Integrating evidence-based PTSD treatment into intensive eating disorders treatment: a preliminary investigation.

PURPOSE: Given data suggesting common co-occurrence and worse outcomes for individuals with eating disorders (EDs) and post-traumatic stress disorder (PTSD), it is critical to identify integrated treatment approaches for this group of patients. Past work has explored the feasibility and initial efficacy of intervention approaches that draw on evidence-based treatments for both EDs and PTSD; however, this work remains limited in scope. In the current study, we explored the feasibility and naturalistic outcomes of PTSD treatment delivered within the context of intensive ED treatment. METHOD: Participants were 57 adult men and women with DSM-5 EDs and comorbid PTSD who completed a course of either Prolonged Exposure (PE; n = 22) or Cognitive Processing Therapy (CPT; n = 35) (Msessions = 10.40; SD = 5.13) and weekly validated measurements of clinical symptoms while enrolled in ED programming. RESULTS: Multi-level models for PTSD symptoms indicated a significant linear effect of time, such that participants demonstrated significant decreases over time in PTSD symptoms, regardless of treatment modality. CONCLUSION: Our preliminary investigation provides support for the feasibility and efficacy of an integrated approach to treating EDs and PTSD. It is critical for future work to undertake randomized tests of this integrated approach using large, heterogeneous samples. LEVEL OF EVIDENCE: Level IV, multiple time series with intervention.

Evaluating the use of lamotrigine to reduce mood lability and impulsive behaviors in adults with chronic and severe eating disorders.

BACKGROUND: Gold-standard psychological and pharmacological treatments for bulimic-spectrum eating disorders only result in remission for around 50% of patients; patients with affective lability and impulsivity represent a subgroup with particularly poor outcomes. Both dialectical behavior therapy (DBT), a treatment for emotion dysregulation, and lamotrigine, a mood stabilizer, have demonstrated promise for targeting affective lability and impulsivity; however, data exploring the combination of these interventions remain limited. OBJECTIVE: We followed a group of women with recurrent dysregulated eating behaviors (N = 62) throughout intensive DBT treatment and compared the symptom trajectory of those prescribed lamotrigine (n = 28) and those who were not (n = 34). METHOD: Participants completed surveys every 2 weeks throughout treatment. RESULTS: Group analyses suggested that all participants self-reported decreases in emotional reactivity, negative urgency, and symptoms of borderline personality disorder (BPD). The lamotrigine group reported greater elevations in BPD symptoms at baseline, but demonstrated steeper decreases in emotion and behavioral dysregulation than the non-matched comparison group. Within-subject analyses suggested that within the lamotrigine group, subjects reported greater decreases in symptoms following prescription of lamotrigine. CONCLUSIONS: Findings provide initial data suggesting that lamotrigine could be useful as an adjunctive treatment for patients with affective lability and impulsivity. LEVEL OF EVIDENCE: IV, time series without randomization.

Altered stress responses in adults born by Caesarean section.

Birth by Caesarean-section (C-section), which increases the risk for metabolic and immune disorders, disrupts the normal initial microbial colonisation of the gut, in addition to preventing early priming of the stress and immune-systems.. Animal studies have shown there are enduring psychological processes in C-section born mice. However, the long-term impact of microbiota-gut-brain axis disruptions due to birth by C-section on psychological processes in humans is unknown. Forty age matched healthy young male university students born vaginally and 36 C-section delivered male students were recruited. Participants underwent an acute stressor, the Trier social stress test (TSST), during a term-time study visit. A subset of participants also completed a study visit during the university exam period, representing a naturalistic stressor. Participants completed a battery of cognitive tests and self-report measures assessing mood, anxiety, and perceived stress. Saliva, blood, and stool samples were collected for analysis of cortisol, peripheral immune profile, and the gut microbiota. Young adults born by C-section exhibit increased psychological vulnerability to acute stress and a prolonged period of exam-related stress. They did not exhibit an altered salivary cortisol awakening response to the TSST, but their measures of positive affect were significantly lower than controls throughout the procedure. Both C-section and vaginally-delivered participants performed equally well on cognitive assessments. Most of the initial effects of delivery mode on the gut microbiome did not persist into adulthood as the gut microbiota profile showed modest changes in composition in adult vaginally-delivered and C-sectioned delivered subjects. From an immune perspective, concentrations of IL-1ß and 1L-10 were higher in C-section participants. These data confirm that there is a potential enduring effect of delivery mode on the psychological responses to acute stress during early adulthood. The mental health implications of these observations require further study regarding policies on C-section use.

Improvements in sleep indices during exam stress due to consumption of a Bifidobacterium longum.

Targeting the gut microbiome as an effective therapeutic strategy for psychological disorders has shown promise in recent years. Variation in the composition of the microbiota and restoration of a stable microbiome using targeted interventions (psychobiotics) including Bifidobacteria have shown promise in pre-clinical studies, but more human data is required on the potential health benefits of these live microorganisms. Bifidobacterium including Bif. longum 1714 has been shown to dampen the effects of acute stress in humans. However, its effects over a period of prolonged stress have not been examined. A randomised, placebo-controlled, repeated measures, cross-over intervention study was conducted to examine the effects of a probiotic intervention on measures of stress, cognitive performance, and mood in healthy human volunteers. Twenty male students participated in this crossover study. Post-intervention assessments took place during the university exam period, which was used as a naturalistic chronic stressor. Self-reported measures of stress, depression, sleep quality, physical activity, gastrointestinal symptoms, cognition, and mood were assessed by questionnaire. In addition, tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were administered to all participants. Stress and depression scores increased in both placebo and probiotic treated groups during the exam period. While overall sleep quality and duration of sleep improved significantly in the probiotic treated group during exam stress compared with the placebo treated group, B. longum 1714, similar to placebo treatment, showed no efficacy in improving measures of working memory, visual memory, sustained attention or perception. Overall, while B. longum 1714 shows promise in improving sleep quality and duration, it did not alleviate symptoms of chronic stress, depression, or any measure of cognitive assessment. Thus, further mechanistic studies into the ability of B. longum 1714 to modulate sleep during prolonged periods of stress are now warranted.

Acute stress increases monocyte levels and modulates receptor expression in healthy females.

There has been a growing recognition of the involvement of the immune system in stress-related disorders. Acute stress leads to the activation of neuroendocrine systems, which in turn orchestrate a large-scale redistribution of innate immune cells, such as monocytes. Even though acute stress/monocyte interactions have been well-characterized in mice, this is not the case for humans. As such, this study aimed to investigate whether acute stress modulates blood monocyte levels in a subtype-dependent manner and whether the receptor expression of stress-related receptors is affected in humans. Blood was collected from healthy female volunteers at baseline and 1 h after the socially evaluated cold pressor test, after which blood monocyte levels and receptor expression were assessed by flow cytometry. Our results reveal a stress-induced increase in blood monocyte levels, which was independent of monocyte subtypes. Furthermore, colony stimulating factor 1 receptor (CSF-1R) and CD29 receptor expression was increased, while CD62L showed a trend towards increased expression. These results provide novel insights into how acute stress affects the innate immune system.

Recipe for a Healthy Gut: Intake of Unpasteurised Milk Is Associated with Increased Lactobacillus Abundance in the Human Gut Microbiome.

INTRODUCTION: The gut microbiota plays a role in gut-brain communication and can influence psychological functioning. Diet is one of the major determinants of gut microbiota composition. The impact of unpasteurised dairy products on the microbiota is unknown. In this observational study, we investigated the effect of a dietary change involving intake of unpasteurised dairy on gut microbiome composition and psychological status in participants undertaking a residential 12-week cookery course on an organic farm. METHODS: Twenty-four participants completed the study. The majority of food consumed during their stay originated from the organic farm itself and included unpasteurised milk and dairy products. At the beginning and end of the course, participants provided faecal samples and completed self-report questionnaires on a variety of parameters including mood, anxiety and sleep. Nutrient intake was monitored with a food frequency questionnaire. Gut microbiota analysis was performed with 16S rRNA gene sequencing. Additionally, faecal short chain fatty acids (SCFAs) were measured. RESULTS: Relative abundance of the genus Lactobacillus increased significantly between pre- and post-course time points. This increase was associated with participants intake of unpasteurised milk and dairy products. An increase in the faecal SCFA, valerate, was observed along with an increase in the functional richness of the microbiome profile, as determined by measuring the predictive neuroactive potential using a gut-brain module approach. CONCLUSIONS: While concerns in relation to safety need to be considered, intake of unpasteurised milk and dairy products appear to be associated with the growth of the probiotic bacterial genus, Lactobacillus, in the human gut. More research is needed on the effect of dietary changes on gut microbiome composition, in particular in relation to the promotion of bacterial genera, such as Lactobacillus, which are recognised as being beneficial for a range of physical and mental health outcomes.

Emotion Regulation Difficulties During and After Partial Hospitalization Treatment Across Eating Disorders.

Emotion regulation deficits are associated with eating disorder (ED) symptoms, regardless of eating disorder diagnosis. Thus, recent treatment approaches for EDs, such as dialectical behavior therapy (DBT), have focused on teaching patients skills to better regulate emotions. The present study examined changes in emotion regulation among adult patients with EDs during DBT-oriented partial hospital treatment, and at follow-up (M[SD] = 309.58[144.59] days from discharge). Exploratory analyses examined associations between changes in emotion regulation and ED symptoms. Patients with anorexia nervosa, restricting (AN-R, n = 77), and binge-eating/purging subtype (AN-BP, n = 46), or bulimia nervosa (BN, n = 118) completed the Difficulties in Emotion Regulation Scale (DERS) at admission, discharge, and follow-up. Patients with BN demonstrated significant improvements across all facets of emotion dysregulation from admission to discharge and maintained improvements at follow-up. Although patients with AN-BP demonstrated statistically significant improvements on overall emotion regulation, impulsivity, and acceptance, awareness, and clarity of emotions, from admission to discharge, these improvements were not significant at follow-up. Patients with AN-R demonstrated statistically significant improvements on overall emotion dysregulation from treatment admission to discharge. Changes in emotion regulation were moderately correlated with changes in ED symptoms over time. Results support different trajectories of emotion regulation symptom change in DBT-oriented partial hospital treatment across ED diagnoses, with patients with BN demonstrating the most consistent significant improvements.

Differences in emotion regulation difficulties among adults and adolescents across eating disorder diagnoses.

OBJECTIVE: Although much empirical attention has been devoted to emotion regulation (ER) in individuals with eating disorders, little is known about ER across a wide age range and among different ED subtypes. The current study sought to examine ER in a sample of eating disorder patients. METHOD: A total of 364 adults and adolescents with anorexia nervosa restricting subtype (AN-R), anorexia nervosa binge/purge subtype (AN-BP), or bulimia nervosa (BN) were assessed with the Difficulties in Emotion Regulation Scale (DERS). RESULTS: Older ages were associated with higher DERS total, nonacceptance, goals, and impulsivity scores. When controlling for age, patients with BN and AN-BP had higher overall DERS scores than those with AN, and there were some differences among diagnostic subtypes on specific facets of ER. CONCLUSIONS: These results indicate that treatments for emotion dysregulation may be applied across eating disorder diagnoses and ages, and inform how these strategies apply to different diagnostic groups.

Efficacy of a partial hospital programme for adults with eating disorders.

Partial hospital programmes (PHPs) have demonstrated efficacy in the treatment of eating disorders (EDs); however, few programmes have examined long-term outcomes across diagnoses, including subtypes of anorexia nervosa (AN). The present study examined the effectiveness of PHP for adult patients (n = 243) with AN-restricting subtype (n = 79), AN binge/purge subtype (n = 46), and bulimia nervosa (n = 118). These patients tended to have long-standing courses of illness (43%, illness duration >7 years) and high levels of psychiatric comorbidity (92.2%). Patients completed questionnaires at admission, discharge, and follow-up, M (SD) = 11.50 months (5.29). Through follow-up, all diagnoses demonstrated significant improvements in weight, ED psychopathology, and comorbid symptoms, with some exceptions for the AN binge/purge group. In exploratory analyses, 49% of patients met criteria for full or partial remission at discharge and 37% at follow-up. Results provide support for the effectiveness of PHP in improving ED outcomes in a severe sample through longer-term follow-up.

A pilot open series of lamotrigine in DBT-treated eating disorders characterized by significant affective dysregulation and poor impulse control.

BACKGROUND: There is little effective psychopharmacological treatment for individuals with eating disorders who struggle with pervasive, severe affective and behavioral dysregulation. METHODS: This pilot open series evaluated lamotrigine, a mood stabilizer, in the treatment of patients with eating disorders who did not respond adequately to antidepressant medications. Nine women with anorexia nervosa- or bulimia nervosa-spectrum eating disorders in partial hospital or intensive outpatient dialectical behavior therapy (DBT)-based eating disorder treatment took lamotrigine for 147 ± 79 days (mean final dose = 161.1 ± 48.6 mg/day). Participants completed standardized self-report measures of emotion dysregulation and impulsivity after lamotrigine initiation and approximately biweekly thereafter. Mood and eating disorder symptomatology were measured at lamotrigine initiation and at time of final assessment. RESULTS: Lamotrigine and concurrent DBT were associated with large reductions in self-reported affective and behavioral dysregulation (ps < 0.01). Eating disorder and mood symptoms decreased moderately. CONCLUSIONS: Although our findings are limited by the confounds inherent in an open series, lamotrigine showed initial promise in reducing emotional instability and behavioral impulsivity in severely dysregulated eating-disordered patients. These preliminary results support further investigation of lamotrigine for eating disorders in rigorous controlled trials.

Psychometric Evaluation and Norms for the Multidimensional Assessment of Interoceptive Awareness (MAIA) in a Clinical Eating Disorders Sample.

Altered interoceptive awareness (IA) has been implicated in the pathophysiology of eating disorders; however, few comprehensive self-report measures of IA exist in eating disorders. The present study sought to validate the Multidimensional Assessment of Interoceptive Awareness (MAIA), originally developed to assess IA in individuals practicing mind-body therapies, in an eating disorder sample. Adult and adolescent patients (n = 376) completed assessments upon admission to a partial hospital programme. Analyses examined the factor structure of the MAIA, scale means, scale-scale correlations, internal consistency and construct validity. Analyses also examined associations between MAIA subscales and eating disorder symptoms. Results supported the original eight-factor structure of the MAIA. Internal consistency was acceptable, and the scales converged with associated measures. Importantly, Not Distracting, Self-regulation, Body Listening and Trusting were most strongly associated with eating disorder symptoms. Results support use of the MAIA among eating disorders and provide further support for the relevance of IA in eating disorders. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Treating Eating Disorders at Higher Levels of Care: Overview and Challenges.

Higher levels of care (HLC)-including inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment-are frequently utilized within routine care for eating disorders. Despite widespread use, there is limited research evaluating the efficacy of HLC, as well as clinical issues related to care in these settings. This review describes the different levels of care for eating disorders and briefly reviews the most up-to-date guidelines and research regarding how to choose a level of care. In addition, as HLC approaches for ED continue to be developed and refined, pragmatic and conceptual challenges have emerged that provide barriers to clinical efficacy and the execution of high-quality treatment research. This review includes a discussion of various issues specific to HLC, as well as a summary of recent literature addressing them.

A Narrative Review of Outcome Studies for Residential and Partial Hospital-based Treatment of Eating Disorders.

OBJECTIVE: The objective of this study was to review the current eating disorders outcome literature after residential or partial hospitalization programme (PHP) treatment. METHOD: Articles were identified through a systematic search of PubMed and PsycINFO. RESULTS: Twenty-two PHP and six residential treatment studies reported response at discharge and tended to find improvement. Fewer studies (nine PHP and three residential) reported outcome at some interval after discharge from treatment. These tended to find sustained improvement. A substantial proportion of patients were lost to follow-up, particularly for residential treatment. Only two follow-up studies used controlled trials; both showed efficacy for PHP compared with inpatient treatment with regard to maintaining symptom remission. CONCLUSIONS: Improvement at discharge may not predict long-term outcome. Long-term follow-up studies were confounded by high dropout rates. While higher levels of care may be essential for reversing malnutrition, there remains a lack of controlled trials showing long-term efficacy, particularly for residential treatment settings. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Integrating Family-Based Treatment and Dialectical Behavior Therapy for Adolescent Bulimia Nervosa: Preliminary Outcomes of an Open Pilot Trial.

Adolescent bulimia nervosa (BN) remains relatively understudied, and the complex interaction between core eating psychopathology and emotional regulation difficulties provides ongoing challenges for full symptom remission. In an open pilot trial, we aimed to investigate the efficacy of a program integrating family-based treatment (FBT) and dialectical behavior therapy (DBT) in treating adolescent BN, without exclusion criteria. Participants were 35 adolescents who underwent partial hospital treatment for BN, and outcomes included measures of core BN pathology and emotional regulation difficulties, as well as parental measures of self-efficacy, completed at intake and discharge. Results indicate significant improvements in overall eating disorder pathology, t(68) = 4.52, p = .002, and in core BN symptoms, including objective binge episodes, t(68) = 2.01, p = .041, and self-induced vomiting, t(68) = 2.90, p = .005. Results also illustrated a significant increase in parental efficacy throughout the course of treatment, t(20) = .081, p = .001, although no global improvement in difficulties in emotion regulation was noted, t(68) = 1.12, p = .285. These preliminary findings support the utility of this integration of FBT and DBT, although raise interesting questions as to the mechanism of symptom remission.

The Binge and the Brain.

Who hasn't dipped into that pint of Häagen-Dazs with the best of intentions and ended up finishing the entire container? Knowing where the line is when it comes to out-of-control impulse consumption is at the heart of binge-eating disorder (BED), a newly recognized mental condition that effects affects millions of people and that we are just beginning to better understand-from both a neurobiological and clinical standpoint.