Ethical implications of defining longstanding anorexia nervosa.

The label severe and enduring anorexia nervosa (SE-AN) is widely used in the literature on longstanding anorexia nervosa (AN). However, the process of constructing the criteria and the use of the label SE-AN has ethical implications that have not been taken into account. Through combining existing literature and lived experience perspective, this paper addresses to what extent the current criteria do and do not reflect the lived experience. Arguments are presented on why the process of constructing the criteria for SE-AN and the application of the label can be both identified as, and give rise to, epistemic injustice. Epistemic injustice is an injustice that is done to a person as an individual with the capacity of acquiring and sharing knowledge. This type of injustice can occur at any stage of an interaction between people in which knowledge is shared with one another. The paper concludes by giving suggestions on how to pursue epistemic justice in the process of defining longstanding AN.

Some patients with anorexia nervosa (AN) develop a longstanding eating disorder. Over the years different labels, such as 'chronic AN' or 'treatment resistant AN', have been used to describe longstanding AN. Currently, the label that is used most often in scientific literature is 'severe and enduring AN' (SE-AN) and criteria for what entails SE-AN have been proposed. This paper looks at the possible ethical issues that have arisen in the process of constructing the criteria and possible ethical problems that may result from using the label SE-AN. The paper focuses on injustice that may arise when people with specific experiences, such as lived experience of longstanding AN, are not acknowledged as people with important knowledge to share. The paper concludes by giving suggestions on how to overcome this type of injustice.

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).

Perspectives of underweight people with eating disorders on receiving Imagery Rescripting trauma treatment: a qualitative study of their experiences.

BACKGROUND: The prognosis for underweight individuals with an eating disorder (ED) and posttraumatic stress disorder (PTSD) is worse than for their peers without these comorbid symptoms. This qualitative study explores the experiences of trauma-focused Imagery Rescripting (ImRs) therapy of underweight inpatients being treated for an ED. OBJECTIVE: To test the feasibility and to improve ImRs by understanding the experiences and perspectives of people with an ED and PTSD who, when underweight, received ImRs as an adjunct to their inpatient ED treatment. METHOD: To explore how underweight people with an ED experience and perceive ImRs, we used a qualitative study design involving semi-structured interviews with 12 participants. After analysis, the data were summarized and classified within a thematic framework that focused on experiences and improving the ImRs method. RESULTS: The thematic analysis resulted in the following 6 main themes; (1) Expectations of ImRs; (2) Ability to participate in ImRs; (3) Effect of ImRs; (4) Experience of ImRs technique; (5) Conditions under which ImRs is given; (6) In depth-analysis. The results show that despite the fear of disappointment the participants appreciate addressing the PTSD and ED symptoms simultaneously. Further, results showed that it had been possible for them to attend ImRs but that the effects of ImRs were not uniformly perceived. Also, participants indicated that a caring context is important and that ImRs should not be scheduled immediately before a meal. Finally, the treatment generated hope. CONCLUSIONS: The findings of this study demonstrated the feasibility of the integration of ImRs trauma treatment for individuals who are being treated in an ED inpatient treatment setting, and are in contrast to standard practice where the focus of inpatient treatment has been ED-symptom improvement without comprehensively addressing past traumatic experiences during an underweight phase. Trial registration International Clinical Trials Registry Platform (ICTRP) (NTR6094). Date of registration 09/23/2016. https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6094.

A proportion of those with eating disorders have also experienced traumatic events and ongoing symptoms of PTSD such as re-experiencing of the trauma and nightmares. We implemented an innovative trauma intervention called Imagery Rescripting (ImRs) to explore whether for those undergoing inpatient treatment for an eating disorder (in an underweight phase), it would be possible to treat the various trauma-related symptoms as well as the eating problems. Since this has not been investigated before, we asked the participants in this study to recount their experiences. Twelve participants who were underweight, reported a past history of trauma and were in an inpatient eating disorder treatment program participated in ImRs therapy intervention. One of these participant did not engage in the ImRs therapy because she discontinued the inpatient ED treatment. Analysis of interviews with these participants found that -although they were reluctant before the start of the treatment- the ImRs treatment during their inpatient admission had given them hope again. They added that it was important to have support from group members, sociotherapists and therapists. They shared a number of ways that the ImRs treatment could be adapted to people with eating disorders. Their experiences indicated that given these factors it was possible to treat PTSD during an underweight phase. This is important: until now, treatment for eating disorders has not specifically been trauma-focused and these tips have scope to improve the ImRs intervention and eating disorder treatment more broadly in the future.

Treating PTSD with Imagery Rescripting in underweight eating disorder patients: a multiple baseline case series study.

BACKGROUND: Eating disorder patients with posttraumatic stress disorder have worse treatment results regarding their eating disorder than patients without posttraumatic stress disorder. Many eating disorder patients with co-morbid posttraumatic stress disorder symptoms are not treated for posttraumatic stress disorder symptoms during an underweight state. We propose that treatment of posttraumatic stress disorder is possible for underweight patients and that their trauma symptoms decrease with the use of Imagery Rescripting. We also investigated whether treatment of trauma influences eating disorder pathology in general and the process of weight gain specifically. METHOD: Ten patients in clinical treatment (BMI 14-16.5) participated. A multiple baseline design was used, with baseline varying from 6 to 10 weeks, a 6-week treatment phase, a 3-week follow-up period and a 3-month follow-up measurement. Data were analysed with mixed regression. RESULTS: Evidence was found that Imagery Rescripting had strong positive effects on posttraumatic stress disorder symptoms without interfering with eating disorder treatment. Positive effects were also found on a range of secondary emotional and cognitive measures. CONCLUSION: Imagery Rescripting of traumatic memories is a possible and safe intervention for underweight eating disorder patients. It also had positive clinical effects. Trial registration Netherlands trial register (NTR) Trial NL5906 (NTR6094). Date of registration 09/23/2016. https://www.trialregister.nl/trial/5906 .

The present study was the first to investigate treatment of posttraumatic stress symptoms, such as re-experiences and flash backs, in underweight eating disorder patients.This research is important because these patients: Often do not receive treatment for trauma symptoms while they are underweight. Have worse eating disorder treatment results than patients without posttraumatic stress disorder. Patients and patient organisations have for years expressed the wish that posttraumatic stress disorder be treated during the weight gaining phase of eating disorder treatment. The results of this study are important because they show that treatment for trauma is possible for patients that are underweight.Ten patients received trauma treatment. Trauma and eating disorder symptoms were measured before, during and after treatment. We tested whether trauma symptoms were reduced during and after treatment.This research was done because patients requested posttraumatic stress disorder treatment while they were underweight. Previous patients were involved in the development of the interview and all participants were interviewed about their experiences. The findings will be published and presented at eating disorder conferences attended by patients.

Evaluation of the cognitive behavioural theory of eating disorders: A network analysis investigation.

OBJECTIVE: One of the prevailing theories of eating disorders (ED) is the transdiagnostic cognitive behavioural theory of eating disorders, which suggests that certain ED symptoms, such as over-valuation of eating, shape, and weight, may be more central than others. In the present study, network analyses were used to evaluate these assumptions in a patient sample. METHODS: Participants were 336 individuals receiving treatment at an expert center for ED in the Netherlands. Eating disorder symptoms were used to create transdiagnostic and diagnosis-specific networks and assess symptom centrality and density of the networks. RESULTS: Networks for patients with bulimia nervosa and binge eating disorder confirmed that over-valuation of shape, weight, and eating is the most central symptom in the network. A transdiagnostic network of ED symptoms and separate networks for patients with anorexia nervosa and bulimia nervosa showed that strict dieting was an additional central ED symptom. An exploratory analysis revealed that, although eating disorder symptoms decreased, there were no differences in density of the eating disorder networks before and after treatment with cognitive behavioural therapy. DISCUSSION: In conclusion, the current study confirmed that over-valuation of shape, weight, and eating is a central symptom across eating disorders, in agreement with the transdiagnostic cognitive behavioural model of eating disorders. Specifically targeting this symptom in treatment could lead to other symptoms improving as a result.

The Co-Development of Parenting Stress and Childhood Internalizing and Externalizing Problems.

Although the detrimental influence of parenting stress on child problem behavior is well established, it remains unknown how these constructs affect each other over time. In accordance with a transactional model, this study investigates how the development of internalizing and externalizing problems is related to the development of parenting stress in children aged 4-9. Mothers of 1582 children participated in three one-year interval data waves. Internalizing and externalizing problems as well as parenting stress were assessed by maternal self-report. Interrelated development of parenting with internalizing and externalizing problems was examined using Latent Growth Modeling. Directionality of effects was further investigated by using cross-lagged models. Parenting stress and externalizing problems showed a decrease over time, whereas internalizing problems remained stable. Initial levels of parenting stress were related to initial levels of both internalizing and externalizing problems. Decreases in parenting stress were related to larger decreases in externalizing problems and to the (stable) course of internalizing problems. Some evidence for reciprocity was found such that externalizing problems were associated with parenting stress and vice versa over time, specifically for boys. Our findings support the transactional model in explaining psychopathology.

Alcohol expectancies in young children and how this relates to parental alcohol use.

According to the cognitive model of intergenerational transference, modeling of alcohol use is an indirect process in which parental drinking shapes alcohol expectancies of children, which in turn are associated with later alcohol use in adolescents. The present study examined whether parental alcohol use was related to alcohol expectancies and experimentation with alcohol use in young children. A community sample of 240 children aged 8.02 (SD=1.13) participated. Alcohol expectancies were assessed by means of the Berkeley Puppet Interview. Children reported consistently and reliably on the positive and negative consequences of alcohol use among adults. Their positive and negative expectancies were equally strong. Compared to younger children, older children had more negative and less positive expectancies. For girls, more paternal alcohol use was associated with less negative alcohol expectancies. For older children, more alcohol use of the mother was related to less positive expectancies, while more alcohol use of the father was related to more positive expectancies. The present study showed that young children already have clear ideas about the positive and negative consequences alcohol can have among adults, which can be captured with the Berkeley Puppet Interview. These expectancies are partly associated with alcohol use of their parents.

Mediation and moderation effects of an in-home family intervention: the "in control: no alcohol!" pilot study.

The aim of this study was to examine the effect of a theory-based in-home family intervention (In control: No alcohol!) on adolescent alcohol cognitions via its putative mediators using a randomized controlled design. In the South Holland region of the Netherlands, a total of 213 children (11-12 years) and their mothers were randomly assigned to the prevention program (108 dyads) and the control condition (105 dyads). Mediation effects were analyzed using pretest and two follow-up measurements (5 and 12 months after baseline). A path model was estimated (using Mplus) to examine the effect of the intervention on the putative mediators (frequency- and quality of mother-child communication, rules about alcohol, establishing a nondrinking agreement, and parental monitoring of the child's whereabouts). Outcomes were adolescents' perceived harmfulness of drinking and intention to drink. Multigroup analyses were performed to examine potential differences across gender. The program led to an increase in frequency of alcohol-specific communication, nondrinking agreements, and parental monitoring. Moreover, adolescents in the experimental condition perceived drinking to be more harmful and had less intention to drink compared to adolescents in the control condition. The effect of the program on adolescent alcohol cognitions was significantly mediated through having more frequent conversations about alcohol, yet only among boys. Although results on actual drinking need to be added, findings indicate that this relatively inexpensive, easy-to-administer home intervention is promising.

Intergenerational transmission of drinking motives and how they relate to young adults' alcohol use.

AIMS: This study examined whether parental drinking motives are associated with young adults' drinking motives, and their association with young adults' drinking behaviors. METHODS: The sample consisted of 290 18-year-old and 289 20-year-old drinking young adults and their parents. RESULTS: For the younger group, stronger maternal coping motives were related to stronger social and enhancement motives, while stronger paternal coping motives were associated with stronger young adult coping motives. For the older group, stronger maternal coping motives were related to stronger social motives and stronger paternal enhancement motives were associated with stronger overall young adult drinking motives. For the younger group, both enhancement and conformity motives were predictive of their alcohol use. For the older group, only higher social motives were predictive of higher alcohol use. Both groups' higher coping and enhancement motives were associated with more drinking problems. CONCLUSIONS: While, concerning content, there are some differences due to parent gender and adolescent age, stronger parental drinking motives are indeed associated with stronger adolescent drinking motives, which in turn are quite consistently related to more adolescent alcohol use and alcohol-related problems.

Alcohol-specific parenting, adolescent alcohol use and the mediating effect of adolescent alcohol-related cognitions.

OBJECTIVES: Previous research indicated that alcohol-specific parenting is an important precursor of adolescent alcohol use, but failed to define the underlying mechanism. Based on social cognitive theory, alcohol-related cognitions such as alcohol refusal self-efficacy and alcohol-related expectancies were hypothesised to mediate this link. DESIGN: A cross-sectional survey included 1349 mothers and their sixth grade (11-12 years old) adolescent offspring. Structural equation modelling was employed to test the association between alcohol-specific parenting and adolescent alcohol use, mediated by adolescent alcohol-related cognitions. MAIN OUTCOME MEASURES: Adolescent alcohol use, drinking refusal self-efficacy and alcohol expectancies. RESULTS: The associations between frequency of communication, maternal alcohol use and adolescent alcohol use were mediated by negative alcohol-related expectancies. The associations between quality of communication, rules and disclosure and adolescent alcohol use were mediated by self-efficacy. CONCLUSIONS: The present study provides a first indication that the underlying mechanism of the association between the most important alcohol-specific parenting practices and adolescent alcohol use can be contributed to the mediating effect of alcohol-refusal self-efficacy.

The mediating role of alcohol-related memory associations on the relation between perceived parental drinking and the onset of adolescents' alcohol use.

AIMS: The aim of the current study was to examine the mediating role of alcohol-related memory associations in the relation between perceived parental drinking and the onset of adolescents' alcohol use. Gender and grade were also included in the analyses. DESIGN: We tested a mediation model within a structural path modelling framework using longitudinal data (two waves). SETTING AND PARTICIPANTS: The sample consisted of 608 Canadian adolescents (42.9% boys), who did not have any alcohol experiences at the first measurement. The adolescents were recruited from all grades 7-9 classes in a large school district in western Canada. MEASUREMENTS: Alcohol-related memory associations were tested with the Word Association Test. We used adolescent self-reports of alcohol use and parental drinking. FINDINGS: Results clearly showed a mediation effect of alcohol-related memory associations [estimate = 0.023, 95% confidence interval (CI): 0.002-0.044). That is, parental drinking as perceived by the adolescent was related positively to alcohol-related memory associations, which in turn predicted adolescents' alcohol use a year later. Gender and grade were related to alcohol-related memory associations. That is, boys and adolescents of higher grades had more memory associations. CONCLUSIONS: Children appear to form memory associations related to alcohol before they ever drink alcohol themselves, and these associations appear to mediate the link between their perceptions of their parents' drinking and their own initial alcohol use.

Parental alcohol-specific rules and alcohol use from early adolescence to young adulthood.

BACKGROUND: Several studies stress the importance of alcohol-specific rules during adolescence to prevent them from drinking early and heavily. However, most studies have short follow-up periods and do not cover the relevant developmental period in which direct parental control diminishes and adolescent alcohol use increases. The current study aimed to provide a developmental perspective on the link between alcohol-specific rules and alcohol use from early adolescence until early adulthood in the Netherlands. METHODS: The sample consisted of 428 Dutch families including fathers, mothers and adolescents from 2 age groups (13 and 15 years old) at Time 1 (T1), who have been surveyed annually for 6 years. To address the effect of alcohol-specific rules on adolescent alcohol use over time, a latent growth curve analytic approach with time-varying covariates was employed. RESULTS: Over time, adolescent alcohol use increased, whereas alcohol-specific rules decreased. Most importantly, however, the lagged paths of alcohol-specific rules consistently predicted subsequent alcohol use across the 6 assessments for both younger and older siblings. Thus, strict alcohol-specific rules at a certain point in time were related to a lower intensity of adolescent alcohol use a year later. CONCLUSIONS: Although parents turn somewhat less strict in alcohol-specific rules over time, and adolescent alcohol use increases over time, the specific rules parents set remain important in restraining the alcohol use of their adolescent offspring. Thus, parents should and can feel confident about their parenting capabilities, and they should maintain being strict to prevent their offspring from drinking.

Results of the 'in control: no alcohol!' pilot study.

More than 50% of Dutch 12-year olds already started drinking. Since it is known that delaying the onset of alcohol use results in a lower risk of alcohol-related problems, the recently developed 'In control: No alcohol!' prevention program is targeted at elementary school children and their mothers. In this pilot study, the success of program implementation and impact of the program on quality of alcohol-specific communication, rules and monitoring were evaluated, using a randomized controlled design. A total of 108 children (11-12 years) and their mothers participated in the prevention program, while the control group consisted of 105 dyads. Families participating in the experimental condition showed an increase in frequency of alcohol-specific communication and 75% of the dyads reported that they took part in at least 3 of 5 magazines, suggesting implementation was successful. The program led to an increase in quality of communication but only for those dyads in which mothers' alcohol use was above average. The program led parents to set up a non-drinking contract with their children and to monitor their children more closely. Results are promising but need to be replicated in a larger longitudinal study.

Effectiveness of the home-based alcohol prevention program "In control: no alcohol!": study protocol of a randomized controlled trial.

BACKGROUND: In the Netherlands, children start to drink at an early age; of the Dutch 12-year olds, 40% reports lifetime alcohol use, while 9.7% reports last-month drinking. Starting to drink at an early age puts youth at risk of developing several alcohol-related problems later in life. Recently, a home-based prevention program called "In control: No alcohol!" was developed to delay the age of alcohol onset in children. The main aim of this project is to conduct a Randomized Controlled Trial (RCT) to evaluate the effectiveness of the program. METHODS/DESIGN: The prevention program will be tested with an RCT among mothers and their 6 grade primary school children (11-12 years old), randomly assigned to the prevention or control condition. The program consists of five printed magazines and an activity book designed to improve parental alcohol-specific socialization. Parent-child dyads in the control group receive a factsheet information brochure, which is the standard alcohol brochure of the Trimbos Institute (the Netherlands Institute for Mental Health and Addiction).Outcome measures are initiation of alcohol use (have been drinking at least one glass of alcohol), alcohol-specific parenting, susceptibility to drinking alcohol, alcohol expectancies, self-efficacy, and frequency and intensity of child alcohol use. Questionnaires will be administered online on secured Internet webpages, with personal login codes for both mothers and children. Mothers and children in both the experimental and control condition will be surveyed at baseline and after 6, 12, and 18 months (follow-ups). DISCUSSION: The present study protocol presents the design of an RCT evaluating the effectiveness of the home-based "In control: No alcohol!" program for 6 grade primary school children (11-12 years old). It is hypothesized that children in the prevention condition will be less likely to have their first glass of alcohol, compared to the control condition. When the prevention appears to be effective, it can easily and relatively quickly be implemented as a standard alcohol prevention program on a large scale. TRIAL REGISTRATION: Nederlands Trial Register NTR2564.

Parental alcohol use, alcohol-related problems, and alcohol-specific attitudes, alcohol-specific communication, and adolescent excessive alcohol use and alcohol-related problems: An indirect path model.

Alcohol-specific parent-child communication has often been studied in relation to regular alcohol use of adolescents. However, it might be as important to focus on adolescent problematic alcohol use. In addition, the way parents communicate with their children about alcohol might depend on their own (problematic) drinking behaviors. Therefore, the current study examined the direct effects of parental alcohol use, alcohol-related problems, and parental alcohol-specific attitudes on adolescent excessive drinking and alcohol-related problems later in life. It also looked at indirect effects via alcohol-specific communication. The sample consisted of 428 Dutch families including fathers, mothers and adolescents from two age groups (13 and 15 years old) at T1, who have been surveyed annually for 5 years. We tested the model with structural equation modeling (SEM). The results showed that parental alcohol-related problems were positively associated with communication about alcohol, which in turn was related with less excessive adolescent drinking and alcohol-related problems. Lenient parental attitudes about alcohol and parental alcohol-related problems were directly related to more excessive drinking and alcohol-related problems in adolescents. In conclusion, alcohol-specific communication intervenes in the relationship between parental alcohol-related problems and adolescent excessive drinking and alcohol-related problems. This indicates that in family alcohol interventions targeted at youth alcohol use, parental alcohol-related problems should be taken into account.

Facial attractiveness and self-esteem in adolescence.

Facial attractiveness has been associated with many (social) advantages in life, like greater popularity, acceptance, and social competence. Because social evaluations and acceptance are important factors contributing to self-esteem (SE), we hypothesized that high levels of attractiveness would be related to increased levels of SE. To test this assumption, 230 adolescents from two age groups (13 and 15 years) were surveyed annually for 5 years. A latent growth curve model was used to model the influence of facial attractiveness on the development of SE over time. Results showed that younger adolescents with higher levels of attractiveness had lower levels of SE at baseline. Attractiveness was not found to be a significant predictor in explaining the development of SE over time. These findings indicate that attractive children are more likely to have lower levels of SE when they enter early adolescence compared to their less attractive counterparts.