Evaluation of an online modular eating disorders training (PreparED) to prepare healthcare trainees: a survey study

BACKGROUND

Eating disorders (EDs) are serious, complex disorders for which broad-based clinical training is lacking. This study aimed to evaluate the efficacy of a free, brief, web-based curriculum, PreparED, in increasing comfort and confidence with, and knowledge about EDs in healthcare trainees, and to obtain program feedback from key stakeholders (i.e., learners).

METHODS

This programmatic evaluation study was designed as a quantitative, repeated measures (i.e., pre- and post-test intervention) investigation. A convenience sample of two groups of healthcare trainees across geographically diverse training sites completed an anonymous survey pre- and post- engagement with PreparED. The survey included items to assess prior exposure to EDs, as well as program feasibility. The main educational outcomes included (1) Confidence and Comfort with EDs and (2) Knowledge of EDs. User experience variables of interest were likeability, usability, and engagement with the training modules. Mixed effects linear regression was used to assess the association between PreparED and educational outcome variables.

RESULTS

Participants (N = 67) included 41 nutrition graduate students and 26 nurse practitioner students recruited from Teacher's College/Columbia University in New York, NY, USA, Columbia University School of Nursing in New York, NY, USA and North Dakota State University School of Nursing in Fargo, ND, USA. Confidence/Comfort scores and Knowledge scores significantly improved following engagement with PreparED (β = for effect of intervention = 1.23, p < 0.001, and 1.69, p < 0.001, respectively). Neither training group nor prior exposure to EDs moderated the effect on outcomes. All learners agreed the program was easy to follow; the overwhelming majority (89.4%) felt the length of the modules was "just right." All participants perceived that PreparED had increased their knowledge of EDs, and the majority (94.0%) reported greater confidence in and comfort with caring for people with these disorders, including assessment of symptoms, awareness of associated medical complications, and likelihood of future screening.

CONCLUSIONS

Findings suggest that brief, user-friendly, online courses can improve knowledge and attitudes about EDs, filling a critical gap in healthcare training.

Perspectives on relapse prevention following intensive treatment of anorexia nervosa: A focus group study

OBJECTIVE

Including the perspectives of individuals with lived experience of mental health issues is a critical step in research and treatment development. Focus groups with patients with a history of treatment for anorexia nervosa (AN) were conducted in anticipation of a clinical trial of Relapse Prevention and Changing Habits (REACH+).

METHODS

Seven female adults (23-51 years) who had previously received inpatient treatment for AN, now in remission, participated in one of two semistructured focus groups. Rapid qualitative analysis was used to examine participants' contributions and identify common topics.

RESULTS

Transcript analysis yielded three topics related to relapse prevention: (1) recovery aids, including a sense of agency in treatment decisions and finding new interests/passions, (2) recovery hindrances, such as lack of access to care, and (3) identification of members of support system. Aspects of REACH+ received positive feedback, such as continuity of care from the inpatient setting and the use of telehealth. Viewpoints differed with respect to the helpfulness of obtaining patient weights in treatment. The REACH+ online platform received positive comments regarding content and usability, as well as suggestions for additional content.

DISCUSSION

Qualitative feedback from patients with a history of AN highlighted the value of engaging patients in their own treatment decisions, as well as in treatment design and innovation. Within this small group, there were differences of opinion about treatment components, specifically weight assessment, that suggest the need for further data. User-centered design provides opportunities to improve the acceptability and, therefore, dissemination of novel treatments.

PUBLIC SIGNIFICANCE

Relapse prevention is a critical treatment need for patients with anorexia nervosa, as this illness too often follows a protracted course. There are challenges in both obtaining specialized care and in retaining patients in treatment. Here, patient perspectives on these challenges offer input to allow for optimization of relapse prevention treatment. Shared decision-making may be particularly valuable to support an individual's sense of agency and engagement in care.

Optimizing relapse prevention and changing habits (REACH+) in anorexia nervosa

INTRODUCTION

Relapse rates in anorexia nervosa (AN) are high, even after full weight restoration. This study aims to develop a relapse prevention treatment that specifically addresses persistent maladaptive behaviors (habits). Relapse Prevention and Changing Habits (REACH+) aims to support patients in developing routines that promote weight maintenance, encourage health, and challenge habits that perpetuate illness. The clinical trial design uses the Multiphase Optimization STrategy (MOST) framework to efficiently identify which components of treatment contribute to positive outcomes.

METHODS

Participants will be 60 adults with AN who have achieved weight restoration in an inpatient setting. Treatment will consist of 6 months of outpatient telehealth sessions. REACH+ consists of behavior, cognitive, and motivation components, as well as food monitoring and a skill consolidation phase. A specialized online platform extends therapy between sessions. Participants will be randomly assigned to different versions of each component in a fractional factorial design. Outcomes will focus on maintenance of remission, measured by rate of weight loss and end-of-trial status. Interventions that contribute to remission will be included in an optimized treatment package, suitable for a large-scale clinical trial of relapse prevention in AN.

Predictors of illness course and health maintenance following inpatient treatment among patients with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a life-threatening psychiatric disorder associated with significant medical and psychosocial impairment. Hospital-based behavioral treatment is an effective intervention in the short-term. However, relapse rates following discharge are high and thus, there is a need to identify predictors of longitudinal outcome. The current study provides information regarding illness course and health maintenance among patients with AN over 5 years following discharge from an eating disorder inpatient unit.

METHODS

Participants were individuals with AN who were discharged from a specialized, inpatient behaviorally-based unit. Prior to discharge, height and weight were measured and participants completed self-report measures of eating disorder severity and general psychopathology (depression, anxiety, harm avoidance). Participants were contacted annually for self-report measures of weight, eating disorder severity and clinical impairment. Outcome was defined by illness course (body mass index (BMI) and clinical impairment during the 5 years) and health maintenance (categories of weight and eating disorder symptom severity) across follow-up, using all available data. Linear mixed models were used to examine whether demographic and clinical parameters at discharge predicted BMI and clinical impairment over time. Additional analyses examined whether these variables significantly influenced an individual's likelihood of maintaining inpatient treatment gains.

RESULTS

One-hundred and sixty-eight individuals contributed data. Higher trait anxiety at discharge was associated with a lower BMI during follow-up (p = 0.012). There was a significant interaction between duration of illness and time, whereby duration of illness was associated with a faster rate of weight loss (p = 0.003) during follow-up. As duration of illness increased, there was a greater increase in self-reported clinical impairment (p = 0.011). Increased eating disorder severity at discharge was also associated with greater clinical impairment at follow-up (p = 0.004). Higher BMI at discharge was significantly associated with maintaining healthy weight across a priori BMI-based definitions of health maintenance.

CONCLUSIONS

Weight status (higher BMI) and duration of illness are key factors in the prognosis of AN. Higher weight targets in intensive treatments may be of value in improving outcomes.

Between wellness, relapse, and remission: Stages of illness in anorexia nervosa

OBJECTIVE

Psychiatric illnesses, like medical illnesses, can sometimes be considered as progressing through stages. Understanding these stages can lead to a better understanding of pathophysiology, and clarification of prognosis and treatment needs. Opinions from experts in the field of anorexia nervosa (AN) were sought to create a model of stages of illness.

METHOD

The Delphi approach was used to achieve consensus from a panel of 31 individuals from a range of disciplines with expertise in AN. Over three iterative rounds, participants rated agreement with statements about an overall staging framework and definitions of specific stages.

RESULTS

Agreement was reached about a longitudinal progression including Subsyndromal, Full Syndrome, Persistent Illness, and Partial and Full Remission. The panel achieved consensus in defining Subsyndromal AN as characterized by body image disturbance and mild to moderate restrictive eating. Overall, there was consensus that restrictive eating is central to the behavioral features of all stages of AN, and agreement that its absence is essential to any stage of health. There was little consensus about biological markers, other than body mass index, and no consensus about quality of life indices associated with different stages.

DISCUSSION

This panel discussion yielded an expert-informed staging model for AN. This model now needs to be tested for its validity. The lack of consensus in several areas highlighted other research questions to address in order to develop an empirically valid and scientifically useful model of the progression of AN.

Habits are stronger with longer duration of illness and greater severity in anorexia nervosa

OBJECTIVE

The aim of this study was to examine the relationship between habit strength and clinical features of anorexia nervosa (AN). Habit strength, separate from intention, relates to the persistence of behavior, and is measured by the Self-Report Habit Index (SRHI). We hypothesized that habit strength would be greater among individuals with AN than healthy controls (HC) and that habit strength would be associated with duration and severity of illness.

METHOD

Participants were 116 women with AN (n = 69) and HC (n = 47) who completed the SRHI, the Eating Disorder Examination-Questionnaire (EDE-Q), and a multi-item laboratory meal. The SRHI assessed four domains and these subscales were averaged for the total score.

RESULTS

Individuals with AN demonstrated significantly greater habit strength than HC in the total score (t₁₁₄ = 7.00, p < .01), and within each domain (restrictive eating, compensatory behavior, delay of eating, and rituals). Total SRHI score was significantly associated with EDE-Q scores for both AN and HC groups (r_AN = .59, p_AN = <.001; r_HC = .32, p_HC = .030). Among patients, there was a significant association between SRHI and duration of illness (r = .38, p = .001). There was no significant association between SRHI and caloric intake (r_AN = -.20, p_AN = .10; r_HC = -.25, p_HC = .09).

DISCUSSION

Habit strength was related to chronicity and severity of AN, suggesting that habit formation may play an important role in illness. These data suggest avenues for mechanism research and treatment development.

Supporting the well-being of health care providers during the COVID-19 pandemic: The CopeColumbia response

OBJECTIVE

COVID-19 is an international public health crisis, putting substantial burden on medical centers and increasing the psychological toll on health care workers (HCW).

METHODS

This paper describes CopeColumbia, a peer support program developed by faculty in a large urban medical center's Department of Psychiatry to support emotional well-being and enhance the professional resilience of HCW.

RESULTS

Grounded in evidence-based clinical practice and research, peer support was offered in three formats: groups, individual sessions, and town halls. Also, psychoeducational resources were centralized on a website. A Facilitator's Guide informed group and individual work by including: (1) emotional themes likely to arise (e.g., stress, anxiety, trauma, grief, and anger) and (2) suggested facilitator responses and interventions, drawing upon evidence-based principles from peer support, stress and coping models, and problem-solving, cognitive behavioral, and acceptance and commitment therapies. Feedback from group sessions was overwhelmingly positive. Approximately 1/3 of individual sessions led to treatment referrals.

CONCLUSIONS

Lessons learned include: (1) there is likely an ongoing need for both well-being programs and linkages to mental health services for HCW, (2) the workforce with proper support, will emerge emotionally resilient, and (3) organizational support for programs like CopeColumbia is critical for sustainability.

Targeting habits in anorexia nervosa: a proof-of-concept randomized trial

BACKGROUND

Habits are behavioral routines that are automatic and frequent, relatively independent of any desired outcome, and have potent antecedent cues. Among individuals with anorexia nervosa (AN), behaviors that promote the starved state appear habitual, and this is the foundation of a recent neurobiological model of AN. In this proof-of-concept study, we tested the habit model of AN by examining the impact of an intervention focused on antecedent cues for eating disorder routines.

METHODS

The primary intervention target was habit strength; we also measured clinical impact via eating disorder psychopathology and actual eating. Twenty-two hospitalized patients with AN were randomly assigned to 12 sessions of either Supportive Psychotherapy or a behavioral intervention aimed at cues for maladaptive behavioral routines, Regulating Emotions and Changing Habits (REaCH).

RESULTS

Covarying for baseline, REaCH was associated with a significantly lower Self-Report Habit Index (SRHI) score and significantly lower Eating Disorder Examination-Questionnaire (EDE-Q) global score at the end-of-treatment. The end-of-treatment effect size for SRHI was d = 1.28, for EDE-Q was d = 0.81, and for caloric intake was d = 1.16.

CONCLUSIONS

REaCH changed habit strength of maladaptive routines more than an active control therapy, and targeting habit strength yielded improvement in clinically meaningful measures. These findings support a habit-based model of AN, and suggest habit strength as a mechanism-based target for intervention.

Overcoming fear of eating: A case study of a novel use of exposure and response prevention

Even after successful weight restoration, many patients with anorexia nervosa (AN) continue to exhibit maladaptive eating including repetitive behaviors (i.e., food rituals) used to decrease anxiety about food, and to describe fears related to food content, including its effect on shape and weight. Although there are important differences between eating disorders and anxiety disorders, the shared clinical phenomena suggest potentially useful overlap in treatment strategies. This case study will describe treatment of a woman with AN using Exposure and Response Prevention for Anorexia Nervosa (AN-EXRP) as an adjunct to concurrent inpatient treatment. This is a novel use of a treatment approach with established efficacy in the treatment of anxiety disorders. AN-EXRP specifically targets eating-related anxiety with the intent to improve the restrictive eating patterns that persist after acute weight restoration. The case study described includes descriptions of (a) the treatment rationale and its phases of implementation, (b) illustrative sample dialogue between the patient and therapist, (c) pre- and posttreatment data on outcome measures of interest (e.g., food intake at a laboratory meal, self-report anxiety ratings, self-report eating-related rituals, and preoccupations), and (d) therapist considerations (e.g., maintaining alliance, adhering to treatment frame). (PsycINFO Database Record

The eating disorder assessment for DSM-5 (EDA-5): Development and validation of a structured interview for feeding and eating disorders

OBJECTIVE

Existing measures for DSM-IV eating disorder diagnoses have notable limitations, and there are important differences between DSM-IV and DSM-5 feeding and eating disorders. This study developed and validated a new semistructured interview, the Eating Disorders Assessment for DSM-5 (EDA-5).

METHOD

Two studies evaluated the utility of the EDA-5. Study 1 compared the diagnostic validity of the EDA-5 with the Eating Disorder Examination (EDE) and evaluated the test-retest reliability of the new measure. Study 2 compared the diagnostic validity of an EDA-5 electronic application ("App") with clinician interview and self-reported assessments.

RESULTS

In Study 1, the kappa for EDE and EDA-5 eating disorder diagnoses was 0.74 across all diagnoses (n = 64), with a range of κ = 0.65 for other specified feeding or eating disorder/unspecified feeding or eating disorder to κ = 0.90 for binge eating disorder. The EDA-5 test-retest kappa coefficient was 0.87 across diagnoses. For Study 2, clinical interview versus App conditions revealed a kappa of 0.83 for all eating disorder diagnoses (n = 71). Across individual diagnostic categories, kappas ranged from 0.56 for other specified feeding or eating disorder/unspecified feeding or eating disorder to 0.94 for BN.

DISCUSSION

High rates of agreement were found between diagnoses by EDA-5 and the EDE, and EDA-5 and clinical interviews. Because this study supports the validity of the EDA-5 to generate DSM-5 eating disorders and the reliability of these diagnoses, the EDA-5 may be an option for the assessment of anorexia nervosa, bulimia nervosa, and binge eating disorder. Additional research is needed to evaluate the utility of the EDA-5 in assessing DSM-5 feeding disorders.

Cognitive behavioral therapy for bulimia nervosa

Cognitive-behavioral therapy (CBT) is a first-line psychotherapeutic treatment for bulimia nervosa (BN). This article outlines three specific interventions--introducing and using the CBT model of BN, self-monitoring of eating and related experiences, and psychoeducation regarding various aspects of BN--representative of CBT overall but unique in their application to individuals with BN. The theoretical basis and supporting research relevant to each technique are highlighted. Clinical vignettes are provided to illustrate how these interventions might be integrated into the psychotherapy.

Self-efficacy beliefs and eating behavior in adolescent girls at-risk for excess weight gain and binge eating disorder

OBJECTIVE

To examine the relationship between self-related agency beliefs and observed eating behavior in adolescent girls with loss of control (LOC) eating.

METHOD

One-hundred eleven adolescent girls (14.5 ± 1.7 years; BMI: 27.1 ± 2.6 kg/m(2)) were administered the General Self-Efficacy Scale and the Weight Efficacy Lifestyle Questionnaire (WEL). Adolescents then participated in a laboratory test meal.

RESULTS

Greater general and eating self-efficacy were associated with fewer episodes of LOC eating. General self-efficacy was inversely related to total intake at the meal (p < .01). Only the WEL availability subscale score, but not the other WEL subscales, was inversely related to total energy, snack, and dessert intake (ps < 0.05).

DISCUSSION

General self-related agency beliefs may be important in relation to energy consumption. Among girls susceptible to disordered eating and obesity, the domain-specific belief in one's ability to refrain from eating when food is widely available may be especially salient in determining overeating in the current food environment. Further research is therefore needed to assess the predictive validity of these beliefs on eating and weight outcomes.

A pilot study of interpersonal psychotherapy for preventing excess weight gain in adolescent girls at-risk for obesity

OBJECTIVE

Interpersonal psychotherapy (IPT) is effective at reducing binge episodes and inducing weight stabilization in obese adults with binge eating disorder.

METHOD

We piloted the administration of IPT to girls at-risk for excess weight gain (BMI 75th-97th percentile; IPT-WG) with and without loss of control (LOC) eating. Thirty-eight girls (12-17 years) were randomized to IPT-WG or a standard-of-care health education group.

RESULTS

All 38 girls completed the programs and all follow-up visits through 6 months. Thirty-five of 38 returned for a complete assessment visit at 1 year. Among girls with baseline LOC (n = 20), those in IPT-WG experienced greater reductions in such episodes than girls in health education (p = .036). Regardless of LOC status, over 1 year girls in IPT-WG were less likely to increase their BMI as expected for their age and BMI percentile (p = .028).

DISCUSSION

IPT-WG is feasible and acceptable to adolescent girls at-risk for adult obesity and may prevent excess weight gain over 1 year.

Does percent body fat predict outcome in anorexia nervosa?

OBJECTIVE

The goal of this study was to investigate the relationship of body composition and neuroendocrine levels with clinical outcome in women with anorexia nervosa in a relapse-prevention trial.

METHOD

Body composition and fasting cortisol and leptin levels were assessed before random assignment in 32 weight-recovered subjects with anorexia nervosa from the New York site of the Fluoxetine to Prevent Relapse in Women With Anorexia Nervosa trial. Clinical outcome at the end of study participation was defined using modified Morgan-Russell criteria (full, good, fair, poor), then dichotomized into treatment "success" or "failure."

RESULTS

In a binary logistic regression model examining the effect of percent body fat, body mass index, anorexia nervosa subtype, waist-to-hip ratio, and serum cortisol and leptin levels on treatment outcome, only percent body fat was significantly associated with outcome.

CONCLUSIONS

In recently weight-restored women with anorexia nervosa, lower percent body fat was associated with poor long-term outcome.

Preventing excessive weight gain in adolescents: interpersonal psychotherapy for binge eating

The most prevalent disordered eating pattern described in overweight youth is loss of control (LOC) eating, during which individuals experience an inability to control the type or amount of food they consume. LOC eating is associated cross-sectionally with greater adiposity in children and adolescents and seems to predispose youth to gain weight or body fat above that expected during normal growth, thus likely contributing to obesity in susceptible individuals. No prior studies have examined whether LOC eating can be decreased by interventions in children or adolescents without full-syndrome eating disorders or whether programs reducing LOC eating prevent inappropriate weight gain attributable to LOC eating. Interpersonal psychotherapy, a form of therapy that was designed to treat depression and has been adapted for the treatment of eating disorders, has shown efficacy in reducing binge eating episodes and inducing weight stabilization among adults diagnosed with binge eating disorder. In this paper, we propose a theoretical model of excessive weight gain in adolescents at high risk for adult obesity who engage in LOC eating and associated overeating patterns. A rationale is provided for interpersonal psychotherapy as an intervention to slow the trajectory of weight gain in at-risk youth, with the aim of preventing or ameliorating obesity in adulthood.

Validation of the emotional eating scale adapted for use in children and adolescents (EES-C)

OBJECTIVE

Eating in response to negative emotions is associated with binge or loss of control (LOC) eating in adults. Although children report engaging in LOC eating, data on emotional eating among youth are limited.

METHOD

We adapted the adult Emotional Eating Scale (Arnow et al., Int J Eat Disord, 18, 79-90, 1995) to be used with children and adolescents (EES-C). Fifty-nine overweight (BMI > or = 95th percentile for age and sex) and 100 non-overweight (BMI 5th-94th percentile) participants (mean age +/- SD 14.3 +/- 2.4 years) completed the EES-C, and measures of recent LOC eating and general psychopathology. Test-retest reliability was assessed in 64 children over a 3.4 +/- 2.6 month interval.

RESULTS

A factor analysis generated three subscales: eating in response to anxiety, anger, and frustration (EES-C-AAF), depressive symptoms (EES-C-DEP), and feeling unsettled (EES-C-UNS). Internal consistency for the subscales was established; Cronbach's alphas for the EES-C-AAF, EES-C-DEP, and EES-C-UNS were 0.95, 0.92, and 0.83, respectively. The EES-C had good convergent validity: children reporting recent LOC eating episodes scored higher on all subscales (p's < 0.05). The EES-C-AAF and EES-C-UNS subscales demonstrated good discriminant validity and the EES-C-DEP revealed adequate discriminant validity. Intra-class correlation coefficients revealed good temporal stability for each subscale (EES-C-AAF = 0.59, EES-C-DEP = 0.74, EES-C-UNS = 0.66; p's < 0.001).

CONCLUSION

The EES-C has good convergent and discriminant validity, and test-retest reliability for assessing emotional eating in children. Further investigation is required to clarify the role emotional eating may play in children's energy intake and body weight.

Binge eating in overweight treatment-seeking adolescents

OBJECTIVE

To examine the frequency and recency of binge eating in relation to psychopathology in overweight, treatment-seeking adolescents.

METHODS

We investigated psychological correlates of the frequency and recency of reported loss of control (LOC) eating episodes in 160 overweight (body mass index [BMI]: 40.7 +/- 8.8 kg/m(2)) adolescents. On the basis of the responses to the eating disorder examination (EDE), participants were categorized into one of four groups: full-syndrome binge eating disorder (BED); recent but infrequent binge eating (episodes within the 3 months before interview; RECENT-BINGE); remote and infrequent LOC eating (episodes occurring >3 months before assessment; PAST-LOC), or no history of LOC episodes (NE).

RESULTS

The BED group reported higher EDE scores (global, p < .01), and more negative mood and anxiety than all other groups (p's < .01). Compared with NE, RECENT-BINGE also reported more anxiety and higher EDE scores (p's < .01).

CONCLUSIONS

Overweight, treatment-seeking adolescents with BED are clearly distinguishable from teens without the disorder on measures of eating-related psychopathology, mood, and anxiety. RECENT-BINGE, but not PAST-LOC, is also associated with significantly greater eating-related and general psychopathology.