Longitudinal trajectories and psychological predictors of weight loss and quality of life until 3 years after metabolic and bariatric surgery.

OBJECTIVE: This study aimed to describe longitudinal trajectories of Total Weight Loss (%TWL), and mental and physical health related quality of life (HRQOL), as well as to identify preoperative psychological predictors of these trajectories. METHODS: A prospective observational study including Dutch patients treated with metabolic and bariatric surgery (n = 420, age 44.8 ± 10.3 years, 78.6% females) was performed. Trajectories of %TWL and HRQOL from screening to 1-, 2-, and 3-years post-surgery were described using growth mixture modelling. Multivariable and lasso regression models were used to identify predictors. RESULTS: Three trajectories described %TWL, varying in the degree of first-year weight loss. No pre-surgical psychological factors were associated with %TWL trajectories. We identified four physical and five mental HRQOL trajectories. Approximately 25-30% of patients exhibited patterns of initial improvements followed by decline, or persistently low levels of HRQOL. Higher depressive symptoms were associated with these unfavourable physical HRQOL trajectories (OR 1.20, 95%CI 1.04-1.39), adjusted for confounders. Unfavourable mental HRQOL trajectories were predicted by depressive and anxiety symptoms, neuroticism, insecure attachment, and maladaptive coping. In contrast, self-esteem, extraversion, and conscientiousness were associated with favourable mental HRQOL trajectories. DISCUSSION: Psychological factors did not predict weight loss, but they significantly impacted patient's HRQOL after metabolic and bariatric surgery. A subgroup with unsuccessful HRQOL after surgery was identified, who would benefit from tailored preoperative counselling to optimize surgery outcomes. Metabolic and bariatric surgery may not be universally beneficial for all patients, challenging the conventional approach to surgical interventions for severe obesity and advocating for a more nuanced, individualized assessment of potential candidates.

First things first: An exploration of the effects of psychoeducation for older autistic adults.

LAY ABSTRACT: After receiving an autism diagnosis, psychoeducation (i.e. information regarding autism) is a first intervention. We adjusted a psychoeducation program that was originally developed by the Dutch Association for Autism for older adults to enhance its feasibility and efficacy in later life. We expected that participants would report an increase in knowledge and acceptance of the diagnosis and that people close to them would also observe this. Indeed, we found this and participants and those close to them agreed on this. Furthermore, we found some evidence that older autistic adults were better at coping with their autism. We found no positive intervention effects on psychological distress. The feedback of participants and informants about the psychoeducation program was largely positive. In future research, we advise using larger group samples and larger time scales and we also advise to further adjust the program to the needs and requirements of older adults, and to help older autistic adults to construct a new narrative of themselves, and the life they have lived, in the light of the recent autism diagnosis.

The effectiveness of individual schema therapy in older adults with borderline personality disorder: A multiple-baseline case series design.

OBJECTIVE: The aim of this study was to explore the effectiveness of schema therapy (ST) in older adults with borderline personality disorder (BPD). METHODS: Multiple baseline case series design with five BPD patients, with a mean age of 66. After a baseline phase with random length, patients received weekly ST sessions for a year, followed by follow-up sessions during 6 months. Participants rated the credibility of negative core beliefs weekly; various secondary outcome measures were assessed every 6 months (severity of BPD, early maladaptive schemas, schema modes, personality functioning, maladaptive personality traits, psychological distress and quality of life), and BPD diagnosis was assessed before baseline and after follow-up. Data were analysed with mixed regression analyses and paired t-tests. RESULTS: Results revealed that ST led to a significant decrease in credibility of negative core beliefs, with high effect sizes. All participants remitted from their BPD diagnosis. CONCLUSION: This is the first study exploring the effectiveness of ST for BPD in older adults, and it suggests that ST can be a powerful intervention for this group of patients.

Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment program for patients with borderline personality disorder (BPD). The program was intended to be highly accessible, both for patients and therapists. During STEPPS, patients are taught emotion regulation and behavior management skills. This systematic review synthesizes the current empirical status of STEPPS, focusing on research designs, quality of studies, target groups, protocols, and outcome. We selected 20 studies, with three randomized controlled trials. Patients with BPD, subthreshold BPD, and patients with BPD and comorbid antisocial personality disorder were investigated. One study was conducted in adolescents. There were no studies in older adults. Results demonstrated STEPPS to be associated with reduced BPD symptoms, improved quality of life, decreased depressive symptoms, and decreased negative affectivity. Mixed results were found for impulsivity and suicidal behaviors. STEPPS has both been studied as an add-on therapy to patients' ongoing treatment, and, with the addition of individual STEPPS sessions, as a stand-alone treatment. High attrition rates were found in patients attending STEPPS, complicating the generalizability of the results. Although the evidence for STEPPS is promising, further research is needed before firm conclusions can be drawn. Recommendations for future research are discussed.

Systems training for emotional predictability and problem solving in older adults with personality disorders: a pilot study.

BACKGROUND: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a cognitive behavioural therapy-based group treatment programme for patients with borderline personality disorder (BPD). STEPPS has demonstrated its effectiveness for (younger) adults. However, there are no studies into the effects of STEPPS for older adults. AIM: The aim was to explore the outcome of STEPPS in older adults with personality disorders. METHOD: In this naturalistic pre- vs post-treatment study, older patients with a personality disorder, reporting emotion regulation difficulties, were included. The primary outcome was BPD symptoms. Secondary outcomes included psychological distress and maladaptive personality functioning. RESULTS: Twenty-four patients, with a mean age of 63.9 years (SD=4.6), completed the 19-week programme. Nine patients (23.1%) did not complete the treatment. There were no significant differences in age, gender or global severity between completers and patients dropping out. There was a significant pre- vs post-treatment decrease of BPD symptoms, with a large effect size (Cohen's d=1.577). Self-control improved significantly and demonstrated a large effect size (r=.576). Furthermore, identity integration improved significantly, with a medium effect size (Cohen's d=.509). No significant differences were reported for most domains of psychological distress and maladaptive interpersonal personality functioning. CONCLUSIONS: The findings in this pilot study suggest STEPPS is a feasible treatment programme for older adults with personality disorders and emotion regulation difficulties. Adaptations to the program, for a better fit for older adults, however, might be needed.

Age-neutrality of the SCID-II: Differential Item Functioning in Younger Outpatients (Aged 20-45) and Older Outpatients (Aged 65+).

OBJECTIVES: Measurements are often developed for the assessment of personality disorders (PDs) in younger adults and seldom evaluated on the applicability in older adults. Remarkably, research has not yet been conducted into age-group appropriateness of the gold standard for the assessment of PDs, known as Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II). Therefore, the current study empirically investigated the age-neutrality of the PDs assessed by the SCID-II. METHODS: Age-neutrality was examined in 84 younger adults (aged 20-45 years) and 68 older adults (aged 65-85) by Differential Item Functioning (DIF). The impact of DIF on scale level was further examined using Differential Test Functioning analyzes to examine the impact of the amount of DIF variance in the items on scale level. RESULTS: Overall, the great majority, 95.8% of the categorically measured items and 87.5% of the dimensionally measured items, was endorsed in the same way by younger adults and older adults with equal scores on the PD scale. Subsequent analyzes revealed no large DTF for PD scales. CONCLUSIONS: Overall the SCID-II in an outpatient population is age-neutral for both categorically and dimensionally scored PD scales. CLINICAL IMPLICATIONS: The SCID-II can be used for the assessment of PDs in older adults.

Clinical Staging as a Novel Approach for Selecting Psychological Treatment Levels for Older Adults with Borderline Personality Disorder.

OBJECTIVES: In this paper, a novel approach is presented for selecting psychological treatment levels for older adults with borderline personality disorder (BPD). BPD tends to be a lifelong disorder persisting into old age, with a specific presentation of BPD symptoms in later life, which is illustrated by three different clinical cases. METHODS: Recently, a clinical staging and health management model for BPD was presented to assist in selecting appropriate treatment approaches. RESULTS: We combined this clinical staging model for BPD across the lifespan with psychotherapeutic treatment levels for older adults with personality disorders. CONCLUSIONS: This may allow for a more accurate treatment selection for older adults with BPD and was applied to the three clinical cases. Finally, implications for research and clinical practice are discussed.

[Psychological treatment of personality disorders in older adults: a review]. / Psychologische behandeling van persoonlijk­heids­stoor­nis­sen bij ouderen: stand van zaken en suggesties voor onderzoek.

Despite a still reigning therapeutic nihilism, attention for the psychological treatment of personality disorders in older adults has been growing recently. The first empirical studies have been conducted, but their number is still limited, and varies from expert consensus to the first tests of effectiveness of schema therapy and dialectical behavior therapy. Therefore, there is an urgent need for further empirical studies into psychological treatments that have been optimized for older adults on all three treatment levels.

Positive schemas in schema therapy with older adults: clinical implications and research suggestions.

BACKGROUND: Schema therapy is an effective treatment for borderline personality disorder and other complex disorders. Schema therapy is feasible in older adults, and the first empirical support for its effectiveness in later life was provided in older patients with a cluster C personality disorder. The central concept of the schema therapy model is the early maladaptive schema (EMS). Early adaptive schemas (EAS) give rise to adaptive behaviour, and they also emerge during childhood, when core emotional needs are adequately met by primary caregivers. AIMS: To examine the concept of EAS and its application in schema therapy with older adults. METHOD: Literature review and case example: the role of EAS in schema therapy with older adults is discussed and suggestions for integrating EAS in schema therapy in later life are proposed. RESULTS: Directing attention in therapy to EAS may help strengthen the healthy adult mode, and it might also help change a negative life review. Working with positive schemas may be an important avenue for re-awakening positive aspects of patients, reinforcing the therapeutic relationship, creating a positive working atmosphere, and also for facilitating the introduction of experiential schema therapy techniques. CONCLUSIONS: This review suggests that positive schemas may be important vehicles of therapeutic change when working with older people. There is a need for validating the Young Positive Schema Questionnaire (YPSQ) in older adults, and for examining whether integrating EAS in schema therapy with older adults indeed has a positive effect on therapy outcome.

Mediation of emotional and external eating between dieting and food intake or BMI gain in women.

OBJECTIVE: Dieting to control body weight is often associated with weight gain, particularly so in women; however, the underlying mechanisms are unclear. In a series of studies on women, we examined whether the relationship between dieting and weight gain can be explained by (serial) mediation of emotional eating (EE) and/or subsequent external eating (EX). METHODS: In a pilot study (116 women), we first assessed this (serial) mediation between dieting or dietary restraint and actual food consumption in the laboratory. In Study 1, a four-year follow up on patients with newly diagnosed type 2 diabetes (51 women), we assessed this (serial) mediation between dietary restraint and change in BMI and intake of energy (Kcal; Food Frequency Questionnaire). In Study 2, a three-year follow up study in a representative Dutch sample (287 women), we assessed this (serial) mediation between dieting and change in BMI. RESULTS: There was consistent support for (serial) mediation: In the pilot study, frequency of dieting and dietary restraint were both indirectly associated with grams of crackers eaten through EE and EX. In study 1, dietary restraint had a significant (95% CI) indirect association with subsequent change in measured BMI and a marginally (90% CI) significant indirect association with intake of energy through EE and EX. In study 2, EE marginally (90% CI) acted as a mediator between frequency of dieting and subsequent self-reported change in BMI. In the subsample of overweight women (n = 146) frequency of dieting was indirectly associated with subsequent self-reported change in BMI through EE and EX. CONCLUSION: The possibility that female dieters may gain weight through EE and/or subsequent EX should be taken into account when treating women with overweight or obesity.

The relation between generalized anxiety disorder symptoms and content-specific interpretation biases for auditory stimuli in children.

BACKGROUND AND OBJECTIVES: Cognitive theories of fear suggest that biases in interpretation are content-specific: Fearful children should only interpret materials negatively if they are specifically related to the content of their fear. So far, there are only a few studies available that report on this postulated content-specificity of interpretation processes in childhood fear. The goal of this study was to examine interpretation bias and its content-specificity in children with varying levels of Generalized Anxiety Disorder (GAD) symptoms. METHODS: In an Auditory Interpretation Task (AIT), two words that differ by one phoneme are acoustically blended so that one can hear only one of the words. In the current AIT, we included GAD-related blends, negatively-valenced fear-related blends and positive blends. Multiple-choice (n = 371) or open-ended (n = 295) responses were collected from 666 nonclinical children between 7 and 13 years of age. RESULTS: Children with higher levels of self-reported GAD showed significantly more negative interpretations of ambiguous GAD-related blends in the multiple-choice version than children with lower levels of GAD. There were no differences when interpreting the other ambiguous blends. This result was not found with the open-ended version. LIMITATIONS: Effects were relatively small, some GAD-stimuli were sub-optimal, and the task was administered in a classroom setting. Even though we ensured that all children were able to hear all words clearly, this may have impacted the results. CONCLUSIONS: The findings only partly support the idea that fearful children display cognitive biases specific for fear-relevant stimuli, and more research is needed to replicate the results and test the usability of the AIT.

Is desire to eat in response to positive emotions an 'obese' eating style: Is Kummerspeck for some people a misnomer?

Is desire to eat in response to positive emotions an 'obese' eating style: a style more prevalent in people with obesity? In other words: Is Kummerspeck (German: sorrow-fat) for some people a misnomer? This question was addressed in three studies on women. Study 1 (n = 188) tested the moderator effect of subjective well-being on the association of BMI with the scale on desire to eat in response to negative emotions (DEBQ-E). Study 2 tested in women (n = 832) whether items on desire to eat in response to positive emotions loaded on the same factor as those in response to negative emotions and body mass. Study 3 assessed in the total sample (n = 203) and an overweight subsample (n = 40) a) whether self-reported desire to eat in response to positive emotions predicted actual food intake and b) whether this also held true over and above self-reported desire to eat in response to negative emotions. Study 1 showed only for women with low positive affect a significant positive association of BMI with DEBQ-E. In Study 2, only items on desire to eat in response to negative emotions loaded on the same factor as BMI. Study 3: In the total sample, the significant effect on food intake of the scale on desire to eat in response to positive emotions disappeared when a scale on desire to eat in response to negative emotions was added to the model. In the overweight-subsample there was only an effect on food intake for desire to eat in response to negative emotions. It is concluded that only desire to eat in response to negative emotions is an 'obese' eating style, suggesting that Kummerspeck is not a misnomer.

Anxiety, depression and autonomy-connectedness: The mediating role of alexithymia and assertiveness.

OBJECTIVE: Autonomy-connectedness (self-awareness, sensitivity to others, and capacity for managing new situations) reflects the capacity for self-governance, including in social relationships. Evidence showed that autonomy-connectedness is related to anxiety and depression. Little is known about the underlying mechanisms. We hypothesized that alexithymia and assertiveness would mediate the relationships between autonomy-connectedness and anxiety and depression. METHOD: Relationships among the variables were investigated in 100 patients with a mean age of 42.2 suffering from anxiety and/or depression using a cross-sectional design. RESULTS: The relationship between self-awareness and both anxiety and depression was mediated by alexithymia. For anxiety, there was also a direct effect of sensitivity to others that was not explained by either alexithymia or assertiveness. Assertiveness did not have any mediational effect. CONCLUSIONS: The results indicate that particularly alexithymia explains the association of autonomy-connectedness with anxiety and depression. PRACTITIONER POINTS: The study confirmed the relevance of autonomy-connectedness in anxiety and depression. In treating symptoms of anxiety, it is advisable to give attention to normalizing the patient's sensitivity to others. Treatment of patients with symptoms of anxiety and depression should include assessment of emotional awareness and, in the case of impaired emotional awareness, should be tailored as to promote increased awareness.

Predictors of outcome for cognitive behaviour therapy in binge eating disorder.

The aim of this naturalistic study was to identify pretreatment predictors of response to cognitive behaviour therapy in treatment-seeking patients with binge eating disorder (BED; N = 304). Furthermore, we examined end-of-treatment factors that predict treatment outcome 6 months later (N = 190). We assessed eating disorder psychopathology, general psychopathology, personality characteristics and demographic variables using self-report questionnaires. Treatment outcome was measured using the bulimia subscale of the Eating Disorder Inventory 1. Predictors were determined using hierarchical linear regression analyses. Several variables significantly predicted outcome, four of which were found to be both baseline predictors of treatment outcome and end-of-treatment predictors of follow-up: Higher levels of drive for thinness, higher levels of interoceptive awareness, lower levels of binge eating pathology and, in women, lower levels of body dissatisfaction predicted better outcome in the short and longer term. Based on these results, several suggestions are made to improve treatment outcome for BED patients.

Hunger, inhibitory control and distress-induced emotional eating.

Self-reported emotional eating has been found to significantly moderate distress-induced food intake, with low emotional eaters eating less after a stress task than after a control task and high emotional eaters eating more. The aim of the present study was to explore possible underlying mechanisms by assessing possible associations with (1) ability to experience the typical post-stress reduction of hunger and (2) inhibitory control. We studied these effects in 54 female students who were preselected on the basis of extremely high or low scores on an emotional eating questionnaire. Using a within subject design we measured the difference of actual food or snack intake after a control or a stress task (Trier Social Stress Test). As expected, the moderator effect of emotional eating on distress-induced food intake was found to be only present in females with a failure to report the typical reduction of hunger immediately after a stress task (an a-typical hunger stress response). Contrary to our expectations, this moderator effect of emotional eating was also found to be only present in females with high ability to stop motor impulses (high inhibitory control). These findings suggest that an a-typical hunger stress response but not poor inhibitory control may underlie the moderator effect of emotional eating on distress-induced food intake. However, inhibitory control may play a role whether or not there is a moderator effect of self-reported emotional eating on distress-induced food intake.

Possible pathways between depression, emotional and external eating. A structural equation model.

Emotional and external eating appear to co-occur and both have been shown to correlate to neuroticism, especially depression. However, there is evidence suggesting that emotional and external eating are independent constructs. In this study we revisited the relation between depression, emotional, and external eating. Using structural equation modelling, we examined whether depression, emotional and external eating are directly related and also indirectly related through the intervening concepts alexithymia and impulsivity. Participants were 549 females concerned about their weight. They filled out instruments on emotional and external eating, depression, alexithymia, and impulse regulation. The relational structure between the model variables was explored for one half of the participants and this solution was checked using the other half. Our data showed a moderate relationship between emotional and external eating. Depression was positively and directly associated with emotional eating, but not with external eating. In addition, depression was indirectly related to emotional eating through both alexithymia and impulsivity. A significant relation was found between impulsivity and external eating. Results suggest potential mediating pathways between depression and emotional eating, while no relation appeared to exist between depression and external eating. Emotional and external eating would appear to be different constructs.

Perceived parental food controlling practices are related to obesogenic or leptogenic child life style behaviors.

To better understand whether the parental food controlling practices pressure and restriction to eat are obesity preventing or obesity promoting, this study examined whether these parenting practices are related to other (food or non-food) areas that are generally regarded as obesogenic or leptogenic. Are these foods controlling practices more indicative of obesogenic or leptogenic child life style behaviors? In a sample of 7-12-year-old boys and girls (n = 943) the perceived parental food controlling practices were related to various measures for unhealthy life style. Using factor analysis we assessed whether there is a constellation of lifestyle behaviors that is potentially obesogenic or leptogenic. Remarkably, perceived parental restriction and pressure loaded on two different factors. Perceived parental restriction to eat had a negative loading on a factor that further comprised potential obesogenic child life style behaviors, such as snacking (positive loading), time spend with screen media (television or computer) (positive loadings) and frequency of fruit consumption (negative loading). Perceived parental pressure to eat had a positive loading on a factor that further comprised potential leptogenic life style behaviors such as frequency of eating a breakfast meal and sporting (positive loadings). It is concluded that low perceived parental restriction in regard to food may perhaps be a sign of more uninvolved 'neglecting' or indulgent parenting/obesogenic home environment, whereas high perceived parental pressure to eat may be sign of a more 'concerned' leptogenic parenting/home environment, though more research into style of parenting is needed.

Effects of distress, alexithymia and impulsivity on eating.

OBJECTIVE: To improve our understanding of possible mechanisms underlying emotional overeating this study examined the effects of a distress manipulation on food intake in relation to alexithymia and impulsivity. METHOD: Participants were 86 females who were subjected to a distress manipulation (the anticipation of a public speaking task) prior to an ad lib taste task and filled out questionnaires on impulsivity and the alexithymia constructs difficulty identifying and describing feelings. RESULTS: Alexithymia significantly (p<.05) moderated the relationship between food consumption and distress. Instead of eating less in the distress condition, alexithymic females ate the same or even more, this showing a 'biological unnatural' and 'inapt' response. CONCLUSION: Findings suggest that for the 'natural' distress response (reduction of food intake) good ability to identify and describe feelings to others is required, and that the presence or absence of these abilities may predict which people respond to distress by undereating or by overeating. The results provide empirical support for Bruch's conceptualisation of poor interoceptive awareness as possible predictive factor for emotional overeating.

Tendency toward overeating and restraint as predictors of food consumption.

Restrained eaters have repeatedly been found to overeat following a preload, which phenomenon is called the disinhibition effect. Remarkably, the disinhibition effect is only found when the restraint scale (RS) is used, and never when other measures of restraint, like the three-factor eating questionnaire (TFEQ) or the Dutch eating behavior questionnaire (DEBQ) are applied. Recent research has shown that tendency toward overeating appears to be a better predictor of food consumption than dietary restraint. The present study examines the predictive value of preload, tendency toward overeating and dietary restraint. An experiment was carried out with 209 female participants with the aim to evaluate whether the results of the study [Int J Eating Disorders 28 (2000) 333] are robust. In addition to the RS, the TFEQ and DEBQ were used to measure restraint and tendency toward overeating. Again, no disinhibition effect occurred, confirming the results of the previous study. Restraint, as measured by the three questionnaires, was not related to food consumption. In contrast, tendency toward overeating was significantly related to food consumption. Restraint theory's contentions that dieting leads to overeating might be valid for only some dieters, namely those with a high tendency toward overeating.

Absence of a disinhibition effect of alcohol on food consumption.

Alcohol is frequently mentioned as a disinhibitor of restrained eating behavior although only a small number of studies have investigated this disinhibition effect. The present study was conducted to fill this gap. A total of 116 female college students participated in a questionnaire-based assessment and a taste-test experiment. Before the taste test, half of the participants consumed a preset amount of alcohol-laced orange juice, the other half were given plain orange juice. The dependent variable was the amount of savory crackers eaten during the taste test. The Dutch Eating Behavior Questionnaire (DEBQ), the Three-Factor Eating Questionnaire (TFEQ), and the Restraint Scale (RS) were used to measure eating behavior dimensions, which formed the independent variables in various regression analyses. No disinhibition effect was found. On the contrary, participants scoring high on restraint (DEBQ, TFEQ) proved to consume even less food than those having lower scores. Participants that rated high on the scales measuring tendency toward overeating consumed more food than participants with low scores. These results support earlier contentions that the validity of the Restraint Theory's statement that dieting leads to overeating is questionable.