Mixed methods study of attitudes on location of gynaecological oncology outpatient care: a patient and healthcare professional questionnaire.

OBJECTIVE: Gynaecological oncology place of care is often based on evolution of services, along historical professional boundaries, rather than user needs or preferences. We aimed to assess existing evidence, gather views of patients in the UK on their preferred place of outpatient care for gynaecological malignancies and evaluate alignment with preferences of healthcare professionals (HCP). METHODS: We performed a mixed methods study, including a scoping review, a patient survey and a healthcare practitioner questionnaire. We collected quantitative and qualitative data, performing content analysis to determine current practice and impact on patients. RESULTS: No studies were identified in our scoping review. We received responses from 159 patients and 54 gynaecological oncology HCPs. There was a strong preference for a dedicated gynaecological oncology setting (89% somewhat or very happy) (p<0.0001). Fifty-three percent of patients were somewhat or very unhappy to have care colocated with general obstetrics and gynaecology services. Specifically, two key themes were identified through content analysis of qualitative data from patients: 'environment and getting this right is vital'; and 'our cancer should be the priority'. HCPs underestimated the strong patient preference to be seen in dedicated units. Of those who see patients within general obstetrics and gynaecology, only 50% said patients were seen at separate times/locations from obstetric patients. CONCLUSION: This study demonstrates the significant impact of place of care on gynaecological oncology patients, which may be underestimated by HCPs.

British Gynaecological Cancer Society Recommendations for Evidence Based, Population Data Derived Quality Performance Indicators for Ovarian Cancer.

Ovarian cancer survival in the UK lags behind comparable countries. Results from the ongoing National Ovarian Cancer Audit feasibility pilot (OCAFP) show that approximately 1 in 4 women with advanced ovarian cancer (Stage 2, 3, 4 and unstaged cancer) do not receive any anticancer treatment and only 51% in England receive international standard of care treatment, i.e., the combination of surgery and chemotherapy. The audit has also demonstrated wide variation in the percentage of women receiving anticancer treatment for advanced ovarian cancer, be it surgery or chemotherapy across the 19 geographical regions for organisation of cancer delivery (Cancer Alliances). Receipt of treatment also correlates with survival: 5 year Cancer survival varies from 28.6% to 49.6% across England. Here, we take a systems wide approach encompassing both diagnostic pathways and cancer treatment, derived from the whole cohort of women with ovarian cancer to set out recommendations and quality performance indicators (QPI). A multidisciplinary panel established by the British Gynaecological Cancer Society carefully identified QPI against criteria: metrics selected were those easily evaluable nationally using routinely available data and where there was a clear evidence base to support interventions. These QPI will be valuable to other taxpayer funded systems with national data collection mechanisms and are to our knowledge the only population level data derived standards in ovarian cancer. We also identify interventions for Best practice and Research recommendations.

British Gynaecological Cancer Society recommendations for women with gynecological cancer who received non-standard care during the COVID-19 pandemic.

During the COVID-19 pandemic, pressures on clinical services required adaptation to how care was prioritised and delivered for women with gynecological cancer. This document discusses potential 'salvage' measures when treatment has deviated from the usual standard of care. The British Gynaecological Cancer Society convened a multidisciplinary working group to develop recommendations for the onward management and follow-up of women with gynecological cancer who have been impacted by a change in treatment during the pandemic. These recommendations are presented for each tumor type and for healthcare systems, and the impact on gynecological services are discussed. It will be important that patient concerns about the impact of COVID-19 on their cancer pathway are acknowledged and addressed for their ongoing care.

The quality of randomized controlled trials of psychotherapy for eating disorders.

OBJECTIVE: We investigated the quality of randomized controlled trials (RCTs) that included direct comparisons of psychotherapy for adults with an eating disorder (ED). METHOD: Thirty-five direct comparison RCTs of psychotherapy for adults diagnosed with an ED were rated using the Randomized Controlled Trials Psychotherapy Quality Rating Scale (RCT-PQRS). RESULTS: The mean total RCT-PQRS score (mean = 28.26; SD = 7.04) was in line with those that were reported for RCTs of psychotherapy for depression and anxiety disorders. Several standards of quality were unfulfilled by over half of the RCTs of treatment for EDs, including therapist supervision while treatment was being provided (62.9% unfulfilled); outcome assessment performed by raters blind to treatment group/condition (54% unfulfilled); and adequate sample size (66% unfulfilled). More recent RCTs were of higher quality, and higher quality was moderately associated with lower effect sizes. CONCLUSIONS: To improve the quality of RCTs of psychotherapy of EDs, we recommend that researchers address the quality criteria listed in the RCT-PQRS. Psychotherapy trials should be registered, have a published protocol, and be reported following the Consolidated Standards of Reporting Trials guidelines. Authors should take into account the quality of the research when using that research to inform ED treatment guidelines.

Change in Attachment Dimensions in Women with Binge-Eating Disorder Following Group Psychodynamic Interpersonal Psychotherapy.

OBJECTIVE: To examine the role of attachment dimensions, including coherence of mind and reflective functioning, in developing and maintaining binge-eating disorder (BED) and in determining group psychotherapy outcomes for women with BED. We hypothesize that higher pre-treatment attachment dimension scores will predict better treatment outcomes for women with BED and will increase at follow-up. METHOD: Women with BED attended 16 sessions of group therapy and completed the Adult Attachment Interview (AAI) at pre-treatment. Participants completed outcome measures (i.e., binge-eating frequency and symptoms of depression) at pre-, post-, six months, and 12 months post-treatment. Treatment completers completed the AAI at six months post-treatment. RESULTS: Treatment outcomes improved significantly from pre- to 12 months post-treatment. Greater Reflective Functioning scores at pre-treatment were related to greater decreases in binge eating across the four time points, whereas Coherence of Mind scores were not. For treatment completers, there were significant increases in Reflective Functioning at six months post-treatment, and about a third of treatment completers experienced clinically significant increases in both attachment dimensions at six months post-treatment. CONCLUSIONS: Greater reflective functioning at the outset is important for improvements in binge eating in the longer term and group psychotherapy can facilitate change in reflective functioning.

Change in Attachment Dimensions and Reflective Functioning Following Emotionally Focused Group Therapy for Binge Eating Disorder.

The current study examines change in attachment variables from pre- to six months post-emotionally focused group therapy (EFGT) for binge eating disorder (BED). A clinical sample of 118 women and men with BED attended 20 sessions of EFGT and completed the Adult Attachment Interview pre- and six months post-treatment. There was a significant increase in secure attachment style classification, significant increases in Coherence of Mind and Reflective Functioning scores, and significant decreases in both unresolved/disorganized attachment style classification and scale scores from pre- to six months post-treatment. Interventions specific to EFGT, common therapeutic factors and group process interventions may have contributed to changes in these attachment variables. The current study demonstrated that EFGT is a promising treatment for facilitating change in attachment in women and men with BED.

Change in attachment states of mind of women with binge-eating disorder.

Insecure and unresolved/disorganized attachment states of mind may impact affect regulation and interpersonal functioning that contribute to binge eating in women with binge-eating disorder (BED). Group psychological treatment may facilitate changes from insecure to secure and from unresolved-disorganized to non-unresolved/disorganized attachment states of mind. This study used attachment theory to understand better the psychopathology of BED and co-morbid overweight status and to understand better the treatment response of patients with BED who receive group psychotherapy. Women with BED attended group psychodynamic interpersonal psychotherapy and completed the Adult Attachment Interview pretreatment and 6 months posttreatment. Matched samples of overweight women without BED and normal-weight women without BED completed the Adult Attachment Interview at 1 time point. Women with BED had significantly higher rates of preoccupied and unresolved/disorganized attachment states of mind compared to normal-weight women without BED and had similar rates of insecure and unresolved/disorganized attachment states of mind compared to overweight women without BED. Of the women with BED who had an insecure and/or unresolved/disorganized attachment states of mind at pretreatment, about 60% demonstrated clinically relevant changes to secure and to non-unresolved/disorganized states of mind at 6 months post group psychodynamic interpersonal psychotherapy. Results indicated that some women with BED may benefit from interventions that help them regulate hyperactivated affect and create coherent narratives. Both women with BED and overweight women without BED may benefit from treatments that help them develop more adaptive affect regulation strategies related to unresolved/disorganized attachment states of mind.

The role of coherence of mind and reflective functioning in understanding binge-eating disorder and co-morbid overweight.

Coherence of mind and reflective functioning may impact negative affect and interpersonal functioning over and above the effects of symptoms of depression and interpersonal problems that contribute to symptoms of binge-eating disorder (BED) and overweight/obesity. Matched samples of overweight women with BED and overweight and normal weight women without BED completed the Adult Attachment Interview, a measure of depressive symptoms, and a measure of interpersonal problems. Greater symptoms of depression distinguished women with BED from the matched comparison samples. Greater interpersonal problems differentiated women with BED from overweight women without BED. Coherence of Mind scores did not differentiate the samples. However, lower Reflective Functioning scores did distinguish both women with BED and overweight women without BED from normal weight women. Lower reflective functioning may lead to binge eating independent of depressive symptoms and interpersonal problems.

Feeling Worse Before Feeling Better: A Case of Increased Disorganized Mental States Following Group Psychotherapy.

Is group therapy effective if it results in members revealing greater unresolved/disorganized mental states related to childhood trauma? That is, do patients have to more fully experience partially disavowed trauma before they get better? We found a small proportion of patients whose pre-treatment Adult Attachment Interview (AAI) transcripts were not coded as Unresolved/Disorganized at the start of group treatment, but were coded as such at the end. In one case report, we examined pre- and six months post-AAI transcripts and group therapy interactions to document the emergence of an unresolved/disorganized mental state. Despite the increase in disorganization, the patient showed some symptom improvement and improved reflective functioning. The 16-week psychodynamic group therapy allowed the patient to reflect on her traumatic experiences and their impact on her life. However, this also resulted in a disorganizing effect on her mental state. Longer-term therapy may be necessary to improve interpersonal functioning and affect regulation in patients who experienced early trauma.

Parental bonds and body dissatisfaction in a clinical sample: The mediating roles of attachment anxiety and media internalization.

We evaluated an attachment theory model in which mother and father care were hypothesized to be indirectly related to body dissatisfaction mediated by attachment anxiety and media internalization. Participants were 232 women diagnosed with an eating disorder who completed a retrospective measure of parental bonds, and measures of attachment anxiety, media internalization, and body image. Mother care was negatively associated with body dissatisfaction, suggesting that recollection of mothers as less caring was directly related to poorer body image. Lower father care, was indirectly associated with greater body dissatisfaction mediated by higher attachment anxiety and higher media internalization. That is, women with an eating disorder who recollected fathers as less caring had higher attachment anxiety, which was related to greater internalizing of media-related thin ideals, that in turn was associated with poorer body image. Mothers and fathers may impact body dissatisfaction by differing mechanisms in clinical samples.

Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder.

An interpersonal model of Binge Eating Disorder (BED) posits that difficulties with social functioning precipitate negative affect, which in turn causes binge eating as a means of coping. Thus, long-term decreases in attachment insecurity may be important for women with BED. No research has assessed if long-term change in attachment insecurity is associated with sustained change in other outcomes. In the current study, we hypothesized that changes in attachment anxiety and avoidance will decrease at posttreatment and will be maintained up to 12 months after Group Psychodynamic Interpersonal Psychotherapy (GPIP). We further hypothesized that long-term stability of these changes in attachment insecurity will be related to other long-term outcomes. Women with BED (N = 102) attended 16 sessions of GPIP. Measures were completed pretreatment, posttreatment, at 6 and 12 months follow-up. Attachment anxiety, attachment avoidance, and the other outcome variables decreased significantly at 12 months posttreatment. Reductions in attachment anxiety and avoidance were significantly related to decreases in interpersonal problems up to 12 months posttreatment, and reduction in attachment anxiety was significantly related to decreases in depressive symptoms 12 months posttreatment. Further, the significant relationship between reduced attachment avoidance and decreased interpersonal problems strengthened over the long term. This is the first study to show an association between change in attachment insecurity and change in other outcomes in the long term, and to show an adaptive spiral in which greater reduction in attachment avoidance is increasingly associated with ongoing improvement of interpersonal problems.

Interpersonal learning is associated with improved self-esteem in group psychotherapy for women with binge eating disorder.

Yalom and Leszcz (2005) indicated that interpersonal learning is a key therapeutic factor in group psychotherapy. In this study, we conceptualized interpersonal learning as the convergence over time between an individual's and the group's perception of the individual's cohesion to the group. First, we developed parallel measures of: (a) an individual's self-rated cohesion to the group (Cohesion Questionnaire-Individual Version [CQ-I]), and (b) the group's rating of the individual's cohesion to the group (CQ-G) based on the original Cohesion Questionnaire (CQ; Piper, Marache, Lacroix, Richardsen, & Jones, 1983). Second, we used these parallel scales to assess differences between an individual's self-rating and the mean of the group's ratings of the individual's cohesion to the group. Women with binge eating disorder (N = 102) received Group Psychodynamic Interpersonal Psychotherapy. Participants were assigned to homogeneously composed groups of either high or low attachment anxiety. Outcomes were measured pre- and post-treatment, and the CQ-I and CQ-G were administered every fourth group session. We found significant convergence over time between the CQ-I and mean CQ-G scale scores in both attachment anxiety conditions. Participants with higher attachment anxiety had lower individual self-ratings of cohesion and had greater discrepancies between the CQ-I and CG-G compared with those with lower attachment anxiety. There was a significant relationship between greater convergence in cohesion ratings and improved self-esteem at post-treatment. More accurate self-perceptions through feedback from group members may be a key factor in facilitating increased self-esteem in group therapy. Group therapists may facilitate such interpersonal learning, especially for those higher in attachment anxiety, by noting discrepancies and then encouraging convergence between an individual and the group in their perceptions of cohesion to the group.

Purging disorder: psychopathology and treatment outcomes.

OBJECTIVE: To characterize a tertiary care treatment-seeking sample and assess post-treatment remission and completion rates for purging disorder (PD). METHOD: Consecutively admitted women with PD (n = 122), anorexia nervosa (AN) restricting subtype (AN-R; n = 146), AN binge-purge subtype (AN-B; n = 154), and bulimia nervosa-purging subtype (BN-P; n = 415) were compared on general and eating disorder specific psychopathology. A subsample (n = 256) attended a day treatment program and were assessed for post-treatment remission and completion rates. RESULTS: PD occurred in 17.3% of eating disorders not otherwise specified and 6.7% of total eating disorder referrals. PD patients were similar to AN-B and BN-P, but had higher levels than AN-R, on general and eating disorder psychopathology. PD individuals did not have different post-treatment remission or completion rates compared to other eating disorders. DISCUSSION: The results add to a growing literature on the utility of PD as a diagnosis.

Predictors of treatment acceptance and of participation in a randomized controlled trial among women with anorexia nervosa.

OBJECTIVE: This study aimed to identify predictors of acceptance of intensive treatment and of participation in a randomized controlled trial (RCT) among women with anorexia nervosa (AN). METHOD: Participant data were drawn from a tertiary care intensive treatment programme including a previously published RCT. Women with AN (N = 106) were offered intensive treatment, and 69 were approached to participate in an RCT of olanzapine's efficacy as an adjunctive treatment for AN. AN subtype and pretreatment psychological variables were used to predict acceptance of intensive treatment and RCT participation. RESULTS: AN binge purge subtype and higher depression and body dissatisfaction predicted intensive treatment acceptance. No variable predicted RCT participation among treatment acceptors. DISCUSSION: Clinicians may focus on enhancing motivation or use a stepped care approach to increase intensive treatment acceptance especially among women with AN-restricting type and among all those with AN who have lower levels of distress.

Interpersonal processes in psychodynamic-interpersonal and cognitive behavioral group therapy: a systematic case study of two groups.

This mixed method systematic case study applied an interpersonal stage model of the therapeutic process to examine interpersonal processes among a highly adherent Group Psychodynamic-Interpersonal Psychotherapy (GPIP) therapist and a highly adherent Group Cognitive Behavioral Therapy (GCBT) therapist and their groups of binge eating disordered (BED) patients. This is the first case study to apply the interpersonal stage model of psychotherapy to compare GCBT and GPIP methods and the first to apply the model to group therapy. Early-, middle-, and late-stage transcribed video recordings of sequential interactions among therapists and patients in each of these two time-limited group therapies were analyzed with the Structural Analysis of Social Behavior (SASB). We also provide qualitative presentations of the transcripts from each stage as context for the quantitative analyses. BED patients in both groups achieved positive outcomes for binge eating and depression. Consistent with their treatment model, the GPIP therapist was more autonomy-giving, whereas the GCBT therapist was more controlling/directive. The GPIP therapist and her group had high levels of interpersonal complementary interaction sequences in the early stage followed by lower complementarity in the middle stage. The GCBT therapist and her group showed a high-low-high pattern of complementarity across the three stage of therapy. However, overall the GPIP group had higher levels complementarity than the GCBT group. This mixed method case study of group processes based on an interpersonal stage model of psychotherapy suggested specific therapist behaviors in each modality to maximize positive therapeutic interactions at each stage of group therapy.