Clinical effectiveness, cost-effectiveness and process evaluation of group schema therapy for eating disorders: study protocol for a multicenter randomized controlled trial.

BACKGROUND: Eating disorders (EDs), such as (atypical) Anorexia (AN) and Bulimia Nervosa (BN), are difficult to treat, causing socioeconomic impediments. Although enhanced cognitive behavioral therapy (CBT-E) is widely considered clinically effective, it may not be the most beneficial treatment for (atypical) AN and BN patients who do not show a rapid response after the first 4 weeks (8 sessions) of a CBT-E treatment. Alternatively, group schema therapy (GST) may be a valuable treatment for this ED population. Even though GST for EDs has yielded promising preliminary findings, the current body of evidence requires expansion. On top of that, data on cost-effectiveness is lacking. In light of these gaps, we aim to describe a protocol to examine whether GST is more (1) clinically effective and (2) cost-effective than CBT-E for (atypical) AN and BN patients, who do not show a rapid response after the first 4 weeks of treatment. Additionally, we will conduct (3) process evaluations for both treatments. METHODS: Using a multicenter RCT design, 232 Dutch (atypical) AN and BN patients with a CBT-E referral will be recruited from five treatment centers. Clinical effectiveness and cost-effectiveness will be measured before treatment, directly after treatment, at 6 and at 12 months follow-up. In order to rate process evaluation, patient experiences and the degree to which treatments are implemented according to protocol will be measured. In order to assess the quality of life and the achievement of personalized goals, interviews will be conducted at the end of treatment. Data will be analyzed, using a regression-based approach to mixed modelling, multivariate sensitivity analyses and coding trees for qualitative data. We hypothesize GST to be superior to CBT-E in terms of clinical effectiveness and cost-effectiveness for patients who do not show a rapid response to the first 4 weeks of a CBT-E treatment. DISCUSSION: To our knowledge, this is the first study protocol describing a multicenter RCT to explore the three aforementioned objectives. Related risks in performing the study protocol have been outlined. The expected findings may serve as a guide for healthcare stakeholders to optimize ED care trajectories. TRIAL REGISTRATION: clinicaltrials.gov (NCT05812950).

[Sensory food aversion in the context of a modern approach to eating disorders in early childhood]. / A szenzoros ételelutasítás a kora gyermekkori evészavarok korszeru megközelítésének tükrében.

Sensory food aversion, an early childhood eating disorder, is a serious, permanent form of picky eating, in which the infant or the child consistently and persistently refuses certain foods based on specific characteristics, following one or more previous aversive experiences. Biological (sensory processing disorder, taste sensitivity) and environmental factors contribute to its development. Due to limited diet, specific dietary deficiencies may occur but weight gain is usually normal. Behavioral problems, anxiety disorder, autism spectrum disorder are often associated. Diagnosis can usually be made based on a detailed history, but further assessment may include pediatric examination, nutritionist consultation, and psychologic and occupational therapy assessment. Treatment is based on parent education and support in order to minimize mealtime battles and anxiety and to think together about strategies for expanding the child's diet and to help them to accept new foods. As part of the interdisciplinary team, the pediatrician's role is to monitor appropriate growth and development, exclude dietary deficiencies or prescribe supplementation if necessary. In our article, the screening and treatment of sensory processing disorder as part of the assessment of eating problems are introduced as an example of good clinical practice at the Early Childhood Eating and Sleep Disorder Outpatient Clinic at the Heim Pál National Institute of Pediatrics. Orv Hetil. 2023; 164(45): 1767-1777.

Yoga as an adjunct treatment for the eating disorders: A qualitive enquiry of clinician perspectives.

BACKGROUND: Yoga has been recognised as a beneficial adjunct for eating disorder (ED) treatment due to demonstrating positive effects on ED symptomology. Despite this, research exploring the perspectives of clinicians regarding the use of yoga for the spectrum of the EDs is limited. Consequently, this study utilised qualitative enquiry to explore the experiences and perspectives of clinicians regarding the implementation of yoga as an adjunct for ED treatment. This research examines how yoga may be safely applied for the EDs, to enhance ED treatment approaches and recovery. METHODS: This study employed semi-structured interviews with 12-clincians with up to 20-years of experience working therapeutically with people with EDs. Participants were asked their perspectives on the benefits, risks, and adaptations for delivering safe and suitable yoga programs for the spectrum of EDs. Template thematic analysis was used. RESULTS: Four distinct themes were identified. They included the (1) benefits of yoga, (2) risks associated with the practice, (3) recommendations for adapting yoga for this cohort, and (4) implementing yoga alongside current psychological treatment. CONCLUSIONS: Clinicians viewed yoga as a safe and suitable transdiagnostic treatment, with the potential to support individuals with a more holistic and sustained recovery model. Clinicians raised concerns that might arise with the use of yoga for this cohort, however, they also emphasised the ability for these to be mitigated with a series of key adaptations. Importantly, clinicians recommended that yoga is implemented and monitored alongside ED treatment to ensure its suitability and safety. Key barriers for implementing yoga as an adjunct treatment and future research directions are discussed. Recent research has explored the benefits of yoga for individuals with eating disorders (EDs). However, researchers have not yet interviewed clinicians who work with those with EDs regarding their views on using yoga for their clients. This study therefore interviewed 12 clinicians working with individuals with EDs, to obtain their views for using yoga as a therapeutic treatment for this group. Overall, clinicians viewed yoga as a safe and beneficial treatment for EDs. While some concerns were raised regarding the safety of yoga for this group, clinicians emphasised that these could be relieved by a series of key adaptations. This study offers unique insights into how yoga may be safely applied into the care for ED clients, to enhance their treatment approaches and recovery.

The Role of Religion, Spirituality and Social Media in the Journey of Eating Disorders: A Qualitative Exploration of Participants in the "TastelifeUK" Eating Disorder Recovery Programme.

This study explores the religious and spiritual aspects of eating disorder recovery and the role of social media in the context of a third sector community-based recovery group in the UK. Four online focus groups explored participant perspectives (17 participants in total) using thematic analysis. The qualitative findings highlight that relational support from God is important in eating disorder recovery and coping, although this can be challenged by spiritual struggles and tensions. Relational support from people is also relevant where it offers a place to share different experiences together giving a sense of community belonging. Social media was also found to be important in relation to eating disorders, either providing a community of support or exacerbating existing issues. This study suggests that the role of religion and social media should be acknowledged where it is important for that individual in relation to eating disorder recovery.

Overreliance on BMI and Delayed Care for Patients With Higher BMI and Disordered Eating.

Diagnostic utility of weight and body mass index (BMI) is widely overestimated. Although both are clinically relevant, their use as universal measures of health and wellness can result in missed or incomplete diagnoses, which are neglected sources of iatrogenic harm. This article problematizes overreliance on weight and BMI in assessing disordered eating behaviors and suggests how physicians can prevent harmful delays in indicated interventions. This article also canvasses misconceptions about the prevalence and severity of eating disorders in people with higher BMIs and encourages holistic approaches to caring for patients with obesity.

One size may not fit all: A mapping review of yoga-based interventions for the treatment of eating disorders.

BACKGROUND: While research investigating the potential benefits of yoga for eating disorders (EDs) has expanded, a systematic approach examining how yoga has been implemented for this cohort has not yet been conducted. This research therefore aimed to synthesize the current understanding of how yoga has been implemented for individuals with EDs, with regards to the feasibility, acceptability, and safety of yoga for this cohort. METHODS: This study utilised mapping review technology. The following electronic databases were searched within the month of September 2021 and December 2022: PsycINFO, MEDLINE, CINAHL, and Embase. Articles that applied and documented the use of yoga for the EDs were selected. RESULTS: The review identified ten unique studies. Details regarding the application, feasibility, acceptability, and safety of these yoga programs were extracted. This resulted in an evidence map or visual summary of how yoga has been applied for the EDs. CONCLUSION: While limited, the current literature suggests that yoga is a safe, acceptable, and feasible transdiagnostic intervention for EDs. These findings provide pragmatic support for safely applying yoga for the EDs into clinical practice to support ED recovery.

The usefulness of an intervention with a serious video game as a complementary approach to cognitive behavioural therapy in eating disorders: A pilot randomized clinical trial for impulsivity management.

OBJECTIVE: The aim of the present study was to test the usefulness of an add-on serious video game approach (i.e., Playmancer) to treatment as usual (TAU) on reducing impulsive behaviours and psychopathology in individuals diagnosed with an eating disorder (ED). METHOD: Thirty-seven patients diagnosed with an ED according to the DSM-5 were included in the present randomized clinical trial (RCT; study record 35,405 in ClinicalTrials.gov) and were randomly assigned to either the TAU or TAU + Playmancer group. All participants completed a clinical interview. Impulsivity (UPPS-P self reported questionnaire and Stroop task) and general psychopathology (SCL-90-R) measures were assessed at: baseline, 4 weeks into treatment, at the end of TAU (after 16 weeks), and follow-up (2 years). In addition, patients in the experimental group underwent a total of nine sessions with Playmancer over the span of 3 weeks. RESULTS: Patients in both treatment groups (TAU + Playmancer or TAU) improved on Stroop task performance and psychological distress. Additionally, patients in TAU-Playmancer improved on the impulsive trait domain of lack of perseverance. No statistical differences were found regarding treatment outcomes (i.e., treatment adherence and remission of eating symptomatology) when comparing the two treatment groups. CONCLUSION: Our results suggest that the impulsivity associated with EDs should be addressed and could be modified, as some facets of trait impulsivity improved after Playmancer add-on treatment. Yet, there were no significant differences in treatment outcomes when comparing the two groups and further research needs to be conducted.

Current approaches in the recognition and management of eating disorders.

Eating disorders are now well acknowledged mental health problems that are common and present in people from diverse sociodemographic backgrounds. The past decade has seen a rapid expansion in research into eating disorder interventions. In response to the increasing burden of eating disorders, the Australian Government Department of Health and Aged Care has implemented significant policy changes to improve patient access to Medicare and inpatient treatment facilities. There are several international clinical practice guidelines and a robust evidence base particularly for first line care with specific psychological therapies, including guidelines for the management of eating disorders in individuals with a high weight. Medications play an important adjunct role in care, and novel neuromodulating treatments, such as psychostimulants, are under study. There is emerging evidence for increased person-centred care, with more choice in the form of alternatives to hospital inpatient programs and more respectful consideration of care for all who experience an eating disorder, including people with high weight.

Effect of a long-term art-based group therapy with eating disorders.

Eating disorders (EDs) affect the physical, psychological, emotional and interpersonal areas of the individual and cause serious medical and mental consequences. Their treatment should be handled in a multidisciplinary manner.The objective of this study was to investigate potential benefits of long-term art-based group therapy (ABGT) as an adjunct to treatment for a variety of EDs. This study examined the effects of ABGT on disease symptoms, difficulty regulating emotions, depression, anxiety, targeted problems, functioning of individuals with EDs and therapeutic efficiency of the group. The study was carried out as a pre-test-post-test, quasi-experimental study with a control group, with a small sample diagnosed with an ED. In addition to their standard treatment at the outpatient centre, participants were included in a 30-week long-term semistructured ABGT focused on raising awareness of their psychological problems. Participants who received ABGT had significantly better functioning and lower severity of target problems compared with the control group. The severity of the three most important problems reported by patients post-ABGT compared with pre-ABGT and the effects of these problems on their social/private lives reduction was observed. The participants mostly benefited from catharsis, universality, self-understanding, existential factors and family re-enactment in the group process. Through the artwork, participants recognised the mental conflicts causing the symptoms of their ED. We found that art-based interventions are useful in the treatment of EDs, as they positively changed the functioning and symptoms of people with EDs. We recommend that clinicians keep these interventions in mind in formulating treatment protocols for these disorders.

Music-based intervention impacts for people with eating disorders: A narrative synthesis systematic review.

Eating disorders (EDs) can be life-threatening and cause long-term adverse biopsychosocial effects. Treatment options are limited and treatment seeking barriers exist. The objective of this systematic review was to examine the therapeutic impacts of music-based intervention (MBIs) for people with diagnosed EDs. Five bibliographic databases (PsycInfo, MEDLINE, CINAHL, CENTRAL, Open Dissertations) were searched. Eligible studies examined therapeutic outcomes of MBIs in people with EDs, using quantitative and/or qualitative methods. From 939 studies identified, 16 met the inclusion criteria (N = 349; age:12-65-years-old), and were categorized as: music therapy (5 studies), music medicine (4 studies), and "other MBIs" (7 studies), that is, the intervention included music and was delivered by a non-music therapist health worker and/or musician. A narrative synthesis of the studies was undertaken. Participants were diagnosed with anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder otherwise not specified, or mixed symptoms. MBIs varied widely and were associated with improved mood regulation, emotional well-being, and management of meal-related distress. Vodcast (video podcast) interventions were associated with healthful eating in non-inpatient populations. Studies were assessed using critical appraisal tools. Generalizability of findings is limited due to small samples and suboptimal description of MBIs. Longitudinal research is warranted with larger samples and informed by frameworks for quality reporting of complex MBIs. Review findings may encourage music therapists to further develop and examine how music therapy can help people with EDs to live healthier lives.

Beyond Binge Eating: The Impact of Implicit Biases in Healthcare on Youth with Disordered Eating and Obesity.

(1) Background: Obesity and eating disorders (ED) can coexist resulting in worse health outcomes. Youth with ED are more likely to have obesity relative to peers with a healthy weight. Pediatric providers deliver first-line care to children and youth of all sizes and body shapes from infancy to adolescents. As healthcare providers (HCPs), we bring biases into our practice. Learning to recognize and address these biases is needed to provide the best care for youth with obesity. (2) Purpose: This paper aims to summarize the literature regarding the prevalence of ED beyond binge eating in youth with obesity and discuss how the intersection of weight, gender, and racial biases impact the assessment, diagnosis, and treatment of ED. We provide recommendations for practice and considerations for research and policy. (3) Conclusions: The assessment and treatment of ED and disordered eating behaviors (DEBs) in youth with obesity is complex and requires a holistic approach. This approach begins with identifying and understanding how one's implicit biases impact care. Providing care from a patient-centers lens, which considers how the intersection of multiple stigmatized identities increases the risk for DEBs in youth with obesity may improve long-term health outcomes.

Developing the "single-session mindset" in eating disorder research: Commentary on Schleider et al., 2023 "Realizing the untapped promise of single-session interventions for eating disorders".

Schleider and colleagues' paper on the application of single-session interventions (SSIs) to eating disorders is timely given the broader focus in mental health on flexible approaches to delivering support at the time the person needs it most. The eating disorder field needs to embrace these innovations including developing a "single-session mindset" with greater attention paid to testing the relevance of SSI for eating disorders. The use of well-powered trials of brief, focused and rapidly scalable interventions is an ideal vehicle for generation and evaluation of new and longer interventions. Our future research agenda needs to carefully consider our target audience, the primary outcome variable of most relevance, and the SSI topic that would be most likely to effect change. Research in prevention might focus on weight concern and evaluation of SSIs that focus on self-compassion or cognitive dissonance related to appearance ideals in the media. Work in early intervention could target denial and disordered eating using SSIs on growth mindset, behavioral activation, and imagery rescripting. Treatment waitlists provide another suitable opportunity, evaluating SSIs that aim to increase hope for change, treatment retention, and kick start early change in therapy, a robust predictor of better treatment outcome.

The effect of imagery rescripting on core beliefs and eating disorder symptoms in a subclinical population.

BACKGROUND AND OBJECTIVES: This study compared the effect of imagery rescripting focusing on self-compassion, imagery rescripting focusing on mastery, and a positive memory control condition on (1) emotional responses towards the memory (one day after), (2) changes in the believability of negative core beliefs, and dysfunctional eating behaviors (one week after) in individual at risk for developing an eating disorder. METHODS: Female participants (N = 69) were allocated to one of three conditions: ImRs focusing on self-compassion (N = 24), ImRs focusing on self-mastery (N = 23), and positive memory control condition (N = 22). Participants in the ImRs conditions received a 20-min self-guided ImRs intervention, whereas participants in the control condition received a 20-min self-guided task focusing on an unrelated positive memory. RESULTS: The experimental manipulation successfully induced the use of self-compassion and mastery strategies in the respective imagery rescripting condition. However, our data show that a single 20-min session of self-guided imagery rescripting focusing on compassion and/or mastery has no effect on the emotional response towards the aversive memory or in the change of core beliefs and eating behaviors at follow up. LIMITATIONS: We discuss potential reasons for the null findings, including the use of a single imagery rescripting session, the sample size and the measurement of manipulation checks. CONCLUSION: Future studies are needed to rule out methodological explanations for the null results. These findings may be of value for the development of future experimental lab paradigms which aim to evaluate the causal effects and working mechanisms of imagery rescripting.

Universal healthcare reform for community treatment of eating disorders in Australia: report of the first 2 years of operation.

OBJECTIVE: The Australian Government's landmark 2019 implementation of dedicated Medicare items for people with eating disorders was the first of its kind for a mental illness. We investigate the first 24 months of uptake of these items across regions, settings and healthcare disciplines, including intermediate changes to the program prompted by the COVID-19 pandemic. METHODS: This was a descriptive study using item data extracted from the Australian Medicare Benefits Schedule database for November 2019 to October 2021. Data were cross-tabulated by discipline, setting, consultation type and region. RESULTS: During the first 24 months of implementation of the scheme, 29 881 Eating Disorder Treatment and Management Plans (or care plans) were initiated, mostly by general practitioners with mental health training. More than 265 000 psychotherapy and dietetic sessions were provided, 29.1% of which took place using telehealth during the pandemic. Although the program offers up to 40 rebated psychological sessions, fewer than 6.5% of individuals completed their 20-session review under the scheme. CONCLUSIONS: Uptake of the Medicare item for eating disorders was swift, and the item was used broadly throughout the pandemic. Although feedback from those with lived experience and experts has been overwhelmingly positive, data show that strategic adjustment may be needed and further evaluation conducted to ensure that the reform achieves the best outcomes for patients and families, and its policy intent. Full text.

Incidence and Medical Hospitalization Rates of Patients With Pediatric Eating Disorders.

Objective Eating disorders typically onset in preadolescence and adolescence and cause negative mental and physical health sequelae over the life span. This study examined the incidence and medical hospitalization rates of pediatric eating disorders in an integrated health system in the United States. Methods This retrospective cohort study examined 4883 Kaiser Permanente Northern California members 8-18 years of age with an eating disorder diagnosis from January 2015 to June 2019. Medical hospitalizations include admissions at any of the 13 Kaiser Permanente Northern California hospitals with a primary or secondary eating disorder diagnosis. Results Incidence rates ranged between 177 and 205 per 100,000 adolescents per year. More than half the adolescents were non-White: 10.8% Asian, 4.3% Black, 26.7% Hispanic/Latinx, 8.4% multiracial, 0.3% Native American/Alaskan Native, and 0.5% Native Hawaiian/Pacific Islander. Thirteen percent had a body mass index (BMI) below the 5th percentile, 61.8% had a BMI between the 5th and the 84th percentiles, 19.7% had a BMI above the 85th percentile, and 5.6% had an unknown BMI. During the 12-month follow-up period, 5.4% of adolescents had medical hospitalizations. Conclusions This study adds to the evidence that eating disorders affect children/adolescents across all weight/BMI ranges and racial/ethnic backgrounds. Future studies call for exploration on treatment strategies that tailor to the diverse populations.

Animal-assisted therapy in eating disorder treatment: A systematic review.

INTRODUCTION: Eating disorders (EDs) are deadly illnesses with high relapse rates, highlighting need for better interventions. Animal-assisted therapy (AAT) has been implemented supplementally for EDs, with horses utilized at many residential facilities. AAT shows promise with meta-analyses of randomized control trials (RCTs) showing significant decreases in depression, anxiety, and negative affect; however, no review to date has evaluated efficacy for EDs. Therefore, this study conducted a systematic review of primary literature to investigate the efficacy of AAT for EDs. METHOD: A systematic review was conducted via PubMed, PsycInfo, and Google Scholar, up to and including September 2021, yielding 10 studies. Therapy animals included horses (n = 8), dogs (n = 1), and dolphins (n = 1). Populations included AAT ED therapists and patients (ages 11 to adult). The PRISMA methodology was used (registration PROSPERO CRD42021256239). Risk of bias assessment used Cochrane method for quantitative studies, Critical Appraisal Skills Programme checklist for qualitative studies, and JBI Critical Appraisal Checklist for Case Reports. Given study type heterogeneity, neither synthesis nor certainty assessments were conducted. RESULTS: Case and qualitative studies reported improvement in cognitive flexibility, ability to relinquish control, and confidence. Quantitative studies demonstrated an inverse relationship between AAT utilization and ED symptoms post-treatment. Effect sizes, when reported, were mostly moderate. All but one study had low, or unclear, risk of bias. Limited randomization and a lack of RCTs measuring ED symptomology directly makes drawing conclusions difficult. CONCLUSION: While preliminary research indicates possible benefits of AAT as a complement to traditional ED treatment, more research is needed to establish efficacy. Future studies should employ randomized control trials and examine key mechanisms of change.

Anorexia Nervosa, Body Image Perception and Virtual Reality Therapeutic Applications: State of the Art and Operational Proposal.

Anorexia Nervosa (AN) patients exhibit distorted body representation. The purpose of this study was to explore studies that analyze virtual reality (VR) applications, related to body image issues, to propose a new tool in this field. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, Scopus, and Web of Science databases were explored; the review included 25 studies. Research has increased over the last five years. The selected studies, clinical observational studies (n = 16), mostly concerning patients' population with AN (n = 14) or eating disorders (EDs) diagnosis, presented multiple designs, populations involved, and procedures. Some of these studies included healthy control groups (n = 7). Studies on community sample populations were also selected if oriented toward clinical applications (n = 9). The VR technologies in the examined period (about 20 years) have evolved significantly, going from very complex and bulky systems, requiring very powerful computers, to agile systems. The advent of low-cost VR devices has given a big boost to research works. Moreover, the operational proposal that emerges from this work supports the use of biofeedback techniques aimed at evaluating the results of therapeutic interventions in the treatment of adolescent patients diagnosed with AN.

Mindfulness and Eating Disorders: A Network Analysis.

Higher trait mindfulness may be protective against eating disorder (ED) pathology. However, little is understood about which specific mindfulness processes connect to specific ED symptoms. This study (N = 1,056 undergraduates) used network analysis at the symptom/process level to identify: (1) central nodes, or symptoms/processes with the greatest collective connection with all other symptoms/processes; and (2) bridge nodes, or symptoms/processes driving interconnection between mindfulness processes and ED symptoms. We conducted analyses both with and without food- and body-related mindfulness items. Central nodes included: describing how one feels in detail, expressing how one feels in words, and feeling guilty about eating due to shape/weight. Bridge nodes connecting higher mindfulness processes with lower ED symptoms included: the eating disorder symptom, being uncomfortable about others seeing one eat, and the mindfulness process, not criticizing oneself for having irrational/inappropriate emotions. Bridge nodes connecting higher mindfulness processes with higher ED symptoms included: noticing sensations of the body moving when walking and noticing how food/drinks affect thoughts, bodily sensations, and emotions. Findings suggest that future research should explore whether mindfulness-based interventions for EDs may be more effective by targeting mindfulness processes related to describing, expressing, and accepting emotions, accepting discomfort when eating with others, and reducing hyper-focus on and reactivity to food-and-body related sensations.

Holistic nursing care for people diagnosed with an eating disorder: A qualitative study based on patients and nursing professionals' experience.

PURPOSE: To analyze eating disorder patients and nursing professionals' views and experience of the relationship-based care established. DESIGN AND METHODS: A qualitative study that employs an interpretative phenomenological analysis. Nineteen patients and 19 nurses participated in the research through interviews and narrations. FINDINGS: Nurses' help is both unexpected and relevant during the patients' recovery process. They provide care not focusing just on nutritional aspects, other factors such as mutual help, the psychological, emotional, social, and personal aspects are highlighted. PRACTICE IMPLICATIONS: This study provides a deep understanding of the relationship-based care established that makes it possible to expand knowledge and to individualize the care provided.