1
|
Robinson L, Flynn M, Cooper M. Individual differences in motivation to change in individuals with eating disorders: A systematic review. Int J Eat Disord 2024; 57:1069-1087. [PMID: 38436481 DOI: 10.1002/eat.24178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Motivation to change has been suggested to significantly impact treatment outcomes in eating disorders (EDs). This review will investigate factors associated with motivation to change in EDs with the aim of supporting clinicians to be aware and sensitive to factors that might obstruct recovery and to inform motivation-based interventions. METHOD Using PRISMA guidelines, this article identified 24 studies through database searches meeting eligibility criteria. Only correlates of motivation were identified, limiting the ability of this review to identify causal relationships. Factors that changed alongside changes in motivation were identified from longitudinal studies. RESULTS This review identified factors such as individual characteristics, co-morbid psychopathology, lack of treatment autonomy and relationships with others to be associated with motivation to change in individuals with EDs. In addition, motivation to change significantly increased alongside self-esteem and identity re-negotiation when measured longitudinally. DISCUSSION Motivational interviewing can typically focus on exploring ambivalence to treatment, identifying goals and values, and increasing self-efficacy. However, this review identifies individual and relational factors to be particularly significant and may obstruct recovery from an ED. As such, evidence-based targets have been identified to inform clinicians and motivation-based interventions. PUBLIC SIGNIFICANCE Knowledge of factors associated with motivation to change in EDs is important to understand those who may have poorer treatment outcomes. Motivation may be improved by supporting individuals' relationship with others and tailoring interventions according to temperament and personality traits. Utilizing an individual's social support as they enter ED treatment may be effective in maximizing motivation to recover.
Collapse
Affiliation(s)
- Lauren Robinson
- Oxford Institute of Clinical Psychology Training and Research, Oxford University, Oxford, UK
| | - Michaela Flynn
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Myra Cooper
- Oxford Institute of Clinical Psychology Training and Research, Oxford University, Oxford, UK
| |
Collapse
|
2
|
Zielinski-Gussen IM, Herpertz-Dahlmann B, Dahmen B. Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion. Healthcare (Basel) 2023; 11:3149. [PMID: 38132039 PMCID: PMC10742854 DOI: 10.3390/healthcare11243149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences. METHODS This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families. RESULTS Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.
Collapse
Affiliation(s)
- Ingar M. Zielinski-Gussen
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | | | | |
Collapse
|
3
|
Dialektisch Behaviorale Therapie (DBT-A) bei jugendlichen Patient/innen mit Anorexia nervosa. Prax Kinderpsychol Kinderpsychiatr 2022; 71:415-429. [DOI: 10.13109/prkk.2022.71.5.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
4
|
Sourlier P, Bozzi S, Kabuth B, Lamourette M, Ligier F. Experiences of parents and patients hospitalised in a child psychiatric unit for anorexia nervosa after reorganisation of care imposed by the COVID-19 Pandemic in France: a qualitative study-The QUALICOVID study. J Eat Disord 2022; 10:57. [PMID: 35468851 PMCID: PMC9035507 DOI: 10.1186/s40337-022-00579-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anorexia nervosa is a serious, albeit common mental illness that generally occurs during adolescence. Although outpatient care is recommended, hospitalisation is sometimes required. There is a dedicated hospitalisation unit caring for children and adolescents presenting with anorexia nervosa in Nancy, France. However, on 16 March 2020, a national lockdown was declared by the French government as the COVID-19 pandemic escalated in France. This resulted in the adjustment of hospital admissions accompanied by premature discharge and an intensive outpatient care programme. In the light of such changes, consideration should be given to the potential impact of changes in the care pattern for anorexic patients and their parents. The purpose of our study was to explore the experiences of anorexia nervosa patients hospitalised in the unit, and their parents, following changes in the care strategy. METHODS The study was conducted between weeks four and eight after lockdown was announced. The study cohort included all the patients treated for anorexia nervosa and hospitalised in the treatment unit before 16 March 2020 and their parents. A qualitative method was used and every subject was offered a semi-structured interview. Data were analysed by means of inductive thematic analysis. RESULTS Seven superordinate themes were identified: positive aspects, concerns, preparation, loss of landmarks and hospital security, gradual return to a "normal" life, relational aspects and the likelihood of disease progression. Moreover, all the parents and patients were satisfied with the intensive outpatient care offered on discharge. CONCLUSION Despite initial ambivalence, all patients and their parents viewed this unexpected hospital discharge positively in these exceptional conditions. This suggests that restructuring the care programme could prove beneficial with increasing use of outpatient management, thereby reducing the length of the hospital stay and adjusting the return to school. TRIAL REGISTRATION ID-RCB 2020-A01101-38-This project was approved by the Comité de Protection des Personnes (CPP) Sud Méditerranée IV [South Mediterranean IV Ethics Committee (EC)] on 5 May 2020.
Collapse
Affiliation(s)
- Pauline Sourlier
- Service de Psychiatrie de l'Enfant et de l'Adolescent, Pôle Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, Centre Psychothérapique de Nancy, 1 Rue du Docteur Archambault, 54520, Laxou, France. .,EA 4432 PRISME, Université de Lorraine, 54000, Nancy, France.
| | - Sophie Bozzi
- Service de Psychiatrie de l'Enfant et de l'Adolescent, Pôle Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, Centre Psychothérapique de Nancy, 1 Rue du Docteur Archambault, 54520, Laxou, France.,EA 4432 PRISME, Université de Lorraine, 54000, Nancy, France
| | - Bernard Kabuth
- Service de Psychiatrie de l'Enfant et de l'Adolescent, Pôle Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, Centre Psychothérapique de Nancy, 1 Rue du Docteur Archambault, 54520, Laxou, France.,EA 4432 PRISME, Université de Lorraine, 54000, Nancy, France
| | - Marilou Lamourette
- Service de Psychiatrie de l'Enfant et de l'Adolescent, Pôle Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, Centre Psychothérapique de Nancy, 1 Rue du Docteur Archambault, 54520, Laxou, France.,EA 4360 APEMAC, Université de Lorraine, 54000, Nancy, France
| | - Fabienne Ligier
- Service de Psychiatrie de l'Enfant et de l'Adolescent, Pôle Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, Centre Psychothérapique de Nancy, 1 Rue du Docteur Archambault, 54520, Laxou, France.,EA 4360 APEMAC, Université de Lorraine, 54000, Nancy, France
| |
Collapse
|
5
|
Budde LI, Wilms S, Föcker M, Dalhoff A, Müller JM, Wessing I. Influence of Identity Development on Weight Gain in Adolescent Anorexia Nervosa. Front Psychiatry 2022; 13:887588. [PMID: 35693950 PMCID: PMC9186337 DOI: 10.3389/fpsyt.2022.887588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/03/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Anorexia Nervosa (AN) typically begins during early adolescence, an important phase of personality development. A substantial proportion of adolescent AN patients shows impaired personality functioning, which might be a relevant but understudied aspect of illness severity. The developmental status of identity as key element of personality is suggested to influence inpatient treatment outcome in adolescents with AN. METHODS This study analyzed existing data of N = 60 adolescents with AN. Multilevel models assessed the influence of identity functioning, measured by the Assessment of Identity Development in Adolescence (AIDA) at admission, on weight gain [BMI (body mass index), BMI-SDS (BMI standard deviation score)] during 10 weeks of inpatient treatment. Moreover, the influence of other indicators of illness severity, i.e., eating disorders and comorbid psychopathologies, was explored. RESULTS As expected, higher AIDA scores negatively influenced the course of weight gain. A similar effect was observed for other psychopathology measures, especially body image distortion. In general, higher weight at admission was associated with less weight gain. Higher weight at admission was also predicted by higher other psychopathology measures, but not AIDA scores. CONCLUSION The course of weight gain during inpatient treatment was hampered in adolescent AN patients who have difficulties developing a stable identity. Unlike other aspects of psychopathology, this was independent of the initial weight. Thus, in addition to the level of underweight and other aspects of psychopathology, difficulties in identity development constitute a relevant aspect of illness severity in AN. This recommends consideration of identity development during treatment.
Collapse
Affiliation(s)
- Lynn I Budde
- Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
| | - Simon Wilms
- Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
| | - Manuel Föcker
- Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
| | - Anke Dalhoff
- Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
| | - Joerg M Müller
- Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
| | - Ida Wessing
- Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
| |
Collapse
|
6
|
Peters T, Kolar D, Föcker M, Bühren K, Dahmen B, Becker K, Weber L, Correll CU, Jaite C, Egberts KM, Romanos M, Ehrlich S, Seidel M, Roessner V, Fleischhaker C, von Gontard A, Hahn F, Huss M, Kaess M, Legenbauer T, Renner TJ, Schulze UME, Sinzig J, Wessing I, Antony G, Herpertz-Dahlmann B, Gradl-Dietsch G, Hebebrand J. Reasons for admission and variance of body weight at referral in female inpatients with anorexia nervosa in Germany. Child Adolesc Psychiatry Ment Health 2021; 15:78. [PMID: 34937571 PMCID: PMC8697455 DOI: 10.1186/s13034-021-00427-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Body mass index (BMI) at hospital admission in patients with anorexia nervosa (AN) represents a prognostic marker for mortality, chronicity and future body weight. The current study focused on the associations between BMI standard deviation score (BMI-SDS) at admission and reasons for seeking inpatient treatment. Further interest was given to the relationship between premorbid weight and weight at admission, as well as the effect of both weight at referral and reasons for admission on treatment outcome. METHODS Data ascertained in the German Register of Children and Adolescents with AN were analysed to assess the parental and patient overlap for 23 predefined reasons for admission, using factor analyses and regressions models. RESULTS Complete parent-patient data sets were available for 360 patients out of 769. The highest consensus rates between parents and patients were obtained for weight and eating behavior related reasons and hyperactivity. Based on factor analysis, four factors emerged. Premorbid BMI-SDS, age and 'low body weight' as stated by patients or parents explained almost 40% of the variance of the BMI-SDS at admission. CONCLUSIONS Results underscore the relevance of age and premorbid BMI for BMI at admission. Only single reasons for admission explained further variance, with 'low body weight' having the largest effect. Approximately 40% of the variance of BMI-SDS was explained. For the first time, the effect of premorbid BMI for BMI at admission was robustly demonstrated in a multicenter study. Of the variance in BMI-SDS at discharge, our model could explain 37%, with reasons for admission having a small effect. Further investigation of the reasons for admission would be worthwhile to improve treatment and prognosis.
Collapse
Affiliation(s)
- Triinu Peters
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Essen (AöR), University of Duisburg-Essen, Wickenburgstrasse 21, 45147, Essen, Germany.
| | - David Kolar
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-University, Nußbaumstrasse 7, 80336 Munich, Germany ,grid.410607.4Department of Child and Adolescent Psychiatry Und Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Manuel Föcker
- grid.16149.3b0000 0004 0551 4246Department of Child and Adolescent Psychiatry, University Hospital Münster, Schmeddingstraße 50, 48149 Münster, Germany
| | - Katharina Bühren
- grid.492012.cKBO Heckscher-Klinikum, Deisenhofener Straße 28, 81539 Munich, Germany
| | - Brigitte Dahmen
- grid.1957.a0000 0001 0728 696XDepartment of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, Neuenhofer Weg 21, 52074 Aachen, Germany
| | - Katja Becker
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps-University and University Hospital Marburg, Hans-Sachs-Str. 6, 35039 Marburg, Germany ,grid.8664.c0000 0001 2165 8627Center for Mind, Brain and Behavior (CMBB), University of Marburg and Justus Liebig University Giessen, Marburg, Germany
| | - Linda Weber
- Department for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps-University and University Hospital Marburg, Hans-Sachs-Str. 6, 35039 Marburg, Germany
| | - Christoph U. Correll
- grid.7468.d0000 0001 2248 7639Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Berlin Institute of Health, corporate member of Freie Universität Berlin, Charité—Universitätsmedizin Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353 Berlin, Germany ,grid.512756.20000 0004 0370 4759Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA ,grid.440243.50000 0004 0453 5950Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY USA
| | - Charlotte Jaite
- grid.7468.d0000 0001 2248 7639Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Berlin Institute of Health, corporate member of Freie Universität Berlin, Charité—Universitätsmedizin Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Karin M. Egberts
- grid.411760.50000 0001 1378 7891Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Würzburg, Margarete-Höppel-Platz 1, 97080 Würzburg, Germany
| | - Marcel Romanos
- grid.411760.50000 0001 1378 7891Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Mental Health, University Hospital of Würzburg, Margarete-Höppel-Platz 1, 97080 Würzburg, Germany
| | - Stefan Ehrlich
- grid.4488.00000 0001 2111 7257Division of Psychological and Social Medicine and Developmental Neurosciences, Faculty of Medicine, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany ,grid.4488.00000 0001 2111 7257Translational Developmental Neuroscience Section, Department of Child and Adolescent Psychiatry, Eating Disorder Research and Treatment Center, Faculty of Medicine, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Maria Seidel
- grid.4488.00000 0001 2111 7257Division of Psychological and Social Medicine and Developmental Neurosciences, Faculty of Medicine, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Veit Roessner
- grid.4488.00000 0001 2111 7257Translational Developmental Neuroscience Section, Department of Child and Adolescent Psychiatry, Eating Disorder Research and Treatment Center, Faculty of Medicine, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Christian Fleischhaker
- grid.5963.9Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Freiburg, University Freiburg, Hauptstraße 8, 79104 Freiburg, Germany
| | - Alexander von Gontard
- grid.11749.3a0000 0001 2167 7588Department of Child and Adolescent Psychiatry, Saarland University, Kirrberger Straße 1, 66421 Homburg, Germany
| | - Freia Hahn
- Department of Child and Adolescent Psychiatry and Psychotherapy, LVR-Klinik Viersen, Horionstr. 14, 41749 Viersen, Germany
| | - Michael Huss
- grid.410607.4Department of Child and Adolescent Psychiatry Und Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Michael Kaess
- grid.5734.50000 0001 0726 5157University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Stöckli, 3000 Bern, Switzerland ,grid.5253.10000 0001 0328 4908Clinic of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Tanja Legenbauer
- grid.5570.70000 0004 0490 981XLWL University Hospital Hamm for Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Ruhr University-Bochum, Heithofer Allee 64, 59071 Hamm, Germany
| | - Tobias J. Renner
- grid.10392.390000 0001 2190 1447Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University of Tübingen, Osianderstraße 14-16, 72076 Tübingen, Germany
| | - Ulrike M. E. Schulze
- grid.6582.90000 0004 1936 9748Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, University of Ulm, Steinhövelstraße 5, 89075 Ulm, Germany
| | - Judith Sinzig
- grid.491992.e0000 0000 9702 9846Department of Child and Adolescent Psychiatry, LVR-Klinik Bonn, Kaiser-Karl-Ring 20, 53111 Bonn, Germany
| | - Ida Wessing
- grid.16149.3b0000 0004 0551 4246Department of Child and Adolescent Psychiatry, University Hospital Münster, Schmeddingstraße 50, 48149 Münster, Germany ,grid.16149.3b0000 0004 0551 4246Institute for Biomagnetism and Biosignalanalysis, University Hospital Münster, Malmedyweg 15, 48149 Münster, Germany
| | - Gisela Antony
- Central Information Office, CIO Marburg GmbH, Struthweg 1, 35112 Fronhausen, Germany
| | - Beate Herpertz-Dahlmann
- grid.1957.a0000 0001 0728 696XDepartment of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, Neuenhofer Weg 21, 52074 Aachen, Germany
| | - Gertraud Gradl-Dietsch
- grid.5718.b0000 0001 2187 5445Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Essen (AöR), University of Duisburg-Essen, Wickenburgstrasse 21, 45147 Essen, Germany
| | - Johannes Hebebrand
- grid.5718.b0000 0001 2187 5445Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital Essen (AöR), University of Duisburg-Essen, Wickenburgstrasse 21, 45147 Essen, Germany
| |
Collapse
|
7
|
Manwaring J, Blalock DV, Le Grange D, Duffy A, McClanahan SF, Johnson C, Mehler PS, Plotkin M, Rienecke RD. Motivation to recover for adolescent and adult eating disorder patients in residential treatment. EUROPEAN EATING DISORDERS REVIEW 2021; 29:622-633. [PMID: 33851492 DOI: 10.1002/erv.2828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/22/2021] [Accepted: 02/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to assess how baseline motivation to recover impacts eating disorder (ED) and comorbid symptoms at end-of-treatment (EOT) for adolescents and adults in inpatient/residential treatment. METHOD Two hundred and three adolescent (M = 15.90) and 395 adult (M = 25.45) patients with a Diagnostic Statistical Manual, 5th edition ED diagnosis completed the Decisional Balance Scale (DBS) at baseline, and psychosocial measures (ED symptoms, anxiety, depression, obsessive-compulsive disorder symptoms), and %body mass index (kg/m2 ; BMI) or median %BMI (for adolescents) at baseline and EOT. RESULTS The DBS Avoidance Coping and Burdens subscales at baseline were significantly lower for adolescents than adults (p < 0.001), whereas the DBS Benefits subscale at baseline did not significantly differ between subsamples (p = 0.06). Motivation to recover via DBS subscales was a more reliable predictor of EOT outcomes for both ED and comorbid psychopathology in adults (significant predictor in 19 of 54 total analyses, and 4 significant associations post-Bonferroni correction) than adolescents (significant predictor in 5 of 54 total analyses, and 1 significant association post-Bonferroni correction). CONCLUSIONS Baseline motivation to recover may be an important predictor of outcome for adult patients in inpatient/residential treatment but does not appear associated with outcomes for adolescent patients.
Collapse
Affiliation(s)
- Jamie Manwaring
- Eating Recovery Center and Pathlight Behavioural Health Centers, Denver, Colorado, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA.,Department of Psychiatry and Behavioral Neurosciences, The University of Chicago, Chicago, Illinois, USA
| | - Alan Duffy
- Eating Recovery Center and Pathlight Behavioural Health Centers, Denver, Colorado, USA
| | - Susan F McClanahan
- Eating Recovery Center and Pathlight Behavioural Health Centers, Denver, Colorado, USA.,Department of Psychiatry, Rush University Medical Center, Chicago, Illinois, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| | - Craig Johnson
- Eating Recovery Center and Pathlight Behavioural Health Centers, Denver, Colorado, USA
| | - Philip S Mehler
- Eating Recovery Center and Pathlight Behavioural Health Centers, Denver, Colorado, USA.,ACUTE, Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado, Denver, Colorado, USA
| | - Millie Plotkin
- Eating Recovery Center and Pathlight Behavioural Health Centers, Denver, Colorado, USA
| | - Renee D Rienecke
- Eating Recovery Center and Pathlight Behavioural Health Centers, Denver, Colorado, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
8
|
Kan C, Hawkings YR, Cribben H, Treasure J. Length of stay for anorexia nervosa: Systematic review and meta-analysis. EUROPEAN EATING DISORDERS REVIEW 2021; 29:371-392. [PMID: 33548148 DOI: 10.1002/erv.2820] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 11/23/2020] [Accepted: 12/22/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance. METHOD Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies. RESULTS Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index. CONCLUSIONS This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.
Collapse
Affiliation(s)
- Carol Kan
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Hannah Cribben
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Janet Treasure
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
9
|
Heider KS, Dempfle A, Altdorf S, Herpertz-Dahlmann B, Dahmen B. Motivation to Change in the Course of a Pilot Study of a Step-Down Treatment Approach of Inpatient and Anorexia Nervosa-Specific Home Treatment and Its Effects on Treatment Outcome. Front Psychiatry 2021; 12:693103. [PMID: 34690825 PMCID: PMC8529001 DOI: 10.3389/fpsyt.2021.693103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/23/2021] [Indexed: 02/04/2023] Open
Abstract
Introduction: Anorexia nervosa (AN) is a serious mental disorder that typically manifests in adolescence. Motivation to change is an important predictor for treatment outcome in adolescent AN, even though its development over the often long therapeutic process, with transitions between treatment settings, has not yet been studied. In this pilot study, the course of motivation to change and its effect on treatment outcome were investigated over the course of a step-down treatment approach during a 12-month observation period. Methods: Twenty-one adolescents admitted to inpatient treatment because of AN received multidisciplinary home treatment (HoT) with several weekly visits after short inpatient stabilization. Eating disorder (ED-)specific cognitive [Eating Disorder Inventory 2 (EDI-2) subscales] and physical [% expected body weight (%EBW)] illness severity and motivation to change [Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ)] were assessed at the time of admission, discharge from hospital, at the end of HoT, and at a 12-month follow-up. Changes in motivation over time and its relationship with treatment outcome were investigated. Results: Mean motivation to change improved significantly over the course of treatment from the contemplation stage [2nd stage, mean ANSOCQ sum score 47.26 (SD 17.60)] at admission to the action stage [4th stage, mean ANSOCQ sum score 77.64 (SD 18.97)] at the end of HoT (p < 0.001) and remained stable during the follow-up period. At each assessment, higher motivation to change was significantly correlated with lower ED-specific cognitive illness severity (Spearman ρs: -0.53 to -0.77, all p < 0.05). Only pretreatment motivation to change significantly predicted ED-specific cognitive illness severity after the first inpatient treatment phase when taking prior illness severity into account. Conclusions: Motivation to change is an important aspect of treatment success in adolescent AN, especially in the early phase of treatment. In addition, home treatment contributed significantly to a higher motivation. Further longitudinal research into how motivation to change in adolescent patients with AN is related to outcome in this often severe and enduring disease and into targeted therapeutic strategies and interventions that reliably enhance the motivation to change in adolescent patients with AN seems promising.
Collapse
Affiliation(s)
- Kathrin Sophie Heider
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Astrid Dempfle
- Institute of Medical Informatics and Statistics, Kiel University and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sophie Altdorf
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Brigitte Dahmen
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen University, Aachen, Germany
| |
Collapse
|
10
|
Sansfaçon J, Booij L, Gauvin L, Fletcher É, Islam F, Israël M, Steiger H. Pretreatment motivation and therapy outcomes in eating disorders: A systematic review and meta-analysis. Int J Eat Disord 2020; 53:1879-1900. [PMID: 32954512 DOI: 10.1002/eat.23376] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Identifying modifiable predictors of outcomes following treatment for eating disorders may help to tailor interventions to patients' individual needs, improve treatment efficacy, and develop new interventions. The goal of this meta-analysis was to quantify the association between pretreatment motivation and posttreatment changes in eating disorder symptomology. METHOD We reviewed 196 longitudinal studies reporting on change on indices of overall eating-disorder symptomatology, weight gain, binge-eating, vomiting, anxiety/depression, and treatment adherence. Meta-analyses were performed using two complementary approaches: (a) combined probability analysis using the added Z's method; (b) effect size analyses. Using random-effect models, effect sizes were pooled when there were at least three studies with the same type of statistical design and reporting statistics on the same outcome. Heterogeneity in study outcome was evaluated using Q and I2 statistics. Studies were reviewed qualitatively when the number of studies or reported data were insufficient to perform a meta-analysis. RESULTS Forty-two articles were included. Although samples and treatments differed substantially across studies, results across studies were remarkably consistent. Both combined-probability and effect-size analyses indicated positive effects of pretreatment motivation on improvement in general eating-disorder symptoms (Cohen's r = .17), and an absence of effects on anxiety/depression symptoms. Remaining outcome indices were subject to selective reporting and/or small sample size bias. DISCUSSION Our findings underscore the importance of incorporating treatment engagement approaches in the treatment of eating disorders. Optimal reporting of study findings and improving study quality would improve future efforts to obtain an in-depth understanding of the relationship between motivation and eating disorder symptoms.
Collapse
Affiliation(s)
- Jeanne Sansfaçon
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Linda Booij
- Department of Psychology, Concordia University, Montreal, Quebec, Canada.,Centre de Recherche de l'Hôpital Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Lise Gauvin
- Centre de Recherche du Centre Hospitalier, Université de Montréal, Montreal, Quebec, Canada.,Department of Social & Preventive Medicine, École de santé publique, Université de Montréal, Montreal, Quebec, Canada
| | - Émilie Fletcher
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Farah Islam
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mimi Israël
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,Research Centre, Douglas Mental Health University Institute, Montreal, Quebec, Canada
| | - Howard Steiger
- Eating Disorders Continuum, Douglas Mental Health University Institute, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada.,Research Centre, Douglas Mental Health University Institute, Montreal, Quebec, Canada
| |
Collapse
|
11
|
Walker DC, Heiss S, Donahue JM, Brooks JM. Practitioners' perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study. Int J Eat Disord 2020; 53:1941-1951. [PMID: 32918314 DOI: 10.1002/eat.23381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/03/2020] [Accepted: 08/25/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Treating patients with eating disorders (EDs) is associated with an array of ethical concerns, including balancing patients' health and autonomy, access to care, and use of harm-reduction versus recovery-oriented treatment models. The primary aim of the current study is to gain a better understanding of ethical issues faced by ED practitioners by using a concept mapping, or Q-sort, approach. METHOD A total of 12 practitioners completed the brainstorming phase and generated statements regarding ethical issues they faced while treating patients with EDs. A subsequent 38 practitioners completed a sorting task, where they created and labeled piles, into which they grouped each statement. Of those 38 participants, 30 rated both the frequency with which they encountered each ethical issue and its impact on patient care. RESULTS A total of six clusters emerged: Insufficient Level of Care, Lack of Evidence-Based Practice, Insurance Barriers, Family Involvement, Patient Autonomy, and Limited Access to Expertise. Lack of Evidence-Based Practice, Insurance Barriers, and Insufficient Level of Care was the most frequent problem faced by ED practitioners, whereas Insurance Barriers and Patient Autonomy had the greatest impact. DISCUSSION Findings outline frequent and impactful areas of ethical concern that arise when treating patients diagnosed with EDs. Practitioners most commonly reported that patient- and insurance-driven factors limited patient access to appropriate care. Regulations supporting the provision of evidence-based care should be emphasized in public health policy and advocacy efforts, given their impact in limiting the delivery of adequate patient care.
Collapse
Affiliation(s)
| | - Sydney Heiss
- Department of Psychology, University at Albany, State University of New York, Albany, New York, USA
| | - Joseph M Donahue
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Julia M Brooks
- Department of Psychology, University of Illinois at Chicago, Chicago, Illinois, USA
| |
Collapse
|
12
|
Knoll-Pientka N, Bühlmeier J, Peters T, Albrecht M, Adams F, Wustrau K, Teufel M, Hebebrand J, Föcker M, Libuda L. Risk factors for a low weight gain in the early stage of adolescent anorexia nervosa inpatient treatment: findings from a pilot study. Eat Weight Disord 2020; 25:911-919. [PMID: 31168729 DOI: 10.1007/s40519-019-00705-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/27/2019] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Body weight restoration is a major treatment aim in juvenile inpatients with anorexia nervosa (AN) (i.e., 500-1000 g/week according to the German guidelines). Several studies suggest the early weight gain to be crucial for remission. The identification of patients at risk of a low early weight gain could enable an adequate adaptation of treatment. Thus, we aimed at detecting risk factors of a low weight gain during inpatient treatment. METHODS The presented work analyzes data from a pilot study in 30 female adolescent inpatients with AN (restricting subtype; age range at admission: 12.6-17.6 years). Premorbid characteristics, history of symptomatology, anthropometric data, and eating-disorder psychopathology were compared between those who gained at least an average of 500 g/week during the first 7 weeks of treatment (high weight gainers, HWG) and those who did not (low weight gainers, LWG). RESULTS At admission, LWG (n = 15) had a significantly higher BMI(-SDS) and scored significantly higher in the eating-disorder examination questionnaire (EDE-Q) than HWG (n = 15). A logistic regression analysis indicated both parameters to be independently associated with a low weight gain. CONCLUSION Higher EDE-Q scores seem to be a major risk factor for a low weight gain at the beginning of treatment. Moreover, a higher BMI(-SDS) at admission does not necessarily indicate a less severe AN symptomatic, as it was associated with a lower weight gain in our sample during the first 7 weeks of treatment. Reassessment of our results in larger studies is required to draw firm conclusions for clinical practice. LEVEL OF EVIDENCE Level V.
Collapse
Affiliation(s)
- Nadja Knoll-Pientka
- LVR-Clinic for Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, Essen, Germany. .,Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
| | - Judith Bühlmeier
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Triinu Peters
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Muriel Albrecht
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Frederike Adams
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katharina Wustrau
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Martin Teufel
- LVR-Clinic for Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, Essen, Germany
| | - Johannes Hebebrand
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Manuel Föcker
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Münster, Münster, Germany
| | - Lars Libuda
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
13
|
Martínez-Sánchez SM, Martínez-García TE, Munguía-Izquierdo D. Clinical, Psychopathological, Physical, and Sleep Evolution in Adolescents with Restrictive Anorexia Nervosa Participating in a Day Hospital Program. Psychiatry Investig 2020; 17:366-373. [PMID: 32252510 PMCID: PMC7176561 DOI: 10.30773/pi.2020.0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/15/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To analyze the clinical, psychopathological, physical, and sleep-related evolution of adolescents with restricting-type of anorexia nervosa (AN-R) after 10 weeks of a daytime hospital program. METHODS Body composition, physical activity and sleep were measured objectively before and after 10 weeks of treatment. In addition, psychopathology and body image disturbances were measured with a self-report questionnaire. RESULTS Fourteen female adolescents with AN-R (14.3±1.6 years old) participated in the study. A significant increase was found in eight of the ten variables for body composition (p<0.05). There were no significant changes in psychopathology, body image disturbances or physical activity. Concerning sleep, a significant, moderately standardized and substantial increase in night latency was found (p=0.002), and there was a significant, small standardized and substantial decrease in night efficiency (p=0.035). CONCLUSION After 10 weeks of follow-up with adolescent patients with AN-R who attended a day hospital program, there was a positive evolution of body composition. However, with regard to sleep patterns, there was a worsening of latency and night efficiency. Therefore, sleep care should be addressed in acute treatment programs for adolescents with AN-R.
Collapse
Affiliation(s)
- Sofía M Martínez-Sánchez
- Department of Sports and Computer Science, Section of Physical Education and Sports, Faculty of Sports Sciences, Universidad Pablo de Olavide, Seville, Spain
| | | | - Diego Munguía-Izquierdo
- Physical Performance Sports Research Center, Department of Sports and Computer Science, Section of Physical Education and Sports, Faculty of Sports Sciences, Universidad Pablo de Olavide, Seville, Spain.,Biomedical Research Networking Center on Frailty and Healthy Aging, Madrid, Spain
| |
Collapse
|
14
|
Subjective evaluation of outpatient treatment for adolescent patients with anorexia nervosa. Eat Weight Disord 2020; 25:445-452. [PMID: 30498987 DOI: 10.1007/s40519-018-0620-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 11/16/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The current study investigates determinants of treatment evaluation by adolescent outpatients with anorexia nervosa (AN) and the accordance with their parents' and psychotherapists' evaluation. SAMPLING AND METHODS The sample included 50 female adolescent outpatients (mean age: 16.9 ± 1.8) with AN (DSM-IV). They were randomly assigned to either cognitive-behavior therapy (CBT) or dialectical-behavior therapy (DBT). Before (T1) and after treatment (T2) diagnostic interviews as well as self-report questionnaires were administered measuring eating disorder-specific and general psychopathology. The subjective evaluation of the therapy was assessed by a self-report questionnaire. Data on the evaluation of treatment of 42 parents were considered as well as treatment evaluations of the therapists for 48 patients. RESULTS Our results revealed significant correlations of treatment satisfaction between parents and therapists, whereas patients and therapists as well as patients and parents did not agree in their treatment evaluation. The change in body mass index (BMI) was a significant predictor of the patients' treatment satisfaction. CONCLUSION Adolescent patients displaying high severity of AN at the beginning of treatment put little emphasis on the importance of body weight even after treatment. Satisfaction ratings of this special group of patients could be heavily distorted and have to be interpreted carefully. LEVEL OF EVIDENCE Level I, randomized controlled trial.
Collapse
|
15
|
Couturier J, Isserlin L, Norris M, Spettigue W, Brouwers M, Kimber M, McVey G, Webb C, Findlay S, Bhatnagar N, Snelgrove N, Ritsma A, Preskow W, Miller C, Coelho J, Boachie A, Steinegger C, Loewen R, Loewen T, Waite E, Ford C, Bourret K, Gusella J, Geller J, LaFrance A, LeClerc A, Scarborough J, Grewal S, Jericho M, Dimitropoulos G, Pilon D. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord 2020; 8:4. [PMID: 32021688 PMCID: PMC6995106 DOI: 10.1186/s40337-020-0277-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline. METHODS Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders. RESULTS Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed. CONCLUSIONS Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Wendy Preskow
- National Initiative for Eating Disorders, Toronto, Canada
| | - Catherine Miller
- Canadian Mental Health Association - Waterloo, Wellington, Dufferin, Kitchener, Canada
| | | | | | | | | | | | | | - Catherine Ford
- 9Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - Kerry Bourret
- 10St. Joseph's Care Group - Thunder Bay, Thunder Bay, Canada
| | | | - Josie Geller
- 6The Univeristy of British Columbia, Vancouver, Canada
| | | | | | - Jennifer Scarborough
- Canadian Mental Health Association - Waterloo, Wellington, Dufferin, Kitchener, Canada
| | | | | | | | | |
Collapse
|
16
|
Isserlin L, Spettigue W, Norris M, Couturier J. Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review. J Eat Disord 2020; 8:32. [PMID: 32637099 PMCID: PMC7333407 DOI: 10.1186/s40337-020-00307-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/28/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Recommended first line treatment for children and adolescent eating disorders is outpatient therapy. However, a significant number of children and adolescents with eating disorders continue to require inpatient treatment during the course of their illness. The effect of psychological treatments in an inpatient setting on outcomes at the time of discharge remains unclear. This paper presents the results of a review of the literature on outcomes at the time of discharge following inpatient psychological treatment for children and adolescents with eating disorders. MAIN BODY The majority of studies found were observational and of low quality. The most consistently reported positive outcome of inpatient treatment is weight gain. Results related to symptom change and motivation vary between studies. Within the inpatient setting, there is considerable heterogeneity in the types of treatments offered, goals of treatment, length of stay and outcomes measured. CONCLUSION There remains a paucity of high-quality studies examining the effect of psychological treatments provided to children and adolescents in an inpatient setting. The significant heterogeneity between studies makes it not possible to compare across studies. Future research should aim to resolve these deficiencies in order to better determine the specific factors that contribute to positive outcomes of inpatient treatment for children and adolescents with eating disorders.
Collapse
Affiliation(s)
- Leanna Isserlin
- Department of Psychiatry, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1H 8L1 Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1 Canada
| | - Wendy Spettigue
- Department of Psychiatry, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1H 8L1 Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1 Canada
| | - Mark Norris
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1 Canada.,Division of Adolescent Health, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1H 8L1 Canada
| | - Jennifer Couturier
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON L8N3Z5 Canada
| |
Collapse
|
17
|
Clausen L. Perspectives on Involuntary Treatment of Anorexia Nervosa. Front Psychiatry 2020; 11:533288. [PMID: 33192651 PMCID: PMC7641604 DOI: 10.3389/fpsyt.2020.533288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/16/2020] [Indexed: 01/12/2023] Open
Abstract
Involuntary treatment of anorexia nervosa is an option in cases in which the patient's life or other people's lives are at risk or, in some countries, to prevent the deterioration of the illness. Involuntary treatment is often regarded as controversial and has been intensely debated, although typically with few references to documented knowledge. This paper provides a research perspective of the topic by examine data in the field of the involuntary treatment of anorexia nervosa to pinpoint present knowledge as well as areas demanding clinical action or research attention. The prevalence of involuntary treatment in general as well as specific measures is described and possible early markers of patients at risk of involuntary treatment are discussed. Studies including patients' perspectives of involuntary treatment show the complexity of this treatment, its initiation, and its consequences. To qualify future discussions, improve current practice, and minimize involuntary treatment in general as well as on an individual level, at least four areas need attention: (i) the present specific symptoms of anorexia nervosa and their imminent consequences, (ii) illness history, (iii) overall psychiatric symptoms and general functioning, and (iv) contextual sphere of the patient. In particular, the last two require attention from both clinicians and researchers. Furthermore, critical evaluation of the attitudes of both patients and health care professionals toward each other and the treatment is recommended.
Collapse
Affiliation(s)
- Loa Clausen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
18
|
Sansfaçon J, Gauvin L, Fletcher É, Cottier D, Rossi E, Kahan E, Israël M, Steiger H. Prognostic value of autonomous and controlled motivation in outpatient eating-disorder treatment. Int J Eat Disord 2018; 51:1194-1200. [PMID: 30171769 DOI: 10.1002/eat.22901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 05/15/2018] [Accepted: 05/25/2018] [Indexed: 11/08/2022]
Abstract
UNLABELLED According to Self-Determination Theory, when motivation to reach an objective is fully internal, it is said to be "autonomous"; when driven by external incentives, it is said to be "controlled". Previous research has indicated that autonomously motivated individuals show better response to treatments for eating disorders. OBJECTIVE In individuals undergoing different intensities of outpatient treatment for an eating disorder, we sought to assess associations between autonomous and controlled motivations and response to treatment on the one hand, and likelihood of dropping out of treatment, on the other. METHOD Seven hundred seventy adults meeting DSM-5 criteria for an eating disorder (216 with Anorexia Nervosa, 282 with Bulimia Nervosa, and 272 with Other Specified Feeding or Eating Disorder) were included in this study. Before an interval of outpatient treatment, individuals completed the Eating Disorder Examination Questionnaire and the Autonomous and Controlled Motivations for Treatment Questionnaire. Participants completed the Eating Disorder Examination Questionnaire again at one or two subsequent timepoints. RESULTS After controlling for diagnosis, treatment intensity, and number of previous treatments, analyses showed that higher autonomous motivation was associated with better response on eating-disorder overall symptoms and lower likelihood of dropping out of treatment. In contrast, controlled motivation was not associated with response to treatment. DISCUSSION Our results suggest that autonomous motivation has trans-diagnostic influence upon response to various intensities of treatment for an eating disorder. In support of an autonomy supportive approach to treatment, findings link autonomous motivation with more favorable outcome.
Collapse
Affiliation(s)
- Jeanne Sansfaçon
- Department of Psychiatry, McGill University, Montréal, Canada.,Eating Disorders Program, Douglas Mental Health Institute, Montréal, Canada
| | - Lise Gauvin
- Département de médecine sociale et préventive, Université de Montréal, Montréal, Canada.,CHUM Research Center, Montréal, Canada
| | - Émilie Fletcher
- Eating Disorders Program, Douglas Mental Health Institute, Montréal, Canada
| | - Danaëlle Cottier
- Department of Psychiatry, McGill University, Montréal, Canada.,Eating Disorders Program, Douglas Mental Health Institute, Montréal, Canada
| | - Erika Rossi
- Eating Disorders Program, Douglas Mental Health Institute, Montréal, Canada
| | - Esther Kahan
- Eating Disorders Program, Douglas Mental Health Institute, Montréal, Canada
| | - Mimi Israël
- Department of Psychiatry, McGill University, Montréal, Canada.,Eating Disorders Program, Douglas Mental Health Institute, Montréal, Canada
| | - Howard Steiger
- Department of Psychiatry, McGill University, Montréal, Canada.,Eating Disorders Program, Douglas Mental Health Institute, Montréal, Canada.,Department of Psychology, Université du Québec à Montréal (UQAM), Montréal, Canada
| |
Collapse
|
19
|
Denison-Day J, Appleton KM, Newell C, Muir S. Improving motivation to change amongst individuals with eating disorders: A systematic review. Int J Eat Disord 2018; 51:1033-1050. [PMID: 30189116 DOI: 10.1002/eat.22945] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE People with eating disorders can have low motivation to change their eating disorder behaviors. Interventions aiming to enhance motivation to change have been increasingly advocated in their treatment. Questions remain regarding the strength of the evidence supporting the effectiveness of interventions that specifically focus on improving motivation. This review explored the evidence for improving motivation to change in eating disorders via clinical interventions. METHOD Searches of the published and unpublished literature were conducted by searching databases (PubMed, PsychInfo, Web of Science) and trial registries (WHO ICTRP), and by contacting authors. Studies were included if they investigated an intervention for eating disorder patients, included a pre-post outcome measure of motivation to change and were published in English. Risk of bias was also assessed. RESULTS Forty-two studies were included in the final review. Evidence was found to support the use of interventions to improve motivation to change, though it was unclear whether motivational interventions present a more effective option than approaches that do not exclusively or specifically focus on motivation. However, motivational interventions were identified as being more effective than low intensity treatments. Risk of bias in included studies was generally high. DISCUSSION Motivation was found to increase across treatments in general, whether or not the focus of the intervention was on enhancing motivation. It is unclear if interventions specifically targeting motivation to change provide additional benefit over and above established treatment approaches.
Collapse
Affiliation(s)
- James Denison-Day
- Bournemouth University, Department of Psychology, Research Center for Behavior Change, Bournemouth, United Kingdom
| | - Katherine M Appleton
- Bournemouth University, Department of Psychology, Research Center for Behavior Change, Bournemouth, United Kingdom
| | - Ciarán Newell
- Dorset Healthcare University NHS Foundation Trust, Poole, United Kingdom
| | - Sarah Muir
- Bournemouth University, Department of Psychology, Research Center for Behavior Change, Bournemouth, United Kingdom
| |
Collapse
|
20
|
Fogarty S, Ramjan LM. The tipping point of change in Anorexia Nervosa (AN): Qualitative findings from an online study. Women Health 2017; 58:1050-1061. [PMID: 28922078 DOI: 10.1080/03630242.2017.1372846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The aim of this study was to understand factors related to treatment and/or recovery from self-reported Anorexia Nervosa (AN), including 'the tipping point of change'. An online questionnaire was developed and administered from December 2014 to December 2015 to individuals ≥18 years of age with AN in the past or currently who were recruited through eating disorder organizations in Australia and the United Kingdom. Responses to a specific qualitative question on 'the tipping point of change' were analyzed using conventional content analysis (CCA). One hundred sixty-one participants completed some or all of the questionnaire; only 67 women (41.61%) answered Question six on 'the tipping point of change', and analyses were restricted to data from these women. The themes identified were: 1) realizing the loss of something valuable, 2) the risk of losing something valuable, and 3) something to live for/stay well for. These results are important for health-care providers as they work with patients to identify life experiences, including 'loss/potential loss' and 'the need for preservation', that have personal significance. Some patients may realize that 'enough is enough'; something needs to change. These intrinsic motivating factors may also be the impetus for eventual recovery for some individuals.
Collapse
Affiliation(s)
- Sarah Fogarty
- a School of Medicine , Western Sydney University, Campbelltown, New South Wales, Australia.,b National Institute of Complementary Medicine , Western Sydney University , Campbelltown , New South Wales , Australia
| | - Lucie M Ramjan
- c School of Nursing and Midwifery , Western Sydney University , Parramatta , New South Wales , Australia.,d Centre for Applied Nursing Research , Ingham Institute of Applied Medical Research , Penrith , New South Wales , Australia
| |
Collapse
|
21
|
Gueguen J, Piot MA, Orri M, Gutierre A, Le Moan J, Berthoz S, Falissard B, Godart N. Group Qigong for Adolescent Inpatients with Anorexia Nervosa: Incentives and Barriers. PLoS One 2017; 12:e0170885. [PMID: 28152083 PMCID: PMC5289494 DOI: 10.1371/journal.pone.0170885] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 01/12/2017] [Indexed: 01/28/2023] Open
Abstract
Background Qigong is a mind-body intervention focusing on interoceptive awareness that appears to be a promising approach in anorexia nervosa (AN). In 2008, as part of our multidimensional treatment program for adolescent inpatients with AN, we began a weekly qigong workshop that turned out to be popular among our adolescent patients. Moreover psychiatrists perceived clinical benefits that deserved further exploration. Methods and findings A qualitative study therefore sought to obtain a deeper understanding of how young patients with severe AN experience qigong and to determine the incentives and barriers to adherence to qigong, to understanding its meaning, and to applying it in other contexts. Data were collected through 16 individual semi-structured face-to-face interviews and analyzed with the interpretative phenomenological analysis method. Eleven themes emerged from the analysis, categorized in 3 superordinate themes describing the incentives and barriers related to the patients themselves (individual dimension), to others (relational dimension), and to the setting (organizational dimension). Individual dimensions associated with AN (such as excessive exercise and mind-body cleavage) may curb adherence, whereas relational and organizational dimensions appear to provide incentives to join the activity in the first place but may also limit its post-discharge continuation. Once barriers are overcome, patients reported positive effects: satisfaction associated with relaxation and with the experience of mind-body integration. Conclusions Qigong appears to be an interesting therapeutic tool that may potentiate psychotherapy and contribute to the recovery process of patients with AN. Further analysis of the best time window for initiating qigong and of its place in overall management might help to overcome some of the barriers, limit the risks, and maximize its benefits.
Collapse
Affiliation(s)
- Juliette Gueguen
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, INSERM, Paris, France
- Univ. Paris-Descartes, Paris, France
- * E-mail:
| | - Marie-Aude Piot
- Univ. Paris-Descartes, Paris, France
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
| | - Massimiliano Orri
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, INSERM, Paris, France
- Univ. Paris-Descartes, Paris, France
| | - Andrea Gutierre
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
| | | | - Sylvie Berthoz
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, INSERM, Paris, France
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
| | - Bruno Falissard
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, INSERM, Paris, France
- Univ. Paris-Descartes, Paris, France
| | - Nathalie Godart
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, INSERM, Paris, France
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
| |
Collapse
|
22
|
Pauli D, Aebi M, Winkler Metzke C, Steinhausen HC. Motivation to change, coping, and self-esteem in adolescent anorexia nervosa: a validation study of the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ). J Eat Disord 2017; 5:11. [PMID: 28417002 PMCID: PMC5392907 DOI: 10.1186/s40337-016-0125-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding motivation to change is a key issue in both the assessment and the treatment of eating disorders. Therefore, sound instruments assessing this construct are of great help to clinicians. Accordingly, the present study analysed the psychometric properties of the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), including its relation to coping style and self-esteem. METHODS N = 92 adolescents referred to an eating disorders outpatient clinic meeting criteria for anorexia nervosa gave written informed consent to participate in this study and completed the ANSOCQ, the Eating Disorder Inventory, the Eating Attitudes Test, the Body Image Questionnaire, two questionnaires measuring Self-Related Cognitions and the Coping Across Situations Questionnaire. After a treatment period of nine months, clinical anorexia nervosa diagnosis and the body mass index were re-assessed. In addition to exploratory factor analysis, correlational analysis was used to test for the convergent validity of the ANSOCQ and logistic regression analysis was used to test its predictive validity. RESULTS The ANSOCQ had good psychometric properties. Factor analysis yielded two meaningful factors labelled as 'weight gain and control' and 'attitudes and feelings'. Internal consistencies of the two factors amounted to Cronbach's alpha = .87 and .76, respectively. Significant correlations with other scales measuring eating disorder psychopathology were indicative of meaningful construct validity. Higher motivation to change was related to higher self-esteem and a more active coping style. Higher (positive) ANSOCQ total scores predicted remission of anorexia nervosa after nine months of treatment. A higher score on 'attitudes and feelings' was a protective factor against drop-out from intervention. CONCLUSIONS The ANSOCQ is a clinically useful instrument for measuring motivation to change in adolescents with AN. Two factorial dimensions explain most of the variation. Self-esteem and coping style are relevant additional constructs for the understanding of the motivation to change in anorexia nervosa. TRIAL REGISTRATION NCT02828956. Retrospectively registered July 2016.
Collapse
Affiliation(s)
- Dagmar Pauli
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, Neumünsterallee 3, 8032 Zurich, Switzerland
| | - Marcel Aebi
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, Neumünsterallee 3, 8032 Zurich, Switzerland.,Child and Youth Forensic Psychiatry, Department of Forensic Psychiatry, University Hospital of Psychiatry Zurich, Zurich, Switzerland.,Clinical Psychology for Children/Adolescents and Couples/Families, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Christa Winkler Metzke
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, Neumünsterallee 3, 8032 Zurich, Switzerland
| | - Hans-Christoph Steinhausen
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, Neumünsterallee 3, 8032 Zurich, Switzerland.,Clinical Psychology and Epidemiology, Institute of Psychology, University of Basel, Basel, Switzerland.,Centre for Child and Adolescent Mental Health, Capital Region Psychiatry, Copenhagen, Denmark
| |
Collapse
|
23
|
Schreyer CC, Coughlin JW, Makhzoumi SH, Redgrave GW, Hansen JL, Guarda AS. Perceived coercion in inpatients with Anorexia nervosa: Associations with illness severity and hospital course. Int J Eat Disord 2016; 49:407-12. [PMID: 26578421 DOI: 10.1002/eat.22476] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/22/2015] [Accepted: 09/28/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of coercion in the treatment for anorexia nervosa (AN) is controversial and the limited studies to date have focused on involuntary treatment. However, coercive pressure for treatment that does not include legal measures is common in voluntarily admitted patients with AN. Empirical data examining the effect of non-legal forms of coerced care on hospital outcomes are needed. METHOD Participants (N = 202) with AN, Avoidant/Restrictive Food Intake Disorder (ARFID), or subthreshold AN admitted to a hospital-based behavioral specialty program completed questionnaires assessing illness severity and perceived coercion around the admissions process. Hospital course variables included inpatient length of stay, successful transition to a step-down partial hospitalization program, and achievement of target weight prior to program discharge. RESULTS Higher perceived coercion at admission was associated with increased drive for thinness and body dissatisfaction, but not with admission BMI. Perceived coercion was not related to inpatient length of stay, rate of weight gain, or achievement of target weight although it was predictive of premature drop-out prior to transition to an integrated partial hospitalization program. DISCUSSION These results, from an adequately powered sample, demonstrate that perceived coercion at admission to a hospital-based behavioral treatment program was not associated with rate of inpatient weight gain or achieving weight restoration, suggesting that coercive pressure to enter treatment does not necessarily undermine formation of a therapeutic alliance or clinical progress. Future studies should examine perceived coercion and long-term outcomes, patient views on coercive pressures, and the effect of different forms of leveraged treatment.
Collapse
Affiliation(s)
- Colleen C Schreyer
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Saniha H Makhzoumi
- Department of Psychology, University of Maryland, Baltimore County, 1000 Hilltop Circle, Catonsville, Maryland, 21250
| | - Graham W Redgrave
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Jennifer L Hansen
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| | - Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 101, Baltimore, Maryland, 21287
| |
Collapse
|
24
|
Schlegl S, Diedrich A, Neumayr C, Fumi M, Naab S, Voderholzer U. Inpatient Treatment for Adolescents with Anorexia Nervosa: Clinical Significance and Predictors of Treatment Outcome. EUROPEAN EATING DISORDERS REVIEW 2015; 24:214-22. [PMID: 26603278 DOI: 10.1002/erv.2416] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/27/2015] [Accepted: 10/22/2015] [Indexed: 11/06/2022]
Abstract
This study evaluated the clinical significance as well as predictors of outcome for adolescents with severe anorexia nervosa (AN) treated in an inpatient setting. Body mass index (BMI), eating disorder (ED) symptoms [Eating Disorder Inventory-2 (EDI-2)], general psychopathology and depression were assessed in 238 patients at admission and discharge. BMI increased from 14.8 + 1.2 to 17.3 + 1.4 kg/m(2). Almost a fourth (23.6%) of the patients showed reliable changes, and 44.7% showed clinically significant changes (EDI-2). BMI change did not significantly differ between those with reliable or clinically significant change or no reliable change in EDI-2. Length of stay, depression and body dissatisfaction were negative predictors of a clinically significant change. Inpatient treatment is effective in about two thirds of adolescents with AN and should be considered when outpatient treatment fails. About one third of patients showed significant weight gain, but did not improve regarding overall ED symptomatology. Future studies should focus on treatment strategies for non-responders.
Collapse
Affiliation(s)
- Sandra Schlegl
- Department of Psychiatry and Psychotherapy, University Hospital of Munich (LMU), Munich, Germany
| | - Alice Diedrich
- Department of Psychiatry and Psychotherapy, University Hospital of Munich (LMU), Munich, Germany
| | | | | | | | - Ulrich Voderholzer
- Schön Klinik Roseneck, Prien, Germany.,Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Freiburg, Germany
| |
Collapse
|