Incidence of mental disorders in soldiers deployed to Afghanistan who have or have not experienced a life-threatening military incident-a quasi-experimental cohort study.

Introduction: There is very good international research on deployment-related mental disorders in military personnel. The incidence rates show a very wide range. A new strategy is therefore proposed in order to achieve better standardization and thus better comparability of the studies. In addition to a non-deployed comparison group, we propose to compare deployed soldiers with and without critical military incidents during the deployment. This additional distinction makes it possible to differentiate between the influencing variables of actual threat and general deployment stress. Methods: N = 358 male combat soldiers deployed to Afghanistan were included in the study. Clinical interviews were conducted several days before deployment and after deployment. Of them, n = 80 soldiers suffered a life-threatening military incident during deployment, whereas 278 soldiers did not. Odds ratios (OR) were calculated for the groups with and without critical military incidents and the new onset for PTSD, anxiety disorders and depressive disorders. Results: When comparing both groups, we found significantly higher 1-year incidence rates in the group with critical military incidents: 6.4% vs. 1.1% (OR 6.2) for post-traumatic stress disorder (PTSD); 7.0% vs. 1.1% (OR 6.5) for depression; and 15.9% vs. 2.8% (OR 6.6) for anxiety disorders. The 1-year incidence rate of mental multimorbidity (PTSD with anxiety or depression) was 4.8% vs. 0.4% (OR 12.0). Discussion: These results indicate that life-threatening military incidents during military deployment are important to mental health. As the different threat levels of the various missions are taken into account, additional predictors could be determined more precisely in further research.

Transition support for patients admitted to intensive treatment for anorexia nervosa: qualitative study of patient and carer experiences of a hybrid online guided self-help intervention (ECHOMANTRA).

BACKGROUND: Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides psychoeducation and support to augment usual care. AIMS: To explore patient and carer experiences of receiving the ECHOMANTRA intervention. METHOD: This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts. RESULTS: Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability. CONCLUSIONS: Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.

Virtual food exposure with positive mood induction or social support to reduce food anxiety in anorexia nervosa: A feasibility study.

OBJECTIVE: Aversive emotions toward food and the consequences of eating are at the core of anorexia nervosa. Exposure therapy is effective to reduce anxiety and avoidance toward feared stimuli. Based on the inhibitory learning framework, this study examined the feasibility to induce social support or positive mood to enhance the impact of a single session virtual food exposure on food-related anxiety in anorexia nervosa. METHOD: One hundred and forty-five patients were randomized to: (1) virtual food exposure (i.e., baseline condition), (2) virtual food exposure plus positive mood induction (i.e., positive mood condition), or (3) virtual food exposure plus social support (i.e., social support condition). They completed self-report assessments of anxiety toward virtual foods, general anxiety, positive mood, social support, and hunger, before and after virtual food exposure. Number of eye gazes and touches toward foods were recorded during the virtual reality exposure. RESULTS: Patients had lower levels of anxiety toward virtual foods in the positive mood condition, compared to the baseline condition [F(2,141) = 4.36, p = .015; medium effect size]. They also touched food items more often in the baseline condition. No other significant changes were found. DISCUSSION: Virtual food exposure enhanced by positive mood induction seems a feasible approach to strengthen the impact of food exposure in anorexia nervosa. PUBLIC SIGNIFICANCE: This research contributes to the understanding of how patients with anorexia nervosa can be supported to overcome fear and anxiety around food. Virtual reality enables patients to expose themselves to difficult situations (e.g., kitchen with foods of various calorie contents) while experiencing positive stimuli, such as a loving and kind pet or a supportive avatar.

Every mistake is a treasure: Lessons learned from the TRIANGLE trial for anorexia nervosa.

BACKGROUND: Despite several decades of treatment research for anorexia nervosa (AN), many of the same questions remain: how to boost enrollment, engage participants, prevent attrition, and meet the needs of a diverse patient population within the rigorous framework of a randomized controlled trial (RCT). METHODS: In this research forum, we highlight some of the challenges and opportunities observed over the course of TRIANGLE, the largest RCT for severe AN treatment in the UK to date. We discuss strategies for addressing common challenges and avoiding common pitfalls and propose solutions to future researchers seeking to conduct treatment research in AN. RESULTS: Our experience underscores the value of involving people with lived experience at every stage of intervention research. We offer additional recommendations for treatment researchers, including, (1) early qualitative research to identify patient barriers and obstacles, (2) clear, systematic collaboration with clinical sites for patient recruitment and passive data collection, (3) careful consideration of assessment metrics, including repeated measurement of quality of life, (4) adopting a flexible, patient-centered approach to clinical trial research, and (5) considering the unique needs and obstacles that might impact carer participation in research and their ability to provide support to their loved ones. DISCUSSION: We hope that these lessons learned will prove fruitful for the next generation of researchers embarking on treatment research for AN. PUBLIC SIGNIFICANCE: Using the TRIANGLE trial as an illustrative case study, we highlight the value of lived experience and codesign for developing and testing interventions for AN. We offer several lessons learned over the course of the trial, pertaining to trial enrollment, retention and engagement, measurement of outcomes, and research adaptations for real-world settings, and hope that these recommendations facilitate future treatment research for AN.

Changes in the eating disorder voice over time and the association of voice characteristics at baseline with clinical symptoms in patients with anorexia nervosa.

OBJECTIVE: Patients with eating disorders report the experience of living with an eating disorder voice, a second- or third-person, negative commentary about eating, weight, shape and their implications for self-esteem. Qualitative and cross-sectional studies suggest that the severity and characteristics of the eating disorder voice might play a role in the maintenance of eating disorder symptoms. The goal of this study was to expand the evidence base as to how the eating disorder voice changes over time and whether the characteristics of the voice are associated with changes in eating disorder symptoms during treatment. METHOD: Seventy-two patients with anorexia nervosa receiving intensive eating disorder treatment were recruited. They completed self-report measures of eating disorder symptoms, psychological distress and eating disorder voice's severity and characteristics (e.g., malevolence, benevolence and omnipotence) at baseline and approximately 6 months later. RESULTS: Over time, patients reported lower levels of eating and weight concern (small effect size), shape concern (large effect size) and anxiety (small effect size). They also reported a reduction in the severity, perceived malevolence (medium effect size) and omnipotence (small effect size) of the eating disorder voice. Greater severity and malevolence of the voice, and lower benevolence at baseline predicted greater reductions in eating disorder symptoms (i.e., restraint and shape concern). CONCLUSION: Beliefs about the eating disorder voice (i.e., malevolence) and severity of the voice appear to be malleable to treatment and are associated with a reduction of eating disorder symptoms. The potential of using dialogical approaches to target the eating disorder voice is discussed.

Emotional reactivity and prosocial behaviour in response to witnessing social exclusion in adolescents with eating disorders and healthy controls.

BACKGROUND: Prosocial behaviour can promote positive social interactions and it is a key skill in adolescence. People with emotional problems or psychiatric disorders, such as people with eating disorders might have impairments in prosocial behaviour, due to broader documented difficulties in underlying processes (e.g., mentalizing). METHODS: The aim of this study was to examine prosocial behaviour in adolescents with eating disorders compared to healthy controls, using a computerised behavioural task. Adolescents (N = 123) including patients with eating disorders (n = 61) and healthy adolescents (n = 62) played a four-player computerised Prosocial Cyberball Game with three pre-programmed avatar players. During the task, participants witnessed the exclusion of one of the players, and subsequently had the opportunity to compensate for this by throwing the ball more often to the excluded player. Throughout the game, participants rated the level of negative emotion in themselves and in the excluded player. RESULTS: Patients made significantly fewer ball tosses towards the excluded player during the compensation round compared to healthy controls (large effect size). Patients reported a significantly smaller increase in negative emotion after witnessing the exclusion and a significantly smaller decrease in negative emotion following the compensation round (large effect sizes). Patients also estimated a smaller decrease in negative emotion in the excluded player following the compensation round (medium effect size). There were no significant associations between these outcomes and eating disorder psychopathology in patients. CONCLUSIONS: Compared to healthy adolescents, adolescent patients with eating disorders demonstrated less prosocial compensatory behaviour towards a computerised victim of social exclusion. In addition, they reported flatter negative emotion in themselves in response to witnessing and compensating for exclusion, and in the excluded player following compensation. If these findings are replicated, interventions to target these difficulties might contribute to improvements in social functioning in this patient group.

Prosocial behaviour (actions that benefit others) can promote positive social relationships. People with eating disorders may have impairments in prosocial behaviour because of difficulties in underlying processes (e.g., identifying emotions in oneself and in others). This study explored prosocial behaviour in 61 adolescents with eating disorders (77% anorexia nervosa) and 62 healthy adolescents, with an average age of 16. Each participant joined a 4-player computerised ball-tossing game with three pre-programmed avatars (i.e., only the participant was really playing the game; the three other avatars were not representing real players). Participants were initially included fairly in the game (i.e., the avatars were programmed to toss the ball equally to one another). In the next round, the participant merely observed the game (they could not actively participate). During this observation round, two of the avatars excluded the third avatar. In the final round, the participant was able to participate again, and could toss the ball to any of the three avatar players. Thus, the participant had the opportunity to compensate the avatar victim by tossing the ball more frequently to them. Throughout the game, the participant also rated the levels of negative emotion in themselves and in the avatar victim. After observing the exclusion, on average all participants tossed the ball more frequently to the avatar victim, but patients did so less frequently. Similarly, all participants reported more negative emotion, but this increase was smaller in patients. After the opportunity to compensate the victim, all participants reported less negative emotion in themselves and in the victim, but this decrease was smaller in patients. These outcomes were not linked to the severity of eating disorder symptoms in patients.

Exploring Correlations of Food-Specific Disgust with Eating Disorder Psychopathology and Food Interaction: A Preliminary Study Using Virtual Reality.

The emotion of disgust is thought to play a critical role in maintaining restrictive eating among individuals with anorexia nervosa. This exploratory cross-sectional study examined correlations between food-specific trait and state disgust, eating disorder psychopathology, illness severity (body mass index: BMI), and interactions with virtual foods in people with anorexia nervosa. Food-specific trait disgust and eating disorder symptoms were measured before exposure to virtual foods in one of three virtual reality (VR) kitchens to which participants were randomly allocated. Food interactions (eye gaze and reaching towards virtual foods) were measured during the VR exposure. Food-specific state disgust ratings were collected after the VR exposure. In the entire sample, eating disorder symptoms correlated positively with food-specific trait disgust (rs (68) = 0.45, p < 0.001). We also found a significant association between food-specific state disgust and eating disorder symptoms in each virtual kitchen scenario: virtual kitchen only (rs (22) = 0.40, p = 0.05), virtual kitchen plus pet (rs (22) = 0.80, p < 0.001), and virtual kitchen plus avatar (rs (20) = 0.78, p < 0.001). No significant correlation was observed for the link between food-specific disgust measures and food-related touch. Correlations between food-specific trait disgust and food-related eye gaze differed across scenarios. The current experimental paradigm needs to be improved to draw firm conclusions. Both food-specific trait and state disgust are associated with eating disorder psychopathology, and therefore, effective strategies are warranted to attenuate food-specific disgust.

Food-related aversion in a female sample of people with anorexia nervosa: Cognitive-behavioural correlates, somatic and subjective anxiety, and early experiences.

OBJECTIVE: Food-related anxiety and avoidance are key features of anorexia nervosa, and among the most arduous maintaining processes to address in treatment. This study gathered information on the behavioural and cognitive correlates of food-related anxiety, including their associations with early experiences of aversive learning related to food, and more general anxiety. METHODS: One-hundred and forty-four patients with anorexia nervosa were recruited from clinical services in Italy. They completed online questionnaires to assess food-related anxiety, eating disorder psychopathology, eating disorder safety behaviours and threat cognitions, early experience of aversive learning related to food, and somatic anxiety. RESULTS: Experiences of food-related aversive learning were recalled by the majority of the sample (87.86%), with negative psychological consequences following eating being the most often reported (75%). Safety behaviours and threat cognitions related to the consequences of eating were also reported (14.29%-87.86%, and 36.43-90% respectively, depending on the behaviour/cognition). Eating disorder psychopathology was predicted by both somatic anxiety and negative psychological consequences following eating, whereas self-reported food anxiety was only predicted by somatic anxiety. CONCLUSION: Findings validate an anxiety-based model of anorexia nervosa which establishes the role of safety behaviours, threat cognitions, early aversive learning experiences, and anxiety in the psychopathology of the illness. Exposure-based interventions have the potential to target these factors, and inhibit food-related fear.

Cognitive bias modification training of attention and interpretation to reduce expectations of social rejection in adolescents with eating disorders: A small efficacy randomized controlled trial.

OBJECTIVE: This study aimed to investigate whether a computerized cognitive bias modification training delivered remotely would reduce expectations of rejection in adolescents with eating disorders. METHOD: Sixty-seven adolescents aged 12-18 (99.5% female) with an eating disorder diagnosis (94% anorexia nervosa) and receiving specialist treatment were recruited. Participants were randomized to an intervention condition (n = 37) which included treatment as usual (TAU) supplemented by nine sessions of online cognitive bias modification training for social stimuli (CBMT + TAU), or a control condition (n = 30), which included TAU only. Participants were invited to complete assessments at baseline and post-intervention. RESULTS: In the intervention condition, 22/37 participants completed six or more training sessions and post-intervention measures, the pre-defined criteria to be considered "completers." In the control condition, 28/30 participants completed the post-intervention measures. Participants who completed the intervention displayed a significantly greater reduction in negative interpretations of ambiguous social scenarios, with a medium effect size (p = .048, ηp2 = .090), and eating disorder psychopathology, with a medium effect size (p = .027, ηp2 = .105), compared to participants in the control condition. No significant between-group differences were found on emotional response to criticism, and anxiety and depression symptoms post-intervention (ps > .05; small effect sizes). DISCUSSION: Enhancing treatment as usual with CBMT targeting expectations of social rejection might be feasible and effective to reduce expectations of social rejection and eating disorder psychopathology in adolescents with eating disorders. Training adaptations might be necessary to impact on emotional processing and comorbid psychological distress. PUBLIC SIGNIFICANCE: Adolescents with eating disorders who completed a brief (4-week) online cognitive training intervention, alongside their usual treatment, reported greater reductions in expectations of social rejection and eating disorder psychopathology after the intervention, compared to a separate group of patients who received their usual treatment only. This brief and accessible intervention may be a helpful treatment adjunct for adolescents with eating disorders.

Transitions from intensive eating disorder treatment settings: qualitative investigation of the experiences and needs of adults with anorexia nervosa and their carers.

BACKGROUND: Relapse rates for individuals with anorexia nervosa after intensive hospital treatment (in-patient or full-time day care) are high. Better knowledge about the difficulties and opportunities that arise during this transition is needed to identify factors that support or hinder continued recovery upon discharge. AIMS: The aim of this study was to explore the experiences of adult patients and their chosen carers on the process of transitioning from intensive eating disorder treatment settings to the community. METHOD: Semi-structured interviews were conducted with patients with anorexia nervosa (n = 11) discharged from day or in-patient care from specialised eating disorder units across the UK, and their chosen carers (n = 20). Data were analysed with inductive thematic analysis. RESULTS: Four interrelated themes were identified for both groups. For patients, themes were continuity of care, ambivalence about continued recovery, the value of social support and a call for enhanced transition support. For carers, themes were the impact of the eating disorder on themselves and the family, perceptions of recovery and support post-discharge, the impact of previous treatment and care experiences, and desire to create a supportive transition process. CONCLUSIONS: The study provides an insight into the unique challenges that individuals with anorexia nervosa face upon leaving intensive treatment. A lack of post-discharge planning, support system and identity formation outside of anorexia nervosa were perceived as barriers to continued recovery. Patients and carers advocated for transition support that incorporates a phased, inclusive approach with accessible professional and social support in the community.

Targeting binge eating in bulimia nervosa and binge eating disorder using inhibitory control training and implementation intentions: a feasibility trial.

BACKGROUND: This trial examined the feasibility, acceptability, and effect sizes of clinical outcomes of an intervention that combines inhibitory control training (ICT) and implementation intentions (if-then planning) to target binge eating and eating disorder psychopathology. METHODS: Seventy-eight adult participants with bulimia nervosa or binge eating disorder were randomly allocated to receive food-specific, or general, ICT and if-then planning for 4 weeks. RESULTS: Recruitment and retention rates at 4 weeks (97.5% and 79.5%, respectively) met the pre-set cut-offs. The pre-set adherence to the intervention was met for the ICT sessions (84.6%), but not for if-then planning (53.4%). Binge eating frequency and eating disorder psychopathology decreased in both intervention groups at post-intervention (4 weeks) and follow-up (8 weeks), with moderate to large effect sizes. There was a tendency for greater reductions in binge eating frequency and eating disorders psychopathology (i.e. larger effect sizes) in the food-specific intervention group. Across both groups, ICT and if-then planning were associated with small-to-moderate reductions in high energy-dense food valuation (post-intervention), food approach (post-intervention and follow-up), anxiety (follow-up), and depression (follow-up). Participants indicated that both interventions were acceptable. CONCLUSIONS: The study findings reveal that combined ICT and if-then planning is associated with reductions in binge eating frequency and eating disorder psychopathology and that the feasibility of ICT is promising, while improvements to if-then planning condition may be needed.

A multifaceted study of interpersonal functioning and cognitive biases towards social stimuli in adolescents with eating disorders and healthy controls.

BACKGROUND: Cognitive biases towards social stimuli have been identified as one of the putative modifiable mechanisms to remediate interpersonal difficulties in adolescents with mental disorders. However, evidence for these biases in adolescents with eating disorders is scarce. METHODS: This study assessed interpersonal sensitivity, cognitive biases towards social stimuli, and quantity and quality of social group memberships in adolescents with eating disorders (n = 80), compared to healthy controls (n = 78), and examined whether a negative interpretation bias would mediate the relationship between interpersonal sensitivity, eating disorder symptoms and positive group memberships. RESULTS: Adolescents with eating disorders displayed greater interpersonal awareness, negative interpretation biases of ambiguous social information and poorer quality relationships with their social groups compared to healthy controls. In a simple mediation model, interpersonal awareness predicted eating disorder symptoms, and this effect was partially mediated by a negative interpretation bias. CONCLUSIONS: Psychological interventions which aim to reduce a negative interpretation bias might help to reduce the severity of eating disorder symptoms in adolescents with eating disorders.

An examination of social group memberships in patients with eating disorders, carers, and healthy controls.

This study compared the quantity and quality of social group memberships in patients with anorexia nervosa (n = 30), carers of patients with anorexia nervosa, unrelated to those patients (n = 30), and two cohorts of healthy controls (n = 60) age-matched to these focal groups. A secondary aim was to examine the associations between the quality of group relationships and severity of eating disorder and depression symptoms in patients; and depression symptoms in carers. Participants completed the online Social Identity Mapping Tool, which was used to measure the quantity and quality of social group memberships (e.g., number of social groups, number of groups rated 'highly positive'). Participants also completed self-report measures of clinical symptoms. Compared to controls, patients reported fewer social groups when eating disorder-related groups were included, and significantly fewer social groups, and community groups in particular, when eating disorder-related groups were excluded. Number of positive groups was negatively associated with severity of eating disorder and depression symptoms in patients when eating disorder-related groups were excluded. Carers reported fewer groups overall, fewer family groups, and fewer positive and supportive groups compared to healthy controls. There was a weak association between the number of positive groups and the severity of depression symptoms in carers. Positive group memberships might play a protective role towards developing more severe eating disorder and depression symptoms.

A systematic review of interventions to support transitions from intensive treatment for adults with anorexia nervosa and/or their carers.

AIM: In the short term, intensive treatment focusing on restoring weight for anorexia nervosa can remediate many symptoms. However, there is a high level of relapse after discharge. This paper examines interventions developed to bridge the transition from intensive to less intensive forms of treatment for adult anorexia nervosa. METHOD: We undertook a systematic review of the literature on interventions aimed at providing transition support. The Template for Intervention Description and Replication was used to describe components of the transition interventions. Patient's drop-out rates, weight, eating disorder psychopathology and mood data were extracted at end of treatment and follow-up to describe preliminary efficacy. RESULTS: Fourteen studies were selected: nine used psychological interventions delivered through face-to-face talking therapy or guided self-help, three examined the use of fluoxetine and two assessed stepped-care approaches. Transition support was delivered to patients in 11 studies, to patients and carers in two studies, and carers alone in another study. CONCLUSIONS: There was a great heterogeneity in the content and structure of the transition interventions evaluated. Overall, drop-out rates were lower for psychological support than pharmacological interventions or stepped-care approaches. Changes in eating disorder outcomes and mood were small to moderate throughout for studies that included a comparison group.

A Critical Review of Studies Assessing Interpretation Bias Towards Social Stimuli in People With Eating Disorders and the Development and Pilot Testing of Novel Stimuli for a Cognitive Bias Modification Training.

People with eating disorders display a negative interpretation bias towards ambiguous social stimuli. This bias may be particularly relevant to young people with the illness due to the developmental salience of social acceptance and rejection. The overall aim of this study was to systematically develop and validate stimuli for a cognitive bias modification training to reduce a social rejection-related negative interpretation bias in young people with eating disorders. A mixed-methods design was used to achieve this aim. A review of the literature was conducted using EMBASE, MEDLINE, PsycINFO, Web of Science, and PubMed. Six studies were included in the review. Focus groups were held with patients with eating disorders, carers and healthcare professionals. Content analysis was used to identify key themes from the qualitative data. Based on these themes, a total of 339 scenarios were generated by the researchers. Salient themes identified from the focus group data included virtual rejection/exclusion, rejection associated with an aspect of the eating disorder, rejection triggered by ambiguous/benign comments or behaviors of others and rejection perceived when confiding in others. Patients rated these scenarios in terms of their age-relevance and emotional salience and 301 scenarios were included in the final stimulus set. These materials may be used by researchers conducting future experimental research into the potential benefits of interpretation bias training for young people with eating disorders.

COVID Isolation Eating Scale (CIES): Analysis of the impact of confinement in eating disorders and obesity-A collaborative international study.

Confinement during the COVID-19 pandemic is expected to have a serious and complex impact on the mental health of patients with an eating disorder (ED) and of patients with obesity. The present manuscript has the following aims: (1) to analyse the psychometric properties of the COVID Isolation Eating Scale (CIES), (2) to explore changes that occurred due to confinement in eating symptomatology; and (3) to explore the general acceptation of the use of telemedicine during confinement. The sample comprised 121 participants (87 ED patients and 34 patients with obesity) recruited from six different centres. Confirmatory Factor Analyses (CFA) tested the rational-theoretical structure of the CIES. Adequate goodness-of-fit was obtained for the confirmatory factor analysis, and Cronbach alpha values ranged from good to excellent. Regarding the effects of confinement, positive and negative impacts of the confinement depends of the eating disorder subtype. Patients with anorexia nervosa (AN) and with obesity endorsed a positive response to treatment during confinement, no significant changes were found in bulimia nervosa (BN) patients, whereas Other Specified Feeding or Eating Disorder (OSFED) patients endorsed an increase in eating symptomatology and in psychopathology. Furthermore, AN patients expressed the greatest dissatisfaction and accommodation difficulty with remote therapy when compared with the previously provided face-to-face therapy. The present study provides empirical evidence on the psychometric robustness of the CIES tool and shows that a negative confinement impact was associated with ED subtype, whereas OSFED patients showed the highest impairment in eating symptomatology and in psychopathology.

Exploring the ways in which COVID-19 and lockdown has affected the lives of adult patients with anorexia nervosa and their carers.

OBJECTIVE: This qualitative study explores the ways in which the coronavirus disease 2019 (COVID-19) pandemic and associated lockdown measures have affected the lives of adult patients with anorexia nervosa (AN) and their carers. METHOD: Semi-structured interviews were conducted with patients with AN (n = 21) and carers (n = 28) from the start of UK Government imposed lockdown. Data related directly to the impact of lockdown and COVID-19 were analysed using thematic analysis. RESULTS: Four broad themes were identified for patients and carers separately. Patients experienced: 1. reduced access to eating disorder (ED) services; 2. disruption to routine and activities in the community; 3. heightened psychological distress and ED symptoms; 4. increased attempts at self-management in recovery. Carer themes included: 1. concern over provision of professional support for patients; 2. increased practical demands placed on carers in lockdown; 3. managing new challenges around patient wellbeing; 4. new opportunities. CONCLUSIONS: Reduced access to ED services, loss of routine and heightened anxieties and ED symptoms resulting from COVID-19 and lockdown measures presented challenges for patients and carers. Increased remote support by ED services enabled the continuation of treatment and self-management resources and strategies promoted self-efficacy in both groups.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness.

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

Interpersonal difficulties in obesity: A systematic review and meta-analysis to inform a rejection sensitivity-based model.

Obesity is associated with difficulties due to stigma and loneliness. These impact negatively on individuals' quality of life and behaviour change efforts. Increased sensitivity to others' negative feedback might play a role in the maintenance of these difficulties and could be addressed in psychological interventions. We conducted a systematic review of interpersonal difficulties in individuals with obesity, across the lifespan. We investigated early interpersonal adversity (i.e. frequency of teasing/bullying), perceived interpersonal stress and quality of social life, based on a rejection sensitivity model. The databases PubMed, Web of Knowledge and AGRIS, Embase, Medline and PsychINFO were searched for published peer-reviewed journal articles (1980-June 2018). Thirty-two studies met inclusion criteria. Results from the meta-analyses (n = 16 studies) indicated that overweight/obese individuals reported more frequent experiences of teasing/bullying, greater interpersonal stress and poorer quality of social life than healthy weight individuals. Findings in the systematic review aligned to this evidence. Psychological interventions targeting increased sensitivity to negative interpersonal feedback could improve interpersonal functioning and, in turn, eating behaviours in individuals with obesity.