Moderators and mediators of remission in family-based treatment and adolescent focused therapy for anorexia nervosa

Few of the limited randomized controlled trails (RCTs) for adolescent anorexia nervosa (AN) have explored the effects of moderators and mediators on outcome. This study aimed to identify treatment moderators and mediators of remission at end of treatment (EOT) and 6- and 12-month follow-up (FU) for adolescents with AN (N = 121) who participated in a multi-center RCT of family-based treatment (FBT) and individual adolescent focused therapy (AFT). Mixed effects modeling were utilized and included all available outcome data at all time points. Remission was defined as ≥ 95% IBW plus within 1 SD of the Eating Disorder Examination (EDE) norms. Eating related obsessionality (Yale-Brown-Cornell Eating Disorder Total Scale) and eating disorder specific psychopathology (EDE-Global) emerged as moderators at EOT. Subjects with higher baseline scores on these measures benefited more from FBT than AFT. AN type emerged as a moderator at FU with binge-eating/purging type responding less well than restricting type. No mediators of treatment outcome were identified. Prior hospitalization, older age and duration of illness were identified as non-specific predictors of outcome. Taken together, these results indicate that patients with more severe eating related psychopathology have better outcomes in a behaviorally targeted family treatment (FBT) than an individually focused approach (AFT).     

Weight suppression as a predictor of weight gain and response to intensive behavioral treatment in patients with anorexia nervosa

Previous studies have documented that weight suppression (a person's highest adult weight minus current weight) predicts weight gain and disordered eating symptoms during treatment of bulimia spectrum disorders, but no research has examined weight suppression in individuals with anorexia nervosa (AN). Thus, this study sought to characterize weight suppression in a large sample of patients with AN (N = 185), and to evaluate whether weight suppression at admission for intensive behavioral treatment predicts weight gain and clinical outcomes at discharge. Weight suppression varied from 0 kg to 78 kg (M [SD] = 17.1 [10.8] kg) in AN patients. Higher levels of weight suppression predicted greater total weight gain, a faster rate of weight gain, and bulimic symptoms during intensive treatment even after controlling for body mass index on admission, length and type of intensive treatment received, restricting versus binge-eating/purging AN subtype, and other predictors of study outcomes. These findings converge with previous research documenting the clinical significance of weight suppression in the treatment of eating disorders. Future work is needed to replicate the current findings, and examine whether weight suppression predicts the course of AN following discharge from intensive treatment.     

Involving Family Members in the Treatment of OCD

This review focuses on previous research with families of adults and children with obsessive‐compulsive disorder (OCD). Three primary areas of research are covered: (i) characteristics of family members and the family environment; (ii) the prediction of treatment response based on family variables; and (iii) the inclusion of family members in treatment. Much of the research supports a hypothesized model of family response to symptoms of OCD that ranges on a continuum from overly accommodating to overly antagonistic. Further research indicates that responses at either extreme of this continuum are associated with poorer response to both exposure and response prevention (ERP) and pharmacotherapy. Finally, results of preliminary treatment outcome studies suggest that family‐based interventions aimed at reducing such responses and/or including family members in ERP as coaches or co‐therapists may enhance patients' response to treatment. Based on current theory and research, suggestions for future research and general recommendations for involving family members in treatment are made.     

The Relations of Immigrant‐Specific and Immigrant‐Nonspecific Daily Hassles to Distress Controlling for Psychological Adjustment and Cultural Competence1

In separating immigrant‐specific daily hassles (out‐group, family, and in‐group) from immigrant‐nonspecific general hassles, the relations of hassles to depression and physical symptoms were examined. The respondents were 79 female and 85 male Iranian immigrants to Canada. In Block 1 of a hierarchical multiple regression analysis, the experience of out‐group hassles and of general hassles both contributed to the prediction of depression. In Block 2, psychological adjustment and perceived cultural competence in the host society, along with out‐group hassles, predicted depression. General hassles were the only predictor of physical symptoms. Psychological adjustment, as a buffer, interacted with hassles in enhancing the prediction of distress. The importance of distinguishing and accounting for both immigrant‐specific and immigrant‐nonspecific hassles in predicting outcome measures was considered, as was the importance of assessing dispositional variables in this context.     

A Pilot Study of an Acceptance-Based Separated Family Treatment for Adolescent Anorexia Nervosa

The treatment of adolescent anorexia nervosa (AN) has improved significantly with the increased emphasis on family-based intervention. Yet despite advances, a substantial number of adolescents do not respond optimally to existing treatment models and thus there is a need for treatment alternatives that address barriers to recovery. We developed and piloted an acceptance-based separated family treatment (ASFT) with 6 adolescents with AN or subthreshold AN (eating disorder not otherwise specified, with the primary symptoms of restriction and severe weight loss). Treatment acceptability was adequate. Overall, parents rated the treatment as credible and expected improvement in their child's condition. Five of the 6 adolescents treated with ASFT restored weight to their ideal body mass index as indicated by age, height, and sex and determined by individual growth charts. Many demonstrated improved psychological health and adaptive functioning. There was evidence of broad effects, with parents reporting decreased anxiety and caregiver burden. ASFT holds promise as a treatment option for AN. The efficacy of this therapeutic approach should be tested in larger trials and compared to current family-based interventions to determine unique effects.     

Interoceptive Exposure Therapy Combined with Trauma‐related Exposure Therapy for Post‐traumatic Stress Disorder: a Case Report

Trauma‐related exposure therapy is a useful but not universally effective treatment for post‐traumatic stress disorder. Anxiety sensitivity may play an important role in this disorder, as it does in panic disorder. Studies have shown that interoceptive exposure therapy reduces anxiety sensitivity in panic disorder. The present case study was a preliminary investigation of the merits of including interoceptive exposure therapy in the treatment of post‐traumatic stress disorder, in order to improve treatment outcome for a patient who had no history of panic disorder or panic attacks. Interoceptive exposure therapy (4 sessions) was one component of treatment, combined with trauma‐related exposure therapy (4 sessions of imaginal exposure followed by 4 sessions of in vivo exposure). Treatment outcome was assessed with the Clinician‐Administered Post‐traumatic Stress Disorder Scale, a self‐report measure of post‐traumatic stress disorder symptoms, and measures of symptoms and cognitions commonly associated with post‐traumatic stress disorder. Scores on all outcome measures decreased over the course of treatment, with gains maintained at 1‐ and 3‐month follow‐up. Symptoms of anxiety sensitivity and post‐traumatic stress disorder decreased during interoceptive exposure therapy. The results indicate that interoceptive exposure therapy is a promising adjunctive intervention for post‐traumatic stress disorder. Further research is needed into the merits of combining interoceptive exposure therapy and trauma‐related exposure therapy as a means of boosting treatment efficacy.     

Testing a conceptual model of patient and family predictors of obsessive compulsive disorder (OCD) symptoms

Path analysis was used to test a model linking family member's attributions, criticism, hostility, emotional overinvolvement (EOI) that focused on intrusiveness, and family accommodation to severity of obsessive compulsive symptoms. This study draws upon previous expressed emotion (EE) research by including separate components of EE assessed in relatives and patients, as well as family accommodation measures to build a model of family influences on OCD symptoms. Measures of patient- and relative-perceived criticism, family accommodation, EOI intrusiveness and OCD symptom severity were collected on a single occasion from 50 patients and 50 relatives whom the patient had daily contact with. Novel self-report scales for the three EE components of criticism, hostility and EOI derived from existing instruments showed good to excellent internal consistency. Confirmatory path analyses were used to demonstrate that the data provided an adequate fit to the hypothesized path model. The patient-rated data suggested that patients who perceived their relatives as either critical or hostile were likely to have more severe OCD symptoms. For relative-rated EE, hostility proved to be a better determinant than criticism in the path model. Implications of this model for interventions and for future research are discussed. The measures employed may prove to be a cost-effective alternative to the labor intensive Camberwell Family Interview.     

Critical Time Intervention for Homeless People Making the Transition to Community Living: A Randomized Controlled Trial

To help create an evidence base in Europe for effective interventions that improve the well‐being of homeless people, we tested whether critical time intervention (CTI), a time‐limited intervention developed to support vulnerable people during times of transition, is effective outside the United States. For this multicenter, parallel‐group randomized controlled trial, 183 adults who were moving from shelters in the Netherlands to supported or independent housing were allocated to CTI or care‐as‐usual. The primary outcome was number of days rehoused, which was assessed by interviewing participants four times during a 9‐month follow‐up. Outcomes were analyzed with three‐level mixed‐effects models. The primary outcome did not differ between groups. CTI had a significant effect on family support and, for people experiencing less social support, psychological distress. Groups did not differ significantly on social support, fulfillment of care needs, quality of life, self‐esteem, excessive alcohol use, or cannabis use. Because few participants were homeless at 9 months, more research is needed to establish whether CTI can prevent long‐term recurrent homelessness. Given recent emphasis on informal support in public services and positive effects of CTI on family support and psychological distress, CTI is a fitting intervention for Dutch shelter services.     

Alexithymia and risk preferences: Predicting risk behaviour across decision domains

Risk‐taking is a critical health factor as it plays a key role in several diseases and is related to a number of health risk factors. The aim of the present study is to investigate the role of alexithymia in predicting risk preferences across decision domains. One hundred and thirteen participants filled out an alexithymia scale (Toronto Alexithymia Scale—TAS‐20), impulsivity and venturesomeness measures (I7 scale), and—1 month later—the Cognitive Appraisal of Risky Events (CARE questionnaire). The hierarchical regression analyses showed that alexithymia positively predicted risk preferences in two domains: aggressive/illegal behaviour and irresponsible academic/work behaviour. The results also highlighted a significant association of the alexithymia facet, externally oriented thinking (EOT), with risky sexual activities. EOT also significantly predicted aggressive/illegal behaviour and irresponsible academic/work behaviour. The alexithymia facet, Difficulty Identifying Feelings, significantly predicted irresponsible academic/work behaviour. The results of the present study provide interesting insights into the connection between alexithymia and risk preferences across different decision domains. Implications for future studies and applied interventions are discussed.     

The Role of Maternal Illness Perceptions in Family Functioning in Adolescent Girls with Anorexia Nervosa

Family based treatment of anorexia nervosa (AN) requires heavy parental involvement. To be effective, parents must possess a coherent understanding of the illness and believe that it is treatable. Yet we know little of how parents view the illness, nor whether these views are unique to AN. We examined illness perceptions in AN, how they compare to those of individuals with a serious medical illness, and how they relate to adjustment and coping. Twenty-five girls with AN, 24 girls with Type I diabetes, and their mothers completed measures of family functioning and psychological symptoms. Mothers also completed a measure of illness perceptions. Mothers viewed AN as less chronic, understandable, and controllable than mothers of girls with diabetes viewed their daughter’s respective illness. Such negative cognitions were associated with poor family functioning and maternal and adolescent adjustment. These findings have implications for enhancing family based treatments, as well as for modifying public health messages to reduce the pervasive stigma that influences such unhelpful perceptions about the illness.     

Psychological Intervention in a Case of Bulimia Nervosa: A Case Report

This paper presents a case report detailing the use of an enhanced form of enhanced cognitive behavior therapy (CBT) and other techniques that were employed when faced with impediments in adhering to manualized CBT-E. Ms. S, 22 years old unmarried female pursuing MBBS final year, belonging to upper middle socioeconomic status and urban domicile was provided with 28 weekly sessions of psychotherapy to simultaneously address the patient’s symptoms and try to effect change across multiple domains. A single case design was adopted. Therapy was conducted over 9 months. A total of 28 sessions were taken, with the frequency of two sessions/week initially, and then moving onto one session/week. Pre and Post assessments using Binge Eating Scale, BDI-II, height and weight measurements and frequency of binging episodes using visual analogue scale were done. On measures of pre and post assessment there was 87 % improvement in Binging Episodes, 82 % improvement on Binge Eating Scale and client had 3 kg weight gain with reduction in depression as assessed on BDI-II. The gains were maintained at 1 month follow up. The use and deviations from CBT E, therapy process, role of family and challenges to intervention will be discussed in this case report.     

Techniques of Structural Family Assessment: A Qualitative Analysis of How Experts Promote a Systemic Perspective

The trajectory of assessment in structural family therapy moves from a linear perspective, in which problems are located in the identified patient, to an interactional perspective, in which problems are seen as involving other members of the family. Minuchin, Nichols, & Lee (2007) developed a 4‐step model for assessing couples and families consisting of: (1) broadening the definition of the presenting complaint to include its context, (2) identifying problem‐maintaining interactions, (3) a structurally focused exploration of the past, and (4) developing a shared vision of pathways to change. To study how experts actually implement this model, judges coded video recordings of 10 initial consultations conducted by three widely recognized structural family therapists. Qualitative analyses identified 25 distinct techniques that these clinicians used to challenge linear thinking and move families toward a systemic understanding of their problems. We discuss and locate these techniques in the framework of the 4‐step model.     

The family roles of siblings of people diagnosed with a mental disorder: Heroes and lost children

In order to cope with the diagnosis of mental illness in a family member, siblings may be forced to adjust their roles in the family. Taking into account the crucial role that some siblings play in caregiving for the mentally ill especially when the parents are no longer available, it is imperative to develop awareness of their unique needs and address them. Thirty‐three adult siblings of people diagnosed with a mental disorder completed the Role Behaviour Inventory (RBI) and a general questionnaire including open‐ended questions regarding the roles they played in their families of origin. Findings from the inventory and general questionnaire suggest that the well siblings score higher on two roles, the Hero and Lost Child, and lower on the Mascot and Scapegoat roles relative to a comparison group (N = 33). Being a sibling caregiver emerged as a risk factor to assume certain dysfunctional roles in the family. Implications for future research and therapy are discussed.     

Improving Experience in Personal Social Systems through Family Constellation Seminars: Results of a Randomized Controlled Trial

This study examined the efficacy of family constellation seminars (FCSs) on individuals' experience in their personal social systems, especially the experience of belonging, autonomy, accord, and confidence. We conducted a single‐blind, stratified and balanced, randomized controlled trial. Participants were 208 adults (M = 48 years, SD = 10, 79% women) who were randomly allocated either to the intervention group (3‐day FCSs; 64 active participants, 40 observing participants) or to the wait‐list group (64 active participants, 40 observing participants). Change was measured short‐term (2‐week and 4‐month follow‐up) using the Experience In Social Systems Questionnaire, personal domain (EXIS.pers). EXIS.pers is a new outcome measure being applied for the first time in evaluation research. In addition, we used interpersonal scales derived from established measures (Outcome Questionnaire, OQ‐45; Tool for the Evaluation of the Psychotherapeutic Progress, FEP). The average person in the intervention group showed improved experience in personal social systems, as compared with approximately 73% of the wait‐list group after 2 weeks (total score: Cohen's d = .61, p = .000) and 69% of the wait‐list group after 4 months (total score: d = .53, p = .000). The results were confirmed in per‐protocol analyses (n = 191) by the results of the EXIS.pers dimensions (Belonging, Autonomy, Accord, and Confidence) and the interpersonal scales derived from the OQ‐45 and FEP. No adverse events were reported. This RCT provides first evidence that FCSs tend to positively influence participants' experience in their social systems.     

Prospective Pilot Study of the Mastering Each New Direction Psychosocial Family Systems Program for Pediatric Chronic Illness

Psychosocial interventions for pediatric chronic illness (CI) have been shown to support health management. Interventions that include a family systems approach offer potentially stronger and more sustainable improvements. This study explores the biopsychosocial benefits of a novel family systems psychosocial intervention (MEND: Mastering Each New Direction). Forty‐five families participated in a 21‐session intensive outpatient family systems‐based program for pediatric CI. Within this single arm design, families were measured on five domains of Health‐Related Quality of Life (HRQL) self‐report measures; Stress, Cognitive Functioning, Mental Health, Child HRQL, Family Functioning. Both survey and biological measures (stress: catecholamine) were used in the study. Results from multivariate general linear models showed positive pre‐, post‐, and 3‐month posteffects in all five domains. The program effects ranged from small to moderate (η² = .07–.64). The largest program effects were seen in the domains of cognitive functioning (η² = .64) and stress (η² = .27). Also, between disease groups, differences are noted and future implications for research and clinical practice are discussed. Conclusions suggest that the MEND program may be useful in helping families manage pediatric chronic illnesses. Study results also add to the growing body of literature suggesting that psychosocial interventions for pediatric chronic illness benefit from a family systems level of intervention.     

The Role of Numeracy and Intelligence in Health‐Risk Estimation and Medical Data Interpretation

Despite ample evidence that numeracy is an important influence on patient understanding and use of health‐related information, there is a dearth of studies examining the concept's relationship to other individual differences measures that may underlie complex judgments in the health domain. In this study, we compared the relative contributions of selected extant numeracy measures and general intelligence and other measures to varied judgment and decision‐making outcomes. Two hundred participants completed numeracy items, subscales of the Wechsler Adult Intelligence Scales, the need for cognition scale, and four relevant outcome measures including risk estimation and medical data interpretation. A numeracy scale constructed using item response and confirmatory factor analyses was consistently the strongest predictor across all outcome measures and accounted for unique variance over and above general intelligence. The results support the concept of numeracy as an independent construct that merits consideration in patient communication. Copyright © 2013 John Wiley & Sons, Ltd.     

Perceptions of Family Relationship Factors and Depressive Symptoms in Adolescents: What Roles Do Parents and Gender Play?

The association of adolescents’ perceptions of family relationships and adolescent depressive symptoms was investigated using a sample of 2,918 youth participating in the National Longitudinal Survey of Youth 1997. Boys showed fewer depressive symptoms than girls, as hypothesized. In general, adolescents’ perceptions of family relationships were negatively related to depressive symptoms. Mother support of father predicted depressive symptoms for girls only, whereas father support of mother predicted depressive symptoms for boys only. These findings contradict previous research that suggested family functioning is more related to outcomes of adolescent girls than boys. Suggestions for future research and implications for marital and family therapists are discussed.     

Anorexia nervosa: treatment satisfaction

Patient satisfaction plays a central role in treatment alliance and outcome. Investigating patient expectations and experiences of treatment sheds light on its importance. This study examines adolescent anorexia nervosa patients and their parents' satisfaction with family‐based treatment. Patients and parents answered a questionnaire at the eighteen‐month follow‐up focusing on expectations and experiences of treatment, therapists, aims of treatment and accomplishment. The results show that 73 per cent of the patients and 83 per cent of the parents felt that their pre‐treatment expectations had been fulfilled. The majority agreed that individual patient sessions and parental sessions were of great help, while the patients valued family therapy sessions as being less helpful than did parents. In overall terms, parents were more pleased with the therapists than were the patients. These data suggest that family‐based treatment with individual sessions for patients, in parallel with parental sessions combined with family sessions, corresponds well to patients' and parents' treatment expectations.     

Metabolic and endocrine disturbances in psychiatric disorders: a multidisciplinary approach to appropriate atypical antipsychotic utilization

Patients with psychiatric disorders have an increased rate of cardiovascular morbidity and mortality compared with the general population. Metabolic issues such as weight gain, dyslipidemia, diabetes mellitus, diabetic ketoacidosis,and pancreatitis have been reported with the use of antipsychotic agents. Although atypical antipsychotics have not been linked directly to the development of metabolic syndrome, these medications have been shown to increase risk factors that can lead to metabolic and endocrine disturbances. Therefore, clinicians should provide ongoing monitoring for patients who are being treated for psychiatric disorders with these agents. According to the 2004 Consensus Report on Antipsychotics, screening measures should include baseline and follow-up monitoring of personal/family histories, weight (body mass index), waist circumference, blood pressure, fasting plasma glucose, and fasting lipid profile.