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1.  A pragmatic randomised multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa 
BMC Psychiatry  2016;16:422.
Considerable progress has been made in recent years in developing effective treatments for child and adolescent anorexia nervosa, with a general consensus in the field that eating disorders focussed family therapy (often referred to as Maudsley Family Therapy or Family Based Treatment) currently offers the most promising outcomes. Nevertheless, a significant number do not respond well and additional treatment developments are needed to improve outcomes. Multifamily therapy is a promising treatment that has attracted considerable interest and we report the results of the first randomised controlled trial of multifamily therapy for adolescent anorexia nervosa.
The study was a pragmatic multicentre randomised controlled superiority trial comparing two outpatient eating disorder focussed family interventions - multifamily therapy (MFT-AN) and single family therapy (FT-AN). A total of 169 adolescents with a DSM-IV diagnosis of anorexia nervosa or eating disorder not otherwise specified (restricting type) were randomised to the two treatments using computer generated blocks of random sizes to ensure balanced numbers in the trial arms. Independent assessors, blind to the allocation, completed evaluations at baseline, 3 months, 12 months (end of treatment) and 18 months.
Both treatment groups showed clinically significant improvements with just under 60% achieving a good or intermediate outcome (on the Morgan-Russell scales) at the end of treatment in the FT-AN group and more than 75% in the MFT-AN group - a statistically significant benefit in favour of the multifamily intervention (OR = 2.55 95%; CI 1.17, 5.52; p = 0.019). At follow-up (18 months post baseline) there was relatively little change compared to end of treatment although the difference in primary outcome between the treatments was no longer statistically significant. Clinically significant gains in weight were accompanied by improvements in mood and eating disorder psychopathology. Approximately half the patients in FT-AN and nearly 60% of those in MFT-AN had started menstruating.
This study confirms previous research findings demonstrating the effectiveness of eating disorder focused family therapy and highlights the additional benefits of bringing together groups of families that maximises the use of family resources and mutual support leading to improved outcomes.
Trial Registration
Current Controlled Trials ISRCTN11275465; Registered 29 January 2007 (retrospectively registered)
PMCID: PMC5122159  PMID: 27881106
Anorexia nervosa; Adolescents; Family therapy; Multi-family therapy; Randomised controlled trial
2.  Central Coherence in Eating Disorders: A Synthesis of Studies Using the Rey Osterrieth Complex Figure Test 
PLoS ONE  2016;11(11):e0165467.
Large variability in tests and differences in scoring systems used to study central coherence in eating disorders may lead to different interpretations, inconsistent findings and between study discrepancies. This study aimed to address inconsistencies by collating data from several studies from the same research group that used the Rey Osterrieth Complex Figure Test (Rey Figure) in order to produce norms to provide benchmark data for future studies.
Data was collated from 984 participants in total. Anorexia Nervosa, Bulimia Nervosa, recovered Anorexia Nervosa, unaffected family members and healthy controls were compared using the Rey Figure.
Poor global processing was observed across all current eating disorder sub-groups and in unaffected relatives. There was no difference in performance between recovered AN and HC groups.
This is the largest dataset reported in the literature and supports previous studies implicating poor global processing across eating disorders using the Rey Figure. It provides robust normative data useful for future studies.
PMCID: PMC5091879  PMID: 27806073
3.  The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives 
BMC Medicine  2016;14:69.
Evidence-based practice in eating disorders incorporates three essential components: research evidence, clinical expertise, and patient values, preferences, and characteristics. Conceptualized as a ‘three-legged stool’ by Sackett et al. in 1996 (BMJ), all of these components of evidence-based practice are considered essential for providing optimal care in the treatment of eating disorders. However, the extent to which these individual aspects of evidence-based practice are valued among clinicians and researchers is variable, with each of these stool ‘legs’ being neglected at times. As a result, empirical support and patient preferences for treatment are not consistently considered in the selection and implementation of eating disorder treatment. In addition, clinicians may not have access to training to provide treatments supported by research and preferred by patients. Despite these challenges, integrating these three components of evidence-based practice is critical for the effective treatment of eating disorders.
Current research supports the use of several types of psychotherapies, including cognitive-behavioral, interpersonal, and family-based therapies, as well as certain types of medications for the treatment of eating disorders. However, limitations in current research, including sample heterogeneity, inconsistent efficacy, a paucity of data, the need for tailored approaches, and the use of staging models highlight the need for clinical expertise. Although preliminary data also support the importance of patient preferences, values, and perspectives for optimizing treatment, enhancing treatment outcome, and minimizing attrition among patients with eating disorders, the extent to which patient preference is consistently predictive of outcome is less clear and requires further investigation.
All three components of evidence-based practice are integral for the optimal treatment of eating disorders. Integrating clinical expertise and patient perspective may also facilitate the dissemination of empirically-supported and emerging treatments as well as prevention programs. Further research is imperative to identify ways in which this three-legged approach to eating disorder treatment could be most effectively implemented.
PMCID: PMC4832531  PMID: 27081002
Anorexia nervosa; Binge eating disorder; Bulimia nervosa; Eating disorders; Treatment outcome
4.  Process evaluation of the MOSAIC trial: treatment experience of two psychological therapies for out-patient treatment of Anorexia Nervosa 
This study is part of a series of process evaluations within the MOSAIC Trial (Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions). This randomised controlled trial (RCT) compared two psychological treatments, the Maudsley Model for Treatment of Adults with Anorexia Nervosa (MANTRA) and Specialist Supportive Clinical Management (SSCM) for adult outpatients with Anorexia Nervosa. The present process study integrates quantitative (treatment acceptability and credibility) and qualitative (written) feedback to evaluate patients’ treatment experiences.
All 142 MOSAIC participants were asked to (a) rate treatment acceptability and credibility on visual analogue scales (VAS) at six and 12 months post-randomisation, and (b) provide written feedback regarding their views on their treatment at 12 months. Transcripts were first analysed thematically and then rated according to the global valence of feedback (positive, mixed/negative).
114/142 (80.3 %) MOSAIC participants provided VAS data and 82 (57.7 %) provided written feedback. At 12 months, MANTRA patients gave significantly higher acceptability and credibility ratings compared to SSCM patients. A significantly higher proportion of MANTRA patients provided written feedback. MANTRA patients also tended to write in more detail and to give globally more positive feedback when compared to individuals receiving SSCM. Qualitative themes suggest that patients experienced the two treatments differently in terms of characteristics and outcomes.
This study highlights the benefits of incorporating qualitative and quantitative data into RCT process evaluations. MANTRA patients were more willing to express their views on treatment and generally felt more positively about this than those receiving SSCM.
PMCID: PMC4748560  PMID: 26865980
Anorexia nervosa; MANTRA; Randomised–controlled trial; Specialist supportive clinical management; Process evaluation
5.  Habitual Starvation and Provocative Behaviors: Two Potential Routes to Extreme Suicidal Behavior in Anorexia Nervosa 
Behaviour research and therapy  2010;48(7):634-645.
Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.
PMCID: PMC4731222  PMID: 20398895
anorexia; suicide; restricting; purging; self-injury
6.  Interventions for the Carers of Patients With Eating Disorders 
The aim of this study is to evaluate the recent literature on carers/parenting interventions for people with eating disorders. Interesting and important new findings are highlighted as well as the implications that this may have for treatment. We have reviewed and critically analysed the recent literature. Close others often play an important role in recognising the early signs of eating disorders and accessing and implementing treatment. Their role in helping with recovery is to give support and hold a united front themselves and with the professional team to avoid those common interpersonal reactions that adversely impact on outcome such as accommodating to the illness and reacting with high expressed emotion (overprotection and hostility). Managing this role is difficult, and coping resources are often strained. Carers ask for and are now getting expert training in skills to manage this role. There is an overlap between carer/parenting interventions and family therapies. The interface with close others is critical both for early recognition and access and implementation of treatment. Interventions which equip families and close others with the skills to manage eating disorder behaviours are showing potential at improving outcomes.
PMCID: PMC4718944  PMID: 26781554
Eating disorders; Experienced caregivers helping others (echo); Caregivers; Family intervention; Behaviour change
7.  Prevalence of purging at age 16 and associations with negative outcomes among girls in three community-based cohorts 
The co-morbidity of purging behaviours, such as vomiting, inappropriate use of laxatives, diuretics or slimming medications, has been examined in literature. However, most studies do not include adolescents, individuals who purge in the absence of binge-eating, or those purging at subclinical frequency. This study examines the prevalence of purging among 16-year-old girls across three countries and their association with substance use and psychological co-morbidity.
Data were obtained by questionnaire in 3 population-based cohorts(Avon Longitudinal Study of Parents and Children(ALSPAC), UK, n=1,608; Growing Up Today Study(GUTS), USA, n=3,504; North Finland Birth Cohort(NFBC85/86), Finland, n=2,306). Multivariate logistic regressions were employed to estimate associations between purging and outcomes. Four models were fit adjusting for binge-eating and potential confounders of these associations.
In ALSPAC, 9.8% of girls reported purging in the 12-months prior to assessment, 7.3% in GUTS, and 3.5% in NFBC. In all 3 cohorts, purging was associated with adverse outcomes such as binge-drinking (ALSPAC:odds ratio(OR)=2.0, 95% confidence interval(CI)= 1.4-2.9; GUTS: OR=2.5,95%CI=1.5-4.0; NFBC:OR=1.7,95%CI=1.0-2.8), drug use (ALSPAC:OR=2.9,95%CI=1.8-4.7; GUTS:OR=4.5, 95%CI=2.8-7.3; NFBC:OR=4.1,95%CI=2.6-6.6), depressive symptoms in ALSPAC(OR=2.2,95%CI=1.5-3.1) and GUTS(OR=3.7,95%CI=2.2-6.3), and several psychopathology measures including clinical anxiety/depression in NFBC(OR=11.2, 95%CI=3.9, 31.7).
Results show a higher prevalence of purging behaviours amongst girls in the UK compared to those in the USA and Finland. Our findings support evidence highlighting that purging in adolescence is associated with negative outcomes, independent of its frequency and binge-eating.
PMCID: PMC4303957  PMID: 24975817
Adolescence; epidemiology; prevalence; eating behaviour; eating disorder
8.  Refining Behavioral Dysregulation in Borderline Personality Disorder Using a Sample of Women with Anorexia Nervosa 
Personality disorders  2010;1(4):250-257.
One of the primary facets of borderline personality disorder (BPD) is behavioral dysregulation, a wide array of behaviors that are difficult to control and harmful to the individual. The purpose of this study was to explore the association between BPD and a variety of dysregulated behaviors, some of which have received little empirical attention. Using a large sample of individuals diagnosed with anorexia nervosa, 41 individuals diagnosed with BPD were compared to the rest of the sample on the presence of dysregulated behaviors using logistic regression analyses. Anorexia nervosa subtypes, age, and other Cluster B personality disorders were used as covariates. Results support an association between BPD and alcohol misuse, hitting someone/breaking things, provoking fights/ arguments, self-injury, overdosing, street drug use, binge-eating, impulsive spending, shoplifting/stealing and risky sexual behaviors. Differences between dichotomous and continuous measures of BPD yielded somewhat different results.
PMCID: PMC4688899  PMID: 22448667
borderline personality disorder; behavioral dysregulation; substance abuse; anorexia nervosa
9.  Therapist adherence in the strong without anorexia nervosa (SWAN) study: A randomized controlled trial of three treatments for adults with anorexia nervosa 
To develop a psychotherapy rating scale to measure therapist adherence in the Strong Without Anorexia Nervosa (SWAN) study, a multi-center randomized controlled trial comparing three different psychological treatments for adults with anorexia nervosa. The three treatments under investigation were Enhanced Cognitive Behavioural Therapy (CBT-E), the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), and Specialist Supportive Clinical Management (SSCM).
The SWAN Psychotherapy Rating Scale (SWAN-PRS) was developed, after consultation with the developers of the treatments, and refined. Using the SWAN-PRS, two independent raters initially rated 48 audiotapes of treatment sessions to yield inter-rater reliability data. One rater proceeded to rate a total of 98 audiotapes from 64 trial participants.
The SWAN-PRS demonstrated sound psychometric properties, and was considered a reliable measure of therapist adherence. The three treatments were highly distinguishable by independent raters, with therapists demonstrating significantly more behaviors consistent with the actual allocated treatment compared to the other two treatment modalities. There were no significant site differences in therapist adherence observed.
The findings provide support for the internal validity of the SWAN study. The SWAN-PRS was deemed suitable for use in other trials involving CBT-E, MANTRA, or SSCM. © 2015 The Authors. International Journal of Eating Disorders Published by Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:1170–1175)
PMCID: PMC4670702  PMID: 26769445
therapist adherence; anorexia nervosa; CBT-E; MANTRA; SSCM; randomized controlled trial
10.  Are obesity risk genes associated with binge eating in adolescence? 
Obesity (Silver Spring, Md.)  2015;23(8):1729-1736.
Cognitions and behaviors characteristic of binge eating are associated with a polymorphism in the FTO gene, robustly related to body mass index (BMI) and obesity risk. We investigated the association between binge eating and the individual and combined effect of 32 SNPs robustly associated with BMI in a population-based sample. We hypothesized that higher BMI and binge eating might share a common genetic etiology.
Binge eating was assessed in adolescents from the Avon Longitudinal Study of Parents and Children at age 14 (n = 5,958) and 16 years (n = 4,948). We tested associations between 32 BMI-related SNPs and binge eating in crude and BMI-, age-, and gender-adjusted regression models.
Crude analyses showed an association between binge eating and rs1558902 (FTO) that persisted after adjustment for BMI (OR = 1.20, P = 8 × 10−3). A weighted allelic score consisting of all 32 BMI-related SNPs was associated with binge eating (P = 8 × 10−4); this association attenuated (P = 0.08) when rs1558902 was removed from the weighted allelic score.
BMI-related genes are associated with adolescent binge eating, in particular an FTO polymorphism. Although replication is needed, our findings have biological plausibility and are consistent with a postulated effect of FTO on appetite and food intake. Future studies should aim to understand the mechanisms underlying the relationship between FTO, binge eating, and obesity.
PMCID: PMC4660437  PMID: 26193063
14.  Using the Autism-Spectrum Quotient to Measure Autistic Traits in Anorexia Nervosa: A Systematic Review and Meta-Analysis 
Interest in the link between Autism Spectrum Disorder (ASD) and Anorexia Nervosa (AN) has led to estimates of the prevalence of autistic traits in AN. This systematic review and meta-analysis assessed the use of the Autism-Spectrum Quotient (AQ) or abbreviated version (AQ-10) to examine whether patients with AN have elevated levels of autistic traits. Seven studies were identified and subsequent meta-analysis indicated that those with AN appear to have significant difficulties of a manner characteristic of ASD, relative to controls. Whilst this analysis supports previous indications of higher prevalence of ASD in AN, the aetiology of these traits remains unclear. Studies using more robust clinical measures of ASD within AN are needed to confirm what self-report measures appear to show.
PMCID: PMC4746216  PMID: 26542816
Autism; Systematic review; Meta-analysis; Anorexia Nervosa; Autism-Spectrum Quotient; Female
15.  The Impact of Oxytocin on Food Intake and Emotion Recognition in Patients with Eating Disorders: A Double Blind Single Dose Within-Subject Cross-Over Design 
PLoS ONE  2015;10(9):e0137514.
Background and Aim
Social difficulties and problems related to eating behaviour are common features of both anorexia nervosa (AN) and bulimia nervosa (BN). The aim of this study was to examine the impact of intranasal oxytocin on consummatory behaviour and emotional recognition in patients with AN and BN in comparison to healthy controls.
A total of 102 women, including 35 patients with anorexia nervosa (AN), 34 patients with bulimia nervosa (BN), and 33 healthy university students of comparable age and intelligence, participated in a double-blind, single dose placebo-controlled cross-over study. A single dose of intranasal administration of oxytocin (40 IU) (or a placebo) was followed by an emotional recognition task and an apple juice drink. Food intake was then recorded for 24 hours post-test.
Oxytocin produced no significant change in appetite in the acute or 24 hours free living settings in healthy controls, whereas there was a decrease in calorie consumption over 24 hours in patients with BN. Oxytocin produced a small increase in emotion recognition sensitivity in healthy controls and in patients with BN, In patients with AN, oxytocin had no effect on emotion recognition sensitivity or on consummatory behaviour.
The impact of oxytocin on appetite and social cognition varied between people with AN and BN. A single dose of intranasal oxytocin decreased caloric intake over 24 hours in people with BN. People with BN showed enhanced emotional sensitivity under oxytocin condition similar to healthy controls. Those effects of oxytocin were not found in patients with AN.
Trial Registration KCT0000716
PMCID: PMC4581668  PMID: 26402337
16.  Clinical effectiveness of a skills training intervention for caregivers in improving patient and caregiver health following in-patient treatment for severe anorexia nervosa: pragmatic randomised controlled trial 
BJPsych open  2015;1(1):56-66.
Families express a need for information to support people with severe anorexia nervosa.
To examine the impact of the addition of a skills training intervention for caregivers (Experienced Caregivers Helping Others, ECHO) to standard care.
Patients over the age of 12 (mean age 26 years, duration 72 months illness) with a primary diagnosis of anorexia nervosa and their caregivers were recruited from 15 in-patient services in the UK. Families were randomised to ECHO (a book, DVDs and five coaching sessions per caregiver) or treatment as usual. Patient (n=178) and caregiver (n=268) outcomes were measured at discharge and 6 and 12 months after discharge.
Patients with caregivers in the ECHO group had reduced eating disorder psychopathology (EDE-Q) and improved quality of life (WHO-Quol; both effects small) and reduced in-patient bed days (7–12 months post-discharge). Caregivers in the ECHO group had reduced burden (Eating Disorder Symptom Impact Scale, EDSIS), expressed emotion (Family Questionnaire, FQ) and time spent caregiving at 6 months but these effects were diminished at 12 months.
Small but sustained improvements in symptoms and bed use are seen in the intervention group. Moreover, caregivers were less burdened and spent less time providing care. Caregivers had most benefit at 6 months suggesting that booster sessions, perhaps jointly with the patients, may be needed to maintain the effect. Sharing skills and information with caregivers may be an effective way to improve outcomes. This randomised controlled trial (RCT) was registered with Current Controlled Trials ISRCTN06149665.
Declaration of interest
J.T. is a co-author of the book used in the ECHO intervention and receives royalties.
Copyright and usage
© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
PMCID: PMC4998946  PMID: 27703724
17.  Emotional Processing, Recognition, Empathy and Evoked Facial Expression in Eating Disorders: An Experimental Study to Map Deficits in Social Cognition 
PLoS ONE  2015;10(8):e0133827.
Difficulties in social cognition have been identified in eating disorders (EDs), but the exact profile of these abnormalities is unclear. The aim of this study is to examine distinct processes of social-cognition in this patient group, including attentional processing and recognition, empathic reaction and evoked facial expression in response to discrete vignettes of others displaying positive (i.e. happiness) or negative (i.e. sadness and anger) emotions.
One hundred and thirty-eight female participants were included in the study: 73 healthy controls (HCs) and 65 individuals with an ED (49 with Anorexia Nervosa and 16 with Bulimia Nervosa). Self-report and behavioural measures were used.
Participants with EDs did not display specific abnormalities in emotional processing, recognition and empathic response to others’ basic discrete emotions. However, they had poorer facial expressivity and a tendency to turn away from emotional displays.
Treatments focusing on the development of non-verbal emotional communication skills might be of benefit for patients with EDs.
PMCID: PMC4529105  PMID: 26252220
18.  The Role of Leptin, Melanocortin, and Neurotrophin System Genes on Body Weight in Anorexia Nervosa and Bulimia Nervosa 
Although low weight is a key factor contributing to the high mortality in anorexia nervosa (AN), it is unclear how AN patients sustain low weight compared with bulimia nervosa (BN) patients with similar psychopathology. Studies of genes involved in appetite and weight regulation in eating disorders have yielded variable findings in part due to small sample size and clinical heterogeneity. This study: (1) assessed the role of leptin, melanocortin, and neurotrophin genetic variants in conferring risk for AN and BN and (2) explored the involvement of these genes in body mass index (BMI) variations within AN and BN.
Our sample consisted of 745 individuals with AN without a history of BN, 245 with BN without a history of AN, and 321 controls. We genotyped 20 markers with known or putative function among genes selected from leptin, melanocortin, and neurotrophin systems.
There were no significant differences in allele frequencies among individuals with AN, BN, and controls. AGRP rs13338499 polymorphism was associated with lowest illness-related BMI in those with AN (p=0.0013), and NTRK2 rs1042571 was associated with highest BMI in those with BN (p=0.0018).
To our knowledge, this is the first study to address the issue of clinical heterogeneity in eating disorder genetics and to explore the role of known or putatively functional markers in genes regulating appetite and weight in individuals with AN and BN. If replicated, our results may serve as an important first step toward gaining a better understanding of weight regulation in eating disorders.
PMCID: PMC4191922  PMID: 24831852
anorexia nervosa; bulimia nervosa; candidate gene association; body weight; melanocortins; neurotrophins
20.  Do Children and Adolescents with Anorexia Nervosa Display an Inefficient Cognitive Processing Style? 
PLoS ONE  2015;10(7):e0131724.
This study aimed to examine neuropsychological processing in children and adolescents with Anorexia Nervosa (AN). The relationship of clinical and demographic variables to neuropsychological functioning within the AN group was also explored.
The performance of 41 children and adolescents with a diagnosis of AN were compared to 43 healthy control (HC) participants on a number of neuropsychological measures.
There were no differences in IQ between AN and HC groups. However, children and adolescents with AN displayed significantly more perseverative errors on the Wisconsin Card Sorting Test, and lower Style and Central Coherence scores on the Rey Osterrieth Complex Figure Test relative to HCs.
Inefficient cognitive processing in the AN group was independent of clinical and demographic variables, suggesting it might represent an underlying trait for AN. The implications of these findings are discussed.
PMCID: PMC4489794  PMID: 26133552
21.  Validation of the SCOFF Questionnaire for Eating Disorders in a Multiethnic General Population Sample 
This study aimed to validate the SCOFF, an eating disorders (ED) screening questionnaire, in a multiethnic general population sample of adults.
A two-stage design was employed using the South East London Community Health Study phases I and II data. A total of 1,669 participants were screened using the SCOFF in SELCoHI, and 145 were administrated an ED clinical interview in SELCoHII. We explored the diagnostic validity of the questionnaire restricting to the 145 individuals with the clinical questionnaire.
Sensitivity and specificity of the SCOFF were 53.7 and 93.5%, respectively.
The SCOFF showed good levels of specificity but low sensitivity, resulting in a high percentage of false negatives. Given the low sensitivity found in our sample the SCOFF is likely to be a suboptimal measure for the identification of ED in the community. © 2014 The Authors International Journal of Eating Disorders Published by Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:312–316)
PMCID: PMC4407952  PMID: 25504212
SCOFF; eating disorders; diagnostic validity
22.  Self-Help And Recovery guide for Eating Disorders (SHARED): study protocol for a randomized controlled trial 
Trials  2015;16:165.
We describe the theoretical rationale and protocol for Self-Help And Recovery guide for Eating Disorders (SHARED), a trial investigating whether a guided self-care intervention (Recovery MANTRA) is a useful addition to treatment as usual for individuals with anorexia nervosa. Recovery MANTRA, a 6-week self-care intervention supplemented by peer mentorship, is a module extension of the Maudsley Model of Treatment for Adults with Anorexia Nervosa and targets the maintenance factors identified by the cognitive-interpersonal model of the illness.
Patients accessing outpatient services for anorexia nervosa are randomized to either treatment as usual or treatment as usual plus Recovery MANTRA. Outcome variables include change in body weight at the end of the intervention (primary) and changes in body weight and eating disorder symptoms at immediate and extended follow-up (6-months; secondary). Change is also assessed for the domains identified by the theoretical model, including motivation, hope, confidence to change, positive mood, cognitive flexibility, therapeutic alliance and social adjustment. Feedback from peer mentors is gathered to understand the impact on their own well-being of providing guidance.
Results from this exploratory investigation will determine whether a larger clinical trial is justifiable and feasible for this affordable intervention, which has potential for high reach and scalability.
Trial registration NCT02336841.
PMCID: PMC4435653  PMID: 25885697
anorexia nervosa; eating disorders; guided self-help; peer mentoring; task-sharing
23.  Comparing the effectiveness of an enhanced MOtiVational intErviewing InTervention (MOVE IT) with usual care for reducing cardiovascular risk in high risk subjects: study protocol for a randomised controlled trial 
Trials  2015;16:112.
Interventions targeting multiple risk factors for cardiovascular disease (CVD), including poor diet and physical inactivity, are more effective than interventions targeting a single risk factor. A motivational interviewing (MI) intervention can provide modest dietary improvements and physical activity increases, while adding cognitive behaviour therapy (CBT) skills may enhance the effects of MI. We designed a randomised controlled trial (RCT) to examine whether specific behaviour change techniques integrating MI and CBT result in favourable changes in weight and physical activity in those at high risk of CVD. A group and individual intervention will be compared to usual care. A group intervention offers potential benefits from social support and may be more cost effective.
Individuals aged between 40 and 74 years in 11 South London Clinical Commissioning Groups who are at high risk of developing CVD (≥20%) in the next 10 years will be recruited. A sample of 1,704 participants will be randomised to receive the enhanced MI intervention, delivered by trained healthy lifestyle facilitators (HLFs), in group or individual formats, in 10 sessions (plus an introductory session) over one year, or usual care. Randomisation will be conducted by King’s College London Clinical Trials Unit and researchers collecting outcome data will be blinded to treatment allocation. At 12-month and 24-month follow-up assessments, primary outcomes will be change in weight and physical activity (average steps per day). Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score. Incidence of CVD events since baseline will be recorded. A process evaluation will be conducted to evaluate factors which impact on delivery, adherence and outcome. An economic evaluation will estimate relative cost-effectiveness of each type of intervention delivery.
This RCT assesses the effectiveness of a healthy lifestyle intervention for people at high risk of CVD. Benefits of the study include the ethnic and socioeconomic diversity of the study population and that, via social support within the group setting and long-term follow-up period, the intervention offers the potential to support maintenance of a healthy lifestyle.
Trial registration
This trial is registered with the ISRCTN registry (identifier: ISRCTN84864870, registered 15 May 2012).
PMCID: PMC4399238  PMID: 25886569
Cardiovascular disease; Physical activity; Diet; Accelerometer; Motivational interviewing; CBT; Primary care; Health trainers
24.  Disseminating skills to carers of people with eating disorders: an examination of treatment fidelity in lay and professional carer coaches 
Family members of people with eating disorders (EDs) have high levels of stress and can use maladaptive methods of coping. We have developed an intervention, using motivational interviewing (MI) strategies that trains lay and professional carer coaches (CCs) to support carers of adolescents with EDs to use more adaptive coping procedures. The aim of this study is to measure treatment integrity in coaches with either academic or lived experience. Eleven coaches were trained and supervised by an expert trainer and an ‘expert by experience’ trainer. Six of the coaches had prior training in clinical work and/or psychology and five had personal experience of supporting a loved one with an ED. Two audio-taped sessions (Sessions 3 and 7) from each family coached (n = 22) were assessed for fidelity to MI. Half the sessions (50% n = 11) had a Motivational Interviewing Treatment Integrity global score above the suggested cut-off for recommended competency. Prior clinical training was related to higher treatment fidelity and experiential training (having coached a greater number of families) improved treatment fidelity in the lay carer group. These preliminary findings suggest that: “lay CCs” can be trained to deliver an intervention based on MI. Further exploration of a more effective means of training, monitoring and supervision is required to maximise the quality of the intervention.
PMCID: PMC4346011  PMID: 25750802
eating disorders; anorexia nervosa; carer support; skills training programmes; carer coaching
25.  Confirmatory factor analysis for two questionnaires of caregiving in eating disorders 
Objective: Caring for someone diagnosed with an eating disorder (ED) is associated with a high level of burden and psychological distress which can inadvertently contribute to the maintenance of the illness. The Eating Disorders Symptom Impact Scale (EDSIS) and Accommodation and Enabling Scale for Eating Disorders (AESED) are self-report scales to assess elements of caregiving theorised to contribute to the maintenance of an ED. Further validation and confirmation of the factor structures for these scales are necessary for rigorous evaluation of complex interventions which target these modifiable elements of caregiving. Method: EDSIS and AESED data from 268 carers of people with anorexia nervosa (AN), recruited from consecutive admissions to 15 UK inpatient or day patient hospital units, were subjected to confirmatory factor analysis to test model fit by applying the existing factor structures: (a) four-factor structure for the EDSIS and (b) five-factor structure for the AESED. Results: Confirmatory factor analytic results support the existing four-factor and five-factor structures for the EDSIS and the AESED, respectively. Discussion: The present findings provide further validation of the EDSIS and the AESED as tools to assess modifiable elements of caregiving for someone with an ED.
PMCID: PMC4346074  PMID: 25750785
caregiving; eating disorders; confirmatory factor analysis; burden; accommodation and enabling

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