Exposure therapy is a widely used and effective form of treatment in anxiety disorders and addict... more Exposure therapy is a widely used and effective form of treatment in anxiety disorders and addictions but evidence for its usefulness in eating disorders (ED) is inconsistent. This paper systematically reviews the literature on the use of exposure therapy in ED, the theory underpinning its use, and the deficits in current knowledge. Databases were searched to 2012. In addition, potential improvements in the use of exposure techniques in ED are considered by drawing upon theory and research involving neuropharmacology, basic and clinical neuroscience, contemporary behavioural and neurobiological research, and technologies such as virtual reality (VR).
To investigate the social support networks of patients with anorexia nervosa (AN) and bulimia ner... more To investigate the social support networks of patients with anorexia nervosa (AN) and bulimia nervosa (BN). Social support was measured using the Significant Others Scale for 44 patients with AN, 81 patients with BN, and 86 polytechnic students. Eating disorder patients had smaller social networks than the students. AN patients were significantly less likely than BN patients to have a spouse or partner as a support figure. Both AN and BN patients reported less actual emotional and practical support than students. AN patients perceived their social support to be adequate, whereas BN patients were dissatisfied with their support. Patients set lower ideals for support than the students. Social support was not correlated with duration of illness. AN and BN patients have deficient social networks. In BN patients there is disturbance in both the size and perceived adequacy of social relationships.
The aim of the study was to examine the factor structure of alexithymia in patients with eating d... more 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.
Previous reports have suggested differences between early and late onset cases both in anorexia n... more 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. 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. 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%). 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.
The British journal of general practice : the journal of the Royal College of General Practitioners, 2005
Depression is a common and important public health problem most often treated by GPs. A self-help... more Depression is a common and important public health problem most often treated by GPs. A self-help approach is popular with patients, yet little is known about its effectiveness. Our primary aim was to review and update the evidence for the clinical effectiveness of bibliotherapy in the treatment of depression. Our secondary aim was to identify which of these self-help materials are generally available to buy and to examine the evidence specific to these publications. Medline, CINAHL, EMBASE, PsycINFO, CCTR, PsiTri and the National Research Register were searched for randomised trials that evaluated self-help books for depression which included participants aged over 16 years with a diagnosis or symptoms of depression. Clinical symptoms, quality of life, costs or acceptability to users were the required outcome measures. Papers were obtained and data extracted independently by two researchers. A meta-analysis using a random effects model was carried out using the mean score and stand...
This study aimed to investigate theory of mind (ToM) in individuals with bulimia nervosa (BN), an... more This study aimed to investigate theory of mind (ToM) in individuals with bulimia nervosa (BN), an area neglected by empirical research despite social functioning difficulties in this disorder and evidence of ToM deficits in people with anorexia nervosa (AN). ToM was assessed in 48 BN and 34 Eating Disorder Not Otherwise Specified BN-type (EDNOS-BN) outpatients and 57 healthy controls (HCs) using the Reading the Mind in the Eyes and the Reading the Mind in the Films (RMF), an ecologically valid task novel to BN research. Overall performance in BN and EDNOS-BN groups was equivalent to HCs on both tasks. Individuals with BN had enhanced negative emotion recognition on the RMF. Individuals with AN and BN have distinct socio-cognitive profiles. Further research into social cognition is required to establish the link between interpersonal difficulties and psychopathology in people with BN.
To evaluate the feasibility and acceptability of a novel systemic cognitive behavior therapy-base... more To evaluate the feasibility and acceptability of a novel systemic cognitive behavior therapy-based intervention for carers of people with anorexia nervosa (AN). The intervention provides information and promotes skills development in managing the illness. Carers were also offered professional support. Twenty-seven carers were recruited. Outcomes measuring carer distress, experience of care-giving, level of expressed emotion and problem solving were measured pre- and post-intervention and at follow-up. Carers also gave feedback. There was a significant reduction in carers' anxiety and depression, negative experiences of caregiving and expressed emotion and a significant increase in positive experiences in caregiving after the intervention. Most improvements were maintained at follow-up. The intervention was well received. The results of this pilot study indicate that the intervention is acceptable to carers and may have a positive impact on carers' mental health and experience of care-giving. Further investigation of the intervention is warranted.
We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ... more We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.
The International journal of eating disorders, 2006
Even with the best available treatment, most bulimia nervosa (BN) sufferers are not symptom free ... more Even with the best available treatment, most bulimia nervosa (BN) sufferers are not symptom free at the end of therapy and, for those who have achieved remission, risk of relapse is high. Thus, there is a need for aftercare or relapse prevention interventions after therapy. It is not yet known what type of intervention should be delivered, and how to suit patient needs while being mindful of cost and time constraints of service providers. This pilot study was conducted to explore the feasibility, acceptability, and efficacy of a text messaging (short messaging service [SMS])-based intervention in the aftercare of BN patients who had received outpatient psychotherapy. A total of 21 patients with BN participated in the 6-month SMS-based intervention as a step-down treatment after outpatient therapy. Levels of use of the program were relatively low and attrition high, indicating limited acceptance of the intervention. This study suggests that the SMS-based intervention would benefit fr...
Experienced Carers Helping Others (ECHO) is an intervention for carers of people with eating diso... more Experienced Carers Helping Others (ECHO) is an intervention for carers of people with eating disorders. This paper describes the theoretical background and protocol of a pilot multicentre randomised controlled trial that will explore the use of two variants of ECHO for improving outcomes for adolescents with anorexia nervosa (AN) referred for outpatient care. Adolescent patients and their carers (typically parents and close others in a supportive role) will be recruited from 38 eating disorder outpatient services across the UK. Carers will be randomly allocated to receive 'ECHOc' guided self-help (in addition to treatment as usual), 'ECHO' self-help only (in addition to treatment as usual) or treatment as usual only. Primary outcomes are a summary measure of the Short Evaluation of Eating Disorders at 6- and 12-month follow-ups. Secondary outcomes are general psychiatric morbidity of AN patients and carer, carers' coping and behaviour, and change in healthcare use and costs at 6- and 12-month follow-ups. Therapist effects will be examined, and process evaluation of ECHOc will be completed. The findings from this pilot trial will be used in preparation for executing a definitive trial to determine the impact of the preferred variant of ECHO to improve treatment outcomes for AN.
This study examined pretreatment variables to predict outcome in two treatments for bulimia nervo... more This study examined pretreatment variables to predict outcome in two treatments for bulimia nervosa. Patients were offered either 16 weeks of cognitive-behavioral therapy (CBT) or a self-treatment manual followed by up to 8 weeks of CBT (sequential group). Using complete data, stepwise regression analyses were performed. It was found that a longer duration of illness and lower binge frequency predicted a better outcome both at the end of treatment (p < .001) and at 18 months of follow-up (p < .005). In the sequential group, lower pretreatment binge frequency predicted better outcome at the end of treatment (p < .05) and at 18 months of follow-up (p < .05). In the CBT group, longer duration of illness predicted better outcome at the end of treatment (p < .02). It is concluded that (1) those with more frequent binging may require a more intense intervention and (2) those who have been ill longer may be more motivated to respond to treatment.
Exposure therapy is a widely used and effective form of treatment in anxiety disorders and addict... more Exposure therapy is a widely used and effective form of treatment in anxiety disorders and addictions but evidence for its usefulness in eating disorders (ED) is inconsistent. This paper systematically reviews the literature on the use of exposure therapy in ED, the theory underpinning its use, and the deficits in current knowledge. Databases were searched to 2012. In addition, potential improvements in the use of exposure techniques in ED are considered by drawing upon theory and research involving neuropharmacology, basic and clinical neuroscience, contemporary behavioural and neurobiological research, and technologies such as virtual reality (VR).
To investigate the social support networks of patients with anorexia nervosa (AN) and bulimia ner... more To investigate the social support networks of patients with anorexia nervosa (AN) and bulimia nervosa (BN). Social support was measured using the Significant Others Scale for 44 patients with AN, 81 patients with BN, and 86 polytechnic students. Eating disorder patients had smaller social networks than the students. AN patients were significantly less likely than BN patients to have a spouse or partner as a support figure. Both AN and BN patients reported less actual emotional and practical support than students. AN patients perceived their social support to be adequate, whereas BN patients were dissatisfied with their support. Patients set lower ideals for support than the students. Social support was not correlated with duration of illness. AN and BN patients have deficient social networks. In BN patients there is disturbance in both the size and perceived adequacy of social relationships.
The aim of the study was to examine the factor structure of alexithymia in patients with eating d... more 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.
Previous reports have suggested differences between early and late onset cases both in anorexia n... more 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. 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. 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%). 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.
The British journal of general practice : the journal of the Royal College of General Practitioners, 2005
Depression is a common and important public health problem most often treated by GPs. A self-help... more Depression is a common and important public health problem most often treated by GPs. A self-help approach is popular with patients, yet little is known about its effectiveness. Our primary aim was to review and update the evidence for the clinical effectiveness of bibliotherapy in the treatment of depression. Our secondary aim was to identify which of these self-help materials are generally available to buy and to examine the evidence specific to these publications. Medline, CINAHL, EMBASE, PsycINFO, CCTR, PsiTri and the National Research Register were searched for randomised trials that evaluated self-help books for depression which included participants aged over 16 years with a diagnosis or symptoms of depression. Clinical symptoms, quality of life, costs or acceptability to users were the required outcome measures. Papers were obtained and data extracted independently by two researchers. A meta-analysis using a random effects model was carried out using the mean score and stand...
This study aimed to investigate theory of mind (ToM) in individuals with bulimia nervosa (BN), an... more This study aimed to investigate theory of mind (ToM) in individuals with bulimia nervosa (BN), an area neglected by empirical research despite social functioning difficulties in this disorder and evidence of ToM deficits in people with anorexia nervosa (AN). ToM was assessed in 48 BN and 34 Eating Disorder Not Otherwise Specified BN-type (EDNOS-BN) outpatients and 57 healthy controls (HCs) using the Reading the Mind in the Eyes and the Reading the Mind in the Films (RMF), an ecologically valid task novel to BN research. Overall performance in BN and EDNOS-BN groups was equivalent to HCs on both tasks. Individuals with BN had enhanced negative emotion recognition on the RMF. Individuals with AN and BN have distinct socio-cognitive profiles. Further research into social cognition is required to establish the link between interpersonal difficulties and psychopathology in people with BN.
To evaluate the feasibility and acceptability of a novel systemic cognitive behavior therapy-base... more To evaluate the feasibility and acceptability of a novel systemic cognitive behavior therapy-based intervention for carers of people with anorexia nervosa (AN). The intervention provides information and promotes skills development in managing the illness. Carers were also offered professional support. Twenty-seven carers were recruited. Outcomes measuring carer distress, experience of care-giving, level of expressed emotion and problem solving were measured pre- and post-intervention and at follow-up. Carers also gave feedback. There was a significant reduction in carers' anxiety and depression, negative experiences of caregiving and expressed emotion and a significant increase in positive experiences in caregiving after the intervention. Most improvements were maintained at follow-up. The intervention was well received. The results of this pilot study indicate that the intervention is acceptable to carers and may have a positive impact on carers' mental health and experience of care-giving. Further investigation of the intervention is warranted.
We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ... more We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.
The International journal of eating disorders, 2006
Even with the best available treatment, most bulimia nervosa (BN) sufferers are not symptom free ... more Even with the best available treatment, most bulimia nervosa (BN) sufferers are not symptom free at the end of therapy and, for those who have achieved remission, risk of relapse is high. Thus, there is a need for aftercare or relapse prevention interventions after therapy. It is not yet known what type of intervention should be delivered, and how to suit patient needs while being mindful of cost and time constraints of service providers. This pilot study was conducted to explore the feasibility, acceptability, and efficacy of a text messaging (short messaging service [SMS])-based intervention in the aftercare of BN patients who had received outpatient psychotherapy. A total of 21 patients with BN participated in the 6-month SMS-based intervention as a step-down treatment after outpatient therapy. Levels of use of the program were relatively low and attrition high, indicating limited acceptance of the intervention. This study suggests that the SMS-based intervention would benefit fr...
Experienced Carers Helping Others (ECHO) is an intervention for carers of people with eating diso... more Experienced Carers Helping Others (ECHO) is an intervention for carers of people with eating disorders. This paper describes the theoretical background and protocol of a pilot multicentre randomised controlled trial that will explore the use of two variants of ECHO for improving outcomes for adolescents with anorexia nervosa (AN) referred for outpatient care. Adolescent patients and their carers (typically parents and close others in a supportive role) will be recruited from 38 eating disorder outpatient services across the UK. Carers will be randomly allocated to receive 'ECHOc' guided self-help (in addition to treatment as usual), 'ECHO' self-help only (in addition to treatment as usual) or treatment as usual only. Primary outcomes are a summary measure of the Short Evaluation of Eating Disorders at 6- and 12-month follow-ups. Secondary outcomes are general psychiatric morbidity of AN patients and carer, carers' coping and behaviour, and change in healthcare use and costs at 6- and 12-month follow-ups. Therapist effects will be examined, and process evaluation of ECHOc will be completed. The findings from this pilot trial will be used in preparation for executing a definitive trial to determine the impact of the preferred variant of ECHO to improve treatment outcomes for AN.
This study examined pretreatment variables to predict outcome in two treatments for bulimia nervo... more This study examined pretreatment variables to predict outcome in two treatments for bulimia nervosa. Patients were offered either 16 weeks of cognitive-behavioral therapy (CBT) or a self-treatment manual followed by up to 8 weeks of CBT (sequential group). Using complete data, stepwise regression analyses were performed. It was found that a longer duration of illness and lower binge frequency predicted a better outcome both at the end of treatment (p < .001) and at 18 months of follow-up (p < .005). In the sequential group, lower pretreatment binge frequency predicted better outcome at the end of treatment (p < .05) and at 18 months of follow-up (p < .05). In the CBT group, longer duration of illness predicted better outcome at the end of treatment (p < .02). It is concluded that (1) those with more frequent binging may require a more intense intervention and (2) those who have been ill longer may be more motivated to respond to treatment.
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