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Fernández García S, Quiles Marcos Y. Effectiveness of the Maudsley Model of Anorexia Nervosa Treatment for Adults: A systematic review. EUROPEAN EATING DISORDERS REVIEW 2024. [PMID: 38961594 DOI: 10.1002/erv.3122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/04/2024] [Accepted: 06/22/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Maudsley Model of Anorexia nervosa (AN) Treatment for Adults (MANTRA) is recommended by NICE for the treatment of adults with AN. However, despite this fact, the approach remains relatively understudied. The aim of this study was to systematically update the research evidence regarding the use of the MANTRA in the treatment of Eating Disorders (ED). METHOD The databases used were Web of Science, Scopus, and PsycInfo, including studies up to 31 May 2023. PRISMA guidelines were followed, and Cochrane tools were used to assess the risk of bias. The search focused on identifying published articles that discussed the usefulness of MANTRA as a component of treatment for ED, following PICO criteria. RESULTS Nine studies spanning the period from 2011 to 2023 were included. Findings suggested that MANTRA was effective in improving body mass index (BMI), eating symptomatology and emotional state. There were generally no significant differences compared to other treatment conditions. Limitations to interpreting this systematic review include the methodological quality of included studies and the elevated risk of bias. CONCLUSIONS This review was the first to examine the effectiveness of MANTRA. The results indicate that MANTRA has shown effectiveness similar to other treatments for adults AN patients in addressing key clinical variables. It has been used in different populations (adolescents, males, inpatients) and formats (group, online) However, more research is needed to determine its effectiveness.
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Affiliation(s)
| | - Yolanda Quiles Marcos
- Department of Behavioral Sciences and Health, Miguel Hernández University, Elche, Spain
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Marcolini F, Ravaglia A, Tempia Valenta S, Bosco G, Marconi G, De Ronchi D, Atti AR. Severe enduring anorexia nervosa (SE-AN) treatment options and their effectiveness: a review of literature. J Eat Disord 2024; 12:48. [PMID: 38654374 DOI: 10.1186/s40337-024-01006-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/16/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION For nearly 20% of patients diagnosed with Anorexia Nervosa (AN), the eating disorder (ED) is prolonged and becomes long-lasting. It has been reported that patients diagnosed with Severe Enduring Anorexia Nervosa (SE-AN) have worse ED symptoms, higher rates of lifetime hospitalization, and lower psychosocial well-being compared to patients with shorter disease duration. OBJECTIVES This review aims to describe the treatments proposed to date and their effectiveness on SE-AN-related outcomes. METHODS We conducted a PubMed search for studies addressing the issue of treatment approach to SE-AN adults, that were published between 2003 and 2023, peer-reviewed, written in the English language, and available in full-text. Next, we inductively created relevant macro-themes by synthesizing the data from the included articles. RESULTS Of 251 PubMed studies, 25 articles were considered for data extraction, all published between 2003 and 2022. We identified three macro-themes. The first macro-theme, "Psychotherapy", mostly takes into consideration treatment effectiveness of cognitive behavioral therapy (CBT). Various reports determined its greater effectiveness compared to Specialist Supportive Clinical Management (SSCM), and one study proved that outpatient CBT is a valid alternative to hospitalization. The second one involves "Pharmacological Treatments". Research on dronabinol, a synthetic orexigenic cannabinoid, antipsychotics (in particular, olanzapine and haloperidol), and ketamine showed some mixed results regarding the often-complementary areas of weight gain and improvement in ED-related symptoms. Regarding the third macro-theme, "Brain Stimulation Therapies," such as Repetitive Transcranial Magnetic Stimulation (rTMS) and Deep Brain Stimulation (DBS), we found promising results in improving ED-related psychological traits (such as mood and anxiety), affective regulation, and quality of life. However, we have observed divergent results regarding outcome measures such as BMI and weight gain. CONCLUSIONS SE-AN patients are predicted to encounter both medical complications and psychological distress of increasing severity that will inevitably affect their quality of life; to our knowledge, research evidence on treatment options for SE-AN remains limited, and the methodological quality of studies is generally low. These findings denote the need to focus future research efforts on effective treatment strategies specific to long-lasting EDs.
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Affiliation(s)
- Federica Marcolini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy.
| | - Alessandro Ravaglia
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
| | - Silvia Tempia Valenta
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
| | - Giovanna Bosco
- Department of Clinical Nutrition, AUSL Bologna, Bologna, Italy
| | - Giorgia Marconi
- U.O. Cure Primarie, AUSL Area Vasta Romagna, Ambito di Rimini, Rimini, Italy
| | - Diana De Ronchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
| | - Anna Rita Atti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Viale Pepoli 5, 40123, Bologna, Italy
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3
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Purvis F, Thorpe A, Turner H, Lawrence P. Evidence of effectiveness of specialist supportive clinical management for anorexia nervosa in routine clinical practice: Outcomes from a clinical case series. Int J Eat Disord 2023; 56:1941-1946. [PMID: 37458520 DOI: 10.1002/eat.24022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/30/2023] [Accepted: 07/01/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVE This study provides a preliminary report on the effectiveness of Specialist Supportive Clinical Management (SSCM) in a clinical case series of adults with anorexia nervosa, to supplement evidence of efficacy from controlled trials. METHOD Body mass index (BMI), eating disorder symptoms, mood and anxiety were measured at the start and end of treatment for 42 adults who received SSCM in a community eating disorders service. RESULTS Significant improvements were observed on all outcome measures, with larger effect sizes for symptom change than BMI. Recovery rates appear similar to those in clinical trials. DISCUSSION The study offers preliminary support for the effectiveness of SSCM in routine settings and identifies several areas for further research.
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Affiliation(s)
- Francesca Purvis
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Alexandra Thorpe
- Department of Psychology, University of Southampton, Southampton, UK
| | - Hannah Turner
- Hampshire Eating Disorders Service, Southern Health NHS Foundation Trust, Winchester, UK
| | - Pete Lawrence
- Department of Psychology, University of Southampton, Southampton, UK
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4
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Pellizzer ML, Wade TD. Developing a definition of body neutrality and strategies for an intervention. Body Image 2023; 46:434-442. [PMID: 37573765 DOI: 10.1016/j.bodyim.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/06/2023] [Accepted: 07/16/2023] [Indexed: 08/15/2023]
Abstract
The aim of this study was to provide a definition for body neutrality and understand the key strategies recommended to improve body neutrality for testing in future interventions. There is minimal academic literature on body neutrality and thus this study focused on examining websites where the concept has been discussed for some time. This was achieved using a realist synthesis of websites and a common elements approach to extract the key definition elements of body neutrality, strategies to improve body neutrality, in addition to the common critiques of both the body positivity and body neutrality movements. The initial search found 175 websites, of which 107 were included in the final synthesis, and common elements analysis followed after removal of duplicates and ineligible websites. Three elements, with several sub-elements, best operationalised the definition of body neutrality. Six strategies were found for development of a body neutrality intervention. This innovative study paves the way for rigorous evaluation of body neutrality. Recommendations for future work are provided, including the use of current measures, creating a new measure, and evaluating prevention and intervention programs including Single Session Interventions (SSIs).
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Affiliation(s)
- Mia L Pellizzer
- Blackbird Initiative, Flinders University, Adelaide, Australia; Flinders University Institute of Mental Health and Wellbeing, Flinders University, Adelaide, Australia.
| | - Tracey D Wade
- Blackbird Initiative, Flinders University, Adelaide, Australia; Flinders University Institute of Mental Health and Wellbeing, Flinders University, Adelaide, Australia
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5
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Zhu J, Hay PJ, Yang Y, Le Grange D, Lacey JH, Lujic S, Smith C, Touyz S. Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa. Cochrane Database Syst Rev 2023; 8:CD011570. [PMID: 37610143 PMCID: PMC10445422 DOI: 10.1002/14651858.cd011570.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
BACKGROUND Anorexia nervosa is a psychological condition characterised by self-starvation and fear or wait gain or other body image disturbance. The first line of treatment is specific psychological therapy; however, there is no consensus on best practice for treating people who develop severe and enduring anorexia nervosa (SEAN). Notably, there is no universal definition of SEAN. OBJECTIVES To evaluate the benefits and harms of specific psychological therapies for severe and enduring anorexia nervosa compared with other specific therapies, non-specific therapies, no treatment/waiting list, antidepressant medication, dietary counselling alone, or treatment as usual. SEARCH METHODS We used standard, extensive Cochrane search methods. The last search date was 22 July 2022. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs) of people (any age) with anorexia nervosa of at least three years' duration. Eligible experimental interventions were any specific psychological therapy for improved physical and psychological health in anorexia nervosa, conducted in any treatment setting with no restrictions in terms of number of sessions, modality, or duration of therapy. Eligible comparator interventions included any other specific psychological therapy for anorexia nervosa, non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic treatment (with or without psychological therapy), antidepressant treatment (with or without psychological therapy), dietary counselling, and treatment as usual as defined by the individual trials. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were clinical improvement (weight restoration to within the normal weight range for participant sample) and treatment non-completion. Results were presented using the GRADE appraisal tool. MAIN RESULTS We found two eligible studies, but only one study provided usable data. This was a parallel-group RCT of 63 adults with SEAN who had an illness duration of at least seven years. The trial compared outpatient cognitive behaviour therapy for SEAN (CBT-SEAN) with specialist supportive clinical management for SEAN (SSCM-SE) over eight months. It is unclear if there is any difference between the effect of CBT-SEAN versus SSCM-SE on clinical improvement at 12 months (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.05) or treatment non-completion (RR 1.72, 95% CI 0.45 to 6.59). There were no reported data on adverse effects. The trial was at high risk of performance and detection bias. We rated the GRADE level of evidence as very low-certainty for both primary outcomes, downgrading for imprecision and risk of bias concerns. AUTHORS' CONCLUSIONS This review reports evidence from one trial that evaluated CBT-SEAN versus SSCM-SE. There was very low-certainty evidence of little or no difference in clinical improvement and treatment non-completion between the two therapies. There is a need for larger high-quality trials to determine the benefits of specific psychological therapies for people with SEAN. These should take into account the duration of illness as well as participants' previous experience with evidence-based psychological therapy for anorexia nervosa.
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Affiliation(s)
- James Zhu
- Sydney Local Health District, Sydney, NSW, Australia
| | - Phillipa J Hay
- Translational Health Research Institute, Western Sydney University, Campbelltown, Australia
- Mental Health Services, WSLHD, Campbelltown, Australia
| | - Yive Yang
- Translational Health Research Institute, Western Sydney University, Campbelltown, Australia
| | | | | | - Sanja Lujic
- Centre for Big Data Research in Health, UNSW, Sydney, Australia
| | - Caroline Smith
- NICM Health Research Institute, Western Sydney University, Penrith, Australia
| | - Stephen Touyz
- School of Psychology and InsideOut Institute, University of Sydney, Sydney, Australia
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Schubert E, Bode S. Positive emotions and their upregulation increase willingness to consume healthy foods. Appetite 2023; 181:106420. [PMID: 36513297 DOI: 10.1016/j.appet.2022.106420] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
While highly relevant for everyday life, it is unclear whether experiencing incidental positive or negative emotional states, and active emotion regulation, influence the weighting of perceived taste and health in food choices. In Experiment 1, we examined two emotion regulation strategies, reappraisal and distraction, used to decrease negative emotions. Participants were cued to experience or decrease their emotional response for either neutral or negative incidental emotion-inducing images. They subsequently rated their willingness to consume foods, which varied in their taste and health attributes. Mixed-effects model analysis showed that compared to neutral, negative emotions decreased willingness to consume, regardless of perceived taste and health, but neither emotion regulation strategy had a significant effect. Experiment 2 used images inducing incidental positive emotions in combination with three emotion regulation strategies: reappraisal, distraction, and increasing positive emotions. Experiencing positive emotions generally increased willingness to consume, with stronger effects for tasty and healthy foods. Decreasing positive emotions via reappraisal decreased willingness to consume, particularly for healthy foods. Increasing positive emotion intensity further increased willingness to consume, with stronger effects for healthy foods. The results suggest that experiencing positive emotions increases desire particularly strongly for healthy foods, which can additionally be modulated via emotion regulation. This has important implications for designing health-related interventions targeting mood improvement.
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Affiliation(s)
- Elektra Schubert
- Melbourne School of Psychological Sciences, The University of Melbourne, Australia
| | - Stefan Bode
- Melbourne School of Psychological Sciences, The University of Melbourne, Australia.
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Ciwoniuk N, Wayda-Zalewska M, Kucharska K. Distorted Body Image and Mental Pain in Anorexia Nervosa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010718. [PMID: 36613039 PMCID: PMC9819498 DOI: 10.3390/ijerph20010718] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 06/12/2023]
Abstract
(1) Background: Body image is being defined as the picture of our own body in our mind with its size and shape, and with a perceptive and attitudinal evaluation of this body. It appears to be a complex clinical construct predisposing an individual to developing and maintaining anorexia nervosa (AN), as well as having considerable impact on prolonging the duration of this illness and its relapse risk. The aim of the research work was to assess whether the symptomatology of eating disorders, level of depression, and mental pain are associated with body image, and examine the influence of a distorted body image as well as eating disorders and depression symptoms on mental pain in AN; (2) Methods: A total of 36 women diagnosed with AN and 69 healthy controls (HC) participated in this study. All participants completed a battery of the following scales: EAT-26, BSQ-34, BIDQ, BDD-YBOCS, CESDR, and the Mental Pain Scale; (3) Results: Results show statistically significantly greater body image disturbances and higher level of depression and mental pain intensity in the AN compared to the HC group. Regression analysis indicates a greater impact of distorted body image, eating disorders, and depression symptoms on mental pain in AN; (4) Conclusions: As assumed, distorted body image and mental pain are central components of AN that should be especially emphasized in the therapeutical process of treating AN. Future research should focus on the etiopathogenesis of distorted body image in relation to the chronicity of mental pain and depression in AN, and address these outcomes in clinical practice to minimize suicide risk in this high-risk group of patients.
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8
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Kaa BS, Bünemann JMN, Clausen L. A benchmark study of a combined individual and group anorexia nervosa therapy program. Nord J Psychiatry 2022:1-8. [PMID: 36398931 DOI: 10.1080/08039488.2022.2143558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Anorexia nervosa (AN) is a treatment-resistant illness. Up to half of the patients show limited or no significant treatment response. First, we aimed to describe a new stepped-care outpatient treatment combining group and individual therapy (CIGAN) with a strong focus on normalizing eating and weight and in vivo meal support for adults with moderate to severe AN. Second, we aimed to compare CIGAN with specialized treatments of Specialized Supportive Clinical Management (SSCM) and the Maudsley model of AN (MANTRA). METHOD The study includes 137 adults with moderate to severe AN and the primary outcome (BMI) at six and twelve months was compared with the outcomes published for SSCM and MANTRA using the Chi-squared test and Student's t-test. The paired t-test and Cohen's d were used to compare the within-group follow-up data with the baseline data. RESULTS CIGAN patients changed significantly on all outcome measures at 6 and 12 months, with effect sizes on BMI of 1.37 and 1.51 and on the weight of 1.36 and 1.60, respectively. Except for the 12-month comparison with MANTRA, patients had a higher BMI and larger BMI increase at both 6 and 12 months than SSCM (BMI p = 0.002 and 0.023, BMI increase p < 0.001 and 0.003) and MANTRA (BMI p = 0.031 and 0.168, BMI increase p < 0.001 and 0.037). DISCUSSION CIGAN, including a stepped care approach, is a promising treatment, and further research on the effective elements is warranted.
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Affiliation(s)
- Bo Skytte Kaa
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | | | - Loa Clausen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Keegan E, Byrne S, Hay P, Touyz S, Treasure J, Schmidt U, McIntosh VVW, Wade TD. An exploratory examination of executive functioning as an outcome, moderator, and predictor in outpatient treatment for adults with anorexia nervosa. J Eat Disord 2022; 10:83. [PMID: 35715854 PMCID: PMC9206373 DOI: 10.1186/s40337-022-00602-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE People with anorexia nervosa often exhibit inefficiencies in executive functioning (central coherence and set shifting) that may negatively impact on treatment outcomes. It is unclear from previous research whether these inefficiencies can change over treatment. We aimed to (1) investigate whether executive functioning can improve over treatment, (2) determine whether baseline executive functioning moderates treatment outcome, and (3) examine whether baseline executive functioning predicts early change (i.e., increase in body mass index over the first 13 weeks of treatment) or remission. METHOD We conducted linear mixed model and logistic regression analyses on data from the Strong Without Anorexia Nervosa trial (Byrne et al. in Psychol Med 47:2823-2833, 2017). This study was a randomised controlled trial of three outpatient treatments for people with anorexia nervosa: Enhanced Cognitive Behavioural Therapy, Maudsley Model Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management. RESULTS While set shifting clearly improved from baseline to end of treatment, the results for central coherence were less clear cut. People with low baseline central coherence had more rapid reductions in eating disorder psychopathology and clinical impairment than those with high baseline central coherence. Baseline executive functioning did not predict early change or remission. DISCUSSION The detail-focused thinking style commonly observed among people with anorexia nervosa may aid treatment outcomes. Future research that is more adequately powered should replicate this study and examine whether the same pattern of results is observed among people with non-underweight eating disorders.
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Affiliation(s)
- Ella Keegan
- Discipline of Psychology, Blackbird Initiative, Órama Research Institute, Flinders University, GPO Box 2100, Adelaide, South Australia, 5001, Australia.
| | - Susan Byrne
- SWAN Centre, Perth and School of Psychology, University of Western Australia, Perth, Australia
| | - Phillipa Hay
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia
| | - Stephen Touyz
- InsideOut Institute, Sydney University, Sydney, Australia
| | - Janet Treasure
- Department of Psychological Medicine, Kings College London, London, UK
| | - Ulrike Schmidt
- Department of Psychological Medicine, Kings College London, London, UK
| | - Virginia V W McIntosh
- School of Psychology, Speech and Hearing, University of Canterbury Christchurch, Christchurch, New Zealand
| | - Tracey D Wade
- Discipline of Psychology, Blackbird Initiative, Órama Research Institute, Flinders University, GPO Box 2100, Adelaide, South Australia, 5001, Australia
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McIntosh VVW, Carter JD, Jordan J, Loughlin A. Specialist supportive clinical management for anorexia nervosa: Analysis of therapy content and relation to outcome. Int J Eat Disord 2022; 55:717-722. [PMID: 35258113 DOI: 10.1002/eat.23697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Psychotherapy for anorexia nervosa (AN) is complex and multifaceted, with little known about likely effective components of treatments. The current study explored the spoken content of specialist supportive clinical management (SSCM) for AN, a treatment with evidence of effectiveness in several randomized clinical trials. METHOD One hundred seventy-eight therapy sessions constituting all ten therapist-patient dyads of those who completed SSCM treatment in the original clinical trial of SSCM, were transcribed verbatim. Themes were developed and content analyzed using qualitative content analysis of complete therapy sessions by four analysts, with 10% of sessions cocoded for interrater agreement. RESULTS Over three quarters of session content was within the clinical management theme, the largest subtheme relating to normalizing eating, followed by weight, mechanics of SSCM, and encouragement of self-care. Approximately 20% of total content was in the supportive psychotherapy theme, half about relationships. The relative proportion of clinical management content remained high, decreasing during the last five sessions. Those achieving good outcome did not have a lower ratio of clinical management to supportive psychotherapy content. DISCUSSION The current study revealed strong clinical management focus on core symptoms of AN-normalization of eating and weight gain-throughout SSCM for AN. PUBLIC SIGNIFICANCE Six clinical trials have found SSCM to be effective in treating AN. Content of SSCM sessions in the original trial was classified using qualitative content analysis. Study findings revealed strong clinical management focus on core AN symptoms-normalization of eating and weight gain-throughout SSCM, with the ratio of clinical management to supportive psychotherapy greater for those with a good outcome.
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Affiliation(s)
| | - Janet Deborah Carter
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Jennifer Jordan
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
- Canterbury District Health Board, Christchurch, New Zealand
| | - Alex Loughlin
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
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11
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Fetahi E, Søgaard AS, Sjögren M. Estimating the Effect of Motivational Interventions in Patients with Eating Disorders: A Systematic Review and Meta-Analysis. J Pers Med 2022; 12:jpm12040577. [PMID: 35455693 PMCID: PMC9028385 DOI: 10.3390/jpm12040577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 12/10/2022] Open
Abstract
Motivation to change behavior is seen as an important factor in achieving a better treatment effect in patients with eating disorders (ED). The aim of this systematic review was to assess whether motivational interviewing (MI) and motivational enhancement therapy (MET) might (1) increase motivation to change behavior and (2) improve eating disorder psychopathology (EDP) and body mass index (BMI) in patients with ED. To investigate this, a literature search was conducted on 9 March 2021 on four scientific databases: Cochrane, Embase (Ovid), MEDLINE (PubMed), and PsycInfo (EBSCO). A total of 2647 publications were identified and following a rigorous stepwise procedure to assess titles and abstracts and, thereafter, full texts of relevant publications, 13 studies were included in the data extraction and analyses. A few individual studies (n = 5) found a significant increase in motivation, two a decrease in ED symptoms (n = 2), while none found an effect on BMI. However, the meta-analysis of each outcome found effect sizes near zero, thereby confirming the results of previous narrative reviews that have described a lack of effect of MET/MI on motivation in ED. Since the individual studies differ substantially in design, and the outcomes were inconsistently assessed with regards to instruments and duration, the effect of MET/MI on motivation for behavioral change, ED psychopathology, and BMI is still unclear.
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Affiliation(s)
- Egzona Fetahi
- Eating Disorder Research Unit, Psychiatric Centre Ballerup, 2750 Ballerup, Denmark; (E.F.); (A.S.S.)
| | - Anders Stjerne Søgaard
- Eating Disorder Research Unit, Psychiatric Centre Ballerup, 2750 Ballerup, Denmark; (E.F.); (A.S.S.)
| | - Magnus Sjögren
- Eating Disorder Research Unit, Psychiatric Centre Ballerup, 2750 Ballerup, Denmark; (E.F.); (A.S.S.)
- Institute for Clinical Science, Umeå University, 901 85 Umeå, Sweden
- Correspondence:
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12
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Kiely L, Touyz S, Conti J, Hay P. Conceptualising specialist supportive clinical management (SSCM): current evidence and future directions. J Eat Disord 2022; 10:32. [PMID: 35255984 PMCID: PMC8900319 DOI: 10.1186/s40337-022-00557-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/23/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Current evidence-based treatments for adult anorexia nervosa (AN) have limitations, with high attrition, very poor outcomes for 20% of people, and no clearly superior manualised therapy for adults with AN. Specialist Supportive Clinical Management (SSCM) was designed as a control treatment but has evolved as a valid first line treatment. The present paper aims to provide an overview of the evidence base for SSCM and a pedagogical reconceptualization with expansion by theoretical integration (TI). BODY: A secondary meta-analysis endorses SSCM as a promising treatment. This paper positions SSCM as a manualised therapy for adult AN with six unique features, namely (1) a philosophy which is person-centred, non-prescriptive, and informed by the person's strengths and values, (2) a focus on the person through inclusion of supportive psychotherapy and problem (clinical management), within target symptoms as defined in relation to AN, (3) a flexible and responsive therapy that could be delivered by a variety of clinicians with experience treating AN (4) a commitment to reversing starvation though a directional approach and a defined yet flexible stance on dietetic intervention (5) a commitment to the therapeutic relationship within all three phases of treatment, and (6) a therapy 'uncluttered' by specific mandates. In addition, this paper positions SSCM as a treatment that may be strengthened by other modalities and may also be adapted to the treatment of other eating disorders (ED), not just AN. The level of therapist sophistication to deliver upon the supportive psychotherapy component is explored and future directions are offered. CONCLUSION SSCM is a unique and valid first line treatment for AN and would benefit from further expansion in line with emerging understandings of AN to strengthen it as a treatment. Speculation on aspects of potency would benefit from further testing. The proposed re-conceptualisation of SSCM in the context of its evidence may strengthen it as a treatment overall, position it as adaptable for treatment of other eating disorders and make it more accessible to clinicians.
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Affiliation(s)
- Laura Kiely
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia.
| | - Stephen Touyz
- University of Sydney InsideOut Institute, Camperdown, NSW, Australia
| | - Janet Conti
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia.,School of Psychology, Western Sydney University, Penrith, Australia
| | - Phillipa Hay
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia.,Camden and Campbelltown Hospitals, SWSLHD, Campbelltown, NSW, 2560, Australia
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Oldershaw A, Lavender T, Basra R, Startup H. SPEAKS study: study protocol of a multisite feasibility trial of the Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) intervention for outpatients with anorexia nervosa or otherwise specified feeding and eating disorders, anorexia nervosa type. BMJ Open 2022; 12:e050350. [PMID: 35193902 PMCID: PMC8867350 DOI: 10.1136/bmjopen-2021-050350] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Anorexia nervosa (AN) is a severe mental health condition associated with high mortality rates and significantly impaired quality of life. National guidelines outline psychotherapeutic interventions as treatments of choice for adults with AN, but outcomes are limited and therapy drop-out high, resulting in calls for new innovative treatments. The Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) research programme sought to develop the SPEAKS intervention avoiding some difficulties inherent in development of earlier interventions, such unclear hypotheses about change processes. SPEAKS focuses on a core hypothesised maintaining factor (emotional experience) with clear proposed model of change. The current feasibility trial aims to provide an initial test of SPEAKS and inform design of a full randomised controlled trial protocol. METHODS AND ANALYSIS This study employs a multisite, single-arm, within-group, mixed-methods design. Up to 60 participants (36 therapy completers) meeting inclusion criteria will be offered the SPEAKS intervention instead of treatment-as-usual (TAU). SPEAKS is a weekly psychotherapy lasting nine to 12 months, provided by trained and experienced eating disorders therapists. All other clinical input remains inline with TAU. Acceptability will be assessed using VAS scales and end of therapy interview. Reach and recruitment, such as recruitment yield, will be monitored. To support sample size estimation and economic estimation, data pertaining to eating disorder-related symptoms will be recorded every 3 months, alongside service usage and intervention-specific measures. Videoed therapy sessions will inform model adherence. Additional analyses coding videoed therapy will test SPEAKS change process hypotheses. ETHICS AND DISSEMINATION Ethical approval has been granted by London-Bromley Research Ethics Committee (NHS Rec Reference: 19/LO/1530). Data will be disseminated via high-impact, peer-reviewed journals (Open Access preferred), conferences, service user and charity networks (eg, UK charity BEAT) and through a free open conference hosted by National Health Service Trusts and Higher Education Institutions. TRIAL REGISTRATION NUMBER ISRCTN11778891. TRIAL STATUS Recruitment began on 12 December 2019 and ends on 28 February 2021. All data will be collected and the trial ended by 28 February 2022. PROTOCOL VERSION SPEAKS protocol V.3.0 (30 August 2020). Changes were made to the original protocol due to the COVID-19 pandemic. A further set of changes were made to incorporate the measures of change processes, resulting in this being the third version of the protocol.
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Affiliation(s)
- Anna Oldershaw
- Kent and Medway All Age Eating Disorder Service, North East London NHS Foundation Trust, Kent, UK
- Salomons Institute for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells, UK
| | - Tony Lavender
- Salomons Institute for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells, UK
| | - Randeep Basra
- Kent and Medway All Age Eating Disorder Service, North East London NHS Foundation Trust, Kent, UK
| | - Helen Startup
- Brighton and Hove Eating Disorder Service, Sussex Partnership NHS Foundation Trust, Brighton, UK
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14
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Gan JKE, Wu VX, Chow G, Chan JKY, Klainin-Yobas P. Effectiveness of non-pharmacological interventions on individuals with anorexia nervosa: A systematic review and meta-analysis. PATIENT EDUCATION AND COUNSELING 2022; 105:44-55. [PMID: 34059364 DOI: 10.1016/j.pec.2021.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 03/15/2021] [Accepted: 05/19/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This study aimed to synthesize the best available evidence regarding the effectiveness of non-pharmacological interventions on body mass index (BMI), body dissatisfaction, depression and anxiety among individuals with anorexia nervosa (AN). METHODS Published studies in English were searched using seven databases (such as PubMed). Grey literature was searched using ProQuest and Scopus. Studies were screened, appraised and extracted by two independent reviewers. Meta-analysis was performed and standardized mean difference was used as an effect measure. Heterogeneity was determined by I2 statistics and Cochran χ2 test. Publication bias was appraised using funnel plots. Sensitivity and subgroup analyses were also conducted. RESULTS Nineteen RCTs from eight different countries were included in this review. Behavioral family system therapy (BFST) was found to enhance BMI while conjoint family therapy (CFT) was more effective in ameliorating depression. Studies implementing combined family and individual therapy and those with longer therapeutic durations produced larger effect sizes. CONCLUSION This review provided evidence to support BSFT, CFT and combined family and individual therapy for adolescents with AN. PRACTICAL IMPLICATIONS Healthcare professionals may offer the two interventions to adolescents with AN in clinical settings. Future research may further investigate the effectiveness of BSFT and CFT on BMI and depression.
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Affiliation(s)
- Javeil Ke En Gan
- Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
| | - Vivien Xi Wu
- Alice Lee Centre for Nursing Studies, National University of Singapore, Level 2, Clinical Research Centre, 10 Medical Drive, Singapore 117597, Singapore.
| | - Gigi Chow
- Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore.
| | | | - Piyanee Klainin-Yobas
- Alice Lee Centre for Nursing Studies, National University of Singapore, Level 2, Clinical Research Centre, 10 Medical Drive, Singapore 117597, Singapore.
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15
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Mulchandani M, Shetty N, Conrad A, Muir P, Mah B. Treatment of eating disorders in older people: a systematic review. Syst Rev 2021; 10:275. [PMID: 34696804 PMCID: PMC8543781 DOI: 10.1186/s13643-021-01823-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 09/28/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Historically, eating disorders were not identified in older populations and it is only in more recent times that there is greater recognition of the existence of eating disorders among the elderly. This is despite the high level of morbidity and mortality associated with these disorders. Current guidelines focus on treatment of eating disorders within the adolescent and general adult age groups, without apparent concessions made for the older age group. The aim of this study was to review existing literature on the demographics and treatment of eating disorders in older people. METHODS/DESIGN A systematic review of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsycInfo, Scopus, and Web of Science to identify publications focusing on treatment of eating disorders in people over the age of 65 years, age of diagnosis, gender distribution, treatment setting, and treatment outcomes. RESULTS A total of 35 articles (reporting on 39 cases) were relevant to our study, with 33 of the 35 articles being either case studies or case series. The mean age of participants was 73.2 years (range 66-94 years) with the majority (84.6%) being female. Most cases (84.6%) were diagnosed with anorexia nervosa, and 56.4% of all cases were reported as late onset (i.e., after age 40 years). The vast majority (94.8%) received treatment, of which 51.5% was hospital-based treatment. In case descriptions where improvement was reported, the majority described a multidimensional approach that included a combination of hospital admission, therapy and pharmacotherapy. Overall, 79.5% of cases who underwent treatment for an eating disorder improved, while 20.5% relapsed or died as a result of the complications from their eating disorder. There were significant inconsistencies and omissions in the way cases were described, thereby impacting on the interpretation of the results and potential conclusions. CONCLUSIONS The information available on the treatment of eating disorders in people over the age of 65 years is limited. The quality of case reports to date makes it difficult to suggest specific assessment or treatment guidelines for this population.
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Affiliation(s)
- Megha Mulchandani
- Hunter New England Mental Health Service, PO Box 833, Newcastle, NSW, 2300, Australia.,Older People's Mental Health Service, Hunter New England Mental Health Service, PO Box 833, Newcastle, NSW, 2300, Australia
| | - Namrata Shetty
- Hunter New England Mental Health Service, PO Box 833, Newcastle, NSW, 2300, Australia.,Older People's Mental Health Service, Hunter New England Mental Health Service, PO Box 833, Newcastle, NSW, 2300, Australia
| | - Agatha Conrad
- Hunter New England Mental Health Service, PO Box 833, Newcastle, NSW, 2300, Australia. .,Centre for Brain and Mental Health Research (CBMHR), The University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Petra Muir
- Hunter New England Mental Health Service, PO Box 833, Newcastle, NSW, 2300, Australia.,Older People's Mental Health Service, Hunter New England Mental Health Service, PO Box 833, Newcastle, NSW, 2300, Australia
| | - Beth Mah
- Centre for Brain and Mental Health Research (CBMHR), The University of Newcastle, Callaghan, NSW, 2308, Australia.,Karitane Residential Service, 138 The Horsely Drive, Carramar, NSW, 2163, Australia
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16
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Mountford VA, Allen KL, Tchanturia K, Eilender C, Schmidt U. Implementing evidence-based individual psychotherapies for adults with eating disorders in a real world clinical setting. Int J Eat Disord 2021; 54:1238-1249. [PMID: 33719036 DOI: 10.1002/eat.23504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of evidenced-based psychological treatments (specifically, Cognitive-Behaviour Therapy for Eating Disorders [CBT-ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology. METHOD Three hundred and seventy-nine participants meeting criteria for DSM-5 anorexia nervosa, bulimia nervosa, binge-eating disorder or other specified feeding or eating disorder completed pre- and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging. RESULTS Ninety seven percent of participants received treatment in line with evidence-based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m2 over treatment, with similar outcomes for MANTRA and CBT-ED. DISCUSSION These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence-based psychotherapies to real-world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders.
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Affiliation(s)
- Victoria A Mountford
- Eating Disorder Service, South London and Maudsley NHS Foundation Trust, Middle House, Maudsley Hospital, London, UK.,Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK.,Maudsley Health, Abu Dhabi, UAE
| | - Karina L Allen
- Eating Disorder Service, South London and Maudsley NHS Foundation Trust, Middle House, Maudsley Hospital, London, UK.,Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Kate Tchanturia
- Eating Disorder Service, South London and Maudsley NHS Foundation Trust, Middle House, Maudsley Hospital, London, UK.,Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Cara Eilender
- Eating Disorder Service, South London and Maudsley NHS Foundation Trust, Middle House, Maudsley Hospital, London, UK.,Department of Clinical Psychology, University College London, London, UK
| | - Ulrike Schmidt
- Eating Disorder Service, South London and Maudsley NHS Foundation Trust, Middle House, Maudsley Hospital, London, UK.,Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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17
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Ashkan K, Mirza AB, Tambirajoo K, Furlanetti L. Deep brain stimulation in the management of paediatric neuropsychiatric conditions: Current evidence and future directions. Eur J Paediatr Neurol 2021; 33:146-158. [PMID: 33092983 DOI: 10.1016/j.ejpn.2020.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/21/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Neurosurgery has provided an alternative option for patients with refractory psychiatric indications. Lesion procedures were the initial techniques used, but deep brain stimulation (DBS) has the advantage of relative reversibility and adjustability. This review sets out to delineate the current evidence for DBS use in psychiatric conditions, with an emphasis on the paediatric population, highlighting pitfalls and opportunities. METHODS A systematic review of the literature was conducted on studies reporting the use of DBS in the management of psychiatric disorders. The PRISMA guidelines were employed to structure the review of the literature. Data was discussed focusing on the indications for DBS management of psychiatric conditions in the paediatric age group. RESULTS A total of seventy-three full-text papers reported the use of DBS surgery for the management of psychiatric conditions matching the inclusion criteria. The main indications were Tourette Syndrome (GTS) (15 studies), Obsessive Compulsive Disorder (OCD) (20), Treatment Resistant Depression (TRD) (27), Eating Disorders (ED) (7) and Aggressive Behaviour and self-harm (AB) (4). Out of these, only 11 studies included patients in the paediatric age group (≤18 years-old). Among the paediatric patients, the indications for surgery included GTS, AB and ED. CONCLUSIONS The application of deep brain stimulation for psychiatric indications has progressed at a steady pace in the adult population and at a much slower pace in the paediatric population. Future studies in children should be done in a trial setting with strict and robust criteria. A move towards personalising DBS therapy with new stimulation paradigms will provide new frontiers and possibilities in this growing field.
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Affiliation(s)
- Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Kantharuby Tambirajoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Luciano Furlanetti
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK.
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18
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Startup H, Franklin-Smith M, Barber W, Gilbert N, Brown Y, Glennon D, Fukutomi A, Schmidt U. The Maudsley Anorexia Nervosa Treatment for Adults (MANTRA): a feasibility case series of an integrated group based approach. J Eat Disord 2021; 9:70. [PMID: 34130755 PMCID: PMC8207787 DOI: 10.1186/s40337-021-00424-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with Anorexia Nervosa (AN) typically struggle in social and emotional contexts. An Integrated Group Based approach for the delivery of MANTRA - The Maudsley Anorexia Nervosa Treatment for Adults - extends current NICE recommended therapy by augmenting treatment with opportunities for experiential practice in a group context. A feasibility case series, delivered across three NHS community services is presented. METHODS The design was a case series of four Integrated Group MANTRA treatments delivered across three NHS sites (N = 29). Feasibility data of: retention, acceptability and effectiveness; alongside the qualitative capture of participant experiences of treatment is presented. RESULTS Primary outcomes suggest treatment acceptability. Participants committed to treatment with only 2 dropouts. There was significant change with medium effect sizes for eating disorder cognitions and symptoms (as measured by the global score on EDEQ) and BMI. Core themes emerging from qualitative analysis captured the value of the relational aspect of the treatment, the incorporation of experiential methods, and the opportunity to draw on the support of the group members to reduce shame and stigma. CONCLUSIONS An Integrated Group based MANTRA approach is a feasible and effective alternative intervention for community Eating Disorder services.
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Affiliation(s)
- Helen Startup
- Sussex Partnership NHS Foundation Trust, Sussex Eating Disorders Service, Brighton, UK.
| | - Mary Franklin-Smith
- Leeds Partnership NHS Foundation Trust, CONNECT: The West Yorkshire Adult Eating Disorder Service, Leeds, UK
| | - William Barber
- Sussex Partnership NHS Foundation Trust, Sussex Eating Disorders Service, Brighton, UK
| | - Nicola Gilbert
- Sussex Partnership NHS Foundation Trust, Sussex Eating Disorders Service, Brighton, UK
| | - Yael Brown
- South London and Maudsley NHS Foundation Trust, Eating Disorders Outpatient Service, London, UK
| | - Danielle Glennon
- South London and Maudsley NHS Foundation Trust, Eating Disorders Outpatient Service, London, UK
| | - Akira Fukutomi
- South London and Maudsley NHS Foundation Trust, Eating Disorders Outpatient Service, London, UK
| | - Ulrike Schmidt
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK
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19
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Solmi M, Wade TD, Byrne S, Del Giovane C, Fairburn CG, Ostinelli EG, De Crescenzo F, Johnson C, Schmidt U, Treasure J, Favaro A, Zipfel S, Cipriani A. Comparative efficacy and acceptability of psychological interventions for the treatment of adult outpatients with anorexia nervosa: a systematic review and network meta-analysis. Lancet Psychiatry 2021; 8:215-224. [PMID: 33600749 DOI: 10.1016/s2215-0366(20)30566-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND No consistent first-option psychological interventions for adult outpatients with anorexia nervosa emerges from guidelines. We aimed to compare stand-alone psychological interventions for adult outpatients with anorexia nervosa with a specific focus on body-mass index, eating disorder symptoms, and all-cause dropout rate. METHODS In this systematic review and network meta-analysis, we assessed randomised controlled trials about stand-alone pharmacological or non-pharmacological treatments of adult outpatients with anorexia nervosa, defined according to standardised criteria, with data for at least two timepoints relating to either body-mass index or global eating disorder psychopathology. We searched Cochrane CENTRAL, CINAHL, MEDLINE, and PsychINFO for published and unpublished literature from inception until March 20, 2020. The primary outcomes were the change in body mass index and clinical symptoms, and the secondary outcome was all-cause dropout rate, which were all assessed for treatment as usual, cognitive behavioural therapy (CBT), Maudsley anorexia treatment for adults, family-based treatment, psychodynamic-oriented psychotherapies, a form of CBT targeting compulsive exercise, and cognitive remediation therapy followed by CBT. Global and local inconsistencies for the network meta-analysis were measured, and CINeMA was used to assess the confidence in evidence for primary outcomes. The protocol is registered in PROSPERO (CRD42017064429). FINDINGS Of 14 003 studies assessed for their title and abstract, 16 (0·1%) randomised controlled trials for psychological treatments were included in the systematic review, of which 13 (0·1%) contributed to the network meta-analysis, with 1047 patients in total (of whom 1020 [97·4%] were female). None of the interventions outperformed treatment as usual in our primary outcomes, but the all-cause dropout rate was lower for CBT than for psychodynamic-oriented psychotherapies (OR 0·54, 95% CI 0·31-0·93). Heterogeneity or inconsistency emerged only for a few comparisons. Confidence in the evidence was low to very low. INTERPRETATION Compared with treatment as usual, specific psychological treatments for adult outpatients with anorexia nervosa can be associated with modest improvements in terms of clinical course and quality of life, but no reliable evidence supports clear superiority or inferiority of the specific treatments that are recommended by clinical guidelines internationally. Our analysis is based on the best data from existing clinical studies, but these findings should not be seen as definitive or universally applicable. There is an urgent need to fund new research to develop and improve therapies for adults with anorexia nervosa. Meanwhile, to better understand the effects of available treatments, participant-level data should be made freely accessible to researchers to eventually identify whether specific subgroups of patients are more likely to respond to specific treatments. FUNDING Flinders University, National Institute for Health Research Oxford Health Biomedical Research Centre.
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Affiliation(s)
- M Solmi
- Neurosciences Department and Neuroscience Centre, University of Padua, Padua, Italy
| | - T D Wade
- Discipline of Psychology, Flinders University, Adelaide, SA, Australia
| | - S Byrne
- School of Psychological Sciences, The University of Western Australia, Perth, WA, Australia
| | - C Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - C G Fairburn
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - E G Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health National Health Service Foundation Trust, Warneford Hospital, Oxford, UK
| | - F De Crescenzo
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - C Johnson
- Discipline of Psychology, Flinders University, Adelaide, SA, Australia
| | - U Schmidt
- Department of Psychological Medicine, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, London, UK
| | - J Treasure
- Department of Psychological Medicine, King's College London, London, UK; South London and Maudsley National Health Service Foundation Trust, London, UK
| | - A Favaro
- Neurosciences Department and Neuroscience Centre, University of Padua, Padua, Italy
| | - S Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital Tübingen, Tübingen, Germany
| | - A Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health National Health Service Foundation Trust, Warneford Hospital, Oxford, UK.
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20
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Gutiérrez E, Carrera O. Severe and Enduring Anorexia Nervosa: Enduring Wrong Assumptions? Front Psychiatry 2021; 11:538997. [PMID: 33658948 PMCID: PMC7917110 DOI: 10.3389/fpsyt.2020.538997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 12/17/2020] [Indexed: 11/13/2022] Open
Abstract
To the extent that severe and lasting anorexia nervosa (SE-AN) is defined in terms of refractoriness to the best treatments available, it is mandatory to scrutinize the proven effectiveness of the treatments offered to patients. The array of so-called current evidence-based treatments for anorexia nervosa (AN) encompasses the entire spectrum of treatments ranging from specialized brand-type treatments to new treatments adapted to the specific characteristics of people suffering from AN. However, after several randomized control trials, parity in efficacy is the characteristic among these treatments. To further complicate the landscape of effective treatments, this "tie score" extends to the treatment originally conceived as control conditions, or treatment as usual conditions. In retrospection, one can understand that treatments considered to be the best treatments available in the past were unaware of their possible iatrogenic effects. Obviously, the same can be said of the theoretical assumptions underpinning such treatments. In either case, if the definition of chronicity mentioned above is applied, it is clear that the responsibility for the chronicity of the disorder says more about the flagrant inefficacy of the treatments and the defective assumptions underpinning them, than the nature of the disorder itself. A historical analysis traces the emergence of the current concept of "typical" AN and Hilde Bruch's contribution to it. It is concluded that today's diagnostic criteria resulting from a long process of acculturation distort rather than capture the essence of the disorder, as well as marginalizing and invalidating patients' perspectives.
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Affiliation(s)
- Emilio Gutiérrez
- Department of Clinical Psychology and Psychobiology, College of Psychology, University of Santiago, Santiago de Compostela, Spain
- Venres Clínicos Unit, College of Psychology, University of Santiago, Santiago de Compostela, Spain
| | - Olaia Carrera
- Venres Clínicos Unit, College of Psychology, University of Santiago, Santiago de Compostela, Spain
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21
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Muratore AF, Attia E. Current Therapeutic Approaches to Anorexia Nervosa: State of the Art. Clin Ther 2020; 43:85-94. [PMID: 33293054 DOI: 10.1016/j.clinthera.2020.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022]
Abstract
Anorexia nervosa (AN) is a devastating psychiatric disorder characterized by extreme restriction of food intake and low body weight, both associated with significant medical and psychological morbidity. The clinical severity of AN has prompted the consideration and study of behavioral and pharmacological treatments in efforts to establish empirically based methods to reduce the burden of the disorder. Among adolescents, family-based treatment is considered a first-line behavioral treatment. Research continues to explore the efficacy of family-based treatment and predictors of treatment response to further improve outcomes. Several behavioral treatments for adults also exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain. Despite this, no one treatment is considered superior, and all existing behavioral approaches leave a proportion of adults symptomatic or at a high risk of relapse. As such, among adults, there is continued need for development of novel, mechanism-based approaches to better target the core symptoms of AN. Although antidepressants impart little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with AN. Most recently, the field's evolving conceptualization of AN as a biologically based disorder coupled with technological advancements has led to consideration of varying neuromodulation strategies as a potential therapeutic approach that remains under investigation.
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Affiliation(s)
- Alexandra F Muratore
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA.
| | - Evelyn Attia
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA
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22
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Guerrero Alzola F, Casas Rivero J, Martínez-Álvarez R. Stereotactic surgery on a female patient with severe chronic anorexia nervosa: 10-year follow-up. Eat Weight Disord 2020; 25:1827-1831. [PMID: 31595460 DOI: 10.1007/s40519-019-00787-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/25/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Anorexia nervosa (AN) is a serious disease with a high rate of chronification. In chronic and serious cases, psychotherapeutic and pharmacological treatments are not sufficient to control the disease. CASE REPORT We present the case of a female patient with severe chronic restrictive anorexia nervosa resistant to psychomedical treatment. During the 31 years the illness evolved, the patient required multiple hospital admissions. With a body mass index (BMI) of 12.8 kg/m2 and consequent risk of death, stereotactic cingulotomy was performed comprising bilateral blocking of the anterior cingulate cortex by stereotactic radiofrequency thermocoagulation, confirmed by tractography 5 years later. After 10 years of follow-up, the patient is clinically stable with an increased BMI and improved neuropsychological indicators. DISCUSSION Stereotactic surgery may be an option for patients with chronic anorexia nervosa where conventional treatments have proved insufficient.
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Affiliation(s)
| | | | - Roberto Martínez-Álvarez
- Department of Radiosurgery and Functional Neurosurgery, Rúber International Hospital, Madrid, Spain
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23
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Jordan J, McIntosh VV, Bulik CM. Specialist Supportive Clinical Management for anorexia nervosa: what it is (and what it is not). Australas Psychiatry 2020; 28:156-159. [PMID: 31523976 DOI: 10.1177/1039856219875024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Specialist Supportive Clinical Management (SSCM) is a psychotherapy comprising a clinical management focus addressing anorexia nervosa (AN) symptoms and a supportive therapy component. SSCM has been an active control therapy in randomised controlled trials for AN, but has proven to be an effective therapy in its own right. There has been speculation about how this relatively straightforward therapy works. Some of the commentaries and descriptors used for SSCM, however, do not reflect the content or principles of SSCM. This paper clarifies areas of misunderstanding by describing what SSCM is and what it is not, particularly in relation to commentary about its constituent characteristics. CONCLUSIONS SSCM utilises well established clinical management for AN (with a sustained focus on normalised eating and weight restoration) coupled with supportive therapy principles and strategies. Common factors across both arms include core counselling skills and a positive therapeutic alliance to promote adherence and retention in treatment for AN. Compared to other comparator therapies to date, SSCM is a simpler therapy without unique or novel theoretically derived strategies. Comparable outcomes with more complex psychotherapies raise the question of whether the combined core components of SSCM may be sufficient for many people with AN.
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Affiliation(s)
- Jennifer Jordan
- Senior Lecturer, Department of Psychological Medicine, University of Otago, Christchurch, New Zealand, and; Clinical Psychologist, Canterbury District Health Board, Christchurch, New Zealand
| | - Virginia Vw McIntosh
- Senior Lecturer and Clinical Psychologist, Psychology Department, University of Canterbury, New Zealand
| | - Cynthia M Bulik
- Distinguished Professor, Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, and; Professor, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden, and; Professor, Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Compassion-focused acceptance and commitment therapy for women with restrictive eating and problematic body-checking: A multiple baseline across participants study. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2020. [DOI: 10.1016/j.jcbs.2020.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Zhu J, Yang Y, Touyz S, Park R, Hay P. Psychological Treatments for People With Severe and Enduring Anorexia Nervosa: A Mini Review. Front Psychiatry 2020; 11:206. [PMID: 32265758 PMCID: PMC7106475 DOI: 10.3389/fpsyt.2020.00206] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/03/2020] [Indexed: 12/26/2022] Open
Abstract
This Mini-Review presents recent research into evidence for psychological treatments for people with severe and enduring anorexia nervosa (SEAN). Two psychological therapies, specialist supportive clinical management (SSCM), and cognitive behavior therapy for anorexia nervosa (CBT-AN) have limited (one randomized controlled study) evidence of efficacy. Both have had adaptations for SEAN, notably with revision of the primary treatment goal of improved quality of life and full weight recovery a secondary goal. A major issue with existing studies is poor definition of SEAN, and the large deficit in research that has used an agreed definition of SEAN. In particular, it may be problematic to extrapolate from studies of people with either severe and/or enduring but not intractable or "resistant" illness. People with longstanding AN who have not received evidence based care should be offered this with an expectation of recovery. Similarly, people with SEAN may be offered care with judicious mitigation of expectations. In the future, trials should include people with SEAN clearly defined. Trials with a subsample of participants likely to have SEAN, if identified at randomisation, are an opportunity for secondary analyses of such participants. This would widen the evidence base for psychological treatments providing hope for people with this devastating illness. Finally, there is an urgent need not only to strengthen our existing knowledge with studies of sufficient power, but also, fundamentally, to derive novel conceptualizations of what "treatment" involves.
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Affiliation(s)
- James Zhu
- South West and North Coast Psychiatry Training Network, Sydney Local Health District, Sydney, NSW, Australia
| | - Yive Yang
- School of Health Sciences, University of Newcastle, Callaghan, NSW, Australia
| | - Stephen Touyz
- InsideOut Institute, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- School of Psychology, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Park
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
| | - Phillipa Hay
- Western Sydney University, Translational Health Research Institute, Sydney, NSW, Australia
- South Western Sydney Local Health District, Camden and Campbelltown Hospitals, Sydney, NSW, Australia
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Treasure J, Willmott D, Ambwani S, Cardi V, Clark Bryan D, Rowlands K, Schmidt U. Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness. J Clin Med 2020; 9:E630. [PMID: 32120847 PMCID: PMC7141127 DOI: 10.3390/jcm9030630] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/21/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023] Open
Abstract
The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.
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Affiliation(s)
- Janet Treasure
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, SE5 8AF London, UK; (J.T.); (V.C.); (D.C.B.); (K.R.); (U.S.)
| | - Daniel Willmott
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, SE5 8AF London, UK; (J.T.); (V.C.); (D.C.B.); (K.R.); (U.S.)
| | - Suman Ambwani
- Department of Psychology, Dickinson College, Carlisle, PA17013, USA;
| | - Valentina Cardi
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, SE5 8AF London, UK; (J.T.); (V.C.); (D.C.B.); (K.R.); (U.S.)
| | - Danielle Clark Bryan
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, SE5 8AF London, UK; (J.T.); (V.C.); (D.C.B.); (K.R.); (U.S.)
| | - Katie Rowlands
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, SE5 8AF London, UK; (J.T.); (V.C.); (D.C.B.); (K.R.); (U.S.)
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, SE5 8AF London, UK; (J.T.); (V.C.); (D.C.B.); (K.R.); (U.S.)
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27
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Gutierrez E, Birmingham CL. Editorial: New Perspectives to Unlock the Current Impasse in Treating Anorexia Nervosa. Front Psychol 2020; 11:207. [PMID: 32132954 PMCID: PMC7040163 DOI: 10.3389/fpsyg.2020.00207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/29/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Emilio Gutierrez
- Departamento de Psicología Clínica y Psicobiología and Unidad Venres Clínicos, Facultad de Psicología, Universidad de Santiago, Santiago de Compostela, Spain
| | - C Laird Birmingham
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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28
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Holmqvist Larsson K, Lowén A, Hellerstedt L, Bergcrona L, Salerud M, Zetterqvist M. Emotion regulation group skills training: a pilot study of an add-on treatment for eating disorders in a clinical setting. J Eat Disord 2020; 8:12. [PMID: 32266070 PMCID: PMC7118896 DOI: 10.1186/s40337-020-00289-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Emotion regulation difficulties appear to play a role in the development and maintenance of several eating disorders. This pilot study aimed at examining whether a short add-on group skills training in emotion regulation for young adults with different eating disorders was feasible in a psychiatric clinical setting. We also investigated if the treatment increased knowledge of emotions, and decreased self-reported difficulties with emotion regulation, alexithymia, symptoms of eating disorder, anxiety and depression, as well as clinical impairment. METHODS Six skills training groups were piloted with a total of 29 participants (M = 21.41 years, SD = 1.92). The treatment consisted of five sessions dealing with psychoeducation about emotions and emotion regulation skills training. Paired samples t-test was used to compare differences between before-and-after measures. RESULTS The primary outcomes measures difficulties in emotion regulation (p < 0.001) and alexithymia (p < 0.001) showed significant improvement after treatment. The total eating disorder score (p = 0.009) was also significantly reduced, as was clinical impairment (p < 0.001). Acceptance/valued direction, identifying primary emotions and learning about secondary emotions was rated as especially helpful. CONCLUSIONS This preliminary pilot study showed that group training targeting emotion regulation skills was feasible and appreciated by participants, as well as being potentially promising as an adjunctive treatment for different eating disorders. Further controlled studies are needed. TRIAL REGISTRATION The study was retrospectively registered NCT04148014 on October 30th 2019.
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Affiliation(s)
- Kristina Holmqvist Larsson
- Department of Child and Adolescent Psychiatry, Region Östergötland, 581 85 Linköping, Sweden.,2Department of Biomedical and Clinical Sciences, Linköping university, 581 83 Linköping, Sweden
| | - Anna Lowén
- Department of Child and Adolescent Psychiatry, Region Östergötland, 581 85 Linköping, Sweden
| | - Linda Hellerstedt
- Department of Child and Adolescent Psychiatry, Region Östergötland, 581 85 Linköping, Sweden
| | - Linn Bergcrona
- Department of Child and Adolescent Psychiatry, Region Östergötland, 581 85 Linköping, Sweden
| | - Mimmi Salerud
- Department of Child and Adolescent Psychiatry, Region Östergötland, 581 85 Linköping, Sweden
| | - Maria Zetterqvist
- Department of Child and Adolescent Psychiatry, Region Östergötland, 581 85 Linköping, Sweden.,2Department of Biomedical and Clinical Sciences, Linköping university, 581 83 Linköping, Sweden
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Rantala MJ, Luoto S, Krama T, Krams I. Eating Disorders: An Evolutionary Psychoneuroimmunological Approach. Front Psychol 2019; 10:2200. [PMID: 31749720 PMCID: PMC6842941 DOI: 10.3389/fpsyg.2019.02200] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022] Open
Abstract
Eating disorders are evolutionarily novel conditions. They lead to some of the highest mortality rates of all psychiatric disorders. Several evolutionary hypotheses have been proposed for eating disorders, but only the intrasexual competition hypothesis is extensively supported by evidence. We present the mismatch hypothesis as a necessary extension to the current theoretical framework of eating disorders. This hypothesis explains the evolutionarily novel adaptive metaproblem that has arisen when mating motives conflict with the large-scale and easy availability of hyper-rewarding but obesogenic foods. This situation is exacerbated particularly in those contemporary environments that are characterized by sedentary lifestyles, ever-present junk foods, caloric surplus and the ubiquity of social comparisons that take place via social media. Our psychoneuroimmunological model connects ultimate-level causation with proximate mechanisms by showing how the adaptive metaproblem between mating motives and food rewards leads to chronic stress and, further, to disordered eating. Chronic stress causes neuroinflammation, which increases susceptibility to OCD-like behaviors that typically co-occur with eating disorders. Chronic stress upregulates the serotonergic system and causes dysphoric mood in anorexia nervosa patients. Dieting, however, reduces serotonin levels and dysphoric mood, leading to a vicious serotonergic-homeostatic stress/starvation cycle whereby cortisol and neuroinflammation increase through stringent dieting. Our psychoneuroimmunological model indicates that between-individual and within-individual variation in eating disorders partially arises from (co)variation in gut microbiota and stress responsivity, which influence neuroinflammation and the serotonergic system. We review the advances that have been made in recent years in understanding how to best treat eating disorders, outlining directions for future clinical research. Current evidence indicates that eating disorder treatments should aim to reduce the chronic stress, neuroinflammation, stress responsivity and gut dysbiosis that fuel the disorders. Connecting ultimate causes with proximate mechanisms and treating biopsychosocial causes rather than manifest symptoms is expected to bring more effective and sophisticated long-term interventions for the millions of people who suffer from eating disorders.
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Affiliation(s)
| | - Severi Luoto
- English, Drama and Writing Studies, University of Auckland, Auckland, New Zealand
- School of Psychology, University of Auckland, Auckland, New Zealand
| | - Tatjana Krama
- Department of Biotechnology, Daugavpils University, Daugavpils, Latvia
| | - Indrikis Krams
- Department of Biotechnology, Daugavpils University, Daugavpils, Latvia
- Institute of Ecology and Earth Sciences, University of Tartu, Tartu, Estonia
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Gordon G, Brockmeyer T, Schmidt U, Campbell IC. Combining cognitive bias modification training (CBM) and transcranial direct current stimulation (tDCS) to treat binge eating disorder: study protocol of a randomised controlled feasibility trial. BMJ Open 2019; 9:e030023. [PMID: 31640997 PMCID: PMC6830595 DOI: 10.1136/bmjopen-2019-030023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 08/01/2019] [Accepted: 08/05/2019] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Binge eating disorder (BED) is a common mental disorder, closely associated with obesity. Existing treatments are only moderately effective with high relapse rates, necessitating novel interventions. This paper describes the rationale for, and protocol of, a feasibility randomised controlled trial (RCT), evaluating the combination of transcranial direct current stimulation (tDCS) and a computerised cognitive training, namely approach bias modification training (ABM), in patients with BED who are overweight or obese. The aim of this trial is to obtain information that will guide decision-making and protocol development in relation to a future large-scale RCT of combined tDCS+ABM treatment in this group of patients, and also to assess the preliminary efficacy of this intervention. METHODS AND ANALYSIS 66 participants with Diagnostic and Statistical Manual-5 diagnosis of BED and a body mass index (BMI) of ≥25 kg/m2 will be randomly allocated to one of three groups: ABM+real tDCS; ABM+sham tDCS or a wait-list control group. Participants in both intervention groups will receive six sessions of ABM+real/sham tDCS over 3 weeks; engaging in the ABM task while simultaneously receiving bilateral tDCS to the dorsolateral prefrontal cortex. ABM is based on an implicit learning paradigm in which participants are trained to enact an avoidance behaviour in response to visual food cues. Assessments will be conducted at baseline, post-treatment (3 weeks) and follow-up (7 weeks post-randomisation). Feasibility outcomes assess recruitment and retention rates, acceptability of random allocation, blinding success (allocation concealment), completion of treatment sessions and research assessments. Other outcomes include eating disorder psychopathology and related neurocognitive outcomes (ie, delay of gratification and inhibitory control), BMI, other psychopathology (ie, mood), approach bias towards food and surrogate endpoints (ie, food cue reactivity, trait food craving and food intake). ETHICS AND DISSEMINATION This study has been approved by the North West-Liverpool East Research Ethics Committee. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN35717198.
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Affiliation(s)
- Gemma Gordon
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Timo Brockmeyer
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Gottingen, Goettingen, Niedersachsen, Germany
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iain C Campbell
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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31
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Albano G, Hodsoll J, Kan C, Lo Coco G, Cardi V. Task-sharing interventions for patients with anorexia nervosa or their carers: a systematic evaluation of the literature and meta-analysis of outcomes. Int Rev Psychiatry 2019; 31:367-381. [PMID: 30950660 DOI: 10.1080/09540261.2019.1588711] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The eating disorder clinical and scientific community advocates for the use of a shared approach to healthcare that actively involves patients and carers. A systematic review of the literature on guided self-help or self-help in anorexia nervosa (targeting either the individual affected by the illness or their carers) and meta-analyses of studies using randomised controlled designs for the evaluation of the outcomes: (1) drop-out from end-of-treatment assessment, (2) body mass index (BMI), (3) anxiety, (4) depression and (5) quality of life, were undertaken. Guided self-help was directed to patients in 15 studies and to carers in seven studies. The interventions were based on a variety of theoretical models, used different formats (books and digital materials), and were delivered by individuals with a range of experiences and expertise (e.g. individuals with lived experience of the illness, graduate students, or clinically trained professionals). Guided self-help was associated with significantly lower drop-out from the completion of end-of-treatment assessments compared to a control condition. There was an improvement in carers' wellbeing from skill-sharing interventions. Guided self-help may facilitate patients' treatment engagement and also improve carers' wellbeing.
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Affiliation(s)
- Gaia Albano
- a Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience , King's College London , London , UK.,b Department of Psychology Educational Science and Human Movement , University of Palermo , Palermo , Italy
| | - John Hodsoll
- c Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience , King's College London , London , UK
| | - Carol Kan
- a Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience , King's College London , London , UK
| | - Gianluca Lo Coco
- b Department of Psychology Educational Science and Human Movement , University of Palermo , Palermo , Italy
| | - Valentina Cardi
- a Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience , King's College London , London , UK
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Oldershaw A, DeJong H, Hambrook D, Schmidt U. Social attribution in anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2019; 26:197-206. [PMID: 29687578 DOI: 10.1002/erv.2588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 02/12/2018] [Accepted: 02/14/2018] [Indexed: 11/11/2022]
Abstract
People with anorexia nervosa (AN) report socioemotional difficulties; however, measurement has been criticised for lacking ecological validity and the state or trait nature of difficulties remains unclear. Participants (n = 122) were recruited across 3 groups: people who are currently ill with AN (n = 40); people who recovered (RecAN, n = 18); healthy-control participants (n = 64). Participants completed clinical questionnaires and the Social Attribution Task. The Social Attribution Task involves describing an animation of moving shapes, scored for number of propositions offered, accuracy, and social relevance. Groups were compared cross-sectionally. Those with current AN were assessed prepsychological and postpsychological treatments. People with AN provided fewer propositions than other groups and fewer salient social attributions than healthy-control participants. Those who recovered scored intermediately and not significantly different from either group. Following treatment, people with AN demonstrated (nonsignificant) improvements, and no significance between group differences were observed. Findings suggest difficulties for people with AN in providing spontaneous social narrative and in identifying social salience.
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Affiliation(s)
- Anna Oldershaw
- Eating Disorder Service, Kent & Medway NHS Social Partnership Trust, Maidstone, UK.,Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK.,Salmons Centre for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells, UK
| | - Hannah DeJong
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - David Hambrook
- Talking Therapies Southwark, South London & Maudsley NHS Foundation Trust, London, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK
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Berg E, Houtzager L, Vos J, Daemen I, Katsaragaki G, Karyotaki E, Cuijpers P, Dekker J. Meta‐analysis on the efficacy of psychological treatments for anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2019; 27:331-351. [DOI: 10.1002/erv.2683] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Elske Berg
- Novarum Center for Eating Disorders and Obesity The Netherlands
| | - Laura Houtzager
- Research Department, Arkin Mental Health Institute The Netherlands
| | | | - Inge Daemen
- Research Department, Arkin Mental Health Institute The Netherlands
| | | | - Eirini Karyotaki
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam The Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam The Netherlands
| | - Jack Dekker
- Research Department, Arkin Mental Health Institute The Netherlands
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34
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Treasure J, Schmidt U, Kan C. An illustration of collaborative care with a focus on the role of fathers in Maudsley Anorexia Nervosa Treatment for Adults (MANTRA). J Clin Psychol 2019; 75:1403-1414. [PMID: 31038745 DOI: 10.1002/jclp.22789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The aim of this case study is to illustrate the importance of collaborative care as part of Maudsley Anorexia Nervosa Treatment for Adults (MANTRA). Mothers are often at the foreground of providing support within the family. However, fathers have the potential to play a profound role. In this paper, we describe a patient with anorexia nervosa treated with the MANTRA. The formulation of this case included autistic spectrum traits in both the father and daughter leading to social isolation. We describe how the family members were engaged into treatment and how paternal support was used to promote social connection and an improved quality of life in the daughter. Some details of the case have been altered to maintain confidentiality.
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Affiliation(s)
- Janet Treasure
- Section of Eating Disorder, Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Ulrike Schmidt
- Section of Eating Disorder, Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
| | - Carol Kan
- Section of Eating Disorder, Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, United Kingdom
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35
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Oldershaw A, Startup H, Lavender T. Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa. Front Psychol 2019; 10:219. [PMID: 30886593 PMCID: PMC6410927 DOI: 10.3389/fpsyg.2019.00219] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 01/22/2019] [Indexed: 12/17/2022] Open
Abstract
In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.
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Affiliation(s)
- Anna Oldershaw
- Salmons Centre for Applied Psychology, Canterbury Christ Church University, Canterbury, United Kingdom
- Kent and Medway All Age Eating Disorder Service, North East London NHS Foundation Trust, London, United Kingdom
| | - Helen Startup
- Sussex Eating Disorders Service and Research and Development Department, Sussex Partnership NHS Foundation Trust, Sussex, United Kingdom
| | - Tony Lavender
- Salmons Centre for Applied Psychology, Canterbury Christ Church University, Canterbury, United Kingdom
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36
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Murray SB, Quintana DS, Loeb KL, Griffiths S, Le Grange D. Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized-controlled trials - CORRIGENDUM. Psychol Med 2019; 49:701-704. [PMID: 30430952 DOI: 10.1017/s0033291718003185] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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37
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Murray SB, Quintana DS, Loeb KL, Griffiths S, Le Grange D. Treatment outcomes for anorexia nervosa: a systematic review and meta-analysis of randomized controlled trials. Psychol Med 2019; 49:535-544. [PMID: 30101734 DOI: 10.1017/s0033291718002088] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND To determine the impact of specialized treatments, relative to comparator treatments, upon the weight and psychological symptoms of anorexia nervosa (AN) at end-of-treatment (EOT) and follow-up. METHODS Randomized controlled trials (RCTs) between January 1980 and December 2017 that reported the effects of at least two treatments on AN were screened. Weight and psychological symptoms were analyzed separately for each study. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and studies were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria and Cochrane risk of bias tool. RESULTS We identified 35 eligible RCTs, comprising data from 2524 patients. Meta-analyses revealed a significant treatment effect on weight outcomes at EOT [g = 0.16, 95% CI (0.05-0.28), p = 0.006], but not at follow-up [g = 0.11, 95% CI (-0.04 to 0.27), p = 0.15]. There was no significant treatment effect on psychological outcomes at either EOT [g = -0.03, 95% CI (-0.14 to 0.08), p = 0.63], or follow-up [g = -0.001, 95% CI (-0.11 to 0.11), p = 0.98]. There was no strong evidence of publication bias or significant moderator effects for illness duration, mean age, year of publication, comparator group category, or risk of bias (all p values > 0.05). CONCLUSIONS Current specialized treatments are more adept than comparator interventions at imparting change in weight-based AN symptoms at EOT, but not at follow-up. Specialized treatments confer no advantage over comparator interventions in terms of psychological symptoms. Future precision treatment efforts require a specific focus on the psychological symptoms of AN.
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Affiliation(s)
- Stuart B Murray
- Department of Psychiatry,University of California,San Francisco, CA,USA
| | - Daniel S Quintana
- NORMENT,KG Jebsen Centre for Psychosis Research,Division of Mental Health and Addiction,University of Oslo, and Oslo University Hospital,Oslo,Norway
| | - Katharine L Loeb
- School of Psychology, Fairleigh Dickinson University,Teaneck, NJ,USA
| | - Scott Griffiths
- School of Psychology, University of Melbourne,Melbourne, VIC,Australia
| | - Daniel Le Grange
- Department of Psychiatry,University of California,San Francisco, CA,USA
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Rachid F. Repetitive transcranial magnetic stimulation in the treatment of eating disorders: A review of safety and efficacy. Psychiatry Res 2018; 269:145-156. [PMID: 30149272 DOI: 10.1016/j.psychres.2018.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 07/05/2018] [Accepted: 08/09/2018] [Indexed: 02/07/2023]
Abstract
Eating disorders are a significant public health concern accounting for significant morbidity and mortality. Therapeutic approaches are available to treat eating disorders but less than half of the patients recover. Therapeutic alternatives are needed such as repetitive transcranial magnetic stimulation. I reviewed studies that evaluated the safety and efficacy of this technique for the treatment of eating disorders. The electronic literature on repetitive transcranial magnetic stimulation, theta burst and deep transcranial magnetic stimulation in the treatment of eating disorders was retrieved. The findings were quite heterogeneous in results with some studies showing relatively positive results with reduction of both craving and eating behaviors with active stimulation versus sham. Repetitive transcranial magnetic stimulation was safe. Research in this field was limited by the small number of studies and sample sizes, diversity of stimulation parameters, questionable placebo conditions, the lack of a sham-controlled design and the use of subjective scales lacking in sensitivity. The evidence supporting rTMS for eating disorders is somewhat promising. Future studies on high frequency rTMS of the LDLPFC/DMPFC with increased statistical power, rigorous randomization, outcome measures and optimal parameters are needed to confirm the short- and long-term safety and efficacy of rTMS for the treatment of eating disorders.
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Affiliation(s)
- Fady Rachid
- 7, place de la Fusterie, 1204 Geneva, Switzerland.
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Wade TD, Johnson C, Byrne SM. Randomized controlled psychotherapy trials in eating disorders: Improving their conduct, interpretation and usefulness. Int J Eat Disord 2018; 51:629-636. [PMID: 29693749 DOI: 10.1002/eat.22872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/05/2018] [Accepted: 04/05/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND While randomized controlled trials (RCTs) inform the efficacy and effectiveness of treatments, we need to understand that even RCTs can be associated with sub-optimal execution. This is of special pertinence to eating disorders given the majority of treatment studies involving cognitive behaviour therapy are of poor quality with respect to managing risk of bias adequately. METHODS The current paper outlines the components of a good RCT for psychotherapy, and examines ways to improve the conduct, interpretation, and usefulness of RCTs. RESULTS This includes managing reporting bias, recognizing the limits of randomization, applicability, and ethical considerations. CONCLUSIONS We highlight a number of strategies for future research, including issues related to utilizing a variety of designs to examine treatment outcomes, integrity, openness and reproducibility.
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Affiliation(s)
- Tracey D Wade
- School of Psychology, Flinders University, South Australia, Australia
| | - Catherine Johnson
- School of Psychology, Flinders University, South Australia, Australia
| | - Susan M Byrne
- School of Psychology, University of Western Australia, Western Australia, Australia
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Hormoz E, Pugh M, Waller G. Do eating disorder voice characteristics predict treatment outcomes in anorexia nervosa? A pilot study. Cogn Behav Ther 2018; 48:137-145. [PMID: 29882721 DOI: 10.1080/16506073.2018.1476581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Individuals with anorexia nervosa often describe experiencing an internal "voice" of their disorder, which previous research has associated with multiple dimensions of eating pathology. This pilot study examined whether eating disorder measures use invoice characteristics at the outset of outpatient therapy predicted changes in disordered eating over the course of treatment. Participants were 14 individuals meeting ICD-10 criteria for anorexia nervosa. Participants completed measures relating to the severity of disordered eating and voice-related characteristics (perceived voice power and metacognitive appraisals about its nature) at the start and end of therapy. Results indicated that the perceived power of the eating disorder was reduced over the course of outpatient therapy, although its other characteristics remained stable. Greater levels of voice power, omnipotence and benevolence at the outset of therapy were related to greater improvements in eating attitudes. No voice-related characteristics were associated with changes in weight. These findings suggest that voice-related appraisals do not obstruct the effectiveness of outpatient therapies for anorexia nervosa. Further studies are needed to ratify these preliminary findings.
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Affiliation(s)
- Emma Hormoz
- a St Ann's Eating Disorder Service , London , UK
| | - Matthew Pugh
- b Vincent Square Eating Disorders Service , London , UK
| | - Glenn Waller
- c Department of Psychology , University of Sheffield , Sheffield , UK
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Brockmeyer T, Friederich HC, Schmidt U. Advances in the treatment of anorexia nervosa: a review of established and emerging interventions. Psychol Med 2018; 48:1228-1256. [PMID: 28889819 DOI: 10.1017/s0033291717002604] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments. METHODS We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials. RESULTS We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation. CONCLUSIONS Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.
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Affiliation(s)
- T Brockmeyer
- Department of Psychosomatic Medicine and Psychotherapy,LVR Clinic,Medical Faculty of the Heinrich-Heine-University Düsseldorf,Düsseldorf,Germany
| | - H-C Friederich
- Department of Psychosomatic Medicine and Psychotherapy,LVR Clinic,Medical Faculty of the Heinrich-Heine-University Düsseldorf,Düsseldorf,Germany
| | - U Schmidt
- Section of Eating Disorders,Department of Psychological Medicine,Institute of Psychiatry,Psychology and Neuroscience,King's College London,London,UK
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Oldershaw A, Lavender T, Schmidt U. Are socio-emotional and neurocognitive functioning predictors of therapeutic outcomes for adults with anorexia nervosa? EUROPEAN EATING DISORDERS REVIEW 2018; 26:346-359. [PMID: 29744972 DOI: 10.1002/erv.2602] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/08/2018] [Accepted: 04/10/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Emotional, social, and neurocognitive factors are theorised to maintain anorexia nervosa (AN). Yet whether they predict outcomes or relate to clinical change remains unclear. METHODS Seventy-one consecutive adult outpatient eating disorder service referrals presenting with AN, who participated in a randomised controlled trial comparing 2 psychotherapies, were assessed for emotional processing, social cognition, and neurocognition pretherapy and posttherapy. Intention-to-treat analysis employed maximum-likelihood methods to model missing data. Baseline self-reported emotional processing, social cognitive, or neurocognitive task performance was entered into forward stepwise regression models with posttreatment clinical outcomes (weight, eating disorder psychopathology, psychosocial functioning) as dependent variables. Correlation analyses examined relationships between clinical and self-report/task score change. RESULTS Self-reported emotional avoidance (behavioural/cognitive avoidance, low acceptance) and submissive behaviour predicted clinical outcomes. Social cognitive (emotion recognition, emotional theory of mind) and neurocognitive performance (set-shifting, detail focus) had limited predictive ability. CONCLUSIONS Emotional avoidance and submissiveness may represent maintenance factors for AN.
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Affiliation(s)
- Anna Oldershaw
- Salomons Centre for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells, UK.,Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tony Lavender
- Salomons Centre for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Eating Disorders Unit, South London and Maudsley NHS Foundation Trust, London, UK
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Zeeck A, Herpertz-Dahlmann B, Friederich HC, Brockmeyer T, Resmark G, Hagenah U, Ehrlich S, Cuntz U, Zipfel S, Hartmann A. Psychotherapeutic Treatment for Anorexia Nervosa: A Systematic Review and Network Meta-Analysis. Front Psychiatry 2018; 9:158. [PMID: 29765338 PMCID: PMC5939188 DOI: 10.3389/fpsyt.2018.00158] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/09/2018] [Indexed: 12/17/2022] Open
Abstract
Background: The aim of the study was a systematic review of studies evaluating psychotherapeutic treatment approaches in anorexia nervosa and to compare their efficacy. Weight gain was chosen as the primary outcome criterion. We also aimed to compare treatment effects according to service level (inpatient vs. outpatient) and age group (adolescents vs. adults). Methods:The data bases PubMed, Cochrane Library, Web of Science, Cinahl, and PsychInfo were used for a systematic literature search (until Feb 2017). Search terms were adapted for data base, combining versions of the search terms anorexia, treat*/therap* and controlled trial. Studies were selected using pre-defined in- and exclusion criteria. Data were extracted by two independent coders using piloted forms. Network-meta-analyses were conducted on all RCTs. For a comparison of service levels and age groups, standard mean change (SMC) statistics were used and naturalistic, non-randomized studies included. Results: Eighteen RCTs (trials on adults: 622 participants; trials on adolescents: 625 participants) were included in the network meta-analysis. SMC analyses were conducted with 38 studies (1,164 participants). While family-based approaches dominate interventions for adolescents, individual psychotherapy dominates in adults. There was no superiority of a specific approach. Weight gains were more rapid in adolescents and inpatient treatment. Conclusions: Several specialized psychotherapeutic interventions have been developed and can be recommended for AN. However, adult and adolescent patients should be distinguished, as groups differ in terms of treatment approaches considered suitable as well as treatment response. Future trials should replicate previous findings and be multi-center trials with large sample sizes to allow for subgroup analyses. Patient assessment should include variables that can be considered relevant moderators of treatment outcome. It is desirable to explore adaptive treatment strategies for subgroups of patients with AN. Identifying and addressing maintaining factors in AN remains a major challenge.
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Affiliation(s)
- Almut Zeeck
- Department of Psychosomatic Medicine and Psychotherapy, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Hans-Christoph Friederich
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Timo Brockmeyer
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Gaby Resmark
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrich Hagenah
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Stefan Ehrlich
- Division of Psychological and Social Medicine and Developmental Neurosciences, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universitaet Dresden, Dresden, Germany
| | - Ulrich Cuntz
- Schön Klinik Roseneck, Prien am Chiemsee, Germany
| | - Stephan Zipfel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Armin Hartmann
- Department of Psychosomatic Medicine and Psychotherapy, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
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Byrne S, Wade T, Hay P, Touyz S, Fairburn CG, Treasure J, Schmidt U, McIntosh V, Allen K, Fursland A, Crosby RD. A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychol Med 2017; 47:2823-2833. [PMID: 28552083 DOI: 10.1017/s0033291717001349] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy. METHOD A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment. RESULTS Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up. CONCLUSION The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.
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Affiliation(s)
- S Byrne
- School of Psychology, The University of Western Australia,Perth,Australia
| | - T Wade
- School of Psychology, Flinders University,Adelaide,Australia
| | - P Hay
- School of Medicine & Centre for Health Research, Western Sydney University,Sydney,Australia
| | - S Touyz
- School of Psychology, Sydney University,Sydney,Australia
| | - C G Fairburn
- Department of Psychiatry,Oxford University,Oxford,UK
| | - J Treasure
- Department of Psychological Medicine,Kings College London,London,UK
| | - U Schmidt
- Department of Psychological Medicine,Kings College London,London,UK
| | - V McIntosh
- Department of Psychological Medicine,University of Otago,Christchurch,New Zealand
| | - K Allen
- School of Psychology, The University of Western Australia,Perth,Australia
| | - A Fursland
- Centre for Clinical Interventions,Perth,Australia
| | - R D Crosby
- Department of Psychiatry and Behavioral Sciences,University of North Dakota School of Medicine and Health Sciences,Fargo, ND,USA
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45
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Treasure J, Cardi V. Anorexia Nervosa, Theory and Treatment: Where Are We 35 Years on from Hilde Bruch's Foundation Lecture? EUROPEAN EATING DISORDERS REVIEW 2017; 25:139-147. [PMID: 28402069 DOI: 10.1002/erv.2511] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/13/2017] [Accepted: 02/14/2017] [Indexed: 12/13/2022]
Abstract
Hilde Bruch's foundation lecture in 1982 is a milestone from which to survey current theory and treatment for anorexia nervosa. Bruch described problems in body perception, emotion processing and interpersonal relationships as core theoretical aspects of the illness and built her theory of psychopathology on these aspects, as well as on animal studies on attachment. She also noted that many psychological problems result as consequence of starvation. In the first part of this paper, we parse Bruch's clinical descriptions into elements of psychopathology (disturbances in body perception, attachment, emotion expression, perception and regulation, social comparison, interpersonal, and family and therapeutic relationships), in order to assemble and update the theoretical evidence for a model of the illness. In the second part, we describe and extend her description of three core targets of treatment: family relationships, patient's inner confusion and nutritional restoration. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- Janet Treasure
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, UK
| | - Valentina Cardi
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, UK
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46
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Tchanturia K, Adamson J, Leppanen J, Westwood H. Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2017; 23:123-130. [DOI: 10.1177/1362361317722431] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Previous research has demonstrated links between anorexia nervosa and autism spectrum disorder however, few studies have examined the possible impact of symptoms of autism spectrum disorder on clinical outcomes in anorexia nervosa. The aim of this study was to examine the association between symptoms of autism spectrum disorder and eating disorders, and other psychopathology during the course of inpatient treatment in individuals with anorexia nervosa. Participants with anorexia nervosa (n = 171) completed questionnaires exploring eating disorder psychopathology, symptoms of depression and anxiety, and everyday functioning at both admission and discharge. Characteristics associated with autism spectrum disorder were assessed using the Autism Spectrum Quotient, short version. Autism spectrum disorder symptoms were significantly positively correlated with eating disorder psychopathology, work and social functioning, and symptoms of depression and anxiety, but not with body mass index. Autism Spectrum Quotient, short version scores remained relatively stable from admission to discharge but there was a small, significant reduction in scores. There was no interaction between time and Autism Spectrum Quotient, short version scores on clinical symptom change. In anorexia nervosa, autism spectrum disorder symptoms appear to be associated with a more severe clinical presentation on admission to inpatient care. Autism spectrum disorder symptoms as assessed by self-report measures may be exacerbated by other mental health psychopathology, which warrants further investigation.
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Affiliation(s)
- Kate Tchanturia
- King’s College London, UK
- South London and Maudsley NHS Foundation Trust, UK
- Ilia State University, Georgia
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Hodsoll J, Rhind C, Micali N, Hibbs R, Goddard E, Nazar BP, Schmidt U, Gowers S, Macdonald P, Todd G, Landau S, Treasure J. A Pilot, Multicentre Pragmatic Randomised Trial to Explore the Impact of Carer Skills Training on Carer and Patient Behaviours: Testing the Cognitive Interpersonal Model in Adolescent Anorexia Nervosa. EUROPEAN EATING DISORDERS REVIEW 2017; 25:551-561. [PMID: 28948663 DOI: 10.1002/erv.2540] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 07/14/2017] [Indexed: 12/11/2022]
Abstract
AIM The aim of the study is to establish the acceptability, feasibility and approximate size of the effect of adding a carer intervention [Experienced Caregivers Helping Others (ECHO)] to treatment as usual (TAU) for adolescents with anorexia nervosa. METHODS The study is a pilot randomised trial comparing TAU (n = 50) alone or TAU plus ECHO with (n = 50) or without (n = 49) telephone guidance. Effect sizes (ESs) were regression coefficients standardised by baseline standard deviations of measure. RESULTS Although engagement with ECHO was poor (only 36% of carers in the ECHO group read over 50% of the book), there were markers of intervention fidelity, in that caregivers in the ECHO group showed a moderate increase in carer skills (ES = 0.4) at 12 months and a reduction in accommodating and enabling behaviour at 6 months (ES = 0.17). In terms of efficacy, in the ECHO group, carers spent less time care giving (ES = 0.40, p = 0.04) at 1 year, and patients had a minor advantage in body mass index (ES = 0.17), fewer admissions, decreased peer problems (ES = -0.36) and more pro-social behaviours (ES = 0.53). The addition of telephone guidance to ECHO produced little additional benefit. CONCLUSIONS The provision of self-management materials for carers to standard treatment for adolescent anorexia nervosa shows benefits for both carers and patients. This could be integrated as a form of early intervention in primary care. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- John Hodsoll
- Department of Biostatistics, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Charlotte Rhind
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Nadia Micali
- Behavioural and Brain Sciences Unit, University College London, Institute of Child Health, London, UK.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rebecca Hibbs
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Elizabeth Goddard
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Bruno Palazzo Nazar
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK.,Institute of Psychiatry, Federal University of Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, Brazil
| | - Ulrike Schmidt
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Simon Gowers
- Adolescent Psychiatry, University of Liverpool, Chester, UK
| | - Pamela Macdonald
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Gillian Todd
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Sabine Landau
- Department of Biostatistics, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Janet Treasure
- Department of Psychological Medicine, Section of Eating Disorders, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
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Schmidt U, Sharpe H, Bartholdy S, Bonin EM, Davies H, Easter A, Goddard E, Hibbs R, House J, Keyes A, Knightsmith P, Koskina A, Magill N, McClelland J, Micali N, Raenker S, Renwick B, Rhind C, Simic M, Sternheim L, Woerwag-Mehta S, Beecham J, Campbell IC, Eisler I, Landau S, Ringwood S, Startup H, Tchanturia K, Treasure J. Treatment of anorexia nervosa: a multimethod investigation translating experimental neuroscience into clinical practice. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BackgroundAnorexia nervosa (AN) is a severe psychiatric condition and evidence on how to best treat it is limited.ObjectivesThis programme consists of seven integrated work packages (WPs) and aims to develop and test disseminable and cost-effective treatments to optimise management for people with AN across all stages of illness.MethodsWP1a used surveys, focus groups and a pre–post trial to develop and evaluate a training programme for school staff on eating disorders (EDs). WP1b used a randomised controlled trial (RCT) [International Standard Randomised Controlled Trial Number (ISRCTN) 42594993] to evaluate a prevention programme for EDs in schools. WP2a evaluated an inpatient treatment for AN using case reports, interviews and a quasi-experimental trial. WP2b used a RCT (ISRCTN67720902) to evaluate two outpatient psychological therapies for AN. WP3 used a RCT (ISRCTN06149665) to evaluate an intervention for carers of inpatients with AN. WP4 used actimetry, self-report and endocrine assessment to examine physical activity (PA) in AN. WP5 conducted a RCT (ISRCTN18274621) of an e-mail-guided relapse prevention programme for inpatients with AN. WP6 analysed cohort data to examine the effects of maternal EDs on fertility and their children’s diet and growth. WP7a examined clinical case notes to explore how access to specialist ED services affects care pathways and user experiences. Finally, WP7b used data from this programme and the British Cohort Study (1970) to identify the costs of services used by people with AN and to estimate annual costs of AN for England.ResultsWP1a: a brief training programme improved knowledge, attitudes and confidence of school staff in managing EDs in school. WP1b: a teacher-delivered intervention was feasible and improved risk factors for EDs in adolescent girls. WP2a: both psychological therapies improved outcomes in outpatients with AN similarly, but patients preferred one of the treatments. WP2b: the inpatient treatment (Cognitive Remediation and Emotional Skills Training) was acceptable with perceived benefits by patients, but showed no benefits compared with treatment as usual (TAU). WP3: compared with TAU, the carer intervention improved a range of patient and carer outcomes, including carer burden and patient ED symptomatology. WP4: drive to exercise is tied to ED pathology and a desire to improve mood in AN patients. PA was not increased in these patients. WP5: compared with TAU, the e-mail-guided relapse prevention programme resulted in higher body mass index and lower distress in patients at 12 months after discharge. WP6: women with an ED had impaired fertility and their children had altered dietary and growth patterns compared with the children of women without an ED. WP7a: direct access to specialist ED services was associated with higher referral rates, lower admission rates, greater consistency of care and user satisfaction. WP7b: the annual costs of AN in England are estimated at between £45M and £230M for 2011.ConclusionsThis programme has produced evidence to inform future intervention development and has developed interventions that can be disseminated to improve outcomes for individuals with AN. Directions for future research include RCTs with longer-term outcomes and sufficient power to examine mediators and moderators of change.Trial registrationCurrent Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ulrike Schmidt
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Helen Sharpe
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Savani Bartholdy
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Eva-Maria Bonin
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Helen Davies
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Abigail Easter
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Institute of Child Health, University College London, London, UK
| | - Elizabeth Goddard
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rebecca Hibbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jennifer House
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Alexandra Keyes
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Pooky Knightsmith
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Antonia Koskina
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nicholas Magill
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jessica McClelland
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nadia Micali
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Institute of Child Health, University College London, London, UK
| | - Simone Raenker
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Bethany Renwick
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Charlotte Rhind
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Mima Simic
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Lot Sternheim
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Woerwag-Mehta
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jennifer Beecham
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
- Personal Social Services Research Unit, University of Kent, Canterbury, UK
| | - Iain C Campbell
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Ivan Eisler
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Child Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Sabine Landau
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | - Helen Startup
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Kate Tchanturia
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Janet Treasure
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Elzakkers IFFM, Danner UN, Sternheim LC, McNeish D, Hoek HW, van Elburg AA. Mental capacity to consent to treatment and the association with outcome: a longitudinal study in patients with anorexia nervosa. BJPsych Open 2017; 3:147-153. [PMID: 28584660 PMCID: PMC5445260 DOI: 10.1192/bjpo.bp.116.003905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/15/2017] [Accepted: 05/03/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Relevance of diminished mental capacity in anorexia nervosa (AN) to course of disorder is unknown. AIMS To examine prognostic relevance of diminished mental capacity in AN. METHOD A longitudinal study was conducted in 70 adult female patients with severe AN. At baseline, mental capacity was assessed by psychiatrists, and clinical and neuropsychological data (decision-making) were collected. After 1 and 2 years, clinical and neuropsychological assessments were repeated, and remission and admission rates were calculated. RESULTS People with AN with diminished mental capacity had a less favourable outcome with regard to remission and were admitted more frequently. Their appreciation of illness remained hampered. Decision-making did not improve, in contrast to people with full mental capacity. CONCLUSIONS People with AN with diminished mental capacity seem to do less well in treatment and display decision-making deficiencies that do not ameliorate with weight improvement. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Isis F F M Elzakkers
- , MD, MSc, Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands
| | - Unna N Danner
- , PhD, Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands; Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Lot C Sternheim
- , PhD, Department of Psychology, Utrecht University, Utrecht, The Netherlands
| | - Daniel McNeish
- , PhD, Department of Methodology and Statistics, Utrecht University, Utrecht, The Netherlands
| | - Hans W Hoek
- , MD, PhD, Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands; Parnassia Psychiatric Institute, The Hague, The Netherlands; Department of Psychiatry, University Medical Center Groningen, Groningen, The Netherlands; Department of Epidemiology, Mailman School of Public Health, Columbia University New York, USA
| | - Annemarie A van Elburg
- , MD, PhD, Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, Zeist, The Netherlands; Department of Psychology, Utrecht University, Utrecht, The Netherlands
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Teufel M, Wild B, Giel KE, Friederich HC, Resmark G, de Zwaan M, Herpertz S, Löwe B, Tagay S, von Wietersheim J, Zeeck A, Burgmer M, Dinkel A, Ziser K, Zehnpfennig D, Zipfel S, Herzog W, Junne F. Familie, Partnerschaft, Bildung und berufliche Situation bei Patientinnen mit Anorexia nervosa. PSYCHOTHERAPEUT 2017. [DOI: 10.1007/s00278-017-0194-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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