Online guided self-help to augment standard treatment for people with anorexia nervosa: feasibility, efficacy and process measures

Background: There is mounting evidence on the effectiveness of guided self-help (GSH) interventions to augment, shorten or replace standard care for eating disorders (EDs). However, only few studies have tested the use of GSH for people with anorexia nervosa (AN). Aims: 1) to conduct a systematic review and meta-analysis of GSH in AN, with a focus on clinical outcomes and feasibility; 2) to evaluate the feasibility, acceptability and efficacy of a novel digital GSH intervention for AN (RecoveryMANTRA) tested in addition to treatment as usual (TAU) in the outpatient setting, 3) to assess predictors of drop-out from the RecoveryMANTRA + TAU condition; 4) to establish the role of working alliance (WA) with mentors guiding the use of RecoveryMANTRA on patient’s symptom change over time and 5) to measure how language style matching between mentors and patients predicts clinical outcomes in the RecoveryMANTRA + TAU condition. Method: 187 patients accessing outpatient services for AN across different sites in England were randomized to receive TAU only (n= 88; control group) or TAU plus RecoveryMANTRA (n= 99; experimental group). The primary outcome included change in body mass index (BMI) at the end of six weeks of intervention and changes in eating disorder symptoms at 6 and 12 months follow-up. Process measures, such as motivation for treatment, confidence to change, and working alliance with the therapist at the outpatient service were longitudinally investigated. The GSH intervention was delivered by peer mentors (recovered individuals or carers, n=12) or mentors (psychology graduates, n=14) over six weekly synchronous chat-based sessions. The impact of type of mentorship and of linguistic style matching between patients and mentors on clinical outcomes and treatment adherence was measured. Results: Findings showed that: 1) GSH in AN was associated with significantly lower drop-out rates from the end of treatment assessments compared to a control condition; 2) those in the RecoveryMANTRA + TAU condition reported a trend level reduction in anxiety, higher levels of confidence in own ability to change, and a better alliance with the therapist at the outpatient service; 3) patient’s clinical outcomes were in part associated with the characteristics of the mentor delivering guidance 4) peer mentors working alliance in the previous session was significantly associated with eating psychopathology ratings in the next session, and 5) greater linguistic style matching between patients and mentors was associated to patient’s engagement with clinical treatment. Conclusions: Findings provided empirical support for the feasibility and effectiveness of online GSH for adults with AN. Strengths, weaknesses and clinical implications have been discussed

Social difficulties as risk and maintaining factors in anorexia nervosa:A mixed-method investigation

Anorexia nervosa (AN) is a serious psychiatric disorder characterized by severe restriction of energy intake and dangerously low body weight. Other domains of functioning are affected, including social functioning. Although difficulties within this domain have started to be acknowledged by the literature, some important gaps remain to be filled. Do social difficulties predate the onset of the illness? What difficulties in particular are relevant for the development and maintenance of the illness? The aim of this study is to combine the use of quantitative and qualitative methods to answer these questions. Ninety participants with lifetime AN (88 women and 2 men) completed an online survey assessing memories of involuntary submissiveness within the family, fear of negative evaluation from others, perceived lack of social competence, feelings of social belonging, eating disorder symptoms, and work and social adjustment. Participants also answered three open questions regarding their experience of social relationships before and after the illness onset. The findings provided support for the hypothesized relationships between the study variables. Involuntary submissiveness and fear of negative evaluation predicted eating disorder symptoms and these associations were partially mediated by perceived lack of social competence. Two-thirds of the sample recalled early social difficulties before illness onset and recognized that these had played a role in the development of the illness. A larger proportion of participants stated that the eating disorder had affected their social relationships in a negative way. This study sheds some light on patients' perspective on the predisposing and maintaining role that social difficulties play in AN and identifies key psychological variables that could be targeted in treatment

Patient and mentor language style matching as a predictor of working alliance, engagement with treatment as usual, and eating disorders symptoms over the course of an online guided self-help intervention for anorexia nervosa

Objective The aim of this study was to examine the processes involved in a guided self-help (GSH) pre-treatment intervention (RecoveryMANTRA) for patients with anorexia nervosa (AN), by measuring the levels of patient/mentor Language Style Matching (LSM). RecoveryMANTRA was supported by student mentors or peer mentors (recovered individuals) over six weekly chat-based sessions. We examined whether LSM during RecoveryMANTRA predicted patients'working alliance with the clinic therapist, motivation, eating disorder (ED) and general psychopathology. A further aim was to examine differences in LSM between student mentors and peer mentors. Method 87 AN adults received RecoveryMANTRA plus treatment as usual. The LSM algorithm was used to calculate verbal attunement between patient and mentor. Participants were assessed at baseline and at the end of the intervention. Results Both early (1(st) session) and late (6(th) session) LSM predicted higher working alliance with the clinic therapist. Moreover, late LSM predicted lower EDs symptoms at the end of the RecoveryMANTRA intervention. Patient/peer mentor dyads showed higher late verbal attunement than patient/student mentor dyads. Conclusions These findings suggests that in the early phase of treatment relational aspects can impact on engagement with treatment. Verbal attunement in a GSH for AN is associated with working alliance and better clinical outcome

How Can We Help You?: An Instagram-Based Online Self-Help for Eating Disorders

In recent years, there has been a noticeable increase in online self-help treatments and peer-support programs for eating disorders. The possibility of easily accessing them anytime makes these programs an important support tool and an influencing source for increasing motivation to change. The aim of this work is to describe the #How can we help you? project, its initial feedback received from users, and its future directions. Researchers and clinicians developed an Instagram profile (Dicci Come Aiutarti) based on psychoeducation, aimed at orienting those suffering from a self-reported eating disorder towards clinical care, providing information about eating concerns and related constructs, and increasing motivation for treatment and illness awareness. The contents shared are based on narratives about people who had recovered from an eating disorder, importance and ability to change, and nutrition management. We have provided an overview of the needs of the Instagram profile users, a description of the main interactions recorded since the profile was opened, and examples of the unmet needs shared by users in direct messages. Future directions of the project concern the definition and formalization of the type of support provided by developing a psychoeducational and integrated program and also, the formulation of a research protocol able to assess the usability, effectiveness, and satisfaction of the Instagram profile. © 2023 by the authors

Oncostatin M is overexpressed in NASH-related hepatocellular carcinoma and promotes cancer cell invasiveness and angiogenesis

: Oncostatin M (OSM) is a pleiotropic cytokine of the interleukin (IL)-6 family that contributes to the progression of chronic liver disease. Here we investigated the role of OSM in the development and progression of hepatocellular carcinoma (HCC) in NAFLD/NASH. The role of OSM was investigated in: a) selected cohorts of NAFLD/NASH HCC patients; b) liver cancer cells exposed to human recombinant OSM or stably transfected to overexpress human OSM; c) murine HCC xenografts; d) a murine NASH-related model of hepatic carcinogenesis. OSM was found to be selectively overexpressed in HCC cells of NAFLD/NASH patients, depending on tumor grade. OSM serum levels, barely detectable in patients with simple steatosis or NASH, were increased in patients with cirrhosis, and more evident in those carrying HCC. In this latter group, OSM serum levels were significantly higher in the subjects with intermediate/advanced HCCs and correlated with poor survival. Cell culture experiments indicated that OSM upregulation in hepatic cancer cells contributes to HCC progression by inducing epithelial-to-mesenchymal transition and increased invasiveness of cancer cells as well as by inducing angiogenesis, which is of critical relevance. In murine xenografts, OSM overexpression was associated with slower tumor growth, but an increased rate of lung metastases. Overexpression of OSM and its positive correlation with the angiogenic switch were also confirmed in a murine model of NAFLD/NASH-related hepatocarcinogenesis. Consistent with this, analysis of liver specimens from human NASH-related HCCs with vascular invasion showed that OSM was expressed by liver cancer cells invading hepatic vessels. In conclusion, OSM up-regulation appears to be a specific feature of HCC arising on a NAFLD/NASH background, and it correlates with clinical parameters and disease outcome. Our data highlight a novel pro-carcinogenic contribution for OSM in NAFLD/NASH, suggesting a role of this factor as a prognostic marker and a putative potential target for therapy. This article is protected by copyright. All rights reserved

The impact of emotion regulation and mental health difficulties on health behaviours during COVID19

The COVID-19 outbreak is having a profound impact on individuals' psychological and physical wellbeing. The aim of this study was to assess the extent of this impact and its mechanisms on a sample of adults living in Italy during the first lockdown (April–May 2020). Two hundred ninety-two individuals (67.1% females) were recruited from the community through social media. They completed baseline online questionnaires to collect demographic information, data on past and present general health and health behaviours, and to assess emotion regulation strategies. Participants completed a brief survey to assess mood and health behaviours three times a week, for three weeks. Individuals with lifetime psychiatric disorders (about 50%) reported greater negative mood and use of unhealthy behaviours over time, compared to those with no psychiatric vulnerability. The use of cognitive reappraisal to regulate emotions was associated with greater resilience (i.e., feelings of hope and resourcefulness, and ability to seek social support and enjoyable activities). Cognitive reappraisal is a skill that can be trained and could be utilised to buffer the effect of general stress (i.e. stress caused by the pandemic) on individuals’ wellbeing

Social difficulties as risk and maintaining factors in anorexia nervosa:A mixed-method investigation

Anorexia nervosa (AN) is a serious psychiatric disorder characterized by severe restriction of energy intake and dangerously low body weight. Other domains of functioning are affected, including social functioning. Although difficulties within this domain have started to be acknowledged by the literature, some important gaps remain to be filled. Do social difficulties predate the onset of the illness? What difficulties in particular are relevant for the development and maintenance of the illness? The aim of this study is to combine the use of quantitative and qualitative methods to answer these questions. Ninety participants with lifetime AN (88 women and 2 men) completed an online survey assessing memories of involuntary submissiveness within the family, fear of negative evaluation from others, perceived lack of social competence, feelings of social belonging, eating disorder symptoms, and work and social adjustment. Participants also answered three open questions regarding their experience of social relationships before and after the illness onset. The findings provided support for the hypothesized relationships between the study variables. Involuntary submissiveness and fear of negative evaluation predicted eating disorder symptoms and these associations were partially mediated by perceived lack of social competence. Two-thirds of the sample recalled early social difficulties before illness onset and recognized that these had played a role in the development of the illness. A larger proportion of participants stated that the eating disorder had affected their social relationships in a negative way. This study sheds some light on patients' perspective on the predisposing and maintaining role that social difficulties play in AN and identifies key psychological variables that could be targeted in treatment

A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa

BackgroundOutpatient 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.MethodsParticipants 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.ResultsAdherence 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.ConclusionsAugmenting 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

Social Difficulties As Risk and Maintaining Factors in Anorexia Nervosa: A Mixed-Method Investigation

Anorexia nervosa (AN) is a serious psychiatric disorder characterized by severe restriction of energy intake and dangerously low body weight. Other domains of functioning are affected, including social functioning. Although difficulties within this domain have started to be acknowledged by the literature, some important gaps remain to be filled. Do social difficulties predate the onset of the illness? What difficulties in particular are relevant for the development and maintenance of the illness? The aim of this study is to combine the use of quantitative and qualitative methods to answer these questions. Ninety participants with lifetime AN (88 women and 2 men) completed an online survey assessing memories of involuntary submissiveness within the family, fear of negative evaluation from others, perceived lack of social competence, feelings of social belonging, eating disorder symptoms, and work and social adjustment. Participants also answered three open questions regarding their experience of social relationships before and after the illness onset. The findings provided support for the hypothesized relationships between the study variables. Involuntary submissiveness and fear of negative evaluation predicted eating disorder symptoms and these associations were partially mediated by perceived lack of social competence. Two-thirds of the sample recalled early social difficulties before illness onset and recognized that these had played a role in the development of the illness. A larger proportion of participants stated that the eating disorder had affected their social relationships in a negative way. This study sheds some light on patients’ perspective on the predisposing and maintaining role that social difficulties play in AN and identifies key psychological variables that could be targeted in treatment

Outcomes for adults with anorexia nervosa who do not respond early to outpatient treatment

Objective: To better understand those patients with anorexia nervosa who do not show early response to treatment and are likely to have poorer outcome. Method: From an existing data set of 187 patients with anorexia nervosa across 22 eating disorder outpatient services in the United Kingdom, participants who had started treatment and had at least one body mass index (BMI) observation in the first 6 weeks of treatment were eligible for these secondary analyses (N = 65), a latent class analysis of BMI change over the first 6 weeks of treatment. Fifty-six patients showed no early change in BMI. We used logistic regression to examine predictors of good outcome in the 40 participants who had 12-month follow-up data. Predictors included global EDE-Q, negative affect (Depression, Anxiety, and Stress Scales) and functional impairment (Work and Social Adjustment Scale). Results: Good outcome was achieved by 23% of patients and remission by 15%. Good outcome was predicted by less functional impairment at baseline. Discussion: Further work that can identify sub-groups of patients with anorexia nervosa who do not achieve good outcome after treatment will inform the development of targeted engagement approaches. © 2021 Wiley Periodicals LLC