of space for recovery, hope and motivation for change. Challenges with the time limited nature of the mentee-mentor relationship were expressed.

CONCLUSIONS

The important benefits of a PMP for individuals with eating disorders are further supported. There is a pressing need for high quality, co-produced research, utilising a mixture of designs and fidelity to core peer work principles, to inform further implementation of peer work into eating disorder policy and practice.

"It's like building a new person": lived experience perspectives on eating disorder recovery processes

BACKGROUND

Deeply engaging with the expertise of those who have experienced or supported someone with an eating disorder can add to a growing body of knowledge about recovery processes. In this qualitative study, we sought to explore and generate nuanced understandings of recovery experiences of people with a lived ED experience (first hand or as a caregiver) who were working as mentors in the field. To do this, we focused on changes that occur in personality, traits, and interests over the course of an eating disorder and into recovery.

METHOD

We conducted semi-structured interviews with 27 people with an eating disorder history, either through personal lived experience (n = 14) or as a caregiver of a loved one with an eating disorder (n = 13). We undertook a reflexive thematic analysis of the data through a critical realist lens.

RESULTS

We developed three themes, which illustrate the nonlinearity, relationality, and systemically linked nature of changes across experiences of having and recovering from an eating disorder. The first theme focuses on expansion; participants described how their worlds got bigger as they explored who they were becoming and discovered new ways of living in line with their values. The second theme emphasizes the balance between support and autonomy participants described as important for enabling change to occur across the recovery process. The last theme highlights the ways in which changes throughout the recovery process entwined with systemic factors, including actively pushing back against diet culture and weight stigma.

CONCLUSIONS

Participants' stories highlight interactions between individual, relational, and societal shifts that occur throughout the course of an ED and into recovery. They support ongoing calls to orient to ED recovery as situated within a broader social milieu, which invites us to build supportive environments to enable expansion and flourishing.

A Comprehensive Study of Positive Body Image as a Predictor of Psychological Well-Being in Anorexia Nervosa

Recent data suggest a close association between positive body image (PBI) and eating disorder recovery. Nevertheless, the specific mechanisms through which PBI may facilitate recovery from anorexia nervosa (AN) remain unknown. To advance understanding of these mechanisms, this study examined core indices of PBI within AN, exploring its association with emotion regulation and well-being outcomes. Data were collected from 159 female participants, 64 with AN diagnosis and 95 healthy controls (HCs), who completed measures of PBI (body appreciation, functionality appreciation, and body responsiveness), emotion regulation, and psychological well-being (depression, anxiety, stress, and psychological quality of life). The AN group reported lower levels of PBI and psychological well-being, along with greater difficulties in regulating emotions, relative to HCs. PBI variables significantly predicted emotion regulation and psychological well-being in AN, accounting for 36% to 72% of the variance, with body appreciation emerging as the strongest predictor. These findings lend credence to the view that PBI can serve as a catalyst for psychological health. We hypothesize that enhancing PBI can improve interoceptive awareness, which is crucial for emotion regulation and reducing maladaptive food-related coping. Emphasizing a mind-body connection in lifestyle could be a relevant element to consider for both treating and preventing AN.

Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality

Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.

Characterising illness stages and recovery trajectories of eating disorders in young people via remote measurement technology (STORY): a multi-centre prospective cohort study protocol

BACKGROUND

Eating disorders (EDs) are serious, often chronic, conditions associated with pronounced morbidity, mortality, and dysfunction increasingly affecting young people worldwide. Illness progression, stages and recovery trajectories of EDs are still poorly characterised. The STORY study dynamically and longitudinally assesses young people with different EDs (restricting; bingeing/bulimic presentations) and illness durations (earlier; later stages) compared to healthy controls. Remote measurement technology (RMT) with active and passive sensing is used to advance understanding of the heterogeneity of earlier and more progressed clinical presentations and predictors of recovery or relapse.

METHODS

STORY follows 720 young people aged 16-25 with EDs and 120 healthy controls for 12 months. Online self-report questionnaires regularly assess ED symptoms, psychiatric comorbidities, quality of life, and socioeconomic environment. Additional ongoing monitoring using multi-parametric RMT via smartphones and wearable smart rings ('Ōura ring') unobtrusively measures individuals' daily behaviour and physiology (e.g., Bluetooth connections, sleep, autonomic arousal). A subgroup of participants completes additional in-person cognitive and neuroimaging assessments at study-baseline and after 12 months.

DISCUSSION

By leveraging these large-scale longitudinal data from participants across ED diagnoses and illness durations, the STORY study seeks to elucidate potential biopsychosocial predictors of outcome, their interplay with developmental and socioemotional changes, and barriers and facilitators of recovery. STORY holds the promise of providing actionable findings that can be translated into clinical practice by informing the development of both early intervention and personalised treatment that is tailored to illness stage and individual circumstances, ultimately disrupting the long-term burden of EDs on individuals and their families.

Social support for young people with eating disorders-An integrative review

Eating disorder treatment should be underpinned by a recovery-oriented approach, be therapeutic, personalised and trauma informed. Within such models of care, social support is an important factor to explore in terms of its influence in supporting hope for recovery, reducing stigma, and mitigating life stressors. Limited research has been conducted to understand the types of social support that are available to young people formally diagnosed with an eating disorder, their feasibility and acceptability and the positive outcomes. This integrative review sought to explore the positive outcomes of social support or social support programs for young people with eating disorders. An integrative review was conducted based on a search of five electronic databases from inception to 31 March 2023. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools and findings have been narratively synthesised and presented in accordance with the review's aims and questions. Seven studies (total 429 individuals, range 3-160) published between 2001 and 2023 were included in the final synthesis. Overall social support interventions showed promising preliminary evidence as a feasible and acceptable adjunct to treatment for young people with an eating disorder motivated to change, with some clinical improvements in psychopathology. Social support augmented existing relationships, providing a human element of open dialogue, friendship and a sense of hope for recovery. Despite the small number and heterogeneity of the studies, this review has highlighted some promising preliminary benefits. Future treatment for eating disorders should embrace adjunct modalities that enhance psychosocial recovery for young people with eating disorders.

Factors predicting long-term weight maintenance in anorexia nervosa: a systematic review

PURPOSE

Eating disorder recovery is a poorly defined concept, with large variations among researchers' definitions. Weight maintenance is a key aspect of recovery that remains relatively underexplored in the literature. Understanding the role of weight maintenance may help guide the development of treatments. This paper aims to address this by (1) investigating the factors predicting long-term weight maintenance in anorexia nervosa (AN) patients; (2) exploring differences in predictive factors between adolescent and adult populations; and (3) exploring how weight maintenance is conceptualised in the literature.

METHODS

We conducted a systematic review following PRISMA guidelines to address our research questions. Five databases were searched and filtered according to our exclusion criteria.

RESULTS

From the search, 1059 studies were yielded, and 13 studies were included for review. A range of weight, biological and psychological factors were found to predict weight maintenance among these papers. BMI at admission and discharge from inpatient treatment was the most common predictor among the papers. Few studies investigated biological factors and mixed evidence was found for psychological factors. We found no observable differences between adult and adolescent populations. Finally, weight maintenance was defined and measured differently across studies.

CONCLUSION

This review's findings can help contribute to a well-rounded understanding of weight maintenance, and ultimately, of recovery. This can help support clinicians in tailoring interventions to improve long-term outcomes in AN. Future research should aim to replicate studies to better understand the relationship between the factors identified and weight maintenance.

LEVEL I

Systematic review.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Outcomes in people with eating disorders: a transdiagnostic and disorder-specific systematic review, meta-analysis and multivariable meta-regression analysis

Eating disorders (EDs) are known to be associated with high mortality and often chronic and severe course, but a recent comprehensive systematic review of their outcomes is currently missing. In the present systematic review and meta-analysis, we examined cohort studies and clinical trials published between 1980 and 2021 that reported, for DSM/ICD-defined EDs, overall ED outcomes (i.e., recovery, improvement and relapse, all-cause and ED-related hospitalization, and chronicity); the same outcomes related to purging, binge eating and body weight status; as well as mortality. We included 415 studies (N=88,372, mean age: 25.7±6.9 years, females: 72.4%, mean follow-up: 38.3±76.5 months), conducted in persons with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), other specified feeding and eating disorders (OSFED), and/or mixed EDs, from all continents except Africa. In all EDs pooled together, overall recovery occurred in 46% of patients (95% CI: 44-49, n=283, mean follow-up: 44.9±62.8 months, no significant ED-group difference). The recovery rate was 42% at <2 years, 43% at 2 to <4 years, 54% at 4 to <6 years, 59% at 6 to <8 years, 64% at 8 to <10 years, and 67% at ≥10 years. Overall chronicity occurred in 25% of patients (95% CI: 23-29, n=170, mean follow-up: 59.3±71.2 months, no significant ED-group difference). The chronicity rate was 33% at <2 years, 40% at 2 to <4 years, 23% at 4 to <6 years, 25% at 6 to <8 years, 12% at 8 to <10 years, and 18% at ≥10 years. Mortality occurred in 0.4% of patients (95% CI: 0.2-0.7, n=214, mean follow-up: 72.2±117.7 months, no significant ED-group difference). Considering observational studies, the mortality rate was 5.2 deaths/1,000 person-years (95% CI: 4.4-6.1, n=167, mean follow-up: 88.7±120.5 months; significant difference among EDs: p<0.01, range: from 8.2 for mixed ED to 3.4 for BN). Hospitalization occurred in 26% of patients (95% CI: 18-36, n=18, mean follow-up: 43.2±41.6 months; significant difference among EDs: p<0.001, range: from 32% for AN to 4% for BN). Regarding diagnostic migration, 8% of patients with AN migrated to BN and 16% to OSFED; 2% of patients with BN migrated to AN, 5% to BED, and 19% to OSFED; 9% of patients with BED migrated to BN and 19% to OSFED; 7% of patients with OSFED migrated to AN and 10% to BN. Children/adolescents had more favorable outcomes across and within EDs than adults. Self-injurious behaviors were associated with lower recovery rates in pooled EDs. A higher socio-demographic index moderated lower recovery and higher chronicity in AN across countries. Specific treatments associated with higher recovery rates were family-based therapy, cognitive-behavioral therapy (CBT), psychodynamic therapy, and nutritional interventions for AN; self-help, CBT, dialectical behavioral therapy (DBT), psychodynamic therapy, nutritional and pharmacological treatments for BN; CBT, nutritional and pharmacological interventions, and DBT for BED; and CBT and psychodynamic therapy for OSFED. In AN, pharmacological treatment was associated with lower recovery, and waiting list with higher mortality. These results should inform future research, clinical practice and health service organization for persons with EDs.

A dual-factor model perspective on depressed inpatients: examining the dynamics of mental health and therapy outcomes

Background

The dual-factor model of mental health posits that mental health and mental illness constitute two distinct axes; accordingly the model identifies four mental health groups: (1) complete mental health, (2) troubled, (3) vulnerable, (4) symptomatic but content. Yet, only a few studies investigated effectiveness of therapy on both dimensions of mental health simultaneously. Against this background, the present study aimed to determine proportions and changes of group assignments in depressed inpatients undergoing therapy.

Method

N = 1,044 depressed inpatients (age in years: M = 53.36, SD = 9.81, range: 17-83) completed a pre- and a post-treatment survey including questionnaires on depression, anxiety, and positive mental health. A total of n = 328 persons completed the survey also at 6-month and 12-month follow-up assessments.

Results

In the classification that included depression symptoms and positive mental health, 49% of the participants were classified as troubled and 13.2% were classified as completely mentally healthy at the pre-treatment assessment. At the post-treatment, 9.5% were classified as troubled and 55.7% were classified as completely mentally healthy. In the classification that included anxiety symptoms and positive mental health, 21.9% of the participants were classified as troubled and 14.2% were classified as completely mentally healthy at the pre-treatment assessment. At the post-treatment, 3.7% were classified as troubled and 56.1% were classified as completely mentally healthy. About 10 to 20% of patients showed an improvement in depression/anxiety and positive mental health, whereas another 10 to 20% showed a reduction in depression/anxiety, but only a minor increase in positive mental health between pre- and post-treatment.

Conclusion

Findings are in line with past research inspired by the dual-factor model in showing that enhancing positive mental health and alleviating psychopathology do not always co-occur in treatment. It is therefore important to implement measures of both psychopathology and positive mental health in therapy outcome studies, and to promote interventions targeting both psychopathology and positive mental health.

Eating disorders among queer and trans individuals: Implications for conceptualization, assessment, and treatment

Eating disorders (EDs) have been traditionally viewed as a disorder affecting cisgender, heterosexual women. Yet, the prevalence of EDs among queer and trans (QnT) individuals, coupled with the lack of interventions that attend to contextual factors related to sexual orientation and gender identity, underscore a critical health disparity issue requiring urgent attention. Here, we first review factors pertaining to QnT individuals' minoritized sexual and gender identities that are important to consider in ED conceptualization for this population (e.g., minority stressors, identity-based body image standards). Next, we describe problematic assumptions present in existing ED assessment and propose more inclusive approaches. Lastly, we provide suggestions for practices that providers can implement within their treatment of EDs among QnT individuals.

A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID)

OBJECTIVE

This scoping review identifies and describes psychological interventions for avoidant restrictive food intake disorder (ARFID) and summarizes how outcomes are measured across such interventions.

METHOD

Five databases (Cochrane, Embase, Medline, PsycInfo, Web of Science) were searched up to December 22, 2022. Studies were included if they reported on psychological interventions for ARFID. Studies were excluded if participants did not have an ARFID diagnosis and if psychological interventions were not delivered or detailed.

RESULTS

Fifty studies met inclusion criteria; almost half were single-case study designs (23 studies) and most studies reported on psychological interventions for children and adolescents with ARFID (42 studies). Behavioral interventions (16 studies), cognitive-behavioral therapy (10 studies), and family therapy (5 studies), or combinations of these therapeutic approaches (19 studies) were delivered to support patients with ARFID. Many studies lacked validated measures, with outcomes most commonly assessed via physical health metrics such as weight.

DISCUSSION

This review provides a comprehensive summary of psychological interventions for ARFID since its introduction to the DSM-5. Across a range of psychological interventions and modalities for ARFID, there were common treatment components such as food exposure, psychoeducation, anxiety management, and family involvement. Currently, studies reporting on psychological interventions for ARFID are characterized by small samples and high levels of heterogeneity, including in how outcomes are measured. Based on reviewed studies, we outline suggestions for clinical practice and future research.

PUBLIC SIGNIFICANCE

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by avoidance or restriction of food due to fear, sensory sensitivities, and/or a lack of interest in food. We reviewed the literature on psychological interventions for ARFID and the outcomes used to measure change. Several psychological interventions have been developed and applied to patients with ARFID. Outcome measurement varies widely and requires further development and greater consensus.

Let the Body Talk: Preliminary Data of an Open Trial of Dance Movement Therapy for Eating Disorders

BACKGROUND

There is growing support for considering Dance Movement Therapy (DMT) as an effective approach to improving physical and psychological symptoms in eating disorders (ED), but additional evidence is needed. The current study aims to investigate the effectiveness of a DMT intervention for inpatients with ED during an in-hospital rehabilitation program for ED in reducing emotion dysregulation and alexithymia and improving interoceptive awareness.

METHODS

Forty-nine consecutive inpatient young women with ED (aged between 18 and 34 years) recruited from a clinical center for the rehabilitation of obesity and ED received four group sessions of DMT intervention. All participants completed the Difficulties in Emotion Regulation Scale (DERS), the Toronto Alexithymia Scale (TAS), and the Multidimensional Assessment of Interoceptive Awareness Scale (MAIA) before (Time 0) and after the intervention (Time 1). Paired-sample t-tests were run to assess differences between Time 0 to Time 1.

RESULTS

From pre-to-post interventions, there was a significant reduction in the means of all of the subscales of DERS, suggesting an improvement in emotion regulation competencies, with the only exception for difficulties in awareness that increased (p = 0.016). We also found a significant reduction in alexithymia, as proved by significant differences in all of the subscales and the total score of TAS (p < 0.001), and significant improvements in interoceptive awareness as suggested by increased scores of the noticing (p = 0.043), emotional awareness (p < 0.001), body listening (p < 0.001), and trusting (p < 0.001) subscales of MAIA.

CONCLUSION

Overall, our results point towards the efficacy of dance/movement in reducing symptoms of eating disorders. Our findings also suggest that dancing can be considered a useful intervention to increase emotional regulation, reduce alexithymia, and enhance interoceptive awareness.

The effect of gender in binge eating behavior in Chinese culture: the serial mediation model of body dissatisfaction and self-acceptance

Introduction

The gender difference of binge eating behavior been highlighted by previous studies. However, psychological mechanisms underlying the gender difference of binge eating behavior remain unclear. This study addressed this issue from a sociocultural perspective.

Methods

Firstly, we investigated the mediation effect of body dissatisfaction on the gender difference of binge eating behavior. Secondly, we examine the serial mediating role of body dissatisfaction and self-acceptance in gender differences of binge eating behavior. Here, we analyzed data from 703 Chinese university students using SPSS 26.0 and SPSS PROCESS.

Results

In Chinese culture, body dissatisfaction and self-acceptance independently or through a serial way mediate the gender differences in binge eating behaviors.

Discussion

We discussed the implications and limitations of the present study.

[Unconditional self-acceptance and self-compassion: another clinic for anorexia nervosa?]

People suffering from anorexia have a particular emotional and cognitive profile (altered body and self-perception, emotional dysregulation, perfectionism, obsessive traits), which the disorder can compensate for through emotional distancing strategies. Self-compassion and unconditional self-acceptance have been shown to have therapeutic effects on the barriers to recovery associated with this profile.

Experiences of living with binge eating disorder and facilitators of recovery processes: a qualitative study

BACKGROUND

Binge eating disorder (BED) is the most prevalent eating disorder worldwide. BED is often associated with low quality of life and mental health problems. Given the complexity of the disorder, recovery may be challenging. Since BED was only recently specified as a diagnostic category by the World Health Organization (2021), little is known about how patients experience living with BED in everyday life. This study aimed to explore how patients experience living with BED and to investigate factors perceived as facilitating recovery.

METHOD

Individual interviews were conducted with six patients in a rehabilitation programme for recovery from BED. Interviews were conducted digitally and verbally transcribed between December 2020 and January 2021. The analysis was based on Malterud's systematic text condensation.

RESULTS

Being diagnosed with BED could be experienced as a relief. The participants perceived living with BED as a challenging addiction. They struggled with a low self-image and experienced a lack of understanding from others, resulting in shame. Self-compassion and social support from friends and family and through participation in a rehabilitation programme were important facilitators of recovery.

CONCLUSION

Participants perceived living with BED as a challenging addiction. They struggled with low self-esteem and experienced a lack of understanding from others, resulting in shame. Being diagnosed with BED was perceived as a relief. They appreciated that issues related to mental health were addressed during rehabilitation to better understand the complexity of BED. Knowledge about BED, as well as the difficulties of living with BED among family members and friends might help patients with BED feel less ashamed of their disorder and could thus contribute to increased self-compassion.

First validation of the model of sustainable mental health: Structural model validity and the indirect role of adaptation

OBJECTIVES

There is a growing interest in mental well-being as a vital outcome in clinical practice in addition to mental illness. The model of sustainable mental health (SMH) was recently introduced to delineate how interventions can improve mental health by targeting barriers and resources of adaptation to life stressors, improving the ability to adapt and thereby reducing mental illness and improving mental well-being. The aim of the current study is to empirically validate the conceptual model of SMH as well as the assumed indirect role of ability to adapt.

METHODS

This study used an existing dataset of the general population with self-reported reduced well-being due to the corona crisis (n = 849, mean age 53 years, SD = 15). Measurements of mental illness (depression and anxiety), mental well-being, ability to adapt, a specific barrier for adaptation (i.e., repetitive negative thinking), and a specific resource for adaptation (i.e., positive reframing) were included. Structural equation modeling was used to assess both the structural validity of the model and the indirect effect of ability to adapt.

RESULTS

An acceptable to good fit was found for the model of SMH and all paths between the proposed elements of the model were significant and in the hypothesized direction. Ability to adapt served as an indirect pathway trough which repetitive negative thinking (B = 0.149, 95% confidence interval [CI] = 0.016-0.028) and positive reframing (B = 0.163, 95% CI = 0.065-0.123) were linked with mental illness and mental well-being.

CONCLUSION

The current study provides the first empirical support of the internal validity of the model of SMH in a sample of the general population with reduced well-being, suggesting that barriers and resources to adaptation have an effect on mental illness and mental well-being through the ability to adapt. The model of SMH may therefore be a good model to use in research and clinical practice for developing, implementing, and evaluating a balanced treatment approach targeting both barriers and resources for adaptation.

Stressful life events and resilience in individuals with and without a history of eating disorders: a latent class analysis

BACKGROUND

Eating disorders (EDs) are associated with a range of stressful life events, but few have investigated protective factors that may affect these associations. The current study used mixture modelling to describe typologies in life stress exposure and availability of protective resources in individuals with and without eating disorders (EDs).

METHODS

A case - control sample (n = 916) completed measures of stressful life events, resilience protective factors, emotion regulation, and symptoms of EDs, depression and anxiety. We conducted latent class analyses to identify subgroups of stress exposure and profile analyses of emotional regulation and resilience. The resulting two latent variables were combined to explore effects on ED status and symptomatology, depression, and anxiety as distal outcome variables.

RESULTS

We identified four classes of stressful life events (generally low, some abuse/bullying, sexual/emotional assaults, and high adversity). For protective resources, we identified six profiles that ranged from low to higher levels of protection with variations in social/family resources. The latent protection variable contributed more strongly to the distal outcomes than the latent stress variable, but did not moderate the latent stress and distal outcome variable relationships. Profiles characterized by lower protective resources included higher proportions of individuals with a lifetime ED, and were associated with higher scores on all symptom measures.

CONCLUSIONS

Intra- and interpersonal protective resources were strongly associated with lifetime EDs and current mental health symptom burden after accounting for stressful event exposure, suggesting protective factors may be useful to target in the clinical treatment of patients with ED.

Predicting non-improvement of symptoms in daily mental healthcare practice using routinely collected patient-level data: a machine learning approach

Objectives

Anxiety and mood disorders greatly affect the quality of life for individuals worldwide. A substantial proportion of patients do not sufficiently improve during evidence-based treatments in mental healthcare. It remains challenging to predict which patients will or will not benefit. Moreover, the limited research available on predictors of treatment outcomes comes from efficacy RCTs with strict selection criteria which may limit generalizability to a real-world context. The current study evaluates the performance of different machine learning (ML) models in predicting non-improvement in an observational sample of patients treated in routine specialized mental healthcare.

Methods

In the current longitudinal exploratory prediction study diagnosis-related, sociodemographic, clinical and routinely collected patient-reported quantitative outcome measures were acquired during treatment as usual of 755 patients with a primary anxiety, depressive, obsessive compulsive or trauma-related disorder in a specialized outpatient mental healthcare center. ML algorithms were trained to predict non-response (< 0.5 standard deviation improvement) in symptomatic distress 6 months after baseline. Different models were trained, including models with and without early change scores in psychopathology and well-being and models with a trimmed set of predictor variables. Performance of trained models was evaluated in a hold-out sample (30%) as a proxy for unseen data.

Results

ML models without early change scores performed poorly in predicting six-month non-response in the hold-out sample with Area Under the Curves (AUCs) < 0.63. Including early change scores slightly improved the models' performance (AUC range: 0.68-0.73). Computationally-intensive ML models did not significantly outperform logistic regression (AUC: 0.69). Reduced prediction models performed similar to the full prediction models in both the models without (AUC: 0.58-0.62 vs. 0.58-0.63) and models with early change scores (AUC: 0.69-0.73 vs. 0.68-0.71). Across different ML algorithms, early change scores in psychopathology and well-being consistently emerged as important predictors for non-improvement.

Conclusion

Accurately predicting treatment outcomes in a mental healthcare context remains challenging. While advanced ML algorithms offer flexibility, they showed limited additional value compared to traditional logistic regression in this study. The current study confirmed the importance of taking early change scores in both psychopathology and well-being into account for predicting longer-term outcomes in symptomatic distress.

Mapping the Path to Cognitive Balance: Applying the States of Mind Model and Network Analysis to Eating Disorder Patients

Background: In eating disorders (EDs), cognitive-behavioral therapy (CBT) represents one of the first-line treatment options albeit with sub-optimal results. The assessment of cognitive balance through an index measuring increased adaptive thinking and reduced maladaptive thinking, the desired outcomes, and the ultimate goal of CBT treatments warrants attention. The states of mind model (SOM) provides a framework through which a cognitive balance index can be defined. The current cross-sectional controlled study tested the clinical utility of the SOM model in a sample of ED outpatients. Methods: ED outpatients (n = 199) were assessed at baseline with the attitudes and beliefs scale-2 (ABS-2) for rational beliefs (RBs) and irrational beliefs (IBs), from which a SOM ratio score index (RBs/(RBs + IBs)) was calculated, the eating disorder inventory-3 (EDI-3) for ED symptoms and ED-related psychopathological features, the psychological well-being scales (PWB) for positive psychological functioning. A matched control sample (n = 95) was also assessed with the ABS-2. Results: ED patients exhibited significantly lower SOM and RB scores compared to controls. Network analysis results highlighted the centrality of the SOM-cognitive balance index, PWB-self-acceptance, and EDI-3-general psychological maladjustment, as well as the importance of the influence that cognitive balance and general psychological maladjustment exert on each other. Conclusions: The findings support the clinical utility of the SOM ratio applied to cognitions in EDs. This demonstrates its ability to differentiate such patients from controls and in capturing worse ED-related general psychopathology as well as compromised aspects of psychological well-being, in particular self-acceptance and environmental mastery. It thus might be considered in CBT treatment of EDs a potential cognitive clinimetric and clinical index of ED severity indicating key difficulties in counteracting maladaptive thinking with adaptive thinking.

Modeling the Future of Prevention in Primary Mental Health Care: A Narrative Literature Review

Introduction

Adults in the U.S. have had poor and worsening mental health for years. Poor mental health exacts a high human and economic cost.

Methods

Using PubMed, we conducted a focused narrative literature review on mental well-being and its role in mental and physical health care.

Results

Mental well-being is essential for mental and physical health. High mental well-being is associated with a lower incidence of psychiatric disorder diagnosis and better function for those who do carry a formal diagnosis. High mental well-being also improves health outcomes for several physical diseases. Cultivating mental well-being is both a primary and secondary prevention strategy for mental and physical illness. There is a growing number of low-cost and accessible interventions to promote mental well-being, rooted in the research of positive psychology. These interventions improve mental well-being in multiple populations from different cultural backgrounds. There have been some efforts to incorporate these interventions to improve mental well-being in the clinical setting.

Conclusions

Our mental healthcare system would substantially improve its ability to protect against mental illness and promote positive function if mental well-being was routinely measured in the clinical setting, and interventions to improve mental well-being were routinely incorporated into standard primary and specialty care.

Conceptualisation of severe and enduring anorexia nervosa: a qualitative meta-synthesis

BACKGROUND

Severe and enduring anorexia nervosa (SE-AN) is amongst the most impairing of all mental illnesses. Collective uncertainties about SE-AN nosology impacts treatment refinement. Qualitative research, particularly lived experience literature, can contribute to a process of revision and enrichment of understanding the SE-AN experience and further develop treatment interventions. Poor outcomes to date, as evidenced in clinical trials and mortality for people with SE-AN (1 in 20) demonstrate the need for research that informs conceptualisations and novel treatment directions. This interpretative, meta-ethnographic meta-synthesis aimed to bridge this gap.

METHODS

A systematic search for qualitative studies that explored the AN experiences of people with a duration of greater than 3 years was undertaken. These studies included those that encompassed phenomenology, treatment experiences and recovery.

RESULTS

36 papers, comprising 382 voices of SE-AN experiences informed the meta-ethnographic findings. Four higher order constructs were generated through a synthesis of themes and participant extracts cited in the extracted papers: (1) Vulnerable sense of self (2) Intra-psychic processes (3) Global impoverishment (4) Inter-psychic temporal processes. Running across these meta-themes were three cross cutting themes (i) Treatment: help versus harm, (ii) Shifts in control (iii) Hope versus hopelessness. These meta-themes were integrated into conceptualisations of SE-AN that was experienced as a recursive process of existential self-in-relation to other and the anorexia nervosa trap.

CONCLUSIONS

The alternative conceptualisation of SE-AN proposed in this paper poses a challenge to current conceptualisations of AN and calls for treatments to engage with the complex intra and inter-psychic processes of the SE-AN, more fully. In doing so, clinicians and researchers are asked to continue to be bold in testing novel ideas that may challenge our own rigidity and attachment to dominant paradigms to best serve the individual person with SE-AN. The 'global impoverishment of self', found in this synthesis of AN experiences, should inform proposed diagnostic criteria for SE-AN.

Psychosocial Factors of Subjective Well-Being in Women with Eating Disorders

Eating disorders are known as the most lethal mental health conditions, and lately there has been a significant increase in the prevalence of these disorders. The aim of this research was to determine the perceived quality of professional support, the relationship between subjective well-being, loneliness, resilience, and the quality of family functioning, and the possibility of predicting subjective well-being based on knowledge of psychosocial factors in people with eating disorders. Eighty-six women with a diagnosed eating disorder participated in the online survey. The Diener Subjective Well-Being Scale, the UCLA Loneliness Scale, the Brief Resilience Scale, and the Self-Report Family Inventory were used to measure the constructs. Questions were constructed to collect information about the perceived quality and availability of professional support. Results showed lower levels of life satisfaction and flourishing and more frequent negative experiences. Reports of medium levels of loneliness, lower levels of flourishing, and lower perceived quality of family functioning were also obtained. Significant predictors of subjective well-being were loneliness and resilience, while family cohesion was significant in predicting positive and negative experiences and flourishing. These findings can contribute to the recognition of aspects existent prior to the development of the disorder, based on which experts can determine what to focus on in the treatment process.

A systematic review of people's lived experiences of inpatient treatment for anorexia nervosa: living in a "bubble"

BACKGROUND

Treatment for anorexia nervosa (AN) is typically delivered on a continuum of care, starting with outpatient treatment, and moving onto intensive outpatient, day or residential treatment and/or inpatient hospitalisation. However, minimal attention has been afforded to the lived experiences of persons undergoing inpatient treatment for AN. In particular, qualitative literature pertaining to the lived experiences of specialist inpatient or residential treatment of AN remains fragmented and incomplete. The aim of this review was to synthesise current literature exploring patients' lived experiences of residential and inpatient treatment for AN within eating disorder-specific treatment services.

METHODS

Five databases were searched and a qualitative thematic systematic review and meta-synthesis of 11 studies were conducted.

RESULTS

Eleven studies of 159 participants were included. Four meta-themes were constructed from the data: (1) a medical discourse-"I don't think it's individualised here"; (2) restrictive practice-living in a "bubble"; (3) myself, others and "a similar demon"; and (4) I am "not just another anorexic". The data also revealed two cross-cutting themes: (1) more than a single experience; and (2) meaning making and identity.

CONCLUSIONS

These findings highlight the complex and multifaceted nature of the inpatient treatment experience as well as the inherent conflicts in balancing the necessity of medical and psychological intervention with person-centred treatment approaches in the treatment of AN.

Introduction of the generic sense of ability to adapt scale and validation in a sample of outpatient adults with mental health problems

Introduction

The ability to adapt is a core aspect of daily human life. Recent models and theories emphasize its essential role for health and well-being. It concerns the perceived ability to readjust and actively deal with the psychosocial consequences of challenging events. While many questionnaires measure competences related to adaptability to specific conditions, a scale that measures a generic sense of the ability to adapt is lacking. The aim of the present study is to introduce the Generic Sense of Ability to Adapt Scale (GSAAS) and to examine its psychometric properties.

Methods

The article describes two sub-studies. In the first study the items of the GSAAS were generated and field-tested in a cross-sectional non-clinical sample using item analysis, exploratory factor analysis and Rasch analysis.

Results

This resulted in a 10-item questionnaire measuring a single dimension with good reliability (Cronbach’s α = 0.87). In the second study the 10-item scale was validated using a cross-sectional sample of 496 outpatient adults with mental health problems. Confirmatory factor analysis confirmed the unidimensional structure of the GSAAS and the absence of measurement variance across gender, age and education. Reliability was high (α = 0.89) and moderate to strong correlations between the GSAAS and concurrent validation measures confirmed its convergent validity. Regarding incremental validity, the GSAAS accounted for 7.4% additional explained variance in symptomatic distress above and beyond sense of coherence.

Discussion

In conclusion, the GSAAS appears to be a reliable and valid instrument to assess people’s generic sense of the ability to adapt. It is a practical and quick tool that can be used to measure a vital aspect of health in research and clinical treatment settings.

More than an outcome: a person-centered, ecological framework for eating disorder recovery

BACKGROUND

Eating disorder recovery is a complex phenomenon. While historical understandings focused on weight and behaviours, the importance of psychological factors is now widely recognized. It is also generally accepted that recovery is a non-linear process and is impacted by external factors. Recent research suggests a significant impact of systems of oppression, though these have not yet been named in models of recovery. BODY: In this paper, we propose a research-informed, person-centered, and ecological framework of recovery. We suggest that there are two foundational tenets of recovery which apply broadly across experiences: recovery is non-linear and ongoing and there is no one way to do recovery. In the context of these tenets, our framework considers individual changes in recovery as determined by and dependent on external/personal factors and broader systems of privilege. Recovery cannot be determined by looking solely at an individual's level of functioning; one must also consider the broader context of their life in which changes are being made. To conclude, we describe the applicability of the proposed framework and offer practical considerations for incorporating this framework in research, clinical, and advocacy settings.

The Treatment Experience of Anorexia Nervosa in Adolescents from Healthcare Professionals' Perspective: A Qualitative Study

Anorexia nervosa (AN) is a serious psychiatric illness with a high mortality rate and a poor outcome. AN in adolescents can be difficult to treat. The prognosis of patients with AN depends highly on how early specialized AN treatment starts. Therefore, the purpose of this study was to explore the experiences of healthcare professionals in treating adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, 16 healthcare professionals, including 10 nurses, 3 dieticians and 3 physicians from the paediatric ward at a university-affiliated medical centre in central Taiwan, shared their experiences. Recorded interviews were transcribed and analyzed by content analysis. Five themes and ten subthemes were identified: 1. Building a trusting relationship first: (a) spending time to build trust with the client and (b) establishing a relationship with the client's parents; 2. The key to treatment success: (a) Clients' awareness of the illness and (b) parents' support for clients; 3. Consistency of team treatment goals: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. In conclusion, the findings will provide important information for healthcare professionals to apply in monitoring the psychological and emotional states of adolescents with AN. The findings indicate that healthcare professionals should invite parents to participate in the treatment, support and guide them in their adolescent care, develop scales of family stress and support for AN in adolescents, develop interventions, and establish an early therapeutic alliance.

What are we aiming for? Exploring tensions in healthcare provider perspectives on and communications about eating disorder recovery

Eating disorder recovery is differently understood in multi-disciplinary healthcare contexts. In this study, we sought to better understand how healthcare providers (HCPs) describe recovery and communicating about recovery. We conducted an anonymous, online, qualitative survey with 41 eating disorder HCPs. In their responses, HCPs noted that communicating about recovery was core to their practice of establishing collaboration and communication with clients, as well as enabling “realistic hope” in clinical encounters. Recovery was described as related to the concept of attaining “normalcy” in life. We identified several tensions across HCP accounts, including what “normalcy” might look like, differences in the role of diagnostic and other contextual factors in determining recovery and different perspectives on how symptom remission figures in recovery. Our findings suggest that attending to differences in communication about recovery is an important direction for eating disorders research and treatment.

Lived experience perspectives on a definition of eating disorder recovery in a sample of predominantly white women: a mixed method study

BACKGROUND

There has recently been a push for recovery-focused research in the eating disorder (ED) field, starting with a consensus definition of recovery. One definition, in particular, proposed by Bardone-Cone et al. [21] has received considerable attention given its transdiagnostic nature and validation studies. However, no studies to date have elicited lived experience views of this definition. The goal of the current study was to examine perspectives on this definition of recovery from individuals with a past or present ED and to determine whether participant agreement with the model differed based on diagnostic history or current symptom severity.

METHODS

Sixty-two individuals (95.2% women; 91.9% White/European) participated in a 1-2 h interview aimed at capturing their perspectives on ED recovery. Transcripts were analyzed using qualitative content analysis and codebook thematic analysis to examine agreement with and thoughts on Bardone-Cone's definition of recovery, respectively. Chi-squared tests of independence and binary logistic regression were computed to determine whether agreement with the definition differed across diagnostic history and self-reported symptoms.

RESULTS

Although some participants indicated acceptance of the definition, the majority expressed concerns related to its categorical nature, proposed criteria, feasibility, language, and applications. There were no differences in acceptance based on diagnostic history or current symptom severity.

CONCLUSION

A single definition of recovery does not seem to fit individuals' lived ED experience. Future research may benefit from distinguishing between recovery as an individually-defined phenomenon and related constructs such as remission (i.e., loss of diagnosis or absence of clinical symptoms). A more comprehensive multi-faceted, and person-centered model of recovery may have merit in clinical settings.

Multi-family therapy for bulimia nervosa: a qualitative pilot study of adolescent and family members' experiences

BACKGROUND

Multi-family therapy (MFT-BN) is a new treatment for adolescent bulimia nervosa with emerging empirical support. It extends the bulimia nervosa focussed family therapy model, by offering treatment in a group setting. Up to nine families work together with a team of clinicians over the course of 20 weeks. No qualitative study to date has investigated the experience of MFT-BN. This study aimed to explore this from the adolescent and parent/caregiver perspective.

METHODS

Participants from two consecutive MFT-BN groups facilitated at the Maudsley Hospital in London, UK, were invited to participate in either a focus group or individual qualitative interview about the experience of MFT-BN. Of the 19 eligible participants (from 9 families), 15 (8 parents, 1 older sibling, 6 adolescents) consented and participated. Audio-recordings of interviews and focus groups were transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

Three main themes were identified; (1) seeing and being seen, (2) holistic shift, (3) the unspoken. Participants reported overall shifts in cognitions, emotions, behaviours, and relationships both individually and within the family as a result of attending MFT-BN. Meeting other families with similar struggles and sharing experiences, skills and learning helped reduce isolation and promote change. There was also a sense from participants that some things did not, or could not, be spoken about in the group context and that more direct and challenging conversations might have been helpful at times.

DISCUSSION

The current study identifies some of the perceived benefits and challenges of MFT-BN. The three themes demonstrate the holistic nature of change that can occur across the treatment, as well as the power and limits of the group therapy setting and process. Further research is needed to explore the experience of MFT-BN and its outcomes across a more diverse range of participants and treatment settings.

The experience of healthcare professionals treating adolescents with eating disorders in psychiatric and pediatric inpatient units for adolescents: A qualitative study

OBJECTIVES

The recommended treatment for Eating Disorders (EDs) is multidisciplinary and multimodal. Nonetheless, the complex linkage of the different disciplines involved is not necessarily simple. We analyzed the experience of healthcare professionals faced with psychiatric and psychological symptoms in adolescents with EDs in two "multidisciplinary" inpatient units embedded predominantly in different paradigms - one pediatric and one psychiatric.

METHODS

Qualitative analysis of 20 healthcare staff members' interviews from different professional backgrounds working in inpatient units for EDs in Montreal (Canada) and Paris (France).

RESULTS

The "Complex patients" theme discusses the need for a global approach to the multiplicity of symptoms presented by these patients. "Management and its limits" describes the daily management of psychiatric symptoms in both units. "Psychiatry and Adolescent medicine: from opposition to collaboration" describes the different levels at which these disciplines work together and how this cooperation may be evolving.

CONCLUSIONS

The complex entanglement intrinsic in EDs of the patients' somatic, psychosocial, psychiatric, and adolescent problems requires collaboration between disciplines, but the modalities of this collaboration are multiple and evolve non-linearly in specialized treatment units. A multilevel approach must be offered, with the degree of collaboration (multidisciplinary, interdisciplinary and transdisciplinary) appropriate to the complexity of each adolescent's issues.

Navigating challenges to providing eating disorder support in collegiate recovery programs

There is a significant need for eating disorder support on college campuses. Collegiate recovery programs (CRPs) are providing specialized support for students in recovery from substance use disorders (SUDs) but struggle to support students with eating disorders, despite the high co-occurring rates of SUDs and eating disorders. This is a brief report describing Texas Tech University's experience in delivering eating disorder support in their CRP, outlining the challenges they have recognized, and providing recommendations and resources for overcoming them.

The effects of the COVID-19 lockdown on adolescents with an eating disorder and identifying factors predicting disordered eating behaviour

AIM

To evaluate the impact of the COVID-19 lockdown on adolescents with eating disorders (ED) and identify factors predicting ED behaviour.

METHOD

This study took place during an age-stratified lockdown for those under 20 years in Turkey. Participants completed a survey developed to evaluate the effects of the lockdown on ED behaviour, well-being and quality of life (QoL) and additionally the eating disorder examination questionnaire (EDE-Q), and scales for depression, anxiety and obsessive-compulsive behaviour. The relationship between the EDE-Q-global score and other variables related to ED was examined. Linear regression analysis was performed to examine the predictive power of these variables on ED behaviour.

RESULTS

Thirty-eight ED patients with a mean age of 15.12 ± 1.56 years were included in the study. Of participants, 42.1% reported feeling an improvement in ED symptomatology, 71.0% reported none or rare conflict with parents due to eating, 39.5% reported often or always complying with their meal plan. Of participants, 92.0% agreed to 'understanding the value of being healthy' and stated realizing that 'they were in control' due to the pandemic. Of participants 36.9% scored 'bad' for both overall and ED related QoL. In the stepwise regression analysis depression score had the highest predictive value for ED behaviour.

CONCLUSION

Almost half of the participants felt an improvement in their ED and a majority reported rare parental conflict. However, less than half reported meal plan compliance. As depression had the highest positive predictive value for ED behaviour additional screening for depression during the pandemic maybe warranted in ED patients.

Habits and attitudes about eating and self-weighing among adults who are recovered, recovering, or partially recovered from eating disorders: an open-ended survey study

PURPOSE

The purpose of this study was to add experiential data from individuals with lived experiences of eating disorder recovery to the existing literature, regarding daily habits and attitudes toward eating and self-weighing.

METHODS

An anonymous open-ended online survey was completed by 32 adults. One was excluded due to current eating disordered behaviors. Remaining participants were divided into three self-identified groups: Recovered from an eating disorder, Recovering from an eating disorder, and Partially Recovered from an eating disorder.

RESULTS

Results showed the Recovered group reported more years of recovery than the other two groups, named "recovered" as part of their identity, practiced intuitive or regular eating instead of a prescribed meal plan, and held negative attitudes about self-weighing. The Recovering group reported, "I will always be recovering," and either followed prescribed meal plans or weighed themselves and did not expect to change those behaviors. The Partially Recovered group did not see themselves as recovered, but aspired to become recovered, and if they followed a prescribed meal plan or self-weighed, then they expected to change these behaviors in the future.

CONCLUSIONS

There is a difference in years of recovery, meal planning, and scale attitudes, among people who self-identify in the recovery categories of Recovered, Recovering, and Partially Recovered. These results can (1) help providers better serve clients with eating disorders; (2) help researchers better understand individuals who have suffered from eating disorders and are in the recovery process; and (3) offer guidance and hope for those in recovery.

LEVEL OF EVIDENCE

Level IV, Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Patient perspectives on premature termination of eating disorder treatment: a systematic review and qualitative synthesis

BACKGROUND

High rates of premature treatment termination are a well-reported issue in eating disorder treatment, and present a significant barrier for treatment effectiveness and longer term health outcomes of patients with eating disorders. Understanding patient perspectives on this phenomenon is essential in improving treatment completion rates and informing research and intervention development. The aim of this review is to synthesise qualitative literature on patient perspectives of premature termination of eating disorder treatment and to summarise the key issues leading to discontinuation of treatment.

METHODS

A systematic review of 1222 articles was conducted to identify studies using qualitative methods to investigate patient experiences of prematurely terminating eating disorder treatment. Ten articles were included in the review, with thematic synthesis used to analyse the primary research and develop overarching analytical themes.

RESULTS

Conflict around enmeshment of eating disorder with identity, and lack of support with reconstructing a sense of self without the eating disorder; challenges of managing pressures of social and clinical relationships while feeling unheard and misunderstood by both; expectations and disappointments around treatment; and dissatisfaction with progress were key themes behind premature termination of treatment.

CONCLUSIONS

The findings of this review demonstrate the key issues influencing the decision to end treatment early, highlighting the contribution of individual, environmental, and service-level factors. Implications of these factors are discussed and suggestions raised for future research and service development.

Psychosocial and financial impacts for carers of those with eating disorders in New Zealand

BACKGROUND

Eating disorders (ED) can have profound effects on family members and carers. These impacts can be experienced across multiple domains and may contribute to the maintenance of ED symptoms. In the absence of any New Zealand studies quantifying this, and given country-specific differences in access to care and treatment, this study explores the psychosocial and economic impacts on those caring for someone with an ED in New Zealand.

METHODS

Carers (N = 121) of those who had, or still had, a self-reported ED (82.6% anorexia nervosa) completed an online survey open between December 2016 and October 2020, adapted to the New Zealand context. Questions addressed ED recency and recovery status of the individual cared for, treatment access, and the financial and psychosocial impact on the carer. Data analysis included descriptive statistics, with financial cost data converted to the equivalent of 2020 New Zealand dollars.

RESULTS

Most (88.6%) recruited carers reported still caring for someone with ED symptoms of varying severity. A majority reported difficulty accessing treatment for the person they cared for, with a sizable minority (45%) paying for private treatment, despite few having private insurance. Carer losses typically included reduced income and productivity, travel costs, and other miscellaneous costs. Carers reported significant psychosocial impacts across a range of dimensions including family life, interpersonal relationships, and their own personal well-being.

CONCLUSIONS

Carers in New Zealand report impacts which are far reaching and longstanding, covering their own personal and interpersonal well-being and that of those around them. While most of those they care for get access to public (free) treatment at some time or another, the wider financial and economic impacts on carers are significant, and likely to take years to recoup. Though not unique to EDs, interventions and supports for carers are much needed in New Zealand, alongside more comprehensive research methodology to further determine positive and other impacts of EDs over the long course of the caregiving role.

HIGHLIGHTS

A majority reported difficulty accessing treatment for the person they cared for 45% paid for private treatment, despite few having private insurance Carers reported reduced income and productivity, travel costs, and other costs. Carers reported significant psychosocial impacts on family life, interpersonal relationships, and their own personal well-being. Carers provide a pivotal role in supporting treatment and recovery in their family member with the These findings will be relevant for funders and service providers in developing further approaches to address barriers and gaps in service provision to reduce impacts on carers, and as a result, those with eating disorders.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has significantly affected intensive treatment settings (i.e., inpatient [IP] and day patient [DP]) in specialist eating disorder services. However, the impact on clinicians working in these services is largely unknown. We therefore explored the perspectives of those supporting individuals with severe anorexia nervosa (AN) in intensive treatment settings during the pandemic.

METHODS

Between May 2020 and June 2021, we interviewed clinicians (n = 21) who delivered IP and/or DP treatment to patients with severe AN in four specialist eating disorder services in the United Kingdom. Data relating to experiences during COVID-19 were analysed using reflexive thematic analysis.

RESULTS

We identified six themes: Disruptions to Routine Treatment; Introduction of Virtual Treatment; Separation from Treatment, Others and the World; Impact on Recovery; Impact on Staff; and Pressure on Referral Pathways. COVID-19 posed significant challenges to IP and DP services: forcing closures, operating with restrictions and virtual treatment, and impacting delivery of essential treatment components, referral pathways, clinician wellbeing, risk management, and patient isolation and recovery trajectories. Opportunities arose, in particular in DP services offering virtual support.

CONCLUSIONS

COVID-19 challenged the continuation of multidisciplinary treatment. The findings underline the necessity for medical, psychological, practical, and nutritional support, as well as carer involvement and fostering social connections to remain at the forefront of intensive treatment for severe AN. They also emphasise the uncertainty surrounding which intensive treatment may be best suited to which patient when, particularly within the context of virtual DP support.

From efficacy to effectiveness: child and adolescent eating disorder treatments in the real world (Part 2): 7-year follow-up

BACKGROUND

Eating disorders are often characterised as disabling, chronic or relapsing conditions with high mortality rates. This study reports follow-up outcomes for patients seen at the Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED), whose end of treatment outcomes are reported in a separate paper.

METHODS

Three-hundred-and-fifty-seven former patients, who received evidence-based treatment for an eating disorder as a child or adolescent in MCCAED between 2009 and 2014 were eligible to participate. Current contact information was available for 290, of whom 149 (51.4%) consented to follow-up. Participants were sent links to online questionnaires, with additional demographic information extracted from medical records. Descriptive analyses of key socioeconomic and health outcomes were performed on data collected.

RESULTS

Mean length of follow-up was 6 years 11 months. Ten (6.7%) participants reported a current diagnosis of an eating disorder at follow-up. The great majority reported no (63.8%) or minimal (26.8%) interference from eating disorder difficulties. More than half (53.6%) reported other mental health diagnoses with most reporting no (33.8%) or minimal (50.7%) interference from those difficulties. One third (33.3%) had sought help for an eating disorder and around 20% received prolonged/intensive treatment during the follow-up period. Approximately 70% had sought treatment for other mental health difficulties (mostly anxiety or depression) and 35.4% had substantial treatment. At follow-up more than half (55.5%) reported doing generally well, and around two-thirds reported general satisfaction with their social well-being (65%). The majority (62.7%) had a good outcome on the Morgan Russell criteria, which was consistent with low self-reported ratings on EDE-Q, and low impact of eating disorder or mental health symptoms on work and social engagement. Most of the former patients who had day and/or inpatient treatment as a part of their comprehensive integrated care at MCCAED did well at follow-up.

CONCLUSIONS

Young people seen in specialist eating disorder services do relatively well after discharge at longer-term follow-up especially regarding eating disorders but less favourably regarding other mental health difficulties. Few reported a diagnosable eating disorder, and the great majority went on to perform similarly to their peers in educational and vocational achievements.

Resilience Is Associated with Less Eating Disorder Symptoms in the NutriNet-Santé Cohort Study

Resilience is a positive psychological trait associated with a lower risk of some physical and mental chronic diseases and could be an important protective factor against eating disorders (EDs). The aim of this study was to assess cross-sectional and longitudinal associations between resilience and ED in a large cohort of French adults. In 2017, a total of 25,000 adults from the NutriNet-Santé cohort completed the Brief Resilience Scale (BRS). ED symptoms were measured in 2017 and 2020, with the Sick-Control-One-Fat-Food (SCOFF) questionnaire. Cross-sectional and longitudinal associations between resilience and EDs were analyzed using logistic regression, controlling for sociodemographic and lifestyle characteristics. Cross-sectional analyses showed that more resilient participants exhibited EDs less frequently than did less resilient participants (p < 0.0001). Longitudinal analyses showed that, during the three years of follow up, higher resilience was negatively associated with incident EDs (OR: 0.67, 95%CI: 0.61–0.74), persistent EDs (0.46 (0.42–0.51)), and intermittent EDs (0.66 (0.62–0.71)), compared with no ED. More resilient participants were also less likely to have a persistent ED than to recover from EDs (0.73 (0.65–0.82)). This study showed that resilience was associated with less ED symptoms and a higher chance of recovery.

Impact of eating disorders on paid or unpaid work participation and performance: a systematic review and meta-analysis protocol

BACKGROUND

Eating disorders (ED) can reduce quality of life by limiting participation and performance in social and occupational roles, including paid or unpaid work. The association between ED pathologies and work participation and performance must be well understood to strengthen vocational rehabilitation programmes and prevent occupational disruptions in the ED population. The aims of this study are: (1) to examine the degree of association between ED pathologies and work participation and performance in 15-year-olds and older; (2) to highlight the specific ED symptoms that are most correlated with changes in work performance and participation; (3) to compile the most common metrics and assessments used to measure work participation and performance with ED.

METHODS

Medline, Embase, CINAHL, Web of Science, PsycINFO, and Cochrane Library will be searched for observational and experimental studies that meet the following criteria: (1) a clinical sample of typical or atypical ED; (2) paid or unpaid employment or training; (3) an association between ED pathologies and work participation or performance. Unpublished data will also be examined. Title and abstract, and full-text screening will be conducted in duplicate. Risk of bias and quality of evidence assessments will be completed. A random-effect meta-analysis will be performed.

DISCUSSION

This synthesis can clarify knowledge and gaps around the impact of ED on work functioning, thereby allowing better evaluation, improvements and development of current workplace assessments, interventions, and policies.

TRIAL REGISTRATION

The registration number for this systematic review on PROSPERO is CRD42021255055.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings

BACKGROUND

Admissions to intensive treatment (i.e., inpatient [IP] and/or day patient [DP]) for individuals with severe anorexia nervosa (AN) are common. Growing literature indicates potential risks and benefits of each intensive treatment approach; however, existing research has focused on patient and carer perspectives of these treatments. Also, there is scant empirical evidence available for guiding the parameters of intensive treatments for AN. We therefore explored clinicians' perspectives and experience of supporting adults with severe AN in intensive settings.

METHODS

We conducted twenty one semi-structured interviews with clinicians who deliver intensive treatments (i.e., IP and/or DP) for individuals with severe AN across four specialist Eating Disorder Services in the United Kingdom between May 2020 and June 2021. We asked clinicians about their views and experiences of supporting individuals with severe AN in intensive treatment settings and the challenges and opportunities associated with IP and DP treatment. Data were analysed using reflexive thematic analysis supported by NVivo software.

RESULTS

Five broad and interrelated themes were identified: (1) Intensive Support; (2) The Severity of Patients' Illnesses; (3) Hope and Recovery; (4) Which Treatment When; (5) Limited Resources; and (6) Carer Burden. We identified various similarities between the two intensive treatment approaches, including the value of intensive and multidisciplinary support and carer involvement, and the challenge of managing complex and unique needs in resource-limited intensive settings. We also found differences in the relationship of treatment to patients' home environments, the necessity of patient motivation, and the management of risk.

CONCLUSIONS

Both intensive treatment settings are valued by clinicians; however, there are unique challenges and opportunities for supporting individuals with severe AN within each. Our findings suggest DP treatment may be used as an alternative to IP treatment for individuals with severe AN. However, clear questions remain over which intensive treatment setting is best suited to which patient when and should be the focus of future research.

Exploring occupation in recovery from bulimia nervosa: An interpretative phenomenological analysis

Introduction

Recovering from bulimia nervosa challenges a person to learn, revise, and do occupations that contribute to rather than detract from health. This study utilized Interpretative Phenomenological Analysis to (a) explore the recovery experiences of six adult women with histories of bulimia nervosa and (b) interpret how their accounts reflected the assumptions and characteristics of occupation.

Methods

Data were collected via audio-recorded, semi-structured interviews. Data analysis within and between cases identified six superordinate themes, which included interpretation in terms of criteria of occupation.

Findings

Superordinate themes reflect (1) occupation emerged in recovering from bulimia nervosa through committed action, not doing what fueled bulimia nervosa, adopting new ways of living, prioritizing self-care, connecting with others, and creating supportive environments and (2) recovery from bulimia nervosa can be construed as an occupation.

Conclusion

This study provides insight into nuances of recovery from bulimia nervosa. Results offer novel implications distinct to an occupational therapy lens, for example, consideration of self-care beyond eating and meal preparation; modification of the home, work, and social environment; and setting goals associated with not doing versus doing. Further, the interpretative finding of recovery as occupation holds implications for the evolving philosophical considerations within occupational science and therapy.

Experiences of eating disorders from the perspectives of patients, family members and health care professionals: a meta-review of qualitative evidence syntheses

BACKGROUND

Eating disorders are serious conditions that cause major suffering for patients and their families. Better knowledge about perceptions of eating disorders and their treatment, and which factors that facilitate or hinder recovery, is desired in order to develop the clinical work. We aimed to explore and synthesise experiences of eating disorders from the perspectives of those suffering from an eating disorder, their family members and health care professionals through an overarching meta-review of systematic reviews in the field.

METHODS

A systematic literature search was conducted in the databases PubMed, PsycInfo, Scopus, and CINAHL. Inclusion criteria were systematic reviews of qualitative research on experiences, perceptions, needs, or desires related to eating disorders from the perspective of patients, family members or health care professionals. Systematic reviews that fulfilled the inclusion criteria were assessed for relevance and methodological limitations by at least two researchers independently. The key findings were analysed and synthesised into themes.

RESULTS

We identified 17 systematic reviews that met our inclusion criteria. Of these, 13 reviews reported on the patients' perspective, five on the family members' perspective, and three on the health care professionals' perspective. The study population in the reviews was predominantly girls and young women with anorexia nervosa, whilst systematic reviews focusing on other eating disorders were scarce. The findings regarding each of the three perspectives resulted in themes that could be synthesised into three overarching themes: 1) being in control or being controlled, 2) balancing physical recovery and psychological needs, and 3) trusting relationships.

CONCLUSIONS

There were several similarities between the views of patients, family members and health care professionals, especially regarding the significance of building trustful therapeutic alliances that also included family members. However, the informants sometimes differed in their views, particularly on the use of the biomedical model, which was seen as helpful by health care professionals, while patients and family members felt that it failed to address their psychological distress. Acknowledging these differences is important for the understanding of anorexia nervosa and other eating disorders, and may help clinicians to broaden treatment approaches to meet the expectations of patients and family members.

The Eating Disorders Recovery Questionnaire: psychometric properties and validity

PURPOSE

There is no standardized measurement of recovery from an eating disorder (ED). We examined the psychometric properties and construct validity of the "Eating Disorders Recovery Questionnaire" (EDRQ), which defines recovery beyond symptoms to include self-acceptance, social emotional and physical health.

METHODS

Twenty-eight recovery-related items were administered to 978 people (9.5% men) aged 18-76. 172 participants had a current ED diagnosis (AN, BN or BED), 104 had a past ED diagnosis (AN, BN, BED or > one diagnosis), 105 had another past or present ED, and 579 had no lifetime ED. Participants also completed the Eating Disorders Examination Questionnaire, Dresden Body Image Questionnaire-35, Positive and Negative Affect Schedule-Short Form, Patient Health Questionnaire-9, Satisfaction with Life Scale and Positive Eating Scale.

RESULTS

Exploratory and confirmatory factor analyses yielded four factors (CFI = 0.93, RMSEA = 0.07): lack of symptomatic behavior, acceptance of self and body, social and emotional connection, and physical health. Group comparisons showed that currently ill women scored lower on EDRQ and positive indices and higher on negative indices than controls and previously ill women. Previously ill women scored similarly to controls on ED symptomatology, positive body experiences, depression, and positive and negative affect but had lower BMI, life satisfaction and positive eating. The EDRQ-EDEQ correlation was r = 0.67, indicating both overlap and distinct variance.

CONCLUSION

The EDRQ is a valid, reliable measure of ED recovery, defined more broadly than symptom remission. We recommend its incorporation into a standardized operationalization of recovery and its use by consumers, carers and service providers to monitor ED recovery status.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Recovering Uncertainty: Exploring Eating Disorder Recovery in Context

Attending to the shades of grey in eating disorder recovery may help to illuminate possibilities for navigating recoveries in their full complexity and diversity. There is a need for more complexity and flexibility in understandings of the timelines, processes, endpoints, and versions of eating disorder recoveries. In this article, we explore eating disorder recovery as a dynamic, intercorporeal, and non-linear process. Drawing on interviews with 20 people doing significantly better than they were during a time of acute distress around food and body, we articulate "recoveries" in relation to four themes: Fuzzy Logics of Time, Not Only Recovered, Recovery is Not All Sunshine and Rainbows, and The Life of Recovery. These themes speak to the ways in which participants struggled to articulate the temporalities of their recoveries, situated recovery as one among many events and processes that shaped their being in the world, resisted "too perfect" articulations of recovery journeys/ endpoints, and described preferred versions of and open-ended guidelines for recovery. We argue that eating disorder recoveries are as complicated and messy as lives themselves and are equally entangled in social contexts. We suggest that articulations of recovery be attuned to power dynamics as they operate in dictating which performances of eating disorders and recovery will be honoured as "legitimate" and whose pathways to recovery will be respected.

The Model for Sustainable Mental Health: Future Directions for Integrating Positive Psychology Into Mental Health Care

This position paper proposes a model for systematic integration of positive psychology interventions (PPIs) in mental healthcare. On the one hand, PPIs can contribute to the decrease of dysfunctional processes underlying mental illness. This evidence is at the core of the new domains of positive clinical psychology and positive psychiatry. On the other hand, a growing number of studies demonstrate that mental health is not merely the absence of mental illness. Mental wellbeing represents a related but separate dimension of mental health. Mental wellbeing reduces the risk of future incidence of mental illness and is highly valued by people receiving psychological treatment as an important aspect of personal and complete recovery and personal growth. This makes mental wellbeing a vital outcome of mental healthcare. PPIs can directly increase mental wellbeing. The model of sustainable mental health is presented integrating the science of positive psychology and mental wellbeing into mental healthcare. This heuristic model can guide both practitioners and researchers in developing, implementing, and evaluating a more balanced, both complaint- and strength-oriented, treatment approach. The role of gratitude interventions is discussed as an example of applying the model. Also, three potential modalities for implementing PPIs as positive psychotherapy in treatment are as: positive psychotherapy as primary treatment, as combinatorial treatment, and as intervention for personal recovery of people with severe or persistent mental disorder. Finally, we argue that longitudinal studies are needed to substantiate the model and the processes involved.

Self-injury and Smartphone Addiction: Age and gender differences in a community sample of adolescents presenting self-injurious behavior

This study aimed to identify the variables (i.e., internalizing, and externalizing problems, self-control, emotion dysregulation, and alexithymia) relevant for Smartphone Addiction and non-suicidal self-injury (NSSI), conceptualized as emotion-regulation strategies, also assessing age and gender differences. Based on power analysis, N = 78 Italian adolescents (11-19 years; M_age = 14.24; SD = 1.56; 73.1% females) were considered. Step-wise multivariate linear regressions evidence a mutual association between NSSI and Smartphone Addiction, particularly relevant in pre-adolescence. Low self-control is significantly associated with the Smartphone Addiction, while emotion dysregulation and alexithymia with NSSI. This study supports NSSI and Smartphone Addiction conceptualization as emotion-regulation strategies and the importance of prevention interventions.