Group schema therapy versus group cognitive behavioral therapy for patients with social anxiety disorder and comorbid avoidant personality disorder: A randomized controlled trial.

BACKGROUND: Patients with social anxiety (SAD) and comorbid avoidant personality disorder (AVPD) are severely impaired. Group cognitive behavioral therapy (GCBT) is considered an effective treatment for SAD. More knowledge on treatment of SAD with comorbid AVPD is needed. Schema therapy, developed for personality and chronic mental disorders, may be a promising treatment. METHODS: We conducted a randomized controlled trial in an outpatient population (n = 154) with both SAD and AVPD. Group Schema Therapy (GST) and GCBT were compared on SAD symptoms (Liebowitz Social Anxiety Scale) and manifestations of AVPD (Avoidant Personality Disorder Severity Index). RESULTS: Intention-to-treat analysis showed no significant differences between treatments at 3 months post-treatment and one-year follow-up. Both modalities led to significant and substantial improvements. No significant between-differences were found in depressive symptoms (Inventory of Depressive Symptoms) and quality of life (World Health Organization Quality of Life-BREF). Per-protocol analysis showed similar outcomes and no significant differences in recovery from SAD and AVPD. Significantly more patients completed GST. CONCLUSION: GST and GCBT are valuable treatments for SAD with comorbid AVPD. The higher treatment retention in ST indicates ST is more acceptable than GCBT. Future studies should focus on enhancing treatment effects and improving retention to GCBT.

Goal-Directed Treatment of Patients With Anxiety and Mood Disorders in a Regular Curative Mental Health Care Setting.

This study examined whether goal-directed treatment leads to improved treatment outcomes for patients with a primary mood or anxiety disorder and whether beneficial outcomes are achieved sooner compared to treatment as usual. In a quasi-experimental controlled study with a nested design, 17 therapists received training in goal-directed treatment and treated 105 patients with anxiety or mood disorders using principles of goal-directed treatment. Treatment results on a generic self-report instrument were compared with two control groups: a historical control group consisting of 16 of the 17 participating therapists, who provided treatment as usual to 97 patients before having received training in goal-directed treatment, and a parallel control group consisting of various therapists, who provided treatment as usual to 105 patients. Symptom reduction on a self-report measure was compared using multilevel analysis. A survival analysis was performed to assess whether a satisfactory end state had been reached sooner after goal-directed treatment. The results of this study show that goal-directed treatment only led to a significantly better overall treatment outcome compared to the parallel treatment as usual group. Furthermore, goal-directed treatment was significantly shorter than both treatment as usual groups. In conclusion, this research suggest that goal-directed treatment led to a similar or better treatment outcome in a shorter amount of time.

Fidelity and Clinical Competence in Providing Illness Management and Recovery: An Explorative Study.

Illness Management and Recovery (IMR) is a psychosocial intervention supporting people with serious mental illnesses. In this study, 15 IMR groups were assessed for fidelity and clinician competency to establish the implementation level of all IMR elements and explore complementarity of the IMR Treatment Integrity Scale (IT-IS) to the standard IMR Fidelity Scale. Use of the IT-IS was adapted, similar to the IMR Fidelity Scale. Descriptive statistics were applied. Implementation success of IMR elements varied widely on the IMR Fidelity Scale and IT-IS (M = 3.94, SD = 1.13, and M = 3.29, SD = 1.05, respectively). Twelve IMR elements (60%) were well-implemented, whereas eight (40%) were implemented insufficiently, including some critical cognitive-behavioral techniques (e.g., role-playing). The scales appeared largely complementary, though strongly correlated (r (13) = 0.74, p = 0.002). Providing all IMR elements adequately requires a variety of clinical skills. Specific additional training and supervision may be necessary.

Adding EMDR for PTSD at the onset of treatment of borderline personality disorder: A pilot study.

BACKGROUND AND OBJECTIVES: Eye movement desensitization and reprocessing (EMDR) is an effective treatment for individuals suffering from posttraumatic stress disorder (PTSD). However, EMDR is not typically offered to people with PTSD who also meet the criteria for borderline personality disorder (BPD). This study examines the feasibility and clinical benefits of EMDR for PTSD delivered in addition to the onset of treatment as usual (TAU) for BPD. METHODS: In a non-concurrent, multiple baseline design, 12 patients with BPD and PTSD received fifteen weekly 45-min sessions of TAU. During this period, eight weekly 90-min EMDR sessions were added. Outcome measures were obtained weekly for self-reported PTSD symptoms (PTSD checklist for DSM-5), levels of psychopathology (Brief Symptom Checklist), and the effect of psychopathology on different areas of life (Sheehan Disability Scale). RESULTS: 9 participants completed the treatment protocol. In the EMDR phase, PTSD severity scores decreased significantly between sessions, while no between-session drop in scores occurred during the TAU only phase. Similar results were obtained for general symptoms and disability. No adverse events were reported. LIMITATIONS: Results on the efficacy and safety of EMDR in patients with BPD and PTSD need to be replicated in larger samples and in RCTs before they can be generalized to the entire population. CONCLUSIONS: The results of our study suggest that EMDR may be feasible and effective in reducing PTSD symptoms in patients concurrently receiving BPD treatment. EMDR appears to be a promising intervention for patients with BPD and comorbid PTSD.

Schema therapy for personality disorders in autistic adults: Results of a multiple case series study.

BACKGROUND: To our knowledge, treatment of personality disorder (PD) comorbidity in autistic adults is understudied and is still in its infancy. We investigated the effectiveness of schema therapy (ST) for autistic adults with PD. METHOD: A multiple case series design with 12 adults (aged 19-62 years) was used with baseline, exploration, ST (with cognitive behavioural and experiential techniques) and follow-up conditions. Participants rated dysfunctional core beliefs (primary outcome) weekly during baseline and treatment and monthly during follow-up. Schema modes, general mental health symptoms, social responsiveness, PD traits and common Axis-I mental disorders were assessed. RESULTS: Mixed model analyses indicated significant effects of ST with medium to large effect sizes for dysfunctional core beliefs, functional schema modes, PD traits, general mental health symptoms and social responsiveness. Results remained stable during follow-up. CONCLUSION: The results of this study indicate that ST might be effective in decreasing dysfunctional core beliefs, PD traits and general mental health symptoms and in increasing functional schema modes and social responsiveness. Improvements persisted over time. ST seems effective in treating PD in autistic individuals.

Three- and five-year follow-up results of a randomized controlled trial on the effects of cognitive behavioral therapy before bariatric surgery.

OBJECTIVE: Up to 37% of bariatric surgery patients suffer from insufficient weight loss or weight regain and mental health symptoms in the longer term. Cognitive behavioral therapy (CBT) may be an effective adjunct intervention to optimize patients' psychological functioning and weight loss results. To examine the value of adding preoperative CBT to bariatric surgery, three- and five-year follow-up data are presented. METHOD: In this multi-center randomized controlled trial (RCT; N = 130), a CBT group was compared to a treatment-as-usual (TAU) control group. Measurements were conducted at five time points: pretreatment (T0) and posttreatment/presurgery (T1) and at one- (T2; N = 120), three- (T3; N = 117), and five-year postsurgery (T4; N = 115). The intervention group received a 10-weeks, individual, preoperative CBT focused on self-monitoring, identifying triggers for disordered eating and goal setting for eating behavior and physical exercise, as well as postoperative lifestyle. Outcome measures included weight change, eating behavior, eating disorders, depression, quality of life (QoL), and overall psychological health. RESULTS: Preoperative CBT was not associated with better three- and five-year results than TAU regarding weight, dysfunctional eating behaviors, eating disorders, depression, overall psychological health, and QoL. DISCUSSION: Contrary to our hypothesis, three- and five-year postsurgery differences between groups regarding weight change and mental health were not significant.. Further exploration suggested that in both groups weight problems and depressive symptoms worsened at three and five-year follow-up. Future research should focus on long-term postoperative monitoring of weight and mood and on associated postoperative interventions and their specific timing. PUBLIC SIGNIFICANCE: After bariatric surgery, in the longer term weight problems re-occur in 30% of patients, which is probably partly related to psychopathology. We investigated whether cognitive behavior therapy (CBT) prior to bariatric surgery improved weight maintenance and mental health after surgery. Our study provided definite proof that preoperative CBT is not effective. Long-term postoperative monitoring and prompt psychological intervention after first signs of deterioration, are important to prevent further problems.

Characteristics and stability of hallucinations and delusions in patients with borderline personality disorder.

BACKGROUND: Psychotic features have been part of the description of the borderline personality disorder (BPD) ever since the concept "borderline" was introduced. However, there is still much to learn about the presence and characteristics of delusions and about the stability of both hallucinations and delusions in patients with BPD. METHODS: A follow-up study was conducted in 326 BPD outpatients (median time between baseline and follow-up = 3.16 years). Data were collected via telephone (n = 267) and face-to-face interviews (n = 60) including the Comprehensive Assessment of Symptoms and History interview, Positive And Negative Syndrome Scale and the Psychotic Symptom Rating Scale. RESULTS: The point prevalence of delusions was 26%, with a median strong delusion conviction. For the group as a whole, the presence and severity of both hallucinations and delusions was found to be stable at follow-up. Participants with persistent hallucinations experienced more comorbid psychiatric disorders, and they differed from those with intermittent or sporadic hallucinations with their hallucinations being characterized by a higher frequency, causing a higher intensity of distress and more disruption in daytime or social activities. CONCLUSIONS: Delusions in patients with BPD occur frequently and cause distress. Contrary to tenacious beliefs, hallucinations and delusions in participants with BPD are often present in an intermittent or persistent pattern. Persistent hallucinations can be severe, causing disruption of life. Overall, we advise to refrain from terms such as "pseudo", or assume transience when encountering psychotic phenomena in patients with BPD, but rather to carefully assess these experiences and initiate a tailor-made treatment plan.

First Psychometric Properties of the Dutch Interview for Diagnostic Assessment of Autism Spectrum Disorder in Adult Males Without Intellectual Disability.

For autism spectrum disorder (ASD) in adults there are several diagnostic instruments available with a need for consideration of the psychometric properties. This study aimed to conduct a first psychometric evaluation of a new diagnostic ASD instrument, the NIDA (Dutch Interview for Diagnostic assessment of ASD in adults) in 90 adult males without intellectual disability (age 18-65 years) in the Netherlands: 30 with ASD, 30 with a Personality Disorder and 30 nonpatient controls. The interrater agreement ranged from 0.79 to 1.00, the convergent validity including sensitivity and specificity ranged from 0.76 to 1.00, and we observed an adequate concurrent criterion-related validity. These promising findings can serve as foundation for future psychometric NIDA studies in a more diverse population. TRIAL REGISTRATION: The Netherlands National Trial Register NTR6391. Registered 04 May 2017.

Effects of Illness Management and Recovery: A Multicenter Randomized Controlled Trial.

There have been inconsistent findings in the literature with respect to the efficacy of Illness Management and Recovery (IMR) in the psychosocial treatment of people with schizophrenia or other severe mental illnesses. This study aimed to comprehensively investigate the effectiveness of IMR, including the impact of completion and fidelity. In this randomized controlled trial (RCT), 187 outpatients received either IMR plus care as usual (CAU) or only CAU. Multilevel modeling was implemented to investigate group differences over an 18-month period, comprising 12 months of treatment and six months of follow-up. The primary outcome was overall illness management, which was assessed using the client version of the IMR scale. Secondary outcomes included measures regarding illness management, clinical, personal, and functional recovery, and hospitalizations. The interviewers were blinded to group allocation. This clinical trial was registered with the Netherlands Trial Register (NL4931, NTR5033). Patients who received IMR showed statistically significant improvement in self-reported overall illness management (the primary outcome). Moreover, they showed an improvement in self-esteem, which is a component of personal recovery. There were no effects within the other questionnaires. There were also no statistically significant between-group differences in terms of hospitalizations. Patients in both groups showed statistically significant improvement in clinician-rated overall illness management, social support, clinical and functional recovery, and self-stigma over time. IMR completion was associated with stronger effects. High IMR fidelity was associated with self-esteem. This study confirms the efficacy of IMR in overall illness self-management. To our knowledge, this is the first RCT on IMR to explore the impact of fidelity on treatment efficacy. Future studies should further establish efficacy in personal recovery. To improve efficacy, it appears important to promote IMR completion and fidelity.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care.

OBJECTIVE: The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care. METHODS: Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models. RESULTS: Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders. CONCLUSIONS: Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Seclusion in an enriched environment versus seclusion as usual: A quasi-experimental study using mixed methods.

BACKGROUND: For patients, seclusion during psychiatric treatment is often a traumatic experience. To prevent such experiences, adjustments in the design of seclusion rooms have been recommended. METHODS: As there have been no empirical studies on the matter, we used a quasi-experimental design to compare the experiences in seclusion of two groups of patients: 26 who had been secluded in a room designed according to the principles of healing environment, a so called 'Enriched Environment Seclusion room' (EES), and 27 who had been secluded in a regular seclusion (RS) room. The enrichment included audio-visual facilities, a fixed toilet, a couch and a self-service system to adjust light, colour, blinds and temperature according to the patient's preferences. Insight into their experiences was obtained using the Patient View-of-Seclusion Questionnaire, which comprises nine statements on seclusion, supplemented with open-ended questions. RESULTS: The responses regarding seclusion experiences between the two groups did not differ significantly (U = 280.00, p = .21, r = -.17). Although those who had been secluded in the specially designed room had greatly appreciated the opportunities for distraction, and those who had been secluded in a regular seclusion room expressed the need for more distracting activities during seclusion, both groups described seclusion as a dreadful experience. If seclusion cannot be avoided, patients recommend facilities for distraction (such as those provided in an enriched environment seclusion room) to be available. CONCLUSION: Whatever the physical environment and facilities of a seclusion room, we may thus conclude that seclusion is a burdensome experience.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care.

OBJECTIVE: The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care. METHODS: Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models. RESULTS: Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders. CONCLUSIONS: Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Intervention to prevent and manage the effects of victimization related to social participation for people with severe mental illness: Results from a cluster randomized controlled trial.

OBJECTIVE: Individuals with severe mental illness often face (anticipated) discrimination and (criminal) victimization, which have severe consequences for their social participation. The aim of the present study is to assess the effectiveness of a new intervention to manage and prevent revictimization, and to support safe participation by recognizing and acknowledging the impact of their victimization experiences. METHOD: A multicenter cluster randomized controlled trial was performed by following clients from four intervention teams and four teams providing care as usual. The primary outcomes were social participation, victimization, and discrimination. The secondary outcomes were acknowledgment of difficulties, self-efficacy and empowerment, quality of life, and psychosocial functioning. Data were collected at baseline, and after 10- and 20-month follow-ups. The data were analyzed according to the intention-to-treat principle using linear mixed models and generalized estimating equations. In total, 400 clients were included in the analyses: 216 in the intervention group and 184 in the control group. RESULTS: For experienced discrimination and acknowledgment of difficulties and recovery support, we found small but significant time by condition interactions after 20 months. Both experienced and anticipated discrimination, and self-efficacy increased slightly in both groups. No significant differences were found for other outcome measures. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The intervention had no effect on victimization and participation, but there were indications that it was successful in moderating experienced discrimination. The clients also felt significantly more acknowledged and supported in their recovery process. Further development of the intervention is needed, and future research should focus on improving implementation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Autism Spectrum Disorder Alertness in Dutch Youth and Family Center Physicians: Effects of a Live Online Educational Program.

We investigated the effect of a live online educational program in 93 Dutch Youth and Family Center (YFC) physicians who were screening for Autism Spectrum Disorder (ASD) in the general child population. The educational program raised the physicians' level of specific ASD knowledge and it remained higher at six months follow-up (p < .01). Their self-confidence in detecting ASD was also higher and maintained at follow-up (p < .01). The educational program had no effect on the physicians' stigmatizing attitudes toward mental illness nor on the number of potential ASD referrals in children of 4-6 years of age. In conclusion, the online educational program on early detection of ASD has a six month long effect on YFC physicians' level of ASD knowledge and self-confidence.

Age at autism spectrum disorder diagnosis: A systematic review and meta-analysis from 2012 to 2019.

LAY ABSTRACT: We currently assume that the global mean age at diagnosis of autism spectrum disorder ranges from 38 to 120 months. However, this range is based on studies from 1991 to 2012 and measures have since been introduced to reduce the age at autism spectrum disorder diagnosis. We performed a systematic review and meta-analysis (statistical analysis that combines the results of multiple scientific studies) for studies published between 2012 and 2019 to evaluate the current age at autism spectrum disorder diagnosis. We included 56 studies that reported the age at diagnosis for 40 countries (containing 120,540 individuals with autism spectrum disorder). Results showed the current mean age at diagnosis to be 60.48 months (range: 30.90-234.57 months) and 43.18 months (range: 30.90-74.70 months) for studies that only included children aged ⩽10 years. Numerous factors that may influence age at diagnosis (e.g. type of autism spectrum disorder diagnosis, additional diagnoses and gender) were reported by 46 studies, often with conflicting or inconclusive results. Our study is the first to determine the global average age at autism spectrum disorder diagnosis from a meta-analysis. Although progress is being made in the earlier detection of autism spectrum disorder, it requires our constant attention.

Cognitive Behavioral Therapy Versus Usual Care Before Bariatric Surgery: One-Year Follow-Up Results of a Randomized Controlled Trial.

BACKGROUND: Although early results of bariatric surgery are beneficial for most patients, some patients regain weight later. Cognitive behavioral therapy (CBT) has been suggested as a way to improve patients' psychological health and maintaining weight loss in the longer term. The added value of preoperative CBT to bariatric surgery was examined. Pre- and posttreatment and 1-year follow-up data are presented. METHODS: In a multi-center randomized controlled trial, CBT was compared to a treatment-as-usual (TAU) control group. Measurements were conducted pre- and posttreatment/pre-surgery (T0 and T1) and at 1-year post-surgery (T2). Patients in the intervention group received 10 individual, weekly sessions of preoperative CBT focused on modifying thoughts and behaviors regarding eating behavior, physical exercise, and postoperative life style. Outcome measures included weight change, eating behavior, eating disorders, depression, quality of life, and overall psychological health. RESULTS: Though no significant differences between conditions were found per time point, in the CBT, condition scores on external eating, emotional eating, depressive symptoms, and psychological distress decreased significantly more over time between pre- (T0) and posttreatment (T1) pre-surgery compared to TAU. No significant time x condition differences were found at 1-year post-surgery (T2). CONCLUSIONS: Compared to TAU, preoperative CBT showed beneficial effects on eating behavior and psychological symptoms only from pretreatment to posttreatment/pre-surgery, but not from pre-surgery to 1-year post-surgery. Preoperative CBT does not seem to contribute to better long-term outcomes post-surgery. Recent studies suggest that the optimal time to initiate psychological treatment may be early in the postoperative period, before significant weight regain has occurred. TRIAL REGISTRATION: https://www.trialregister.nl Identifier: Trial NL3960.

Temperament in preadolescence is associated with weight and eating pathology in young adulthood.

OBJECTIVE: Few longitudinal studies have investigated the role of temperament traits on weight and eating problems thus far. We investigated whether temperament in preadolescence influences body weight and the development of eating pathology in adolescence and young adulthood. METHOD: This study used data from TRAILS (Tracking Adolescents' Individual Lives Survey), a Dutch community cohort study (N = 2,230) from preadolescence into adulthood. At age 11, the temperament dimensions negative affectivity and effortful control were measured with the Early Adolescent Temperament Questionnaire-Revised. Body mass index (BMI) was measured at all assessment waves. At age 19, the prevalence of eating disorders was investigated by two-stage screening including interviews by eating disorder experts. At age 22 and 26, the Eating Disorder Diagnostic Scale was used to assess the level of eating pathology. RESULTS: Higher negative affectivity in preadolescence was associated with higher BMI and eating pathology in young adulthood. Lower effortful control in preadolescence was found to be a risk factor for the development of obesity in young adulthood. No association was found between effortful control in preadolescence and eating pathology in later life. DISCUSSION: Both negative affectivity and effortful control play a role in the development of weight or eating problems during adolescence.

Novel Insights into Autism Knowledge and Stigmatizing Attitudes Toward Mental Illness in Dutch Youth and Family Center Physicians.

Professionals' limited knowledge on mental health and their stigmatizing attitudes toward mental illness can delay the diagnosis of autism. We evaluated the knowledge on Autism Spectrum Disorder (ASD) and stigmatizing attitudes in 93 physicians at Dutch Youth and Family Centers (YFC). These physicians screen for psychiatric symptoms in children. We show that their general ASD knowledge scored 7.1 (SD 1.2), but their specific ASD knowledge was only 5.7 (SD 1.7) (weighted means on 1-10 scale, 1 = least knowledge, 10 = most knowledge). Our physicians had positive attitudes toward mental illness (CAMI scores 2.18 (SD 0.33) to 2.22 (SD 0.40) on a 5-point Likert scale) but they had higher levels of stigmatizing attitudes than other Western healthcare professionals. Their levels were considerably lower than in non-Western professionals. We found no relations between ASD knowledge, stigmatizing attitudes and demographic variables. In conclusion, ASD knowledge and stigmatizing attitudes toward mental illness in Dutch YFC physicians require attention.

Effectiveness of enhanced cognitive behavior therapy for eating disorders: A randomized controlled trial.

OBJECTIVE: Enhanced cognitive behavior therapy (CBT-E) is a transdiagnostic treatment suitable for the full range of eating disorders (EDs). Although the effectiveness of CBT(-E) is clear, it is not being used as widely in clinical practice as guidelines recommend. The aim of the present study was to compare the effectiveness of CBT-E with treatment as usual (TAU), which was largely based on CBT principles. METHOD: We conducted a randomized controlled trial on a total of 143 adult patients with an ED who received either CBT-E or TAU. The primary outcome was recovery from the ED. Secondary outcome measures were levels of ED psychopathology, anxiety, and depressive symptoms. Self-esteem, perfectionism, and interpersonal problems were repeatedly measured to examine possible moderating effects. We explored differences in duration and intensity between conditions. RESULTS: After 80 weeks, there were no differences between conditions in decrease in ED psychopathology, or symptoms of anxiety and depression. However, in the first six weeks of treatment there was a larger decrease in ED psychopathology in the CBT-E condition. Moreover, when the internationally most widely used definition of recovery was applied, the recovery rate at 20 weeks of CBT-E was significantly higher (57.7%) than of TAU (36.0%). At 80 weeks, this difference was no longer significant (CBT-E 60.9%; TAU 43.6%). Furthermore, CBT-E was more effective in improving self-esteem and was also the less intensive and shorter treatment. DISCUSSION: With broader use of CBT-E, the efficiency, accessibility and effectivity (on self-esteem) of treatment for EDs could be improved.

ClusterBootstrap: An R package for the analysis of hierarchical data using generalized linear models with the cluster bootstrap.

In the analysis of clustered or hierarchical data, a variety of statistical techniques can be applied. Most of these techniques have assumptions that are crucial to the validity of their outcome. Mixed models rely on the correct specification of the random effects structure. Generalized estimating equations are most efficient when the working correlation form is chosen correctly and are not feasible when the within-subject variable is non-factorial. Assumptions and limitations of another common approach, ANOVA for repeated measurements, are even more worrisome: listwise deletion when data are missing, the sphericity assumption, inability to model an unevenly spaced time variable and time-varying covariates, and the limitation to normally distributed dependent variables. This paper introduces ClusterBootstrap, an R package for the analysis of hierarchical data using generalized linear models with the cluster bootstrap (GLMCB). Being a bootstrap method, the technique is relatively assumption-free, and it has already been shown to be comparable, if not superior, to GEE in its performance. The paper has three goals. First, GLMCB will be introduced. Second, there will be an empirical example, using the ClusterBootstrap package for a Gaussian and a dichotomous dependent variable. Third, GLMCB will be compared to mixed models in a Monte Carlo experiment. Although GLMCB can be applied to a multitude of hierarchical data forms, this paper discusses it in the context of the analysis of repeated measurements or longitudinal data. It will become clear that the GLMCB is a promising alternative to mixed models and the ClusterBootstrap package an easy-to-use R implementation of the technique.