Expressive writing as a therapeutic intervention for people with advanced disease: a systematic review.

BACKGROUND: Expressive writing involves writing about stressful or traumatic experiences. Despite trials in people with advanced disease, no systematic review to date has critiqued the evidence on expressive writing in this population. To synthesise the evidence of the effects of expressive writing on pain, sleep, depression and anxiety in people with advanced disease. METHODS: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, CENTRAL, PsycINFO and PubMed were searched from January 1986 to March 2018. Other sources included clinical data registers and conference proceedings. Studies were included if they were randomised controlled trials that assessed the impact of an intervention involving expressive writing for adults with advanced disease and/or studies involving linguistic analysis on the expressive writing output. Methodological quality was assessed using the Cochrane risk of bias tool and the Mixed Methods Appraisal Tool. The Grading of Recommendations Assessment, Development and Evaluation tool was used to assess the level of evidence for the outcomes of interest. The protocol of this systematic review has been registered on PROSPERO (CRD42017058193). RESULTS: Six eligible studies with a total of 288 participants were identified, including four randomised controlled trials. All of the trials were in cancer and recruited predominantly women. None of the interventions were tailored to the population. Studies had methodological shortcomings and evidence was generally of low quality. Combined analysis of the four trials, involving 214 participants in total, showed no clear difference in the effect of expressive writing on sleep, anxiety or depression compared to an active control. Pain was not evaluated in the trials. In contrast, analysis of the four studies that included linguistic analysis alluded to linguistic mechanisms for potential effects. CONCLUSION: Although the trial results suggest there is no benefit in expressive writing for people with advanced disease, the current evidence is limited. There is a need for more rigorous trials. It would be of benefit first to undertake exploratory research in trial design including how best to measure impact and in tailoring of the intervention to address the specific needs of people with advanced disease. TRIAL REGISTRATION: The protocol of this systematic review has been registered on PROSPERO, which can be accessed here (registration number: CRD42017058193 ).

Helplessness, mastery and the development of eating disorders: exploring the links between vulnerability and precipitating factors.

BACKGROUND: Helplessness and mastery in childhood and in response to the events that trigger onset are implicated in the development of eating disorders. However, no studies have yet explored how these are linked and whether the effects are additive or mediated. METHOD: Semi-structured interviews (Childhood Experience of Care and Abuse; Life Events and Difficulties Schedule; Coping Strategies Interview) were used to assess helplessness and mastery in childhood and in response to a provoking agent in 15 eating disordered and 19 non-eating disordered women. RESULTS: Helplessness and mastery in childhood were related to helplessness and mastery in response to the events and difficulties that triggered onset of the eating disorder. However, only the presence of helplessness and the lack of mastery in response to this provoking agent predicted onset. CONCLUSION: Helplessness and mastery are vulnerability and protective factors but only in those women who develop an eating disorder in the context of later life events. It is suggested that helplessness and mastery in childhood act via their influence on the adequacy of coping in response to later life events.

Adherence to prophylaxis in adolescents and young adults with severe haemophilia: a qualitative study with healthcare professionals.

Aim: to examine healthcare professionals' (HP) perceptions and experiences in relation to adherence to prophylactic treatment among young people living with haemophilia (YPH). Methods: All HPs in four haemophilia centres across England and Wales were invited to participate, and all HPs who agreed to take part (n = 6) were interviewed. Interviews were audio-recorded, transcribed and then analysed using Interpretative Phenomenological Analysis (IPA). Results: HPs estimate that generally young people with haemophilia keep to their treatment regimen well, although they also recognise that adherence may fluctuate with many patients going through shorter periods of non-adherence. The increasingly personalised or flexible approach to prophylaxis makes it harder to assess adherence. The main themes identified through IPA included (1) HPs' suggest that adherence fluctuates (2) Non-adherence is mainly driven by lifestyle and developmental, social and family factors, and (3) Education, HPs' sensitivity to individual needs, and psychological and peer support are key facilitators of good adherence. Conclusion: The increasingly flexible approach to prophylaxis requires a new way of thinking about, and assessment of, adherence. More personalised treatment regimen can be more complicated and may, therefore, lead to accidental non-adherence. The results of this study with HPs complement those of a previous qualitative study with patients but place greater emphasis on a broader perspective on understanding drivers of non-adherence as well as understanding strategies to improve adherence in the minority of patients who appear to struggle.

Adherence to prophylaxis in adolescents and young adults with severe haemophilia A, a qualitative study with patients.

Introduction: Reported levels of adherence to prophylaxis among young people with haemophilia (YPH) vary widely and are predominately based on estimations made by healthcare professionals and parents. Reasons for (non)adherence among YPH in particular have not been evidenced. Aim: to examine experiences in relation to prophylaxis with YPH themselves, and barriers and facilitators to their adherence. Methods: 11 Participants were recruited in five haemophilia centres across England and Wales. All patients who met the inclusion criteria (aged 12-25, diagnosed with haemophilia, on prophylaxis) were approached during a routine check-up appointment, and all participants who agreed to take part were interviewed. Interviews were audio recorded, transcribed and analysed using Interpretative Phenomenological Analysis. Results: Self-reported adherence to prophylaxis was good. Few participants admitted to intentionally skipping injections although they reported sometimes forgetting. However, due to the increasingly personalised and flexible approach to prophylaxis, adherence is not straightforward to define. Barriers to adherence included a busy lifestyle, dislike of the intravenous injection, venous access issues, anxiety or stress and being out of one's normal routine. Support was an important facilitator to adherence, including support from health professionals at the haemophilia centre as well as friends. Parents appear to be very involved with their child's haemophilia management, even after they leave home. Conclusion: What this study adds is that the increasingly flexible and personalised approach to managing prophylaxis in haemophilia may sometimes lead to confusion around treatment frequency and dosing. This may lead to accidental non-adherence, which is distinct from both skipping and forgetting. Advice from haemophilia teams may not always be consistent and is likely to be interpreted differently by different individuals. Some additional training and education of patients and their families to increase their knowledge and skills around prophylaxis may reduce this confusion and therefore is likely to improve adherence further.

The impact of an emotionally expressive writing intervention on eating pathology in female students.

Introduction: Previous research demonstrating emotional influences on eating and weight suggest that emotionally expressive writing may have a significant impact on reducing risk of eating pathology. This study examined the effects of writing about Intensely Positive Experiences on weight and disordered eating during a naturalistic stressor. Method: Seventy-one female students completed an expressive or a control writing task before a period of exams. Both groups were compared on BMI (kg/m2) and the Eating Disorder Examination - Questionnaire (EDE-Q) before the writing task and at 8-week follow-up. A number of secondary analyses were also examined (to identify potential mediators) including measures of attachment, social rank, self-criticism and self-reassurance, stress and mood. Results: There was a significant effect of intervention on changes in the subscales of the EDE-Q (p = .03). Specifically, expressive writers significantly reduced their dietary restraint while those in the control group did not. There was no significant effect of the intervention on changes in BMI or the other subscales of the EDE-Q (Eating, Weight and Shape Concern). There was also no effect of writing on any of the potential mediators in the secondary analyses. Discussion: Emotionally expressive writing may reduce the risk of dietary restraint in women but these findings should be accepted with caution. It is a simple and light touch intervention that has the potential to be widely applied. However, it remains for future research to replicate these results and to identify the mechanisms of action.

Affect systems, changes in body mass index, disordered eating and stress: an 18-month longitudinal study in women.

Background: Evidence suggests that stress plays a role in changes in body weight and disordered eating. The present study examined the effect of mood, affect systems (attachment and social rank) and affect regulatory processes (self-criticism, self-reassurance) on the stress process and how this impacts on changes in weight and disordered eating. Methods: A large sample of women participated in a community-based prospective, longitudinal online study in which measures of body mass index (BMI), disordered eating, perceived stress, attachment, social rank, mood and self-criticism/reassurance were measured at 6-monthly intervals over an 18-month period. Results: Latent Growth Curve Modelling showed that BMI increased over 18 months while stress and disordered eating decreased and that these changes were predicted by high baseline levels of these constructs. Independently of this, however, increases in stress predicted a reduction in BMI which was, itself, predicted by baseline levels of self-hatred and unfavourable social comparison. Conclusions: This study adds support to the evidence that stress is important in weight change. In addition, this is the first study to show in a longitudinal design, that social rank and self-criticism (as opposed to self-reassurance) at times of difficulty predict increases in stress and, thus, suggests a role for these constructs in weight regulation.

Establishing a useful distinction between current and anticipated bodily shame in eating disorders.

Previous research has suggested a role for bodily shame in the development of bulimia. The purpose of the present study was to extend this research by exploring a temporal perspective on bodily shame and eating pathology. Specifically, we were interested in whether bodily shame associated with the possibility of future weight gain was important in determining eating disorder symptoms independently of any association with bodily shame associated with current body size. A brief questionnaire designed to measure bodily shame was developed for the purposes of this study and administered to four samples (total n=428) of eating disordered and non-eating disordered women who also completed a number of measures of eating pathology. Factor analysis of the bodily shame scale identified three sub-scales, two measuring feelings of bodily shame (one measuring shame associated with current body size and one measuring shame that is anticipated should the individual gain weight) and a third measuring the perceived unattractiveness of being overweight. Anticipated bodily shame made a significant additional contribution to predicting eating disorder symptoms over and above that made by current bodily shame. A focus on feelings of bodily shame as they are currently experienced may limit the usefulness of this construct in eating disorder research. Since shame can be both punishing and prohibitive, consideration of the anticipation of shame as a consequence of weight gain may be a useful addition to understanding eating disordered behaviours, particularly in relation to symptoms concerning the prevention of weight gain rather than just the achievement of weight loss.

Guided self-change for bulimia nervosa incorporating use of a self-care manual.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of guided self-change for bulimia nervosa. METHOD: Sixty-two patients with DSM-III-R-defined bulimia nervosa were randomly assigned to 1) use of a self-care manual plus eight fortnightly sessions of cognitive behavior therapy (guided self-change) or 2) 16 sessions of weekly cognitive behavior therapy. RESULTS: At the end of treatment and at follow-up an average of 43 weeks after the end of therapy, substantial improvements had been achieved in both groups on the main outcome measures: eating disorder symptoms according to experts' ratings (Eating Disorder Examination subscores on overeating, vomiting, dietary restraint, and shape and weight concerns), self-reports (Bulimic Investigatory Test Edinburgh), and a 5-point severity scale. Also, improvement was seen on the subsidiary outcome measures: the Beck Depression Inventory, the Self-Concept Questionnaire, and knowledge of nutrition, weight, and shape. At follow-up, 71% of the cognitive behavior therapy group had not binged or vomited during the week preceding. In the guided self-change group, 70% had not binged and 61% had not vomited during the week before follow-up. CONCLUSIONS: Guided self-change incorporating use of a self-care manual offers an approach that can be as effective as standard cognitive behavior therapy in the long term and can considerably reduce the amount of therapist contact required.

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy.

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.

Differential environmental factors in anorexia nervosa: a sibling pair study.

OBJECTIVES: Previous studies have explored differences in psychosocial and familial factors between women who develop anorexia nervosa and those who do not. However, these studies have generally used between-group comparisons. This study looks at the environmental factors which may be antecedents of anorexia nervosa looking at sister pairs where one had anorexia nervosa and the other did not. DESIGN: A paired design was used to compare anorexic women with an unaffected sister on a number of background variables, including sibling interaction, parental care, peer group characteristics and other events unique to the individual. METHODS: The Sibling Inventory of Differential Experience (SIDE) was used to determine non-shared environment. Out of an initial sample of 148 women with past or current anorexia nervosa, 28 were identified who had sisters with no reported history of eating disorders and who also consented to complete the questionnaire. RESULTS: Anorexic sisters perceived more maternal control and reported more antagonism towards and jealousy of their sisters than did unaffected sisters. In addition, anorexic women reported having had fewer friends and boyfriends than their sisters. CONCLUSIONS: These results confirm the perceived differences in background environment between women with and women without anorexia nervosa. These issues are discussed in relation to behavioural genetics, family dynamics and psychosexual development.

Compliance with a self-care manual for bulimia nervosa: predictors and outcome.

Self-directed treatment has been shown to be effective in the treatment of bulimia nervosa. This paper shows that compliance with a manual is related to outcome. Forty per cent of high compliers achieved full remission after eight weeks with a manual, compared with only 5 per cent of low compliers. Furthermore, patients with greater weight and shape concerns were less likely to use a manual while those with a longer duration of illness were more likely to use it.

Perceptual illusions in eating disorders: rigid and fluctuating styles.

This study investigated perceptual styles in anorexia nervosa (AN) and bulimia nervosa (BN) using a perceptual set task. We hypothesised that, consistent with personality style research. AN patients might be more rigid in style than those with BN or no eating disorder. We found that once an illusion had been established, participants with AN and BN showed more illusions than non-ED women. However, while AN patients responded rigidly, giving the same response repeatedly, BN patients were more likely to change their responses. The study suggests interesting differences to be followed up in future research. Differences in rigid and fluctuating perceptual styles may have implications for understanding the phenomenology of eating disorders, and have implications for treatment.

First step in managing bulimia nervosa: controlled trial of therapeutic manual.

OBJECTIVE: To test the short term efficacy of a self directed treatment manual for bulimia nervosa. DESIGN: Randomised controlled trial of the manual against cognitive behavioural therapy and a waiting list. SETTING: Tertiary referral centre. SUBJECTS: 81 consecutive referrals presenting with bulimia nervosa or atypical bulimia nervosa. MAIN OUTCOME MEASURES: Frequency of binge eating, vomiting, and other behaviours to control weight as well as abstinence from these behaviours. RESULTS: Cognitive behavioural treatment produced a significant reduction in the frequency of binge eating, vomiting, and other behaviours to control weight. The manual significantly reduced frequency of binge eating and weight control behaviours other than vomiting, and there was no change in the group on the waiting list. Full remission was achieved in five (24%) of the group assigned to cognitive behavioural treatment, nine (22%) of the group who used the manual, and two (11%) of the group on the waiting list. CONCLUSIONS: A self directed treatment manual may be a useful first intervention in the treatment of bulimia nervosa.

Psychosocial factors in the onset of eating disorders: responses to life-events and difficulties.

A number of studies have proposed a role for stress in the onset of eating disorders. Initially the focus was on the life-events and difficulties themselves. However, the aim of this study was to examine the coping and support elicited in response to the crises that precipitate onset of eating disorders. Thirty-two women who had developed an eating disorder within four years of presentation were administered semi-structured interviews asking about events and difficulties in the year before onset, as well as how they coped and the support they received. Twenty women with no history of eating disorders acted as a comparison group. Results show that the onset of anorexic symptoms is associated with cognitive avoidance in response to a crisis while the onset of bulimic symptoms is associated with cognitive rumination. In addition, women who developed an eating disorder were more likely to be helpless in response to the crisis than women who did not develop an eating disorder. It is concluded that coping interventions may be useful in terms of primary and relapse prevention.

Setting the scene for eating disorders, II. Childhood helplessness and mastery.

BACKGROUND: Previous studies have examined childhood factors that appear to increase the risk of developing an eating disorder (e.g. sexual abuse and parental care). Studies have not yet examined whether the way in which women cope with these adversities in childhood influences the risk. METHOD: Using a semi-structured interview, childhood helplessness and mastery were measured (based on behavioural indices) in women with and without a history of eating disorders. RESULTS: There was a higher rate of childhood helplessness and a lower rate of childhood mastery in women with eating disorders compared to those without. Furthermore, this difference did not appear to be a result of current psychiatric state. CONCLUSION: It is concluded that it is not simply the presence of adversity in childhood which is of aetiological importance in the development of eating disorders but the way in which these are negotiated.

Shame, depressive symptoms and eating, weight and shape concerns in a non-clinical sample.

Shame has been shown to be related both to symptoms of depression and eating pathology. However, the independence of this relationship has not yet been established. The purpose of the present study was to determine whether the relationship between shame and eating disorder symptoms was independent of the relationships of these variables with depression. Seventy non-clinical female participants completed measures of eating disorder-related concerns using the Eating Disorder Examination-Questionnaire version (EDE-Q), depressive symptoms using the Beck Depression Inventory (BDI-II) and two measures of shame, the Other As Shamer Scale (QAS) and the Test of Self-Conscious Affect (TOSCA). Despite a strong association between BDI-II and EDE-Q scores and a moderate relationship between the shame measures, the two measures of shame showed some specificity in their relationships with symptom measures. The OAS was independently related to levels of BDI-II scores while the TOSCA was independently related to scores on the EDE-Q. There are a number of differences between the two measures of shame used in this study. The fact that each was differentially related to eating concerns and depressive symptoms may give clues as to which aspects of shame are important in each of the two types of pathology.

Events and the onset of eating disorders: correcting an "age old" myth.

BACKGROUND: Previous reports have suggested differences between early and late onset cases both in anorexia nervosa and bulimia nervosa. In anorexia nervosa, women with late onset are thought to be more likely to develop symptoms in response to life events than early onset cases. Women developing anorexia in response to life events are also considered to show different background features. In bulimia nervosa, it is not known whether rates of life events before onset differ in bulimics who develop their disorder at different stages in life. METHOD: Previously published data were reanalyzed to examine differences between women whose eating disorder did or did not develop in response to stress. Seventy-two women with anorexia nervosa (48 with a severe provoking agent) and 29 women with bulimia nervosa (22 with a severe provoking agent) were administered semistructured interviews to assess life events and difficulties in the year before onset, childhood adversity, and other clinical features. RESULTS: In both anorexia nervosa and bulimia nervosa, subjects with or without a severe provoking agent did not differ from each other on age or childhood variables. The only significant difference found was that, in women developing anorexia nervosa, those who later developed bulimic symptoms alongside their anorexia reported a lower rate of provoking agents (31%) than those anorexic women who either maintained their restriction (76%) or went on to develop normal weight bulimia nervosa (69%). CONCLUSION: There are no differences between women whose eating disorder develops in response to stress and those who do not. Women presenting for treatment with anorexia nervosa of the binge-purge subtype are unlikely to have developed their illness in response to a severe provoking agent.

Stress, coping, and crisis support in eating disorders.

OBJECTIVE: Recent research has supported the role of stress in the development and maintenance of eating disorders. However, coping and crisis support, important aspects of this stress process, have received little systematic attention. The cognitive-transactional approach to coping emphasizes the importance of the relationship between the individual and the particular problematic situation and yet most studies investigating coping in eating disorders have failed to measure situation-specific coping. METHOD: The present study used semistructured interviews to measure coping and crisis support in response to severe events and/or marked difficulties in 12 women with anorexia nervosa (AN), 21 women with bulimia nervosa (BN), and 21 women without an eating disorder (non-ED). RESULTS: Women with eating disorders were more likely to use cognitive avoidance or cognitive rumination and were less likely to downplay their problems. In addition, BN subjects were more likely to blame themselves and were less likely to receive crisis support from a core-tie. Overall, women with eating disorders were less likely to be masterful in response to crises than women without eating disorders. DISCUSSION: It is concluded that women with eating disorders are less effective in their coping than women without eating disorders.

Feelings and fantasy in eating disorders: a factor analysis of the Toronto Alexithymia Scale.

The aim of the study was to examine the factor structure of alexithymia in patients with eating disorders and to compare scores on these factors with a non-eating disordered population. The Toronto Alexithymia Scale (TAS) was given to patients with restricting anorexia nervosa (AN/R, n = 29), bulimia nervosa (BN, n = 83), anorexia with a subtype bulimia (AN/BN, n = 15), and 79 female students. Factors were extracted using a principal-components factor analysis. Four factors were found--inability to Identify Feelings, Paucity of Fantasy, Noncommunication of Feelings, and Concrete Thinking. All three eating disorder groups were less able to identify their feelings than the comparison group and AN/R patients had a more diminished fantasy life than BN patients and students. Groups did not differ significantly on concrete thinking but there was a trend towards significance on noncommunication of feelings, with patient groups expressing their feelings less than comparison subjects. Differences between patient groups on factors of the TAS suggest that scores are not simply a result of psychopathology in general. Approaches which promote the identification and expression of feelings may be particularly useful in the treatment of eating disorders.