Interventions to Empower Adults with Eating Disorders and Their Partners around the Transition to Parenthood

The transition to parenthood is perceived as a stressful life event, when parents experience an immense change of their psychological focus and a reorientation of roles and responsibilities in the family system. This process may be even more challenging in the presence of a parental eating disorder history. This paper reviews the impact of parental eating disorders on the parents, the couple relationship, and their child during the perinatal period. A parental eating disorder is associated with more negative expectations of parental efficacy as well as specific difficulties in couple communication over the child’s feeding, shape, and weight. Providers who better understand the effects of an eating disorder on parental functioning can more effectively intervene early on. We also present couple- or parent-based, empirically supported interventions for adults with eating disorders and their partners in the prenatal and postnatal periods: Uniting Couples in the treatment of Anorexia Nervosa (UCAN) and Uniting couples In the Treatment of Eating disorders (UNITE) both enhance recovery from the eating disorder through a couple-based intervention; the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) incorporates the support of partners, when appropriate; Parent-Based Prevention (PBP) focuses on improving parental functioning and reducing risk of negative parental and child outcomes. Finally, we discuss the clinical implications of addressing parental eating disorders and encourage more research on these families

Potential Predictors of Injury Among Pre-Professional Ballet and Contemporary Dancers

Injuries occur frequently among ballet and contemporary dancers. However, limited literature exists on injuries to pre-professional dancers in the USA. The goals of this study were to 1. provide a descriptive epidemiology of the incidence of musculoskeletal injuries in an adolescent and young adult dance population and 2. identify parsimonious regression models that could be potentially used to predict injury incidence. The study was based at the University of North Carolina School of the Arts (UNCSA) from Fall 2009 to Spring 2015. An injury was defined as any event that caused a dancer to be seen at the UNCSA Student Health Services and caused the dancer to modify or curtail dance activity for at least 1 day. Injury rate ratios (IRRs) were calculated using negative binomial generalized estimating equations. Models predicting injury rates were built using forward selection, stratified by sex. Among 480 dancers, 1,014 injuries were sustained. Most injuries were to the lower extremity and the result of overuse. There were differences in upper extremity, lower extremity, and traumatic injury rates by demographic subgroups. Among females, the most parsimonious predictive model for injury rates included a self-reported history of depression, age at time of injury, and number of injuries sustained at UNCSA prior to the semester of current injury. Among males, the most parsimonious model was a univariate model with family history of alcohol or drug problems. Strategies for traumatic injury prevention among dancers should be both sex- and style-specific. No differences were observed in overuse injury rates by sex or style, suggesting that generic overuse prevention strategies may not need to be guided by these factors. It is concluded that strategies can be implemented to reduce and mitigate the consequences of injuries if not the injuries themselves

Familial liability for eating disorders and suicide attempts : evidence from a population registry in Sweden

Importance: Suicide attempts are common in individuals with eating disorders. More precise understanding of the mechanisms underlying their co-occurrence is needed. Objective: To examine the association between eating disorders and suicide attempts and whether familial risk factors contribute to the association. Design: A cohort design following a Swedish birth cohort 1979-2001 from age 6 until 31/12/2009. Setting: Information was acquired from Swedish national registers. Participants: Individuals born 1979-2001 and living in Sweden before age 6 (N= 2,268,786) were eligible for the study. Each individual was linked to his/her biological full-siblings, maternal half-siblings, paternal half-siblings, full-cousins, and half-cousins. Eating disorders were captured by three variables: any eating disorder, anorexia nervosa (AN), and bulimia nervosa (BN), identified by any lifetime diagnoses recorded in the registers. Suicide attempts were defined as any suicide attempts, including death by suicide, recorded in the registers. We examined the association between eating disorders and death by suicide separately, but were underpowered to explore familial liability for this association. Results: Individuals with any eating disorder had increased risk of suicide attempts (OR=5.28, 95%CI [5.04, 5.54]) and death by suicide (OR=5.39, 95%CI [4.00, 7.25]). The risks attenuated but remained significant after adjusting for comorbid major depressive disorder, anxiety disorders, and substance use disorder. Similar results were found for AN and BN, except that adjusted OR of death by suicide in BN became insignificant, possibly due to insufficient power. Individuals (index) who had a full-sibling with any eating disorder had increased risk of suicide attempts (OR=1.41, 95%CI [1.29, 1.53]). The risk attenuated for any eating disorder in more distant relatives (maternal half-siblings, OR=1.10, 95%CI [0.90, 1.34]; paternal half-siblings, OR=1.21, 95%CI [0.98, 1.49]; full-cousins, OR=1.11, 95%CI [1.06, 1.18]; half-cousins, OR=0.90, 95%CI [0.78, 1.03]). This familial pattern remained stable after adjusting for the index individuals’ eating disorders. Similar patterns were found for AN and BN. Conclusions and Relevance: Our results suggest increased risk of suicide attempts in individuals with lifetime eating disorders and their relatives. The pattern of familial co-aggregation suggests familial liability for the association between eating disorders and suicide. Psychiatric comorbidities partially explain this association, suggesting particularly high-risk presentations.China Scholarship CouncilAmerican Foundation for Suicide PreventionSwedish Initiative for Research on Microdata in the Social and Medical Sciences framework, 340-2013-5867Swedish Research Council, 538-2013Global Foundation for Eating DisordersSwedish Research Council, 538-2013-8864Manuscrip

Body dissatisfaction in adolescent boys

Body dissatisfaction is a significant mental health symptom present in adolescent girls and boys. However, it is often either disregarded in adolescent boys or examined using assessments that may not resonate with males. The present study addresses these issues, examining the manifestation, etiology, and correlates of 3 facets of body dissatisfaction in adolescent boys. Adolescent male twins aged 16- to 17-years-old from the Swedish Twin Study of Child and Adolescent Development were included along with a female comparison group: 915 monozygotic and 671 dizygotic same-sex twins. Body dissatisfaction was defined using measures of height dissatisfaction, muscle dissatisfaction, and the body dissatisfaction subscale of the Eating Disorder Inventory (EDI-BD). We examined the prevalence of body dissatisfaction, whether the facets of body dissatisfaction were phenotypically and etiologically distinct, and associations with specific externalizing and internalizing symptoms. For boys, muscle dissatisfaction scores were greater than height dissatisfaction scores. Results also indicated that height and muscle dissatisfaction were phenotypically and etiologically distinct from the EDI-BD. Unique associations were observed with externalizing and internalizing symptoms: muscle dissatisfaction with symptoms of bulimia nervosa and the EDI-BD with internalizing symptoms, body mass index, and drive for thinness. The facets of body dissatisfaction were also largely distinct in girls and unique between-sex associations with externalizing and internalizing symptoms emerged. Overall, male-oriented aspects of body dissatisfaction are distinct from female-oriented aspects of body dissatisfaction. To capture the full picture of male body dissatisfaction, multiple facets must be addressed

The Association between Symptom Accommodation and Emotional Coregulation in Couples with Binge Eating Disorder

Intense negative emotions and maladaptive behavioral strategies to reduce emotional distress occur not only in patients with various forms of psychopathology but also in their committed partners. One common strategy to reduce distress is for partners to accommodate to the symptoms of the disorder, which reduces distress short term but maintains symptoms long term. Accommodation is believed to be motivated by the partner reacting behaviorally to the patient's emotions, but the emotions of the partner in this context have yet to be examined. This pilot study examined how partner accommodation related to specific patterns of emotional coregulation between patients with binge eating disorder (BED) and their partners, before and after a couple-based intervention for BED. Vocally encoded emotional arousal was measured during couples’ (n = 11) conversations about BED. As predicted, partners’ emotional reactivity to patients’ emotional arousal was associated with high accommodation before treatment. Thus, partners may use accommodation as a strategy to reduce both the patients’ and their own distress. After treatment, partners’ arousal was no longer associated with the patients’ emotional arousal; instead, partners showed greater emotional stability over time, specifically when accommodation was low. Additionally, patients were less emotionally aroused after treatment. Therefore, treatment may have decreased overall emotionality of patients and altered the association between accommodation and partners’ emotional reactivity. If replicated, this understanding of the emotional context associated with accommodation in BED can inform couple-based treatment by targeting specific emotional precipitants of behaviors that maintain symptoms

A pilot open trial of UNITE-BED: A couple-based intervention for binge-eating disorder

Objective: To evaluate the feasibility, acceptability, and preliminary efficacy of a couple-based intervention for binge-eating disorder (BED), called UNiting couples In the Treatment of Eating disorders-BED edition (UNITE-BED). Method: In an open pilot trial, 11 couples in which one or both adult partners had a diagnosis of DSM-5 threshold or sub-threshold BED participated in 22 weekly sessions of UNITE-BED. Patients also received individual treatment, outside of the context of the trial. Couples completed measures on treatment satisfaction, eating disorder symptom severity, depression, anxiety, emotion regulation, and relational functioning at post-treatment and 3-month follow-up. Statistical analyses were conducted to identify change over the course of treatment. Results: UNITE was feasible and acceptable to the majority of couples (9% dropout; high satisfaction ratings). Objective binge abstinence was 81.8% and subjective binge abstinence was 45.5% by post-treatment. Patient binge-eating symptomatology reduced over the course of treatment with results maintained at follow up. Patients' depression symptoms decreased and patients' emotion regulation improved at both time points. Discussion: Including partners in treatment for BED may be beneficial. Results support further evaluation of the efficacy of couple-based interventions for BED in larger randomized-controlled trials

Cost-effectiveness of internet-based cognitive-behavioral treatment for bulimia nervosa: Results of a randomized controlled trial

Objective: To evaluate the cost-effectiveness of Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN) compared to face-to-face delivery of CBT-BN. Methods: This study is a planned secondary analysis of data from a randomized clinical trial. Participants were 179 adults (98% female, mean age = 28 years) meeting DSM-IV criteria for bulimia nervosa who were randomized to group face-to-face or group Internet-based CBTBN for 16 sessions during 20 weeks. The cost-effectiveness analysis was conducted from a third-party payor perspective, and a partial societal perspective analysis was conducted to investigate cost-utility (ie, cost per gain in quality-adjusted life-years) and patient outof-pocket travel-related costs. Net health care costs were calculated from protocol and nonprotocol health care services using third-party payor cost estimates. The primary outcome measure in the clinical trial was abstinence from binge eating and purging, and the trial start and end dates were 2008 and 2016. Results: The mean cost per abstinent patient at posttreatment was $7,757 (95$4,515, $13,361) for face-to-face and$11,870 (95% CL, $6,486,$22,188) for Internet-based CBT-BN, and at 1-year follow-up was $16,777 (95$10,298, $27,042) for face-to-face and$14,561 (95% CL, $10,165,$21,028) for Internet-based CBT-BN. There were no statistically significant differences between treatment arms in cost-effectiveness or costutility at posttreatment or 1-year follow-up. Out-of-pocket patient costs were significantly higher for face-to-face (mean [95% CL] = $178 [$127, $140]) than Internet-based ($50 [$50,$50]) therapy. Conclusions: Third-party payor cost-effectiveness of Internet-based CBT-BN is comparable with that of an accepted standard. Internet-based dissemination of CBT-BN may be a viable alternative for patients geographically distant from specialist eating disorder services who have an unmet need for treatment

Predictors of dropout in face-to-face and internet-based cognitive-behavioral therapy for bulimia nervosa in a randomized controlled trial

Objective: We sought to identify predictors and moderators of failure to engage (i.e., pretreatment attrition) and dropout in both Internet-based and traditional face-to-face cognitive-behavioral therapy (CBT) for bulimia nervosa. We also sought to determine if Internet-based treatment reduced failure to engage and dropout. Method: Participants (N = 191, 98% female) were randomized to Internet-based CBT (CBT4BN) or traditional face-to-face group CBT (CBTF2F). Sociodemographics, clinical history, eating disorder severity, comorbid psychopathology, health status and quality of life, personality and temperament, and treatment-related factors were investigated as predictors. Results: Failure to engage was associated with lower perceived treatment credibility and expectancy (odds ratio [OR] = 0.91, 95% CI: 0.82, 0.97) and body mass index (BMI) (OR = 1.10; 95% CI: 1.03, 1.18). Dropout was predicted by not having a college degree (hazard ratio [HR] = 0.55; 95% CI: 0.37, 0.81), novelty seeking (HR = 1.02; 95% CI: 1.01, 1.03), previous CBT experience (HR = 1.77; 95% CI: 1.16, 2.71), and randomization to the individual's nonpreferred treatment format (HR = 1.95, 95% CI: 1.28, 2.96). Discussion: Those most at risk of failure to engage had a higher BMI and perceived treatment as less credible and less likely to succeed. Dropout was associated with less education, higher novelty seeking, previous CBT experience, and a mismatch between preferred and assigned treatment. Contrary to expectations, Internet-based CBT did not reduce failure to engage or dropout

Supplementary Material for: CBT4BN: A Randomized Controlled Trial of Online Chat and Face-to-Face Group Therapy for Bulimia Nervosa

<p><b><i>Objective:</i></b> Although cognitive-behavioral therapy (CBT) represents the first-line evidence-based psychotherapy for bulimia nervosa (BN), most individuals seeking treatment do not have access to this specialized intervention. We compared an Internet-based manualized version of CBT group therapy for BN conducted via a therapeutic chat group (CBT4BN) to the same treatment conducted via a traditional face-to-face group therapy (CBTF2F). <b><i>Method:</i></b> In a two-site, randomized, controlled noninferiority trial, we tested the hypothesis that CBT4BN would not be inferior to CBTF2F. A total of 179 adult patients with BN (2.6% males) received up to 16 sessions of group CBT over 20 weeks in either CBT4BN or CBTF2F, and outcomes were compared at the end of treatment and at the 12-month follow-up. <b><i>Results:</i></b> At the end of treatment, CBT4BN was inferior to CBTF2F in producing abstinence from binge eating and purging. However, by the 12-month follow-up, CBT4BN was mostly not inferior to CBTF2F. Participants in the CBT4BN condition, but not CBTF2F, continued to reduce their binge-eating and purging frequency from the end of treatment to the 12-month follow-up. <b><i>Conclusions:</i></b> CBT delivered online in a group chat format appears to be an efficacious treatment for BN, although the trajectory of recovery may be slower than face-to-face group therapy. Online chat groups may increase accessibility of treatment and represent a cost-effective approach to service delivery. However, barriers in service delivery such as state-specific license and ethical guidelines for online therapists need to be addressed.</p