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Eating disorders (EDs) are serious mental illnesses that can be life-threatening. Stage of illness models and early intervention strategies could be informed by a better understanding of symptomatology that precedes the onset of an ED. This review aims to explore which symptoms (both ED and other psychiatric disorder-related) exist prior to the onset of an ED and whether there any prospective associations between these symptomatologies.
A systematic literature review was conducted in MEDLINE, Embase, and PsycINFO for large, longitudinal, prospective studies in nonclinical cohorts of children/adolescents that report symptoms prior to the onset of an ED. A quality assessment of included studies was conducted using the Newcastle-Ottawa Quality Assessment Scale.
A total of 22 studies were included, and over half were assessed to be of good quality. Studies identified the presence of a broad range of ED and other psychiatric disorder-related symptoms prior to ED onset. Possible prospective associations were identified, including early eating and feeding difficulties in childhood, to ED-related symptoms (e.g., dieting and body dissatisfaction) and other psychiatric disorder-related symptoms (e.g., anxiety and depression) in childhood/early adolescence, progressing to severe symptomatology (e.g., extreme weight control behaviors and self-harm) in mid-adolescence/emerging adulthood.
The trajectory of symptoms identified to precede and possibly predict onset of an ED may inform early intervention strategies within the community. Suggestions for further research are provided to establish these findings and the clinical implications of these discussed, in order to inform how best to target prodromal stages of EDs.
Eating disorder services are often separated into child and adolescent eating disorder services (CAEDSs) and adult eating disorder services (AEDSs). Most patients in CAEDSs present with first-episode illness of short duration, which with appropriate treatment, have a good prognosis. However, some individuals receive further treatment as adults. Little is known about service utilisation in adulthood following childhood/adolescent treatment of an eating disorder.
This study aims (a) to estimate the proportion of patients in a CAEDS who use mental health services as young adults, (b) to delineate service utilisation following treatment in CAEDSs and (c) to identify factors in CAEDSs that predict service utilisation in young adulthood.
A consecutive cohort of 322 patients (aged 13–17 years) seen in a CAEDS in the UK over a 5-year period were included in this audit. Data regarding their use of UK-wide adult mental health services as young adults (i.e. when aged 18–25) were extracted from local and national hospital records.
A total of 68.3% of CAEDS patients received no mental health treatment as young adults. Although 13% of people seen in a CAEDS had brief eating disorder treatment as young adults, 10% received longer/or more intensive eating disorder treatment. Overall, 10.8% transitioned directly to an AEDS and 7.6% were re-referred following discharge from CAEDS. In our sample, older age and increased use of CAEDSs predicted increased eating disorder treatment in young adulthood.
Our results indicate that most people seen in CAEDSs do not receive further mental health treatment as young adults. Several features in CAEDSs distinguish mental health service utilisation in young adulthood, which were identified clinically and could be targeted during treatment.
Despite their use in clinical practice, there is little evidence to support the use of therapist written goodbye letters as therapeutic tools. However, preliminary evidence suggests that goodbye letters may have benefits in the treatment of anorexia nervosa (AN).
This study aimed to examine whether therapist written goodbye letters were associated with improvements in body mass index (BMI) and eating disorder symptomology in patients with AN after treatment.
Participants were adults with AN (n = 41) who received The Maudsley Model of Anorexia Treatment for Adults (MANTRA) in a clinical trial evaluating two AN out-patient treatments. As part of MANTRA, therapists wrote goodbye letters to patients. A rating scheme was developed to rate letters for structure and quality. Linear regression analyses were used to examine associations between goodbye letter scores and outcomes after treatment.
Higher quality letters and letters that adopted a more affirming stance were associated with greater improvements in BMI at 12 months. Neither the overall quality nor the style of goodbye letters were associated with improvements in BMI at 24 months or reductions in eating disorder symptomology at either 12 or 24 months.
The results highlight the potential importance of paying attention to the overall quality of therapist written goodbye letters in the treatment of AN, and adopting an affirming stance.
Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa.
Participants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months.
Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks.
Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.
Families express a need for information to support people with severe anorexia nervosa.
To examine the impact of the addition of a skills training intervention for caregivers (Experienced Caregivers Helping Others, ECHO) to standard care.
Patients over the age of 12 (mean age 26 years, duration 72 months illness) with a primary diagnosis of anorexia nervosa and their caregivers were recruited from 15 in-patient services in the UK. Families were randomised to ECHO (a book, DVDs and five coaching sessions per caregiver) or treatment as usual. Patient (n=178) and caregiver (n=268) outcomes were measured at discharge and 6 and 12 months after discharge.
Patients with caregivers in the ECHO group had reduced eating disorder psychopathology (EDE-Q) and improved quality of life (WHO-Quol; both effects small) and reduced in-patient bed days (7–12 months post-discharge). Caregivers in the ECHO group had reduced burden (Eating Disorder Symptom Impact Scale, EDSIS), expressed emotion (Family Questionnaire, FQ) and time spent caregiving at 6 months but these effects were diminished at 12 months.
Small but sustained improvements in symptoms and bed use are seen in the intervention group. Moreover, caregivers were less burdened and spent less time providing care. Caregivers had most benefit at 6 months suggesting that booster sessions, perhaps jointly with the patients, may be needed to maintain the effect. Sharing skills and information with caregivers may be an effective way to improve outcomes. This randomised controlled trial (RCT) was registered with Current Controlled Trials ISRCTN06149665.
The illegal killing and taking of wild birds remains a major threat on a global scale. However, there are few quantitative data on the species affected and countries involved. We quantified the scale and scope of this issue in Northern and Central Europe and the Caucasus, using a diverse range of data sources and incorporating expert knowledge. The issue was reported to be widespread across the region and affects almost all countries/territories assessed. We estimated that 0.4–2.1 million birds per year may be killed/taken illegally in the region. The highest estimate of illegal killing in the region was for Azerbaijan (0.2-1.0 million birds per year). Out of the 20 worst locations identified, 13 were located in the Caucasus. Birds were reported to be illegally killed/taken primarily for sport and food in the Caucasus and for sport and predator/pest control in both Northern and Central Europe. All of the 28 countries assessed are parties to the Bern Convention and 19 are also European Union Member States. There are specific initiatives under both these policy instruments to tackle this threat, yet our data showed that illegal killing and taking is still occurring and is not restricted to Mediterranean European countries. Markedly increased effort is required to ensure that existing legislation is adequately implemented and complied with/enforced on the ground. Our study also highlighted the paucity of data on illegal killing and taking of birds in the region. It is a priority, identified by relevant initiatives under the Bern Convention and the European Union, to implement systematic monitoring of illegal killing and taking and to collate robust data, allowing stakeholders to set priorities, track trends and monitor the effectiveness of responses.
Background: Bulimia nervosa (BN) is an eating disorder with many physical, psychological and social consequences. Guided self-help (GSH) is recommended in the treatment of BN (NICE, 2004). One of the ways in which to provide GSH is via the internet using evidence-based packages with regular support from a clinician or trained support worker. Aims: The aim of this community-based survey was to investigate attitudes towards online self-help for eating disorders and the support required whilst using such an approach. Method: Two-hundred and fifty-three participants with bulimic symptoms completed the survey. The sample was recruited primarily online. The mean age was 29.11 years (SD = 8.67; min = 16, max = 64). Results: Attitudes towards online self-help (SH) for eating disorders were very positive. The inclusion of some form of support to accompany such an intervention was important to the majority of participants. Remote mediums of support such as e-mail, a forum and text messaging were most often selected as helpful. Most participants expressed a preference for weekly support contacts and for flexible support lengths that could respond to support needs as required. Conclusions: Online self-help for eating disorders is a desirable treatment option for many individuals. The information gathered regarding preferences in the type, medium, duration and frequency of support could be used in the development of future self-help strategies in order to maximize uptake, retention and outcomes.
Background: Perfectionism is implicated in a range of psychiatric disorders, impedes treatment and is associated with poorer treatment outcomes. Aims: The aim of this systematic review and meta-analysis was to summarize the existing evidence for psychological interventions targeting perfectionism in individuals with psychiatric disorders associated with perfectionism and/or elevated perfectionism. Method: Eight studies were identified and were analysed in meta-analyses. Meta-analyses were carried out for the Personal Standards and Concern over Mistakes subscales of the Frost Multi-Dimensional Perfectionism Scale (FMPS) and the Self Orientated Perfectionism and Socially Prescribed Perfectionism subscales of the Hewitt and Flett MPS (HMPS) in order to investigate change between pre and postintervention. Results: Large pooled effect sizes were found for the Personal Standards and Concern over Mistakes subscales of the FMPS and the Self Orientated Perfectionism subscale of the HMPS, whilst a medium sized effect was found for change in Socially Prescribed Perfectionism. Medium pooled effect sizes were also found for symptoms of anxiety and depression. Conclusions: There is some support that it is possible to significantly reduce perfectionism in individuals with clinical disorders associated with perfectionism and/or clinical levels of perfectionism. There is also some evidence that such interventions are associated with decreases in anxiety, depression, eating disorder and obsessive compulsive symptoms. Further research is needed in order to investigate the optimal dosage and format of such interventions as well as into specific disorders where there is a lack of evidence for their effectiveness.
Despite its high prevalence, help-seeking for depression is low.
To assess the effectiveness and cost-effectiveness of 1-day
cognitive–behavioural therapy (CBT) self-confidence workshops in reducing
depression. Anxiety, self-esteem, prognostic indicators as well as access
were also assessed.
An open randomised controlled trial (RCT) waiting list control design
with 12-week follow-up was used (trial registration: ISRCTN26634837). A
total of 459 adult participants with depression (Beck Depression
Inventory (BDI) scores of 14) self-referred and 382 participants (83%)
were followed up.
At follow-up, experimental and control participants differed
significantly on the BDI, with an effect size of 0.55. Anxiety and
self-esteem also differed. Of those who participated, 25% were GP
non-consulters and 32% were from Black and minority ethnic groups. Women
benefited more than men on depression scores. The intervention has a 90%
chance of being considered cost-effective if a depression-free day is
valued at £14.
Self-confidence workshops appear promising in terms of clinical
effectiveness, cost-effectiveness and access by difficult-to-engage
Body image dissatisfaction during adolescence is common but not benign. School-based interventions have the potential for wide reach, but scalability of previous programmes is limited by a reliance on external facilitators.
To assess the acceptability, feasibility and efficacy of a teacher-delivered body image intervention.
A pilot clustered randomised controlled trial in which 16 classes of adolescent girls were allocated to a 6-session body image programme (n = 261), or usual curriculum control (n = 187) (registration: ISRCTN42594993).
Students in the intervention group had significantly improved body esteem and self-esteem and reduced thin-ideal internalisation. Effects for body esteem and thin-ideal internalisation were maintained for 3 months. There were no group differences for eating pathology, peer factors or depression. Acceptability, feasibility and efficacy varied between schools.
Teacher-delivered body image lessons have promise but further work is needed to increase efficacy and make interventions suitable across a range of schools.
To examine the use of vitamin D supplements during infancy among the participants in an international infant feeding trial.
Information about vitamin D supplementation was collected through a validated FFQ at the age of 2 weeks and monthly between the ages of 1 month and 6 months.
Infants (n 2159) with a biological family member affected by type 1 diabetes and with increased human leucocyte antigen-conferred susceptibility to type 1 diabetes from twelve European countries, the USA, Canada and Australia.
Daily use of vitamin D supplements was common during the first 6 months of life in Northern and Central Europe (>80 % of the infants), with somewhat lower rates observed in Southern Europe (>60 %). In Canada, vitamin D supplementation was more common among exclusively breast-fed than other infants (e.g. 71 % v. 44 % at 6 months of age). Less than 2 % of infants in the USA and Australia received any vitamin D supplementation. Higher gestational age, older maternal age and longer maternal education were study-wide associated with greater use of vitamin D supplements.
Most of the infants received vitamin D supplements during the first 6 months of life in the European countries, whereas in Canada only half and in the USA and Australia very few were given supplementation.
Very limited evidence is available on how to treat adults with anorexia
nervosa and treatment outcomes are poor. Novel treatment approaches are
To evaluate the efficacy and acceptability of a novel psychological
therapy for anorexia nervosa (Maudsley Model of Anorexia Nervosa
Treatment for Adults, MANTRA) compared with specialist supportive
clinical management (SSCM) in a randomised controlled trial.
Seventy-two adult out-patients with anorexia nervosa or eating disorder
not otherwise specified were recruited from a specialist eating disorder
service in the UK. Participants were randomly allocated to 20 once weekly
sessions of MANTRA or SSCM and optional additional sessions depending on
severity and clinical need (trial registration: ISRCTN62920529). The
primary outcomes were body mass index, weight and global score on the
Eating Disorders Examination at end of treatment (6 months) and follow-up
(12 months). Secondary outcomes included: depression, anxiety and
clinical impairment; neuropsychological outcomes; recovery rates; and
additional service utilisation.
At baseline, patients randomised to MANTRA were significantly less likely
to be in a partner relationship than those receiving SSCM (3/34
v. 10/36; P < 0.05). Patients in
both treatments improved significantly in terms of eating disorder and
other outcomes, with no differences between groups. Strictly defined
recovery rates were low. However, MANTRA patients were significantly more
likely to require additional in-patient or day-care treatment than those
receiving SSCM (7/34 v. 0/37;
Adults with anorexia nervosa are a difficult to treat group. The
imbalance between groups in partner relationships may explain differences
in service utilisation favouring SSCM. This study confirms SSCM as a
useful treatment for out-patients with anorexia nervosa. The novel
treatment, MANTRA, designed for this patient group may need adaptations
to fully exploit its potential.
Background: Difficulties with comprehending and managing emotions are core features of the pathology of anorexia nervosa (AN). Advancements in understanding aetiology and treatment have been made within other clinical domains by targeting worry and rumination. However, worry and rumination have been given minimal consideration in AN. Aims: This study is the largest to date of worry and rumination in AN. Method: Sixty-two outpatients with a diagnosis of AN took part. Measures of worry, rumination, core AN pathology and neuropsychological correlates were administered. Results: Findings suggest that worry and rumination are elevated in AN patients compared with both healthy controls and anxiety disorder comparison groups. Regression analyses indicated that worry and rumination were significant predictors of eating disorder symptomatology, over and above the effects of anxiety and depression. Worry and rumination were not associated with neuropsychological measures of set-shifting and focus on detail. Conclusions: The data suggest that worry and rumination are major concerns for this group and warrant further study.
Carers of people with eating disorders report high levels of distress. In
addition, carers' responses to the illness may perpetuate eating disorder
symptoms. A cognitive interpersonal maintenance model of eating disorders
is proposed and interventions for carers may improve well-being in both
carers and patients.
To examine an interpersonal maintenance model of eating disorders, using
a self-help intervention for carers.
A pre-test–post-test design was used with carers randomised into
self-help or guided self-help, which included the Expert Carers Helping
Others (ECHO) intervention. Carers' distress, well-being, proposed
maintenance factors, and carer reports on the status of the patient were
Carers' distress reduced and secondary outcomes improved. Improvement in
carers' status and perceived improvements in patients were associated
with reductions in expressed emotion and in accommodating and enabling
behaviours. Self-help and guided self-help versions were comparable.
Changes in maintenance factors from the theoretical model were associated
with a reduction in carers' distress and improvement in perceived patient
functioning. Interventions which specifically target maintaining factors
may be of benefit.