Lot Sternheim

Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial

BACKGROUND Very limited evidence is available on how to treat adults with anorexia nervosa and treatment outcomes are poor. Novel treatment approaches are urgently needed. AIMS To evaluate the efficacy and acceptability of a novel psychological therapy for anorexia nervosa (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) compared with specialist supportive clinical management (SSCM) in a randomised controlled trial. METHOD Seventy-two adult out-patients with anorexia nervosa or eating disorder not otherwise specified were recruited from a specialist eating disorder service in the UK. Participants were randomly allocated to 20 once weekly sessions of MANTRA or SSCM and optional additional sessions depending on severity and clinical need (trial registration: ISRCTN62920529). The primary outcomes were body mass index, weight and global score on the Eating Disorders Examination at end of treatment (6 months) and follow-up (12 months). Secondary outcomes included: depression, anxiety and clinical impairment; neuropsychological outcomes; recovery rates; and additional service utilisation. RESULTS At baseline, patients randomised to MANTRA were significantly less likely to be in a partner relationship than those receiving SSCM (3/34 v. 10/36; P<0.05). Patients in both treatments improved significantly in terms of eating disorder and other outcomes, with no differences between groups. Strictly defined recovery rates were low. However, MANTRA patients were significantly more likely to require additional in-patient or day-care treatment than those receiving SSCM (7/34 v. 0/37; P = 0.004). CONCLUSIONS Adults with anorexia nervosa are a difficult to treat group. The imbalance between groups in partner relationships may explain differences in service utilisation favouring SSCM. This study confirms SSCM as a useful treatment for out-patients with anorexia nervosa. The novel treatment, MANTRA, designed for this patient group may need adaptations to fully exploit its potential.

The importance of distinguishing between the different eating disorders (sub)types when assessing emotion regulation strategies

People with eating disorders (ED) have difficulties regulating their emotions adaptively. Little is known about differences and similarities between different types of ED and how these regulation difficulties relate to other emotional problems. The present study examines maladaptive (suppression) and adaptive (cognitive reappraisal) emotion regulation strategies in women with different ED and relationships with anxiety and depression levels. In 32 women with AN restrictive subtype (ANR), 32 with AN binge-purge subtype (ANBP), 30 with bulimia nervosa (BN), 29 with binge eating disorder (BED), and 64 healthy women, the ERQ (emotion regulation) as well as STAI-T (anxiety), BDI-SF (depression), and EDDS (eating pathology) were administered. Women across different ED subtypes were inclined to suppress emotions and lacked the capacity to reappraise emotions (except women with ANBP). Correlational relations of suppression and reappraisal with anxiety and depression levels differed across ED groups. Emotion regulation problems were found across ED subtypes. However, the types of emotion regulation problems, and the effect of coexisting other emotional problems such as anxiety and depression may differ across ED subtypes. These findings illustrate the importance to of considering ED subtypes in emotion regulation research rather than consider ED as a whole.

Understanding catastrophic worry in eating disorders: process and content characteristics.

BACKGROUND AND OBJECTIVES The majority of people with eating disorders (ED) experience high levels of comorbid anxiety and depression, yet the maintenance processes of these in ED remain largely unknown. Worry, a defining cognitive feature and important maintenance factor of anxiety, has not been well-studied amongst people with ED. This is the first study to explore both the process and content characteristics of catastrophic worry in ED. METHODS Twenty-nine patients with anorexia nervosa (AN), 15 patients with bulimia nervosa (BN) and 37 healthy controls (HC) completed measures assessing anxiety, depression, worry and eating disorder pathology. Catastrophic worry was assessed using the Catastrophizing Interview and catastrophic worry content was explored using qualitative Thematic Analysis. RESULTS Compared to HCs, ED groups had higher levels of anxiety, depression and worry and they generated a greater number of catastrophic worry steps. Worry was further found associated with depressive symptomatology in those with ED. Worry content for the ED groups included ED themes, but also themes reflecting broader inter and intrapersonal concerns. LIMITATIONS The degree to which worry is driven by depressive versus anxious symptomatology remains unclear. The current study does not include an anxious or depressed control group, and results should be considered in the light of relatively small samples sizes. CONCLUSION Findings indicate that interventions that target worry processes may be a useful adjunct to treatment for those ED patients with clinical worry levels.

Longitudinal Changes in the Physical Activity of Adolescents with Anorexia Nervosa and Their Influence on Body Composition and Leptin Serum Levels after Recovery

Objective Patients with anorexia nervosa (AN) are often observed to have high levels of physical activity, which do not necessarily diminish after a successful therapy. Previous studies have shown that body fat tissue recovery in these patients is associated with a disproportional restoration of the adipocyte hormone, leptin. Therefore, we wondered whether the individual variation in physical activity in AN patients prior to treatment may be related to body fat percentage and plasma leptin level outcome. Method Body fat percentage, leptin serum, and physical activity levels (accelerometer) were measured in adolescents with an (n=37, age 13 to 17.5 years) at initial assessment, at the end of study participation (median 12 months), and at one-year follow-up. Results Accelerometer data were used to split the patients in two groups: those with low (n=26) and those with high levels of physical activity (HLPA, n=11). These groups did not differ in terms of age, IQ, presence of menses, BMI and season of admission. The HLPA group was characterized by a longer total duration of illness. Physical activity levels during therapy decreased for the group with initially HLPA and increased for the group with low levels of physical activity (to comparable levels). Physical activity remained stable after one year. The increase in body fat percentage and leptin levels were dependent on the recovery status; however, recovered patients with initially HLPA had significantly higher fat mass during the follow-up. Discussion HLPA, an important modulator of AN progression in adolescents, can be successfully diminished by therapeutic intervention. Among recovered patients, those with initially HLPA had higher fat mass levels than those with low levels of physical activity. This finding suggests that HLPA are an important modulator of the body composition recovery mechanism.

Influence of negative affect on choice behavior in individuals with binge eating pathology

Research suggests that individuals with binge eating pathology (e.g., bulimia nervosa (BN) and binge eating disorders (BED)) have decision making impairments and particularly act impulsively in response to negative affect. The aim of this study was to examine the influence of negative affect on choice behavior in women with BN and BED. Ninety women (59 with BN or BED and 31 healthy controls) watched a sad or control film fragment and were subsequently asked to complete a choice behavior task (as measured by a variation of the Bechara Gambling Task (BGT)). Results showed that negative affect influenced choice behavior differently in healthy controls and in women with BN and BED after punishment (but not after reward). In the context of increased negative affect, punishment was associated with more disadvantageous choice behavior in both BN and BED women but not in healthy controls, while the effect was the exact opposite in both groups after a decrease in negative affect. Levels of sadness were not found to influence choice behavior after reward in either groups. These findings suggest that emotional states may have a direct impact on choice behavior of individuals with binge eating pathology and are not only related to pathological behavior itself.

An experimental exploration of social problem solving and its associated processes in anorexia nervosa

People with Anorexia Nervosa (AN) have well-documented socio-emotional and neurocognitive impairments. As yet, little is known about their ability to solve problems in social situations, although a link with cognitive avoidance has been suggested. This study explored social problem-solving (SPS), using an experimental task. Secondly, the role of cognitive avoidance in SPS was investigated. Individuals with AN (n=31) and healthy controls (HC; n=39) completed the Social Problem Resolution Task which consists of problem scenarios involving awkward everyday social situations. Participants were asked to generate both the optimal solution and their personal solution. Solutions were rated in terms of how socially sensitive and practically effective they were. AN patients produced relatively poorer personal solutions compared to optimal solutions than HC participants and had higher scores on a measure of cognitive avoidance than the HC group. In AN patients, cognitive avoidance was partially associated with poor SPS. These findings suggest that whilst people with AN have no difficulty in generating socially sensitive and effective solutions to problems, but may have difficulty applying this knowledge to themselves.

Drive for activity in patients with anorexia nervosa

OBJECTIVE Hyperactivity and elevated physical activity are both considered symptom characteristics of anorexia nervosa (AN). It has been suggested that a drive for activity (DFA) may underlie these expressions, yet research into DFA in AN remains scant. This study investigated DFA levels in patients with AN and its relation to AN severity. Furthermore, as physical exercise may be a way to reduce negative affect, the influence of negative affect (anxiety) on the role of DFA in AN was tested. METHOD Two hundred and forty female patients with AN completed measures for DFA, eating disorder (ED) pathology, anxiety, and clinical parameters. RESULTS A strong relation between DFA levels and ED pathology was found, which remained significant even after controlling for negative affect (anxiety). DISCUSSION After much theorizing about DFA in AN this study provides empirical evidence for DFA as a hallmark feature of AN, independent of anxiety levels. Future research should shed light on the relationships between DFA, actual physical activity, and the course of AN.

Anxiety-related processes in anorexia nervosa and their relation to eating disorder pathology, depression and anxiety

Anxiety aggravates symptoms and hinders treatment in patients with anorexia nervosa (AN). The processes fuelling anxiety in AN remain unspecified. This study investigated the contribution of a number of core anxiety processes to eating disorder (ED) pathology, anxiety and depression in AN patients. Thirty-six women with AN and 38 healthy control women (HC) completed measures of worry, intolerance of uncertainty (IU), meta-cognitive thinking (MCT), cognitive avoidance and negative problem-solving orientation. Compared to HCs, patients with AN scored significantly higher on all of the anxiety-process measures. Scores were comparable to those previously reported for anxiety disorder sufferers. For AN patients, worry and IU contributed significantly to ED pathology but not to body mass index. All of the anxiety processes were implicated in predicting anxiety levels, but only IU and MCT contributed to depression levels. Findings indicate the importance of assessing for and then targeting anxiety-related processes in therapy for AN.

Cognitive remediation therapy (CRT) as a treatment enhancer of eating disorders and obsessive compulsive disorders: Study protocol for a randomized controlled trial

BackgroundAnorexia nervosa (AN) and Obsessive Compulsive Disorder (OCD) are among the most incapacitating and costly of mental disorders. Cognitive Behaviour Therapy (CBT), medication, and combination regimens, to which in AN personalised guidance on weight control is added, are moderately successful, leaving room for more effective treatment algorithms. An underlying deficit which the two disorders share is cognitive inflexibility, a trait that is likely to impede treatment engagement and reduce patients’ ability to benefit from treatment. Cognitive remediation therapy (CRT) is an easy-to-use intervention aimed at reducing cognitive inflexibility and thereby enhancing treatment outcome, which we aim to test in a controled study.MethodsIn a randomized-controlled multicenter clinical trial 64 adult patients with AN and 64 with OCD are randomized to 10 bi-weekly sessions with either CRT or a control condition, after which Treatment As Usual (TAU) is started. All patients are evaluated during single-blind assessments at baseline, post-CRT/control intervention, and after 6 months. Indices of treatment effect are disorder-specific symptom severity, quality of life, and cost-effectivity. Also, moderators and mediators of treatment effects will be studied.DiscussionTo our knowledge, this is the first randomized controlled trial using an control condition evaluating the efficacy and effectiveness of CRT as a treatment enhancer preceding TAU for AN, and the first study to investigate CRT in OCD, moreover taking cost-effectiveness of CRT in AN and OCD into account.Trial registrationThe Netherlands Trial Register NTR3865. Registered 20 february 2013.

Influence of negative affect on decision making in women with restrictive and binge-purge type anorexia nervosa

The present study aims to examine the influence of negative affect on decision making in women with anorexia nervosa (AN) compared to healthy control women and, secondly, to assess differences between the restrictive (ANR) and binge-purge (ANBP) subtypes. One hundred four women (32 with ANR, 32 with ANBP, and 40 healthy controls) participated. All women were asked to watch either a negative or a control film fragment, both followed by the Bechara Gambling Task (BGT). Before and after the fragments negative affect was measured. Additionally, relevant characteristics (e.g., overall depressive symptoms) were assessed. Differences in negative affect did not influence decision making performance. Independent of affective state, decision making was found to be impaired in women with ANBP (no learning effect on the BGT), but not in women with ANR. These findings highlight the importance of considering different AN subtypes when examining decision making processes. However, the role of negative affect on decision making remains uncertain. Since other affect related factors such as affect dysregulation may also play a role, future studies on decision making in AN should take the role of affect into account.