E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis

AbstractThe widespread availability of the Internet and mobile-device applications (apps) is changing the treatment of mental health problems. The aim of the present study was to review the research on the effectiveness of e-therapy for eating disorders, using the methodology employed by the UK's National Institute for Health and Care Excellence (NICE). Electronic databases were searched for published randomised controlled trials of e-therapies, designed to prevent or treat any eating disorder in all age groups. Studies were meta-analysed where possible, and effect sizes with confidence intervals were calculated. The GRADE approach was used to determine the confidence in the effect estimates. Twenty trials met the inclusion criteria. For prevention, a CBT-based e-intervention was associated with small reductions in eating disorder psychopathology, weight concern and drive for thinness, with moderate confidence in the effect estimates. For treatment and relapse prevention, various e-therapies showed some beneficial effects, but for most outcomes, evidence came from single studies and confidence in the effect estimates was low. Overall, although some positive findings were identified, the value of e-therapy for eating disorders must be viewed as uncertain. Further research, with improved methods, is needed to establish the effectiveness of e-therapy for people with eating disorders

Non-equivalence of anti-Müllerian hormone automated assays—clinical implications for use as a companion diagnostic for individualised gonadotrophin dosing

STUDY QUESTION Can anti-Müllerian hormone (AMH) automated immunoassays (Elecsys® and Access) be used interchangeably as a companion diagnostic for individualisation of follitropin delta dosing? SUMMARY ANSWER The Access assay gives systematically higher AMH values than the Elecsys® assay which results in over 29% of women being misclassified to a different follitropin delta dose. WHAT IS KNOWN ALREADY Follitropin delta is the first gonadotrophin to be licenced with a companion diagnostic, the Roche Elecsys® AMH Plus assay. Alternative automated AMH assays including the Beckman Coulter Access immunoassay are considered to provide similar results, but clarification of their suitability as an off-licence companion diagnostic for follitropin delta is required. STUDY DESIGN, SIZE, DURATION We systematically searched the existing literature for studies that had measured AMH using both automated assays in the same cohort of women. Individual paired patient data were acquired from each author and combined with unpublished data. PARTICIPANTS/MATERIALS, SETTING, METHODS We identified five eligible prospective published studies and one additional unpublished study. A 100% response from the authors was achieved. We collected paired AMH data on samples from 848 women. Passing–Bablok regression and Bland–Altman plots were used to compare the analytical performance of the two assays. The degree of misclassification to different treatment categories was estimated should the Access AMH be used as a companion diagnostic instead of the Elecsys AMH in determining the dosing of follitropin delta. MAIN RESULTS AND THE ROLE OF CHANCE The Passing–Bablok regression shows a linear relationship (Access = −0.05 + 1.10 × Elecsys). The Access assay systematically gave higher values by an average of 10% compared with the Elecsys assay (slope = 1.10, 95% CI: 1.09 to 1.12). The average of the difference between the two assays was 2.7 pmol/l. The 95% limits of agreement were −11.7 to 6.3. Overall 253 (29.3%) women would have received an inappropriate follitropin delta dose if the Beckman Coulter Access assay was used. Specifically, a substantial proportion of women (ranging from 49% to 90% depending on the AMH category) would receive a lower dose of follitropin delta based on the Access AMH assay. Up to 10% (ranging from 2.5% to 10%) of women with high ovarian reserve would have been misclassified to a greater dose of follitropin delta based on the Access AMH assay. LIMITATIONS REASONS FOR CAUTION We compared the values of the two principal automated assays, extrapolation of our findings to other automated AMH assays would require similar comprehensive examination. WIDER IMPLICATIONS OF THE FINDINGS An international standard for the calibration of the automated AMH assays is warranted to facilitate efficient use of AMH as a companion diagnostic. The variable calibration of alternative automated AMH assays may adversely impact on the performance of the follitropin delta dosing algorithm. STUDY FUNDING/COMPETING INTEREST(S) No formal funding has been received for this study. SI is funded by a UK Medical Research Council skills development fellowship (MR/N015177/1). SMN has received speakers fees, travel to meetings and participated in advisory Boards for Beckman Coulter, IBSA, Ferring Pharmaecuticals, Finox, Merck Serono, Merck and Roche Diagnostics. SMN has received research support from Ansh laboratories, Beckman Coulter, Ferring Pharmaceuticals and Roche Diagnostics

A 10‐session cognitive‐behavioral therapy (CBT‐T) for eating disorders: Outcomes from a case series of nonunderweight adult patients

Objective Existing forms of evidence-based cognitive behavior therapy for eating disorders (CBT-ED) are relatively effective for nonunderweight cases. However, they are also expensive compared to CBT for other disorders. This study reports the first outcomes for a shorter, 10-session form of CBT-ED (CBT-T) for such cases, designed to be less demanding of resources. Method A case series of 106 nonunderweight eating disordered cases were considered for this effectiveness study. A protocolized 10-session version of CBT-ED was delivered by clinical assistants, under supervision. Measures assessed eating attitudes and behaviors, anxiety, depression, personality pathology, and the working alliance. Intention-to-treat analyses were used. Results Suitability, acceptability, working alliance ratings, and retention were all positive. Outcomes by the end of therapy and at three-month follow-up were positive for all symptoms, with levels of change, abstinence and remission that were comparable to those from effectiveness studies of longer forms of CBT. Higher levels of pretreatment anxiety predicted retention in treatment, but no factors predicted poorer response. Early change in eating attitudes and the working alliance were the strongest predictors of a positive response. Discussion This 10-session form of CBT-ED for nonunderweight eating disorders performed at a level that is comparable to versions of CBT-ED that are twice as long, despite being delivered by nonspecialist therapists. Replication and longer-term follow-ups are needed to ensure retained effects. However, CBT-T has promise as a therapy for use in a range of healthcare settings, to enhance access to treatment for such eating disorders

Self-reported interoceptive deficits in eating disorders: A meta-analysis of studies using the eating disorder inventory

This document is the Accepted Manuscript version of the following article: Paul M. Jenkinson, Lauren Taylor, Keith R. Laws, ‘Self-reported interoceptive deficits in eating disorders: A meta-analysis of studies using the eating disorder inventory’, Journal of Psychosomatic Research, Vol. 110: 38-45, July 2018, under embargo until 19 April 2019. The Version of Record is available online at DOI: https://doi.org/10.1016/j.jpsychores.2018.04.005Objective: An impairment of the ability to sense the physiological condition of the body – interoception – has long been proposed as central to the onset and maintenance of eating disorders. More recent attention to this topic has generally indicated the presence of interoceptive deficits in individuals with an eating disorder diagnosis; however, possible links with specific diagnosis, BMI, age, illness duration, depression, and alexithymia remain unclear from individual studies. This meta-analysis aimed to provide a necessary quantitative overview of self-reported interoceptive deficits in eating disorder populations, and the relationship between these deficits and the previously mentioned factors. Methods: Using a random effects model, our meta-analysis assessed the magnitude of differences in interoceptive abilities as measured using the Eating Disorder Inventory in 41 samples comparing people with eating disorders (n=4308) and healthy controls (n=3459). Follow-up and moderator analysis was conducted, using group comparisons and meta-regressions. Results: We report a large pooled effect size of 1.62 for eating disorders with some variation between diagnostic groups. Further moderator analysis showed that BMI, age and alexithymia were significant predictors of overall effect size. Conclusion: This meta-analysis is the first to confirm that large interoceptive deficits occur in a variety of eating disorders and crucially, in those who have recovered. These deficits may be useful in identifying and distinguishing eating disorders. Future research needs to consider both objective and subjective measures of interoception across different types of eating disorders and may fruitfully examine interoception as a possible endophenotype and target for treatment.Peer reviewe

Text-mining as a methodology to assess eating disorder-relevant factors : comparing mentions of fitness tracking technology across online communities

Objective: Text-mining offers a technique to identify and extract information from a large corpus of textual data. As an example, this study presents the application of text-mining to assess and compare interest in fitness tracking technology across eating disorder and health-related online communities. Method: A list of fitness tracking technology terms was developed, and communities (i.e., ‘subreddits’) on a large online discussion platform (Reddit) were compared regarding the frequency with which these terms occurred. The corpus used in this study comprised all comments posted between May 2015 and January 2018 (inclusive) on six subreddits – three eating disorder-related, and three relating to either fitness, weight-management or nutrition. All comments relating to the same ‘thread’ (i.e., conversation) were concatenated, and formed the cases used in this study (N=377,276). Results: Within the eating disorder-related subreddits, the findings indicated that a ‘pro-eating disorder’ subreddit, which is less recovery focused than the other eating disorder subreddits, had the highest frequency of fitness tracker terms. Across all subreddits, the weight-management subreddit had the highest frequency of the fitness tracker terms’ occurrence, and MyFitnessPal was the most frequently mentioned fitness tracker. Discussion: The technique exemplified here can potentially be used to assess group differences to identify at-risk populations, generate and explore clinically relevant research questions in populations who are difficult to recruit, and scope an area for which there is little extant literature. The technique also facilitates methodological triangulation of research findings obtained through more ‘traditional’ techniques, such as surveys or interviews

A pragmatic effectiveness study of 10-session cognitive behavioural therapy (CBT-T) for eating disorders: Targeting barriers to treatment provision

Objective Ten‐session cognitive behavioural therapy (CBT‐T) for transdiagnostic eating disorders targets several barriers to treatment, including cost, therapist expertise, and lengthy wait lists. Method We used a case series design to investigate the effectiveness of CBT‐T delivered by trainee psychologists in a postgraduate training clinic. Participants were randomly allocated to commence treatment either immediately or after a 4‐week waitlist period. CBT‐T was delivered to 52 patients, by six different trainees under supervision. Measures of eating disorder cognitions and behaviours, quality of life, and general psychopathology were examined in completer and intention‐to‐treat analyses using multilevel modelling. Last observation carried forward was applied for abstinence, remission, and good outcome analyses to aid comparison with prior studies. Results Significant improvements, associated with medium to large effect sizes, were found for eating disorder cognitions, behaviours quality of life, and negative affect from baseline to posttreatment, and at 1‐ and 3‐month follow‐up. Attrition (38.5%) was comparable with other treatment studies. Conclusion Results provide evidence for the effectiveness of CBT‐T delivered by trainee psychologists for transdiagnostic eating disorder patients, thus tackling some important barriers for treatment. Longer follow‐up, randomised controlled trial designs, and moderator analyses will provide more robust evidence about which patients do best with a shorter therapy

Interoception and Autonomic Correlates during Social Interactions. Implications for Anorexia

The aim of this study is to investigate the bodily-self in Restrictive Anorexia, focusing on two basic aspects related to the bodily self: autonomic strategies in social behavior, in which others’ social desirability features, and social cues (e.g., gaze) are modulated, and interoception (i.e., the sensitivity to stimuli originating inside the body). Furthermore, since previous studies carried out on healthy individuals found that interoception seems to contribute to the autonomic regulation of social behavior, as measured by Respiratory Sinus Arrhythmia (RSA), we aimed to explore this link in anorexia patients, whose ability to perceive their bodily signal seems to be impaired. To this purpose, we compared a group of anorexia patients (ANg; restrictive type) with a group of Healthy Controls (HCg) for RSA responses during both a resting state and a social proxemics task, for their explicit judgments of comfort in social distances during a behavioral proxemics task, and for their Interoceptive Accuracy (IA). The results showed that ANg displayed significantly lower social disposition and a flattened autonomic reactivity during the proxemics task, irrespective of the presence of others’ socially desirable features or social cues. Moreover, unlike HCg, the autonomic arousal of ANg did not guide behavioral judgments of social distances. Finally, IA was strictly related to social disposition in both groups, but with opposite trends in ANg. We conclude that autonomic imbalance and its altered relationship with interoception might have a crucial role in anorexia disturbances

Illuminating hydrological processes at the soil-vegetation-atmosphere interface with water stable isotopes

Funded by DFG research project “From Catchments as Organised Systems to Models based on Functional Units” (FOR 1Peer reviewedPublisher PDFPublisher PD

The Relationship between Concurrent Substance Use Disorders and Eating Disorders with Personality Disorders

Objective: The current pilot study investigated whether patients with concurrent substance use disorders and eating disorders (SUD and ED) who experienced a reduction in SUD and ED symptoms following treatment for SUD and ED also experienced a reduction in personality disorder (PD) symptoms. Method: Twenty patients with SUD and ED and PD were assessed pre and post treatment using clinical interviews, self-report questionnaires, and a therapist questionnaire on DSM-IV-TR symptoms for PD. Results: Symptoms for the personality disorders were reduced following treatment. This reduction was correlated with a decrease in the number of symptoms of ED at post treatment. Discussion: Chronic concurrent SUD and ED may make it difficult to separate PD symptoms from co-occurring disorders. Many features attributed to PDs may be reduced when problematic substance use and disordered eating are addressed, a fact that may increase clinician and patients’optimism about therapeutic change

The neurobiology of interoception in health and disease

Interoception is the sensing of internal bodily sensations. Interoception is an umbrella term that encompasses (1) the afferent (body‐to‐brain) signaling through distinct neural and humoral (including immune and endocrine) channels; (2) the neural encoding, representation, and integration of this information concerning internal bodily state; (3) the influence of such information on other perceptions, cognitions, and behaviors; (4) and the psychological expression of these representations as consciously accessible physical sensations and feelings. Interoceptive mechanisms ensure physiological health through the cerebral coordination of homeostatic reflexes and allostatic responses that include motivational behaviors and associated affective and emotional feelings. Furthermore, the conscious, unitary sense of self in time and space may be grounded in the primacy and lifelong continuity of interoception. Body‐to‐brain interactions influence physical and mental well‐being. Consequently, we show that systematic investigation of how individual differences, and within‐individual changes, in interoceptive processing can contribute to the mechanistic understanding of physical and psychological disorders. We present a neurobiological overview of interoception and describe how interoceptive impairments at different levels relate to specific physical and mental health conditions, including sickness behaviors and fatigue, depression, eating disorders, autism, and anxiety. We frame these findings in an interoceptive predictive processing framework and highlight potential new avenues for treatments