Stress, Affect Systems and Eating Pathology in Problematic Weight Regulation

Problematic weight regulation as found in obesity and Anorexia Nervosa (AN) are chronic conditions which require long-term management. In order to develop long-term strategies to manage these conditions, a clearer understanding of the factors that can contribute to the development and also recovery from these conditions are a necessity. Although obesity and AN are at the opposite end of the bodyweight spectrum, some shared psychological processes may drive these states. One factor that has been suggested to contribute to problematic weight regulation is psychosocial stress whilst positive affect systems and affect regulation processes are important for regulating stress-related experiences. Gilbert (2005) describes an affect regulation system which consists of two positive affect systems known as social rank and attachment. Whilst the latter affect system refers to the attachment bond that develops between an infant and its caregiver (which extends to adult relationships), the former is used to form relationships that allow us to compete for limited resources and maintain our status in the social environment. Affect regulation processes in the current research are self-criticism and self-reassurance. Whilst self-critical thoughts and feelings can be triggered by perceptions of being low rank, the idea that people can be self-reassuring or being able to self-reassure at times of difficulty is nested in the positive infant-caregiver attachment bond and a consequence of internalizing parental soothing (Gilbert, 2006). Hence, as stress is suggested to be an important factor in problematic weight regulation and affect systems and processes are central to the regulation of emotional responses to stress-related experiences, the current series of studies examined these factors in relation to problematic weight regulation. The current research consisted of four studies designed to examine the role of stress and affect regulation in relation to weight change, weight regain following weight loss and recovery versus symptom maintenance in AN in women. A longitudinal study (Study One) was conducted to examine the change trajectories of stress, eating pathology and bodyweight, how these changes influence each other and the role of affect regulation systems and processes on these changes in a community based sample (N = 1157). Study Two examined the role of stress and affect regulation as predictors of weight regain in those who have lost weight (N = 42) and Study Three used a measure of life events and difficulties to investigate the role of stressful life changes and affect systems on recovery and relapse following AN (N = 30). Finally, in Study four, an expressive writing task which has been demonstrated to have a positive impact on stress-related health outcomes was used to explore the role of stress, affect systems and processes on problematic weight regulation and eating at times of stress (N = 57). The findings of the research studies demonstrated that there is a concurrent link between stress and the regulation of bodyweight and eating in a community-based sample of women. However, the proposed relationship between stress, bodyweight and eating behaviours was not confirmed when examined longitudinally in a community-based sample, over a 7-month period in women who have lost weight or when examined retrospectively as contributing to symptom maintenance in women with AN. However, the main finding of the current series of studies suggested that affect systems and affect regulation processes do have important implications for regulating stress-related experiences, bodyweight and eating behaviours. Perceived low social status, greater insecurity of attachment, more self-critical and less self-reassuring thoughts and feelings were related to increases in stress levels, higher bodyweight and higher levels of dysfunctional eating patterns. In addition, whilst expressive writing did not reduce stress, influence bodyweight or improve affect regulation at times of difficulty, writing about positive experiences had a positive impact on reducing dietary restraint behaviours during a stressful period. In conclusion, these findings suggest that it may not be stress per se that contributes to unhealthy changes in bodyweight and eating behaviours but how we use our affect systems and processes to manage our emotions at times of difficulty. Consequently, these findings have important implications for practice as weight loss programmes, Eating Disorder prevention programmes and stress management interventions should address the issues of perceived low social status, self-criticism and attachment insecurities

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

© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background Expressive writing involves writing about stressful or traumatic experiences. Despite trials in people with advanced disease, no systematic review to date has critiqued the evidence on expressive writing in this population. To synthesise the evidence of the effects of expressive writing on pain, sleep, depression and anxiety in people with advanced disease. Methods A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, CENTRAL, PsycINFO and PubMed were searched from January 1986 to March 2018. Other sources included clinical data registers and conference proceedings. Studies were included if they were randomised controlled trials that assessed the impact of an intervention involving expressive writing for adults with advanced disease and/or studies involving linguistic analysis on the expressive writing output. Methodological quality was assessed using the Cochrane risk of bias tool and the Mixed Methods Appraisal Tool. The Grading of Recommendations Assessment, Development and Evaluation tool was used to assess the level of evidence for the outcomes of interest. The protocol of this systematic review has been registered on PROSPERO (CRD42017058193). Results Six eligible studies with a total of 288 participants were identified, including four randomised controlled trials. All of the trials were in cancer and recruited predominantly women. None of the interventions were tailored to the population. Studies had methodological shortcomings and evidence was generally of low quality. Combined analysis of the four trials, involving 214 participants in total, showed no clear difference in the effect of expressive writing on sleep, anxiety or depression compared to an active control. Pain was not evaluated in the trials. In contrast, analysis of the four studies that included linguistic analysis alluded to linguistic mechanisms for potential effects. Conclusion Although the trial results suggest there is no benefit in expressive writing for people with advanced disease, the current evidence is limited. There is a need for more rigorous trials. It would be of benefit first to undertake exploratory research in trial design including how best to measure impact and in tailoring of the intervention to address the specific needs of people with advanced disease.Peer reviewedFinal Published versio

Experiential Avoidance in Advanced Cancer: a Mixed-Methods Systematic Review

BACKGROUND: People with advanced cancer experience psychological distress due to physical symptoms, functional decline, and a limited prognosis. Difficult thoughts, feelings, and emotions may exacerbate distress and lead to avoidance of these experiences which is sometimes referred to as experiential avoidance (EA). Advanced cancer patients may be more likely to engage in EA especially when no obvious solutions to their problems exist. This study aims to examine the terms used to describe EA, the processes that might indicate EA, associations between EA and psychological distress, and to understand why individuals might engage in EA. METHODS: A mixed-methods review. Literature search of Medline, Embase, Psych INFO, and CINAHL 1980-October 2019. INCLUSION: adults ≥ 18 years; advanced cancer not amenable to cure. EXCLUSION: no measures of EA or psychological distress. Risk of bias and study quality assessed. Evidence of statistical techniques collected. Themes coded, grouped, and developed based on meaning. RESULTS: Nineteen studies identified, 13 quantitative studies and 6 qualitative. The quantitative of which 6 compared early-stage cancers with advanced cancers and examined subscales of EA alongside mood, quality of life, and psychological distress. EA covers a range or terms of which 'avoidant coping' is the commonest. EA is manifest as cognitive, behavioural, and emotional avoidance. A thematic synthesis suggests the function of EA is to protect people from distress, and from confronting or expressing difficult emotions by avoiding communication about cancer, controlling negative information, and maintaining normality and hope and optimism. CONCLUSIONS: EA may be beneficial in the short term to alleviate distress, but in the longer term, it can impair function and limit engagement in life. Greater clinical awareness of the complexity of EA behaviours is needed. Clinicians and researchers should define EA precisely and be aware of the function it may serve in the short and longer term. Future research studies may consider using specific measures of EA as a primary outcome, to assess the impact of psychological interventions such as ACT

Grief in family carers of people living with dementia: A systematic review

OBJECTIVES: Grief research in family carers of people with dementia has increased. We aimed to report the prevalence of pre-death and post-death grief and to synthesize associated factors and the relationship between pre-death factors and post-death grief and services used to manage grief. DESIGN: (Prospero protocol: CRD42020165071) We systematically reviewed literature from PsycINFO, MEDLINE, CINAHL, and ASSIA until April 2020. Effectiveness of intervention data and studies not written in English were excluded; qualitative studies were additionally excluded during study selection. Study quality was assessed using the Mixed Methods Appraisal Tool. Evidence was narratively summarized. PARTICIPANTS: Family non-paid carers of somebody with any dementia type. MEASUREMENTS: Validated measures of pre-death and/or post-death grief. RESULTS: We included quantitative data from 55 studies (44 rated as high quality). Most included solely spouse or adult child carers. Forty-one studies reported pre-death grief, 12 post-death grief, and 6 service use; eight were longitudinal. 17% met the Prolonged Grief Disorder criteria pre-death (n = 1) and 6-26% (n = 4) of participants met the Complicated Grief criteria post-death. Being a spouse, less educated, caring for somebody with advanced dementia, and greater burden and depression were associated with higher pre-death grief. Lower education level and depression were predictive of higher post-death grief. Pre-death factors found to influence post-death grief were grief and depression. Limited service use evidence was reported. CONCLUSION: Awareness of characteristics which increase the likelihood of higher grief can help identify those in need of support. Future research should focus on what supports or services are beneficial to grief experiences

Effect of a Short-Term Online Version of a Mindfulness-Based Intervention on Self-criticism and Self-compassion in a Nonclinical Sample

Our goal was to investigate the efficacy of a Mindfulness-Based Intervention (MBI) in the form of a short-term, online intervention using exercises from Mindfulness-Based Stress-Reduction program on self-compassion, self-reassurance and self-criticism in a non-clinical population. We conducted pre-, post- and two-month follow-up measures of self-compassion, self-reassurance and self-criticism. A total of 146 participants, recruited through convenience sampling, were randomly allocated to the intervention with daily exercises for consecutive 15 days and to a control condition with no treatment. The intervention group reported a significant reduction in self-criticism and self-uncompassionate responding with effects present at two-month follow- up. There was a short-term effect of the training on self-compassion with no effect present at the two-month follow-up and no significant effect on self-reassurance. A limitation of the study is that participants’ previous experience with meditation was not assessed, and thus the findings may be a result of previous meditation practice and not the intervention itself. Despite this limitation, the findings show that an online short-term MBI may be helpful in reducing selfcriticism in general population, but a larger study taking into account the limitations needs to be conducted to replicate this effect before recommendations for clinical practice can be made

Complementary therapy in palliative care: A synthesis of qualitative and quantitative systematic reviews

BACKGROUND: Interventions delivered in palliative care are complex and their evaluation through qualitative and quantitative research can lead to contrasting results. In a systematic review of trials, the effectiveness results of complementary therapies in palliative care were inconclusive; however, our qualitative synthesis showed participants perceived them to be beneficial. AIM: Use a novel methodology to synthesise evidence from qualitative and quantitative systematic reviews on complementary therapy in palliative care to explore the following: (1) If interventions delivered in trials reflect how participants in qualitative studies report they are delivered in real-life settings and (2) whether quality of life measures used in trials capture perceived benefits that are reported in qualitative studies. METHODS: Two matrix tables were formulated. In one, key components in delivery of the complementary therapy from the qualitative synthesis which are as follows: (1) relationship with therapist, (2) comfortable environment, (3) choices (e.g. area of massage) and (4) frequent sessions, were plotted against intervention description, to explore matches and mismatches. In the other, items included in quality of life scales were compared with perceived benefits of complementary therapy. RESULTS: None of the trials included all four key delivery components. The five quality of life scales used in the trials failed to capture the range of perceived benefits from the complementary therapies and many included inappropriate or redundant items. CONCLUSIONS: By integrating qualitative and quantitative review data, we determined the reasons trials may be inconclusive. This methodological exemplar provides a framework for understanding complexity in outcomes across trials and a direction for future research

Emotional disclosure in palliative care: A scoping review of intervention characteristics and implementation factors

Background:: Emotional disclosure is the therapeutic expression of emotion. It holds potential as a means of providing psychological support. However, evidence of its efficacy in palliative settings is mixed. This may be due to variation in intervention characteristics. Aim:: To derive a greater understanding of the characteristics of potentially effective emotional disclosure-based interventions in palliative care by: (1) Developing a taxonomy of emotional disclosure-based interventions tested in people with advanced disease and (2) Mapping and linking objectives, outcomes, underlying mechanisms, and implementation factors. Design:: A scoping review drawing on Intervention Component Analysis to combine evidence from studies’ methods, results, and discussion sections. Data sources:: Six databases were searched to May 2020 including CINAHL, PsycINFO, and MEDLINE. Studies of emotional disclosure in adults with advanced disease were included. Study quality was appraised using an established tool. Results:: Seven thousand seven hundred ninety-two unique records were screened, of which 25 primary studies were included. Intervention characteristics were grouped into classes within three domains: topic of disclosure, format, and dose. Evidence was not available to determine which, if any, of the characteristics is most effective. Thematic synthesis of evidence from methods and discussion sections identified factors to consider in tailoring an emotional disclosure-based intervention to this setting, including: population characteristics (e.g. time since diagnosis), providing a safe environment, and flexibility in format. Conclusions:: This review approach facilitated a clearer understanding of factors that may be key in developing emotional disclosure-based interventions for palliative populations. Intervention Component Analysis has potential for application elsewhere to help develop evidence-based interventions.Peer reviewedFinal Published versio

How best to capture the impact of complementary therapies in palliative care: A systematic review to identify and assess the appropriateness and validity of multi-domain tools

BACKGROUND: Complementary therapies are widely used in palliative care settings. Qualitative research found that people with advanced disease report a range of physical and psychological benefits from complementary therapies, however evidence of their effectiveness from clinical trials is inconclusive. This may be because trials are limited by use of inappropriate outcome measures. AIMS: To identify tools which capture the impact of massage, reflexology and aromatherapy in people with advanced disease. We (1) identified multi-domain tools used to evaluate these therapies in populations with any chronic health condition and (2) assessed whether tools were valid and psychometrically robust in populations with advanced disease. DESIGN: A two-stage systematic review was conducted using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines (PROSPERO: CRD42020161199). DATA SOURCES: Six databases were searched (August 2021). Study methodological quality, tool psychometric properties and evidence quality were assessed. A global comparison score was generated. RESULTS: Stage 1: 66 trials using 40 different multi-domain tools were identified. Stage 2: Of these tools, we identified papers for seven tools regarding development or validation in advanced disease populations. The majority of psychometric data were inconsistent or inconclusive. Data were mostly of low quality due to methodological issues. CONCLUSION: Of the tools identified, 'Functional Assessment of Cancer Therapy - General' appears to be the most suitable alternative tool against COMSIN criteria, for trials of massage, reflexology and aromatherapy in palliative care. Further tool validation is required before firm recommendations can be made. Co-development of a core outcome set could ensure relevant domains are assessed

A Confirmatory Factor Analysis and Validation of the Vulnerable Attachment Style Questionnaire

This document is the Accepted Manuscript version of the following article: Kupeli, N., Norton, S., Chilcot, J. et al, ‘A Confirmatory Factor Analysis and Validation of the Vulnerable Attachment Style Questionnaire’, Journal of Psychopathology and Behavioral Assessment, Vol. 37(1): 153-163, first published online 24 May 2014. The final publication is available at Springer via http://dx.doi.org/ 10.1007/s10862-014-9432-3The Vulnerable Attachment Style Questionnaire (VASQ; Bifulco et al., Psychological Medicine, 33, 1099–1110, 2003) was developed to assess adult attachment as a vulnerability factor for developing depression and identified two subscales, insecure attachment and proximityseeking. The present study sought to confirm and further validate the factor structure of the VASQ in a large community convenience sample. The VASQ was completed by a large sample of men and women (N=1236) as part of an online survey. The data were randomly split to allow both independent exploratory (EFA) and confirmatory factor analyses (CFA) to be conducted. A four-factor model consisting of two types of proximity-seeking (lack of autonomy and anxious-dependent) and insecurity (ambivalent and avoidantdismissive) attachment patterns proved to be the best-fitting measurement model in this sample (X2=186.7, df=71, p<.001; CFI=.945, TLI=.929, RMSEA=.05). Although similar to the original questionnaire, the new factor structure resulted in the elimination of several items. Validity was confirmed with the shortened VASQ as similar associations with mood, stress, eating pathology and sex were observed for both the new shortened VASQ and original version of the VASQ. The structure of the VASQ was broadly consistent with the original solution although some items were removed and both subscales were further split into two sub-factors. Future research should use this tool in clinical and nonclinical groups to provide further support for its factor structure and to determine the clinical and theoretical usefulness of the different subscales.Peer reviewe

Eating Disorder Examination Questionnaire (EDE-Q) : Norms and psychometric properties in U.K. females and males

The Eating Disorder Examination Questionnaire (EDE-Q) is a widely used assessment of eating disorder psychopathology; however, EDE-Q norms are yet to be provided within a nonclinical U.K. adult sample. Second, there is considerable disagreement regarding the psychometric properties of this measure. Several alternative factor structures have been previously proposed, but very few have subsequently validated their new structure in independent samples and many are often confined to specific subpopulations. Therefore, in the current study, we provide norms of the original four-factor EDE-Q structure, and subsequently assess the psychometric properties of the EDE-Q in females and males using a large nonclinical U.K. sample (total N = 2459). EDE-Q norms were consistently higher in females compared with males across all samples. Initial confirmatory factor analyses (CFA) did not support the original 4-factor structure for females or males (Phase 1). However, subsequent exploratory factor analyses (EFA) revealed a 3-factor structure as being the optimal fit for both females and males, using an 18-item and 16-item model, respectively (Phase 2). For females, the newly proposed 18-item structure was validated within an independent student sample and further validated in an additional nonstudent sample. The 16-item 3-factor male structure was also validated within an independent nonstudent sample, but was marginally below accepted fit indices within an independent student sample (Phase 3). Taken together, the above findings suggest that the EDE-Q factor structure may require further reassessment, with greater focus on the qualitative differences in interpretation of EDE-Q items between females and males. (PsycINFO Database Record (c) 2019 APA, all rights reserved)