Adolescent experience of radically open dialectical behaviour therapy: a qualitative study.

BACKGROUND: Radically Open Dialectical Behaviour Therapy (RO DBT) is a novel transdiagnostic treatment that targets 'maladaptive overcontrol'; a transdiagnostic cluster of traits associated with excessive emotional and behavioural inhibitory control. Outcomes are promising for adults with a range of psychiatric disorders. No study to date has explored the adolescent experience of RO DBT. METHODS: Of the 25 eligible adolescents who received RO DBT between March 2015 and April 2017, 15 (14-17 years) consented and completed a semi-structured interview about their experience of treatment within 1 month of discharge. Interviews were recorded and then transcribed manually. Free text responses were analysed using reflexive thematic analysis. RESULTS: The majority (n = 13) had a primary diagnosis of anorexia nervosa, although comorbidity was the norm, with 80.0% having two or more predicted comorbid psychiatric diagnoses. All had received some prior psychological treatment. Four themes were identified from analysis of transcripts: 1) Broadening Horizons, 2) Building Connections, 3) Flexibility, 4) Information Overload. Generally, RO DBT was perceived as helpful in both content and process. The focus on social and broader well-being, rather than specific mental health symptoms, was considered beneficial by many. Adolescents appreciated the group-based format of skills classes and reported benefiting from learning and practicing skills each week. The fourth theme, Information Overload, highlighted that for some, the amount of content felt overwhelming and that it was hard to remember and digest all the information, suggesting that adaptations, or simplifications, may be required to ensure accessibility for adolescents. CONCLUSIONS: RO DBT is perceived as a relevant and beneficial new treatment for adolescents with maladaptive overcontrol. The broad treatment focus is perceived as unique and of particular benefit. It is reported to help with general and social functioning and foster cognitive and behavioural flexibility. Nevertheless, the amount and complexity of material was felt to be very large by some and may suggest the need for modified adolescent-specific materials.

Associations of specific-age and decade recall body mass index trajectories with obesity-related cancer.

BACKGROUND: Excess body fatness, commonly approximated by a one-off determination of body mass index (BMI), is associated with increased risk of at least 13 cancers. Modelling of longitudinal BMI data may be more informative for incident cancer associations, e.g. using latent class trajectory modelling (LCTM) may offer advantages in capturing changes in patterns with time. Here, we evaluated the variation in cancer risk with LCTMs using specific age recall versus decade recall BMI. METHODS: We obtained BMI profiles for participants from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. We developed gender-specific LCTMs using recall data from specific ages 20 and 50 years (72,513 M; 74,837 W); decade data from 30s to 70s (42,113 M; 47,352 W) and a combination of both (74,106 M, 76,245 W). Using an established methodological framework, we tested 1:7 classes for linear, quadratic, cubic and natural spline shapes, and modelled associations for obesity-related cancer (ORC) incidence using LCTM class membership. RESULTS: Different models were selected depending on the data type used. In specific age recall trajectories, only the two heaviest classes were associated with increased risk of ORC. For the decade recall data, the shapes appeared skewed by outliers in the heavier classes but an increase in ORC risk was observed. In the combined models, at older ages the BMI values were more extreme. CONCLUSIONS: Specific age recall models supported the existing literature changes in BMI over time are associated with increased ORC risk. Modelling of decade recall data might yield spurious associations.

Neuro- and social-cognitive clustering highlights distinct profiles in adults with anorexia nervosa.

OBJECTIVE: This study aimed to explore the neuro- and social-cognitive profile of a consecutive series of adult outpatients with anorexia nervosa (AN) when compared with widely available age and gender matched historical control data. The relationship between performance profiles, clinical characteristics, service utilization, and treatment adherence was also investigated. METHOD: Consecutively recruited outpatients with a broad diagnosis of AN (restricting subtype AN-R: n = 44, binge-purge subtype AN-BP: n = 33 or Eating Disorder Not Otherwise Specified-AN subtype EDNOS-AN: n = 23) completed a comprehensive set of neurocognitive (set-shifting, central coherence) and social-cognitive measures (Emotional Theory of Mind). Data were subjected to hierarchical cluster analysis and a discriminant function analysis. RESULTS: Three separate, meaningful clusters emerged. Cluster 1 (n = 45) showed overall average to high average neuro- and social- cognitive performance, Cluster 2 (n = 38) showed mixed performance characterized by distinct strengths and weaknesses, and Cluster 3 (n = 17) showed poor overall performance (Autism Spectrum disorder (ASD) like cluster). The three clusters did not differ in terms of eating disorder symptoms, comorbid features or service utilization and treatment adherence. A discriminant function analysis confirmed that the clusters were best characterized by performance in perseveration and set-shifting measures. DISCUSSION: The findings suggest that considerable neuro- and social-cognitive heterogeneity exists in patients with AN, with a subset showing ASD-like features. The value of this method of profiling in predicting longer term patient outcomes and in guiding development of etiologically targeted treatments remains to be seen.

Construction of multiple, contiguous quaternary stereocenters in acyclic molecules by lithiation-borylation.

Lithiation of carbamates followed by borylation provides a powerful method for the homologation of boron reagents. However, when applied to hindered systems (secondary carbamates with tBu-boronic esters) for the construction of two quaternary centers, this methodology fails. Instead, using mixed boranes (tBuBMe2), the synthesis of adjacent quaternary stereogenic centers with full stereocontrol was successful. The process can be repeated two or three times in one pot leading to carbon chains bearing multiple contiguous quaternary stereogenic centers. The boranes were converted into tertiary alcohols or C-tertiary amines using chloramine. The origin of the high selectivity for alkyl over Me group migration was determined computationally.

Highly selective allylborations of aldehydes using α,α-disubstituted allylic pinacol boronic esters.

α,α-Disubstituted allylic pinacol boronic esters undergo highly selective allylborations of aldehydes to give tetrasubstituted homoallylic alcohols with exceptional levels of anti-Z-selectivity (>20:1). The scope of the reaction includes both acyclic and cyclic allylic boronic esters which lead to acyclic and exocyclic tetrasubstituted homoallylic alcohols. The use of ß-borylated allylic boronic esters gave fully substituted alkenes bearing a boronic ester which underwent further cross-coupling enabling a highly modular and stereoselective approach to the synthesis of diaryl tetrasubstituted alkenes. Computational analysis revealed the origin of the remarkable selectivity observed.

What is day hospital treatment for anorexia nervosa really like? A reflexive thematic analysis of feedback from young people.

BACKGROUND: A significant proportion of young people do not respond to the NICE recommended treatment for anorexia nervosa: Family Therapy. Whilst historically these young people would be admitted to inpatient services, which are associated with greater treatment cost, greater risk of relapse, and worse outcome, more recently evidence is building for the effectiveness of day programmes. One day programme that has been found to be effective is the Intensive Treatment Programme (ITP) of the Maudsley Centre for Child & Adolescent Eating Disorders in London, UK. However, to-date no studies have investigated how young people experience such a day programme. METHOD: Anonymous feedback was completed via online survey by 51 young people over a 5-year period (2018-2023) on discharge from ITP. RESULTS: Four main themes were identified: (1) Support-young people expressed the importance of boundaries but also of feeling validated, and encouraged; (2) Uniqueness: an experience like no other-ITP was described as different to any other treatment received before (both outpatient and inpatient); (3) Relationships - young people valued connecting with others in a similar situation and reflected that relationships at home changed throughout treatment; (4) Self-development - learning skills, developing independence, and exploring an identity outside of the eating disorder was valued. CONCLUSIONS: It is hoped that the reflections from these young people can help to inform clinicians working in DPs and those hoping to set up novel DPs about key aspects of treatment.

This study examined the experiences of young people who attended an intensive treatment day programme (ITP) over a five-year period. 51 young people completed online questionnaires up to one-month after being discharged from the programme between 2018 and 2023. All young people were between the ages of 11­18 and had a diagnosis of anorexia nervosa. The authors explored all free text responses from the young people (for example: what were the most important parts of ITP) and found four common themes. These were: (1) Support ­ feeling validated, encouraged, and finding boundaries helpful, (2) Uniqueness: an experience like no other ­ treatment was different to any received before, (3) Relationships ­ connecting with others in a similar situation and relationships at home changing, (4) Self-development ­ learning skills, finding their identity, and developing independence. It is hoped that the reflections from these young people can help to inform clinicians working in DPs and those hoping to set up novel DPs about key aspects of treatment.

Patient characteristics and behaviours associated with self-harm and attempted suicide in acute psychiatric wards.

AIMS AND OBJECTIVES: The study examined events before and after incidents of self-harm and attempted suicide and the characteristics of patients who engage in these behaviours. BACKGROUND: Psychiatric inpatient populations have an elevated risk of self-harm and suicide, but relatively little is known about the circumstances of these events during an admission. DESIGN: Retrospective case note analysis. METHOD: Data were collected on conflict (aggression, rule breaking, etc.) and containment (coerced medication, restraint, etc.) during the first two weeks of admission for a sample of 522 acute psychiatric inpatients. RESULTS: One in 10 patients self-harmed, and 4% attempted suicide. Aggression, attempting to leave the ward without permission and medication refusal were frequent precursors to incidents. Pro re nata medication and de-escalation were the most frequent interventions to follow an incident. Self-harm and attempted suicides during the current admission were significantly associated with younger age and a history of self-harm. CONCLUSIONS: A minority of the sample were involved in these behaviours, but incidents occurred soon after admission and sometimes repeatedly during the course of a day. Assessment of risk should be completed as early as possible. RELEVANCE TO CLINICAL PRACTICE: At-risk patients should be monitored for signs of withdrawal from ward activity, wanting to leave the ward without permission or non-compliance with medication to enable early intervention.

Latent class trajectory modelling: impact of changes in model specification.

Latent class trajectory models (LCTMs) are often used to identify subgroups of patients that are clinically meaningful in terms of longitudinal exposure and outcome, e.g. drug response patterns. These models are increasingly applied in medicine and epidemiology. However, in many published studies, it is not clear whether the chosen models, where subgroups of patients are identified, represent real heterogeneity in the population, or whether any associations with clinically meaningful characteristics are accidental. In particular, we note an apparent over-reliance on lowest AIC or BIC values. While these are objective measures of goodness of fit, and can help identify the optimal number of subgroups, they are not sufficient on their own to fully evaluate a given trajectory model. Here we demonstrate how longitudinal latent class models can substantially change by making small modifications in model specification, and the impact of this on the relationship to clinical outcomes. We show that the predicted trajectory patterns and outcome probabilities differ when pre-specified cubic versus linear shapes are tested on the same data. However, both could be interpreted to be the "correct" model. We emphasise that LCTMs, like all unsupervised approaches, are hypotheses generating, and should not be directly implemented in clinical practice without significant testing and validation.

Weight Changes in Type 2 Diabetes and Cancer Risk: A Latent Class Trajectory Model Study.

INTRODUCTION: Body mass index (BMI) is often elevated at type 2 diabetes (T2D) diagnosis. Using latent class trajectory modelling (LCTM) of BMI, we examined whether weight loss after diagnosis influenced cancer incidence and all-cause mortality. METHODS: From 1995 to 2010, we identified 7,708 patients with T2D from the Salford Integrated Record database (UK) and linked to the cancer registry for information on obesity-related cancer (ORC), non-ORC; and all-cause mortality. Repeated BMIs were used to construct sex-specific latent class trajectories. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models. RESULTS: Four sex-specific BMI classes were identified; stable-overweight, stable-obese, obese-slightly-decreasing, and obese-steeply-decreasing; comprising 41%, 45%, 13%, and 1% of women, and 45%, 37%, 17%, and 1% of men, respectively. In women, the stable-obese class had similar ORC risks as the obese-slightly-decreasing class, whereas the stable-overweight class had lower risks. In men, the obese-slightly-decreasing class had higher risks of ORC (HR = 1.86, 95% CI: 1.05-3.32) than the stable-obese class, while the stable-overweight class had similar risks No associations were observed for non-ORC. Compared to the stable-obese class, women (HR = 1.60, 95% CI: 0.99-2.58) and men (HR = 2.37, 95% CI: 1.66-3.39) in the obese-slightly-decreasing class had elevated mortality. No associations were observed for the stable-overweight classes. CONCLUSION: Patients who lost weight after T2D diagnosis had higher risks for ORC (in men) and higher all-cause mortality (both genders) than patients with stable obesity.

Annelids of the eastern Australian abyss collected by the 2017 RV 'Investigator' voyage.

In Australia, the deep-water (bathyal and abyssal) benthic invertebrate fauna is poorly known in comparison with that of shallow (subtidal and shelf) habitats. Benthic fauna from the deep eastern Australian margin was sampled systematically for the first time during 2017 RV 'Investigator' voyage 'Sampling the Abyss'. Box core, Brenke sledge, and beam trawl samples were collected at one-degree intervals from Tasmania, 42°S, to southern Queensland, 24°S, from 900 to 4800 m depth. Annelids collected were identified by taxonomic experts on individual families around the world. A complete list of all identified species is presented, accompanied with brief morphological diagnoses, taxonomic remarks, and colour images. A total of more than 6000 annelid specimens consisting of 50 families (47 Polychaeta, one Echiura, two Sipuncula) and 214 species were recovered. Twenty-seven species were given valid names, 45 were assigned the qualifier cf., 87 the qualifier sp., and 55 species were considered new to science. Geographical ranges of 16 morphospecies extended along the eastern Australian margin to the Great Australian Bight, South Australia; however, these ranges need to be confirmed with genetic data. This work providing critical baseline biodiversity data on an important group of benthic invertebrates from a virtually unknown region of the world's ocean will act as a springboard for future taxonomic and biogeographic studies in the area.

Do traditional BMI categories capture future obesity? A comparison with trajectories of BMI and incidence of cancer.

In 2016, 13 specific obesity related cancers were identified by IARC. Here, using baseline WHO BMI categories, latent profile analysis (LPA) and latent class trajectory modelling (LCTM) we evaluated the usefulness of one-off measures when predicting cancer risk vs life-course changes. Our results in LPA broadly concurred with the three basic WHO BMI categories, with similar stepwise increase in cancer risk observed. In LCTM, we identified 5 specific trajectories in men and women. Compared to the leanest class, a stepwise increase in risk for obesity related cancer was observed for all classes. When latent class membership was compared to baseline BMI, we found that the trajectories were composed of a range of BMI (baseline) categories. All methods reveal a link between obesity and the 13 cancers identified by IARC. However, the additional information included by LCTM indicates that lifetime BMI may highlight additional group of people that are at risk.

Undertaking a face to face Summative OSCE assessment during the COVID-19 Pandemic - a descriptive narrative.

This article was migrated. The article was marked as recommended. The 2020 Covid19 pandemic has caused significant disruption to medical education across the world. At the University of Sheffield final year medical students undertook a virtual OSCE via technology in order to graduate however for our Physician Associate course this was more problematic as following completion of the assessments at the university students are also required to pass a national examination with a formal Objective Structured Clinical Examination (OSCE). Due to this it was felt that it was crucial to run an OSCE examination for our students on a face to face basis but within the context of managing the potential safety and risks inherent in doing so. This piece of work describes the process of running the examination including detail which we feel will be useful to others who may seek to undertake examinations for the same reason within the current health emergency or any future such events. It is important to note that some innovations we put in place with respect to technology enhancing safety will remain for future OSCE examinations in any circumstances.

Exploring the Experiences of Women Who Develop Restrictive Eating Behaviours After Bariatric Surgery.

OBJECTIVE: This study aimed to explore the experiences of women who had developed excessively restrictive eating behaviours following bariatric surgery. METHOD: Five female participants, who were at least nine months post-bariatric surgery and exhibiting restrictive eating behaviours, were recruited from Bariatric Surgery Psychology Services and asked to complete qualitative face-to-face semi-structured interviews. The data was analysed using interpretative phenomenological analysis (IPA). RESULTS: Three super-ordinate themes emerged: (1) experiences of weight stigma and weight history on self, (2) the impact of loose skin, (3) thoughts about food and disordered eating patterns. These captured the impact of past weight-related experiences-including weight stigma, intense fears of weight gain, negative cognitions about the self, the impact of excess skin, changes in the way the women thought about food and restrictive eating behaviours. DISCUSSION: This study is one of the first to specifically explore restrictive eating disorders after bariatric surgery using a qualitative approach. The findings of this study may offer helpful aspects for professionals to hold in mind when identifying individuals with problematic restrictive eating behaviours following bariatric surgery. Body contouring surgery, internalised weight bias and weight stigma are explored in relation to the post-bariatric surgery treatment pathway. The current diagnostic criterion for anorexia nervosa are discussed to highlight difficulties in diagnosing this presentation in the post-bariatric surgery population, where people can have BMIs over 25 kg/m2 but are severely restricting energy intake.

Revision of Hyalopale (Chrysopetalidae; Phyllodocida; Annelida): an amphi-Atlantic Hyalopale bispinosa species complex and five new species from reefs of the Caribbean Sea and Indo-Pacific Oceans.

The formerly monotypic taxon, Hyalopale bispinosa Perkins 1985 (Chrysopetalinae), is comprised of a cryptic species complex from predominantly tropical embayments and island reefs of the Western Atlantic and Indo-Pacific Oceans. Hyalopale species are of meiofaunal size (length: 1-2.8mm), but considered non-interstitial, with the majority of species inhabiting a singular habitat of shallow littoral zones among algae and epifauna overlying sediments in rubble. Hyalopale adults exhibit notochaetal fans characterized by the presence of lateral and midline notochaetal spines. Species of Hyalopale can be distinguished by the shape of glass-like notochaetal paleae and the number of densely stacked ribs. Hyalopale bispinosa forms a western and eastern Atlantic species complex, comprising the type species, Hyalopale bispinosa s.s., a comparatively larger form with the highest number of notochaetal paleael ribs from Florida, and Hyalopale cf. bispinosa, from the western and eastern Mediterranean, a smaller form with a similar notochaetal morphology to the latter. Unfortunately, no molecular sequence data is available for Hyalopale bispinosa s.s. Five new species are described, with molecular sequence data provided for three: Hyalopale leslieae sp. nov., a small form with a comparatively low number of paleal ribs, found from the Florida Keys to Belize, Caribbean Sea, H. zerofskii sp. nov. from southern California and Mexico, eastern Pacific and H. sapphiriglancyorum sp. nov., a distinctive species with the lowest number of paleael ribs, from Raja Ampat, Indonesia and the Great Barrier Reef, Queensland, western Pacific. Two other species are described from morphology alone: H. angeliensis sp. nov. from Dampier, Western Australia and Seychelle Islands, eastern Indian Ocean and H. furfuricula sp. nov. from the Red Sea and Mozambique, western Indian Ocean, possessing a unique paleal brow shape. While well supported as a clade, support for relationships within Hyalopale is low. Hyalopale cf. bispinosa (Mediterranean) was recovered as sister group to the remaining Hyalopale, with H. leslieae sp. nov. as sister to the Hyalopale Pacific clade, comprising H. zerofskii sp. nov. (eastern Pacific) and H. sapphiriglancyorum sp. nov. (western Pacific). Within Chrysopetalinae, Hyalopale and Paleanotus formed a clade that was the sister group to the other paleate chrysopetalids under maximum likelihood, though Paleanotus grouped with the other paleate forms under maximum parsimony. The adult morphology of Hyalopale species is compared with that exhibited in the larvae of Paleanotus species; based on these results, including possession of a shared notochaetal character, Hyalopale is considered to contain paedomorphic taxa.

Physics of animal health: on the mechano-biology of hoof growth and form.

Global inequalities in economic access and agriculture productivity imply that a large number of developing countries rely on working equids for transport/agriculture/mining. Therefore, the understanding of hoof conditions/shape variations affecting equids' ability to work is still a persistent concern. To bridge this gap, using a multi-scale interdisciplinary approach, we provide a bio-physical model predicting the shape of equids' hooves as a function of physical and biological parameters. In particular, we show (i) where the hoof growth stress originates from, (ii) why the hoof growth rate is one order of magnitude higher than the proliferation rate of epithelial cells and (iii) how the soft-to-hard transformation of the epithelium is possible allowing the hoof to fulfil its function as a weight-bearing element. Finally (iv), we demonstrate that the reason for hoof misshaping is linked to the asymmetrical design of equids' feet (shorter quarters/long toe) together with the inability of the biological growth stress to compensate for such an asymmetry. Consequently, the hoof can adopt a dorsal curvature and become 'dished' overtime, which is a function of the animal's mass and the hoof growth rate. This approach allows us to discuss the potential occurrence of this multifaceted pathology in equids.

Seven new species of Paleanotus (Annelida: Chrysopetalidae) described from Lizard Island, Great Barrier Reef, and coral reefs of northern Australia and the Indo-Pacific: two cryptic species pairs revealed between western Pacific Ocean and the eastern Indian Ocean.

Morphological investigation into the paleate genus Paleanotus Schmarda 1861 of the family Chrysopetalidae from northern Australian coral reefs, primarily Lizard Island and outlying reefs, included a complex of very small, slender individuals (length < 5 mm). This complex resolved into 7 new species, described herein: Paleanotus inornatus n. sp., P. adornatus n. sp., P. chrysos n. sp., P. aquifolia n. sp., P. latifolia n. sp., P. silus n. sp., and P. silopsis n. sp. A key is provided to the new species and Paleanotus distinguished from Treptopale and Hyalopale, two closely related genera. Diagnostic features of the apical structure and shape of the notochaetal main paleae plus median paleae shape and raised rib pattern, differentiates each species from the other. Gametous states are described. Two cryptic species pairs (Paleanotus silopsis n. sp. and P. silus n. sp.; Paleanotus aquifolia n. sp. and P. latifolia n. sp.) were identified. In each case one species is restricted to either the NE or NW Australian coast. In each pair the most eastern point for the NW Australian species range occurs at Darwin, western Arnhemland, Northern Territory. Additional material for each species pair extends their respective ranges northwards: NW Australia to Thailand, Andaman Sea, eastern Indian Ocean or NE Australia, Great Barrier Reef to the Philippines, western Pacific Ocean. Cryptic morphology and potential genetic diversity is discussed in Paleanotus inornatus n. sp. and P. adornatus n. sp. that possess overlapping widespread distribution patterns across northern Australia and Indo-Pacific reefs. The smallest bodied taxon, Paleanotus chrysos n. sp. is the only species with a Coral Sea range encompassing Lizard Island, Heron Island and New Caledonia.

The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with specialist supportive clinical management (SSCM) in outpatients with broadly defined anorexia nervosa: A randomized controlled trial.

OBJECTIVE: Anorexia nervosa (AN) in adults has poor outcomes, and treatment evidence is limited. This study evaluated the efficacy and acceptability of a novel, targeted psychological therapy for AN (Maudsley Model of Anorexia Nervosa Treatment for Adults; MANTRA) compared with Specialist Supportive Clinical Management (SSCM). METHOD: One hundred forty-two outpatients with broadly defined AN (body mass index [BMI] ≤ 18.5 kg/m²) were randomly allocated to receive 20 to 30 weekly sessions (depending on clinical severity) plus add-ons (4 follow-up sessions, optional sessions with dietician and with carers) of MANTRA (n = 72) or SSCM (n = 70). Assessments were administered blind to treatment condition at baseline, 6 months, and 12 months after randomization. The primary outcome was BMI at 12 months. Secondary outcomes included eating disorders symptomatology, other psychopathology, neuro-cognitive and social cognition, and acceptability. Additional service utilization was also assessed. Outcomes were analyzed using linear mixed models. RESULTS: Both treatments resulted in significant improvements in BMI and reductions in eating disorders symptomatology, distress levels, and clinical impairment over time, with no statistically significant difference between groups at either 6 or 12 months. Improvements in neuro-cognitive and social-cognitive measures over time were less consistent. One SSCM patient died. Compared with SSCM, MANTRA patients rated their treatment as significantly more acceptable and credible at 12 months. There was no significant difference between groups in additional service consumption. CONCLUSIONS: Both treatments appear to have value as first-line outpatient interventions for patients with broadly defined AN. Longer term outcomes remain to be evaluated.

Asymmetric synthesis of 1-heteroaryl-1-arylalkyl tertiary alcohols and 1-pyridyl-1-arylethanes by lithiation-borylation methodology.

The synthesis of highly enantioenriched α-heterocyclic tertiary alcohols has been achieved via lithiation-borylation of a configurationally stable lithiated carbamate and heterocyclic pinacol boronic esters followed by oxidation. Protodeboronation of the α-heterocyclic tertiary boronic esters using TBAF·3H2O or CsF gave highly enantioenriched 1-pyridyl-1-arylethanes in high er.

The MOSAIC study - comparison of the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: study protocol for a randomized controlled trial.

BACKGROUND: Anorexia nervosa (AN) is a biologically based serious mental disorder with high levels of mortality and disability, physical and psychological morbidity and impaired quality of life. AN is one of the leading causes of disease burden in terms of years of life lost through death or disability in young women. Psychotherapeutic interventions are the treatment of choice for AN, but the results of psychotherapy depend critically on the stage of the illness. The treatment response in adults with a chronic form of the illness is poor and drop-out from treatment is high. Despite the seriousness of the disorder the evidence-base for psychological treatment of adults with AN is extremely limited and there is no leading treatment. There is therefore an urgent need to develop more effective treatments for adults with AN. The aim of the Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC) is to evaluate the efficacy and cost effectiveness of two outpatient treatments for adults with AN, Specialist Supportive Clinical Management (SSCM) and the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA). METHODS/DESIGN: 138 patients meeting the inclusion criteria are randomly assigned to one of the two treatment groups (MANTRA or SSCM). All participants receive 20 once-weekly individual therapy sessions (with 10 extra weekly sessions for those who are severely ill) and four follow-up sessions with monthly spacing thereafter. There is also optional access to a dietician and extra sessions involving a family member or a close other. Body weight, eating disorder- related symptoms, neurocognitive and psychosocial measures, and service use data are measured during the course of treatment and across a one year follow up period. The primary outcome measure is body mass index (BMI) taken at twelve months after randomization. DISCUSSION: This multi-center study provides a large sample size, broad inclusion criteria and a follow-up period. However, the study has to contend with difficulties directly related to running a large multi-center randomized controlled trial and the psychopathology of AN. These issues are discussed.