Cognitive behavior therapy for adult eating disorders in routine clinical care: A systematic review and meta-analysis.

OBJECTIVE: Cognitive behavior therapy (CBT) is a recommended treatment for eating disorders (ED) in adults given its evidence, mainly based on efficacy studies. However, little is known about how CBT works in routine clinical care. The goal of the present meta-analysis is to investigate how CBT works for various ED when carried out in routine clinical settings. METHOD: Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for articles published until June 2023. The outcome of CBT, methodological quality, risk of bias (RoB), and moderators of treatment outcome were examined and benchmarked by meta-analytically comparing with efficacy studies for ED. Fifty studies comprising 4299 participants who received CBT were included. RESULTS: Large within-group effect sizes (ES) were obtained for ED-psychopathology at post-treatment (1.12), and follow-up (1.22), on average 9.9 months post-treatment. Attrition rate was 25.5% and RoB was considerable in the majority of studies. The benchmarking analysis showed that effectiveness studies had very similar ESs as efficacy studies (1.20 at post-treatment and 1.28 at follow-up). CONCLUSION: CBT for ED is an effective treatment when delivered in routine clinical care, with ESs comparable to those found in efficacy studies. However, the evidence needs to be interpreted with caution due to the RoB in a high proportion of studies. PUBLIC SIGNIFICANCE: Eating disorders are common in the population and often lead to multiple negative consequences. CBT has been found effective for ED and is recommended in clinical guidelines. Since these recommendations are primarily based on university studies we wanted to investigate how CBT performs in routine clinical care. Our meta-analysis found that CBT worked as well in routine care as in university setting studies.

OBJETIVO: La terapia cognitivo-conductual (TCC) es un tratamiento recomendado para los trastornos de la conducta alimentaria (TCA) en adultos debido a su evidencia, basada principalmente en estudios de eficacia. Sin embargo, se sabe poco sobre cómo funciona la TCC en la atención clínica rutinaria. El objetivo de este meta-análisis es investigar cómo funciona la TCC para diversos TCA cuando se lleva a cabo en entornos clínicos habituales. MÉTODO: Se realizó una búsqueda sistemática en Ovid MEDLINE, Embase OVID y PsycINFO de artículos publicados hasta junio de 2023. Se examinaron el resultado de la TCC, la calidad metodológica, el riesgo de sesgo y los moderadores del resultado del tratamiento, y se compararon metaanalíticamente con estudios de eficacia para TCA. Se incluyeron cincuenta estudios que comprendían a 4299 participantes que recibieron TCC. RESULTADOS: Se obtuvieron tamaños del efecto (TE) grandes dentro del grupo para la patología de los TCA en el post-tratamiento (1.12) y en el seguimiento (1.22), en promedio 9.9 meses después del post-tratamiento. La tasa de abandono fue del 25.5% y el riesgo de sesgo fue considerable en la mayoría de los estudios. El análisis de comparación mostró que los estudios de efectividad tenían TE muy similares a los estudios de eficacia (1.20 en el post-tratamiento y 1.28 en el seguimiento). CONCLUSIÓN: La TCC para los TCA es un tratamiento efectivo cuando se administra en la atención clínica rutinaria, con TE comparables a los encontrados en estudios de eficacia. Sin embargo, la evidencia debe interpretarse con cautela debido al riesgo de sesgo en una alta proporción de los estudios.

The efficacy of psychological prevention, and health promotion interventions targeting psychological health, wellbeing or resilience among forced migrant children and youth: a systematic review and meta-analysis.

There are over 40 million displaced children and youth worldwide and there is a need promote their mental wellbeing. This study aimed to synthesize evidence regarding promotion interventions to increase wellbeing, resilience, and quality of life (primary outcomes), and prevention interventions to reduce internalizing and externalizing symptoms (secondary outcomes) in this population. The review protocol was registered with PROSPERO (CRD42022329978). Medline, PsycINFO, and Web of Science were searched. Inclusion criteria were: ≥ 10 participants, sample ≤ 18 years of age, no parental participation, explicated forced migrant populations, implementation in non-clinical context, and validated measures. Fifteen studies (N interventions = 18, N participants = 5741) were eligible. Two studies included outcomes related to wellbeing and quality of life. The remaining studies reported depression, PTSD, anxiety, internalizing and externalizing behaviours, and behavioural and emotional problems. There was only sufficient data to perform random-effects meta-analysis of depression scores. No significant effects were observed in comparison to control condition in randomized trials (n = 4994, k = 5) but a small significant positive trend was observed in within-group analyses (n = 537, k = 12). Cochrane's risk of bias tools and the GRADE certainty of evidence tool were applied. No studies achieved low risk of bias and certainty of evidence was very low. In sum, there remains a dearth of rigorous intervention studies investigating the effects of promotive and preventative psychological interventions on the wellbeing, resilience, and quality of life of forcibly displaced minors. However, the few eligible studies in this review indicate promise.

A pilot study of a virtually delivered dissonance-based eating disorder prevention program for young women with type 1 diabetes: within-subject changes over 6-month follow-up.

INTRODUCTION: In an uncontrolled study, we previously demonstrated the feasibility and preliminary efficacy of our virtual diabetes-specific version (Diabetes Body Project) of the eating disorder (ED) prevention program the Body Project. The aim of the current study was to evaluate further this program for women with type 1 diabetes (T1D) by assessing within-subject changes in outcomes from pretest over 6-month follow-up. METHODS: Young women with T1D aged 16-35 years were invited to participate in Diabetes Body Project groups. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks). Primary outcome measures included ED risk factors and symptoms, and secondary outcomes included three T1D-specific constructs previously found to be associated with ED pathology: glycemic control as measured by HbA1c level, diabetes distress, and illness perceptions. RESULTS: Within-subject reductions, with medium-to-large effect sizes, were observed for the primary (ED pathology, body dissatisfaction, thin-ideal internalization, and appearance ideals and pressures) and secondary outcomes (within-condition Cohen's ds ranged from .34 to 1.70). CONCLUSION: The virtual Diabetes Body Project appears to be a promising intervention worthy of more rigorous evaluation. A randomized controlled trial with at least a 1-year follow-up is warranted to determine its efficacy compared to a control condition.

Evaluating whether a peer-led dissonance-based eating disorder prevention program prevents onset of each eating disorder type.

BACKGROUND: This study tested whether the dissonance-based Body Project eating disorder prevention program reduced onset of subthreshold/threshold anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and purging disorder (PD) over long-term follow-up. METHODS: Data were combined from three prevention trials that targeted young women at high-risk for eating disorders (N = 1092; M age = 19.3). Participants were randomized to Body Project groups led by peer educators or expressive writing/educational controls and completed masked diagnostic interviews over 2- to 4-year follow-ups. Logistic regressions tested whether onset of each eating disorder over follow-up differed between Body Project and control participants. RESULTS: Peer-led Body Project groups produced a 46% reduction in onset of subthreshold/threshold BN and a 62% reduction in onset of PD relative to controls over follow-up. Rates of onset of subthreshold/threshold AN and BED did not significantly differ between peer-led Body Project participants and control participants. CONCLUSIONS: Results support the dissemination of the peer-led Body Project for reducing future onset of BN and PD. This study and recent research suggest that thin-ideal internalization, the risk factor for eating disorders targeted in the Body Project, may be more relevant for predicting onset of BN and PD compared to AN and BED. Findings support the development of a version of the Body Project aimed to reduce risk factors that have predicted future onset of all four types of eating disorders (e.g. overvaluation of weight/shape, fear of weight gain), which may more effectively prevent all eating disorder types.

A broad range: From simple and brief to intensive single-session interventions: Commentary on Schleider et al. (2023).

To push research and treatment in the field of eating disorders (EDs) forward, we need to not only systematically develop our current knowledge and skills through established procedures for research and clinical practice, but also make room for disruptive innovations and thinking out of the box. The paper by Schleider et al. (2023, International Journal of Eating Disorders) provides a thoughtful invitation to think differently by considering single-session interventions (SSI) for prevention and treatment of EDs. Beyond expanding our intervention tools, SSI may force us to think more mechanistically about the processes of change, and about the format and delivery of our interventions, both for EDs and from a transdiagnostic perspective. In this commentary, we reflect on the possible benefits and implications of SSI, and the necessity of mechanistically driven and rigorous empirical research for developing efficacious SSI.

The cost-effectiveness of a virtual intervention to prevent eating disorders in young women in Sweden.

OBJECTIVE: To determine the cost-effectiveness of a virtual version of the Body Project (vBP), a cognitive dissonance-based program, to prevent eating disorders (ED) among young women with a subjective sense of body dissatisfaction in the Swedish context. METHOD: A decision tree combined with a Markov model was developed to estimate the cost-effectiveness of the vBP in a clinical trial population of 149 young women (mean age 17 years) with body image concerns. Treatment effect was modeled using data from a trial investigating the effects of vBP compared to expressive writing (EW) and a do-nothing alternative. Population characteristics and intervention costs were sourced from the trial. Other parameters, including utilities, treatment costs for ED, and mortality were sourced from the literature. The model predicted the costs and quality-adjusted life years (QALYs) related to the prevention of incidence of ED in the modeled population until they reached 25 years of age. The study used both a cost-utility and return on investment (ROI) framework. RESULTS: In total, vBP yielded lower costs and larger QALYs than the alternatives. The ROI analysis denoted a return of US $152 for every USD invested in vBP over 8 years against the do-nothing alternative and US $105 against EW. DISCUSSION: vBP is likely to be cost-effective compared to both EW and a do-nothing alternative. The ROI from vBP is substantial and could be attractive information for decision makers for implementation of this intervention for young females at risk of developing ED. PUBLIC SIGNIFICANCE: This study estimates that the vBP is cost-effective for the prevention of eating disorders among young women in the Swedish setting, and thus is a good investment of public resources.

Development of competence in cognitive behavioural therapy and the role of metacognition among clinical psychology and psychotherapy students.

BACKGROUND: There is a paucity of research on therapist competence development following extensive training in cognitive behavioural therapy (CBT). In addition, metacognitive ability (the knowledge and regulation of one's cognitive processes) has been associated with learning in various domains but its role in learning CBT is unknown. AIMS: To investigate to what extent psychology and psychotherapy students acquired competence in CBT following extensive training, and the role of metacognition. METHOD: CBT competence and metacognitive activity were assessed in 73 psychology and psychotherapy students before and after 1.5 years of CBT training, using role-plays with a standardised patient. RESULTS: Using linear mixed modelling, we found large improvements of CBT competence from pre- to post-assessment. At post-assessment, 72% performed above the competence threshold (36 points on the Cognitive Therapy Scale-Revised). Higher competence was correlated with lower accuracy in self-assessment, a measure of metacognitive ability. The more competent therapists tended to under-estimate their performance, while less competent therapists made more accurate self-assessments. Metacognitive activity did not predict CBT competence development. Participant characteristics (e.g. age, clinical experience) did not moderate competence development. CONCLUSIONS: Competence improved over time and most students performed over the threshold post-assessment. The more competent therapists tended to under-rate their competence. In contrast to what has been found in other learning domains, metacognitive ability was not associated with competence development in our study. Hence, metacognition and competence may be unrelated in CBT or perhaps other methods are required to measure metacognition.

School-based self-harm prevention programs: A systematic review with implications for international implementation.

Both self-harm and suicidal behaviors have been targeted through school-based prevention programs, many of which have been developed in the United States. The aims of this systematic review were to assess effects of school-based prevention programs on suicide and self-harm and to evaluate whether they are fit to the exporting culture. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our inclusion criteria, structured according to population/problem, intervention, control/comparison, outome, were: children and youth up to 19 years of age, school-based programs at universal, selective or indicated levels compared with teaching as usual or with other programs, and outcomes of suicide or self-harm measured at least 10 weeks after intervention. Studies without a control group or using non-behavioral outcomes were excluded. A comprehensive and systematic literature search was conducted from the 1990s to March 2022. Risk for bias was assessed with checklists adapted from the Cochrane Risk of Bias (ROB) tool. A total of 1,801 abstracts were retrieved. Five studies fulfilled our inclusion criteria, but one had high risk for bias. Confidence in the evidence for effect was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Studies included in this review were evaluated with respect to applicability in the context of international export. Only two school-based programs demonstrated efficacy in preventing suicidal behaviors. Although implementation of evidence-based interventions is a crucial next step, further replication with simultaneous attention to dissemination and implementation issues are called for. Funding and registration: conducted on assignment by the Swedish government. The protocol is available at the SBU website in Swedish.

Swedish parents' satisfaction and experience of facilitators and barriers with Family Check-up: A mixed methods study.

Family Check-up (FCU) was introduced in Sweden more than a decade ago. Little is known about what parents experience as FCU's key mechanisms leading to changes in parenting. The aim of this study was to investigate Swedish parents' satisfaction with FCU, and their experiences of facilitators and barriers for making changes in their parenting. A mixed methods approach was employed using a parent satisfaction questionnaire (n = 77) and focus groups (n = 15). General satisfaction with FCU was adequate, with an average rating of 4 on a five-point scale (range 3.1-4.6). The analysis of quantitative and qualitative data resulted in eight themes representing facilitators and four themes representing barriers, organized into three categories: (1) access and engagement; (2) therapeutic process; and (3) program components. Ease of access to FCU facilitated initial engagement. Individual tailoring and access to FCU during different phases of change facilitated sustained engagement and change. Therapeutic process facilitators were a meaningful, supportive relationship with the provider, psychological benefits for parents and benefits for the whole family. Program components that facilitated change in parenting were new learning of parenting strategies and use of helpful techniques such as videotaping and home practice. Negative experiences with service systems prior to starting FCU, parent psychological barriers, and parent-provider mismatch were described as potential barriers. Some parents desired other program formats that were not offered, and some felt that new learning was insufficient to improve child behavior. Understanding the parent perspective can contribute to successful future work with implementing FCU.

A European perspective on "clean eating": Commentary on Negowetti et al. (2021).

Negowetti et al. (2021) have provided insightful perspectives on the public health implications of the labeling of "clean" dietary products in the United States through a scoping review, along with feasible strategies to counteract the risks of this trend. Although the European Union has already fairly strict regulations about declaration of ingredients and health claims regarding food that makes it almost impossible to label food products as "clean," the clean eating trend is alive and expanding in Europe, and usage of expressions such as "clean" or "pure" in other ways than on the label may convey similar messages that cannot be regulated by law. Increased regulation, legislation, and information through the U.S. Food and Drug Administration as suggested by Negowetti et al. (2021) is a welcome contribution and will certainly help to prevent some misinformation. However, labels are just one battle field in addressing misleading expressions and trends. Scientists should enter the relevant fields (e.g., Internet, TV, and social media) to a higher extent and provide solid, pedagogical and simple facts, and guidelines to vaccinate people against current and upcoming misleading dietary trends.

Anonymous Online Survey on Disordered Eating, Drive for Muscularity, Sexual Orientation, and Satisfaction with Life in Young Swedish Males.

Psychiatric conditions in general, including eating disorders, are stigmatizing conditions. The stigma of eating disorders is even more pronounced among males. We conducted an anonymous, online survey to explore the feasibility of recruiting participants for collecting sensitive information, and the relation among eating disorders, drive for muscularity, satisfaction with life, and sexual preference in males (N = 824) aged 15-30 years in Sweden. Internet survey method was a feasible way of recruiting males and obtaining sensitive information. Drive for muscularity was positively related to eating psychopathology. Interestingly, only the attitudinal aspect of the drive for muscularity was negatively related to satisfaction with life, whereas the behavioral component of the drive for muscularity was unrelated to quality of life. Drive for muscularity and disordered eating were not significantly different across participants with various sexual orientations. Our findings corroborate and extend previous research by using an anonymous Internet-based survey that may be less contaminated by social desirability or reporting bias due to the sensitivity of some of the questions.

Integrating motivational interviewing with cognitive behavioural therapy for anxiety disorders, depression and co-morbid unhealthy lifestyle behaviours: a randomised controlled pilot trial.

BACKGROUND: A substantial proportion of patients receiving cognitive behavioural therapy (CBT) do not achieve remission, and drop-out is considerable. Motivational interviewing (MI) may influence non-response and drop-out. Previous research shows that MI as a pre-treatment to CBT produces moderate effects compared with CBT alone. Studies integrating MI with CBT (MI-CBT) are scarce. AIMS: To test the feasibility of MI-CBT in terms of therapist competence in MI and various participant measures, including recruitment and retention. In addition, separate preliminary evaluations were conducted, exploring the effects of CBT alone for anxiety disorders and depression, and of MI-CBT for anxiety disorders, depression and unhealthy lifestyle behaviours. METHOD: Using a randomised controlled parallel trial design, participants were recruited in routine psychiatric care and allocated to CBT alone or MI-CBT. Means in feasibility measures and within-condition Hedges' g effect sizes in treatment outcome measures were calculated. Authors were not blind to treatment allocation, while independent raters were blind. RESULTS: Seventy-three patients were assessed for eligibility, and 49 were included. Participant perceptions of treatment credibility, expectancy for improvement, and working alliance were similar for both conditions. Overall, effect sizes were large across outcome measures for both conditions, including anxiety and depressive symptoms and functional impairment. However, therapists did not acquire sufficient competence in MI and the drop-out rate was high. CONCLUSIONS: MI-CBT proved feasible in some respects, but the present study did not support the progression to a randomised controlled trial designed to assess the effectiveness of MI-CBT. Additional pilot studies are needed.

Feasibility of a virtually delivered eating disorder prevention program for young females with type 1 diabetes.

OBJECTIVE: This study aimed to develop a virtual diabetes-specific version of the eating disorder (ED) prevention program the Body Project, and to assess feasibility and preliminary efficacy of this program for young females with type 1 diabetes. METHOD: Young females with type 1 diabetes aged 16-35 years were invited to participate in the study. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks) and completed pretest assessments; 26 participants completed all sessions and posttest assessments (<7 days after last meeting). Primary measures included ED risk factors and symptoms, and secondary outcomes included diabetes-specific constructs previously found to be associated with ED psychopathology (e.g., diabetes distress and illness perceptions). RESULTS: The ease of recruitment, timely conduct of five groups, moderate drop-out rate and appreciation of the intervention by participants indicated that the Diabetes Body Project is feasible. Meaningful reductions occurred on the primary outcomes (i.e., ED psychopathology, body dissatisfaction, and thin ideal internalization) and on internalization of appearance ideals and appearance pressures at posttest (Cohen's d ranging from .63 to .83, which are medium to large effects). Small to medium effect sizes were found for diabetes illness perceptions and distress (.41 and .48, respectively). DISCUSSION: The virtual Diabetes Body Project is a promising and much-needed intervention, worthy of more rigorous evaluation. A randomized controlled trial is warranted to determine its effectiveness compared with a control condition.

A pilot study of the impact of an integrated individual- and family therapy model for self-harming adolescents on overall healthcare consumption.

BACKGROUND: Self-harming behaviors in adolescents cause great suffering and can lead to considerable costs to the healthcare system. The aim of the current study was to investigate the cost of an integrated individual and family therapy (Intensive Contextual Treatment: ICT) and to compare the adolescent's healthcare consumption 1 year before and 1 year after treatment. METHOD: The study had a within group design with repeated measures. The clinical outcomes and the cost of ICT treatment are based on a sample of 49 participants who were previously enrolled in an intervention trial. Participants with significantly improved clinical outcomes (self-harm behavior, or general mental health symptoms) were defined as treatment responders. Calculation of changes in healthcare consumption is based on 25 participants who gave their consent to participate in a retrospective collection of healthcare data from medical records, including inpatient and outpatient care, and prescribed medication. RESULTS: The average estimated cost of ICT per person was €5293. There were no significant differences between the cost of healthcare consumption 1 year before and after ICT, but the results suggested that the adolescents consumed less inpatient and specialized care after treatment. There was a significantly higher cost of psychotropic medication after treatment explained by a higher consumption of central stimulants. Treatment responders (general mental health problems) reduced their consumption of healthcare resources significantly more than non-responders, especially regarding hospital visits and total health care costs. CONCLUSIONS: Good response to the ICT in terms of improved general mental health symptoms seems to be associated with reduced healthcare consumption during the post-treatment period. However, controlled studies with larger sample sizes are needed to draw causal conclusions. The results of this study should be interpreted with caution as it is based on a small sample and attrition rate was high. TRIAL REGISTRATION: This study has been registered with the ISRCTN: 15885573 .

Effects of the PRIMROSE prevention trial of childhood obesity on parental self-efficacy.

BACKGROUND: Parental self-efficacy (PSE) has been suggested as a key factor for enabling parents to support children in the development of healthy dietary and physical activity behaviors and to prevent childhood obesity. However, studies of intervention effects on PSE are lacking. The present study involved a secondary analysis of data on PSE collected in a previous primary prevention trial of childhood obesity called the PRIMROSE trial. The trial involved a family-based intervention using motivational interviewing and principles of cognitive-behavioral therapy within a social-cognitive theory framework. METHODS: In the PRIMROSE trial, parents and their children were randomly allocated to the intervention or usual care. In the present study, 928 mothers who responded to the Parental Self-Efficacy for Promoting Healthy Physical Activity and Dietary Behaviors in Children Scale (PSEPAD) at follow-up assessment were included. Data were analyzed using linear regression based on generalized estimating equations, with adjustment made for PSE at baseline. RESULTS: At follow-up assessment, there was a statistically significant difference of 1.4 units, 95% CI [0.4, 2.4], p = 0.009, between the intervention and control conditions on the subscale of the PSEPAD concerning PSE for promoting healthy dietary behaviors in children. However, this difference was deemed as without clinical importance. On the total scale or other subscales of the PSEPAD there were no statistically significant differences in PSE between conditions. CONCLUSIONS: There was a statistically significant, but not clinically meaningful, intervention effect on PSE. However, because previous research repeatedly has shown positive associations of PSE with dietary and physical activity behaviors in children and that self-efficacy mediates behaviors, the construct may be important for influencing dietary and physical behaviors in children. Therefore, more research is warranted evaluating the effects of interventions on PSE in the context of childhood obesity prevention. TRIAL REGISTRATION: Retrospectively registered 9 October 2013 at ISRCTN (ISRCTN16991919 ).

Psychometric properties of the Eating Disorder Symptom List (EDSL), a brief questionnaire for weekly assessment of eating disorder symptoms.

Frequent assessment of eating disorder (ED) symptoms (e.g., on a weekly basis) may guide treatment planning in clinical services, and be an invaluable tool for improving clinical research. The aim of the present study was to evaluate the psychometric properties of a brief eight-item scale designed to assess ED behaviors during the preceding week (Eating Disorder Symptom List: EDSL). Cross-sectional data were collected in a non-clinical community sample (n = 406) and cross-sectional and longitudinal data were gathered in a clinical ED sample before and after treatment with Enhanced Cognitive Behavior Therapy for eating disorders (n = 47) and weekly during treatment with Radically Open Dialectical Behavior Therapy (n = 13). The EDSL showed acceptable to good internal consistency (α = 0.72-0.82) and test-retest reliability (r = 0.88). Convergent and divergent validity was satisfactory. Also, the EDSL was sensitive to change and could detect changes between before and after treatment, as well as on a weekly basis. We conclude that the EDSL is a brief scale entailing little patient burden, and that initial analyses of the scale provide preliminary evidence of satisfactory psychometric properties. The scale can be used for repeated measures in ED treatment studies and clinics to assess change or absence of change during treatment.

Two randomized controlled trials of the efficacy of acceptance and commitment therapy-based educational course for body shape dissatisfaction.

The main aim of this project was to explore the efficacy of Acceptance and Commitment Therapy (ACT)-based educational course in different formats (i.e., pure and guided self-help with different durations, and guided self-help with and without access to a discussion forum) for body shape dissatisfaction. Two randomized controlled studies (RCT) were carried out. In the first RCT, the participants were randomized to a 12- or 16-week guided self-help, a 16-week pure self-help, or a waitlist control condition. In the second RCT, the efficacy of 12-week guided self-help with or without access to a discussion forum was investigated. ACT-based self-help resulted in promising improvements in body shape dissatisfaction, and modest effects on general health indicators (i.e., symptom of depression, self-esteem, satisfaction with life, and quality of life). The findings also showed no additional effects of support, access to the online discussion forum, and longer duration of self-help, suggesting the 12-week self-help with or without support is a viable option for reducing body shape dissatisfaction.

Study protocol of comprehensive risk evaluation for anorexia nervosa in twins (CREAT): a study of discordant monozygotic twins with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a severe disorder, for which genetic evidence suggests psychiatric as well as metabolic origins. AN has high somatic and psychiatric comorbidities, broad impact on quality of life, and elevated mortality. Risk factor studies of AN have focused on differences between acutely ill and recovered individuals. Such comparisons often yield ambiguous conclusions, as alterations could reflect different effects depending on the comparison. Whereas differences found in acutely ill patients could reflect state effects that are due to acute starvation or acute disease-specific factors, they could also reflect underlying traits. Observations in recovered individuals could reflect either an underlying trait or a "scar" due to lasting effects of sustained undernutrition and illness. The co-twin control design (i.e., monozygotic [MZ] twins who are discordant for AN and MZ concordant control twin pairs) affords at least partial disambiguation of these effects. METHODS: Comprehensive Risk Evaluation for Anorexia nervosa in Twins (CREAT) will be the largest and most comprehensive investigation of twins who are discordant for AN to date. CREAT utilizes a co-twin control design that includes endocrinological, neurocognitive, neuroimaging, genomic, and multi-omic approaches coupled with an experimental component that explores the impact of an overnight fast on most measured parameters. DISCUSSION: The multimodal longitudinal twin assessment of the CREAT study will help to disambiguate state, trait, and "scar" effects, and thereby enable a deeper understanding of the contribution of genetics, epigenetics, cognitive functions, brain structure and function, metabolism, endocrinology, microbiology, and immunology to the etiology and maintenance of AN.

Dimension-specific symptom patterns in trajectories of broad anxiety: A longitudinal prospective study in school-aged children.

Theories of maladaptive anxiety in children have suggested different developmental trajectories across age. Weems (2008) suggested that one subgroup of children demonstrates high and stable levels of broad anxiety, but shifting levels of dimension-specific symptoms in part due to related normative challenges. In a prospective longitudinal design, the current study examined patterns of dimension-specific anxiety symptoms in subgroups of children following different developmental trajectories of broad anxiety. A total of 300 children (150 girls, 150 boys) ages 8-11 at baseline, completed the Spence Children's Anxiety Scale four times over 3 years. Using latent class growth mixture modeling, we found evidence of three subgroups of children following different trajectories of broad anxiety across age: low-stable, moderate-increasing, and high-decreasing. Compared with other children, the subgroup with moderate and increasing levels of broad anxiety demonstrated an initially higher level of separation anxiety with larger improvement across time but, initially, similar levels of generalized and social anxiety with a larger increase across age. High broad anxiety was partly carried by different sets of dimension-specific symptoms at different ages, which suggests that children with high levels of broad anxiety across time may be more sensitive to normative challenges that happen in typical child development.

Providing objective feedback in supervision in motivational interviewing: results from a randomized controlled trial.

BACKGROUND: The effects of the use of objective feedback in supervision on the supervisory relationship and skill acquisition is unknown. AIMS: The objective of this study was to evaluate the effects of two different types of objective feedback provided during supervision in motivational interviewing (MI) on: (a) the supervisory relationship, including potential feelings of discomfort/distress, provoked by the supervision sessions, and (b) the supervisees' skill acquisition. METHOD: Data were obtained from a MI dissemination study conducted in five county councils across five county councils across Sweden. All 98 practitioners recorded sessions with standardized clients and were randomized to either systematic feedback based on only the behavioral component of a feedback protocol, or systematic feedback based on the entire protocol. RESULTS: The two different ways to provide objective feedback did not negatively affect the supervisory relationship, or provoke discomfort/distress among the supervisees, and the group that received the behavioural component of the feedback protocol performed better on only two of the seven skill measures. CONCLUSIONS: Objective feedback does not seem to negatively affect either the supervisor-supervisee working alliance or the supervisees' supervision experience. The observed differences in MI skill acquisition were small, and constructive replications are needed to ascertain the mode and complexity of feedback that optimizes practitioners' learning, while minimizing the sense of discomfort and distress.