Abstract Emetophobia (a specific phobia of vomiting) is an under-researched and often poorly understood condition compared with other anxiety disorders. It is often regarded as part of obsessive-compulsive disorder. It is the most common type of specific phobia that presents for treatment. Practitioners may feel less confident in treating emetophobia than in treating other specific phobias with standard exposure therapy. This article updates an evidence-based CBT approach, including exposure and response prevention, for the treatment of emetophobia. There are new insights into how individuals with emetophobia struggle to tolerate not knowing whether they are going to vomit. It aims to be a practical ‘how to’ guide for therapists, drawing on theory and the authors’ experience in this area. This highlights the need to adapt the general principles of treating specific phobias through exposure therapy. This is particularly true when the presentation shares processes with obsessive-compulsive disorder or is complicated by avoidant and restrictive food intake disorder, or sensory sensitivity due to features of the autistic spectrum. We will also consider new developments in current evidence-based approaches to treating emetophobia, such as virtual reality technology and intensive treatment. Key learning aims This article assumes basic knowledge of key concepts in CBT with exposure using inhibitory learning and developing an alternative understanding of a problem (for example, Theory A/Theory B). By the end of this article, readers will be able to: (1) Understanding the epidemiology, clinical characteristics, co-morbidity, and cognitive behavioural model of emetophobia. (2) Assess and formulate the main presenting difficulties for a person with emetophobia. (3) Select appropriate cognitive, behavioural, and imagery interventions to help individuals with emetophobia.

Emetophobia can have a huge impact on daily life, from avoiding certain foods and alcohol to worrying about travel, pregnancy, hygiene and caring for loved ones when they are ill. This self-help guide will help you to better understand emetophobia and give you the tools to overcome it. Using proven cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) techniques, this book will support you to: · Understand what emetophobia is and what keeps it going · Identify your problems and goals · Set out a step-by-step plan to challenge and defeat your emetophobia · Overcome common challenges and setbacks. The book also includes guidance on medical treatment and advice for friends, partners and family of adults and young people with emetophobia.

Background: Despite their use in clinical practice, there is little evidence to support the use of therapist written goodbye letters as therapeutic tools. However, preliminary evidence suggests that goodbye letters may have benefits in the treatment of anorexia nervosa (AN). Aims: This study aimed to examine whether therapist written goodbye letters were associated with improvements in body mass index (BMI) and eating disorder symptomology in patients with AN after treatment. Method: Participants were adults with AN (n= 41) who received The Maudsley Model of Anorexia Treatment for Adults (MANTRA) in a clinical trial evaluating two AN out-patient treatments. As part of MANTRA, therapists wrote goodbye letters to patients. A rating scheme was developed to rate letters for structure and quality. Linear regression analyses were used to examine associations between goodbye letter scores and outcomes after treatment. Results: Higher quality letters and letters that adopted a more affirming stance were associated with greater improvements in BMI at 12 months. Neither the overall quality nor the style of goodbye letters were associated with improvements in BMI at 24 months or reductions in eating disorder symptomology at either 12 or 24 months. Conclusions: The results highlight the potential importance of paying attention to the overall quality of therapist written goodbye letters in the treatment of AN, and adopting an affirming stance.

Background and Objectives: Specific Phobia of Vomiting (SPOV) may be difficult to treat, and to date only one RCT has been published. Specific Phobias can be successfully treated using time intensive treatment formats. Imagery rescripting (ImRs) has also been shown to be a successful component for treating various anxiety disorders. The present study aims to evaluate the effectiveness of time intensive CBT and ImRs at reducing symptoms in SPOV. Methods: A multiple baseline ABCADE single case experimental design (SCED) was used to monitor symptoms across time in eight participants. The Specific Phobia of Vomiting Inventory (SPOVI) was administered to measure SPOV symptoms at each clinical session. Visual analysis of graphed data was used to compare data across treatment phases. Reliable and clinically significant change was also calculated on the SPOVI at 6-month follow up. Results: Findings suggest that time intensive CBT is associated with improvements across symptoms of SPOV. There was limited support for ImRs in the current study; however, informal discussion of aversive memories of vomiting, and formulation of the problem may be helpful in its own right in treatment of SPOV. Seven out of eight participants (87.5%) achieved reliable improvement and five (62.5%) achieved clinically significant change on the SPOVI at 6-month follow up. Time intensive treatment was associated with high client satisfaction ratings. Limitations: Limitations include lack of measurement of therapist adherence to protocol, and a short period of daily symptom monitoring in between ImRs and intensive treatment phases. Conclusions: Time intensive CBT including an ImRs component may be an effective and acceptable treatment in reducing SPOV symptomatology. Further research using larger sample sizes in a RCT is needed.

Specific Phobia of Vomiting (SPOV) is an under-researched disorder compared to other Specific Phobias. A systematic review was conducted to synthesise existing research across areas of phenomenology, aetiology, epidemiology, co-morbidity, assessment measures and treatment.

Background: Anorexia nervosa (AN) is a severe psychiatric condition and evidence on how to best treat it is limited. Objectives: This programme consists of seven integrated work packages (WPs) and aims to develop and test disseminable and cost-effective treatments to optimise management for people with AN across all stages of illness. Methods: WP1a used surveys, focus groups and a pre–post trial to develop and evaluate a training programme for school staff on eating disorders (EDs). WP1b used a randomised controlled trial (RCT) [International Standard Randomised Controlled Trial Number (ISRCTN) 42594993] to evaluate a prevention programme for EDs in schools. WP2a evaluated an inpatient treatment for AN using case reports, interviews and a quasi-experimental trial. WP2b used a RCT (ISRCTN67720902) to evaluate two outpatient psychological therapies for AN. WP3 used a RCT (ISRCTN06149665) to evaluate an intervention for carers of inpatients with AN. WP4 used actimetry, self-report and endocrine assessment to examine physical activity (PA) in AN. WP5 conducted a RCT (ISRCTN18274621) of an e-mail-guided relapse prevention programme for inpatients with AN. WP6 analysed cohort data to examine the effects of maternal EDs on fertility and their children’s diet and growth. WP7a examined clinical case notes to explore how access to specialist ED services affects care pathways and user experiences. Finally, WP7b used data from this programme and the British Cohort Study (1970) to identify the costs of services used by people with AN and to estimate annual costs of AN for England. Results: WP1a: a brief training programme improved knowledge, attitudes and confidence of school staff in managing EDs in school. WP1b: a teacher-delivered intervention was feasible and improved risk factors for EDs in adolescent girls. WP2a: both psychological therapies improved outcomes in outpatients with AN similarly, but patients preferred one of the treatments. WP2b: the inpatient treatment (Cognitive Remediation and Emotional Skills Training) was acceptable with perceived benefits by patients, but showed no benefits compared with treatment as usual (TAU). WP3: compared with TAU, the carer intervention improved a range of patient and carer outcomes, including carer burden and patient ED symptomatology. WP4: drive to exercise is tied to ED pathology and a desire to improve mood in AN patients. PA was not increased in these patients. WP5: compared with TAU, the e-mail-guided relapse prevention programme resulted in higher body mass index and lower distress in patients at 12 months after discharge. WP6: women with an ED had impaired fertility and their children had altered dietary and growth patterns compared with the children of women without an ED. WP7a: direct access to specialist ED services was associated with higher referral rates, lower admission rates, greater consistency of care and user satisfaction. WP7b: the annual costs of AN in England are estimated at between £45M and £230M for 2011. Conclusions: This programme has produced evidence to inform future intervention development and has developed interventions that can be disseminated to improve outcomes for individuals with AN. Directions for future research include RCTs with longer-term outcomes and sufficient power to examine mediators and moderators of change. Trial registration: Current Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 5, No. 16. See the NIHR Journals Library website for further project information.

Some individuals with specific phobia of vomiting (SPOV) (emetophobia) may present with disordered eating, including food restriction and weight loss. Such cases may be misdiagnosed as anorexia nervosa (AN), thus complicating case conceptualization, formulation, and treatment. This chapter outlines the clinical features of SPOV, including those that overlap with AN and other disorders. Treatment approaches and their evidence base are discussed, and a clinical case example of an individual with SPOV and disordered eating is presented. More research is needed to address the overlap between eating disorders and SPOV in order to better distinguish overlaps in presentation and to develop treatments that effectively target the central fears in these cases.

There is increasing evidence that contextual forms of cognitive-behavioral therapy (CBT) are effective in the management of chronic pain, yet little is understood about the factors that moderate or predict outcomes in these treatments. This systematic review aimed to identify pretreatment participant characteristics associated with positive treatment responses in contextual CBT for chronic pain. Medline, EMBASE, PsychINFO, and CENTRAL were searched to identify eligible studies. Studies were included if the participants were adults with chronic pain, designs were longitudinal, treatments focused on psychological flexibility or mindfulness, and reported results allowed for examination of moderators or predictors of standard treatment outcomes. Of 991 records initially identified, 20 were eligible for inclusion in the review. Some evidence suggested that baseline emotional functioning predicts treatment response, but the direction of this association varied between studies. Substantive findings were inconsistent and inconclusive, however, methodological limitations were consistent. These included treatment heterogeneity, and a lack of theoretical, a priori guidance in examining potential predictors. Future research should adopt a theoretically based approach to examining moderators in relation to specific treatment methods and therapeutic processes. Considering moderation without first considering mediation is probably a limited strategy.Perspective: In this systematic review we examined evidence for potential predictors or moderators of outcomes in contextual CBT for chronic pain. Substantive findings were inconclusive but important methodological limitations and a lack of theoretical guidance were found. Future research should explicitly plan relevant methods and follow clear theoretical models. (C) 2017 by the American Pain Society.

Objective: Case formulation is a core component of many psychotherapies and formulation letters may provide an opportunity to enhance the therapeutic alliance and improve treatment outcomes. This study aimed to determine if formulation letters predict treatment satisfaction, session attendance, and symptom reductions in anorexia nervosa (AN). It was hypothesized that higher quality formulation letters would predict greater treatment satisfaction, a greater number of attended sessions, and greater improvement in eating disorder symptoms.Method: Patients were adult outpatients with AN (n=46) who received Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) in the context of a clinical trial. A Case Formulation Rating Scheme was used to rate letters for adherence to the MANTRA model and use of a collaborative, reflective, affirming stance. Analyses included linear regression and mixed models.Results: Formulation letters that paid attention to the development of the AN predicted greater treatment acceptability ratings (p=0.002). More reflective and respectful letters predicted greater reductions in Eating Disorder Examination scores (p=0.003).Discussion: Results highlight the potential significance of a particular style of written formulation as part of treatment for AN. Future research should examine applicability to other psychiatric disorders. (C) 2016 Wiley Periodicals, Inc.

Several behaviours associated with anorexia nervosa (AN) are hypothesised to be highly salient and rewarding for these people (e.g., food restriction, weight-loss, and driven exercise). Neurobiological and psychophysiological evidence support a role for altered dopaminergic reward processes in the aetiology of AN and in the valued nature of its symptomatology. More specifically, preliminary data support the hypothesis that, in people with AN, alterations in dopamine (DA) reward circuits result from the attribution of motivational salience to illness-related stimuli (e.g., thinness and exercise). Aberrant reward processing in AN may therefore represent an important developmental and maintaining factor to be targeted by treatments.

OBJECTIVEThis study reports follow-up data from a multicenter randomized controlled trial (n = 142) comparing the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with broadly defined anorexia nervosa (AN). At 12 months postrandomization, all patients had statistically significant improvements in body mass index (BMI), eating disorder (ED) symptomatology and other outcomes with no differences between groups. MANTRA was more acceptable to patients. The present study assessed whether gains were maintained at 24 months postrandomization.METHODSFollow-up data at 24 months were obtained from 73.2% of participants. Outcome measures included BMI, ED symptomatology, distress, impairment, and additional service utilization during the study period. Outcomes were analyzed using linear mixed models.RESULTSThere were few differences between groups. In both treatment groups, improvements in BMI, ED symptomatology, distress levels, and clinical impairment were maintained or increased further. Estimated mean BMI change from baseline to 24 months was 2.16 kg/m(2) for SSCM and 2.25 kg/m(2) for MANTRA (effect sizes of 1.75 and 1.83, respectively). Most participants (83%) did not require any additional intensive treatments (e.g., hospitalization). Two SSCM patients became overweight through binge-eating.DISCUSSIONBoth treatments have value as outpatient interventions for patients with AN. © 2016 Crown copyright. International Journal of Eating Disorders. (Int J Eat Disord 2016; 49:793-800).

This study investigated whether dopaminergic systems are involved in the motivation to engage in behaviours associated with anorexia nervosa (AN), specifically, the drive to exercise. Women recovered from AN (AN REC, n = 17) and healthy controls (HC, n = 15) were recruited. The acute phenylalanine/tyrosine depletion (APTD) method was used to transiently decrease dopamine synthesis and transmission. The effect of dopamine precursor depletion on drive to exercise was measured using a progressive ratio (PR) exercise breakpoint task. Both groups worked for the opportunity to exercise, and, at baseline, PR breakpoint scores were higher in AN REC than HC. Compared to values on the experimental control session, APTD did not decrease PR breakpoint scores in AN REC, but significantly decreased scores in HC. These data show that women recovered from AN are more motivated to exercise than HC, although in both groups, activity is more reinforcing than inactivity. Importantly, decreasing dopamine does not reduce the motivation to exercise in people recovered from AN, but in contrast, does so in HC. It is proposed that in AN, drive to exercise develops into a behaviour that is largely independent of dopamine mediated reward processes and becomes dependent on cortico-striatal neurocircuitry that regulates automated, habit- or compulsive-like behaviours. These data strengthen the case for the involvement of reward, learning, habit, and dopaminergic systems in the aetiology of AN.

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.

In anorexia nervosa (AN), motivational salience is attributed to illness-compatible cues (e.g., underweight and active female bodies) and this is hypothesised to involve dopaminergic reward circuitry. We investigated the effects of reducing dopamine (DA) transmission on the motivational processing of AN-compatible cues in women recovered from AN (AN REC, n = 17) and healthy controls (HC, n = 15). This involved the acute phenylalanine and tyrosine depletion (APTD) procedure and a startle eye-blink modulation (SEM) task. In a balanced amino acid state, AN REC showed an increased appetitive response (decreased startle potentiation) to illness-compatible cues (underweight and active female body pictures (relative to neutral and non-active cues, respectively)). The HC had an aversive response (increased startle potentiation) to the same illness-compatible stimuli (relative to neutral cues). Importantly, these effects, which may be taken to resemble symptoms observed in the acute stage of illness and healthy behaviour respectively, were not present when DA was depleted. Thus, AN REC implicitly appraised underweight and exercise cues as more rewarding than did HC and the process may, in part, be DA-dependent. It is proposed that the positive motivational salience attributed to cues of emaciation and physical activity is, in part, mediated by dopaminergic reward processes and this contributes to illness pathology. These observations are consistent with the proposal that, in AN, aberrant reward-based learning contributes to the development of habituation of AN-compatible behaviours.

OBJECTIVEAnorexia nervosa (AN) in adults has poor outcomes, and treatment evidence is limited. This study evaluated the efficacy and acceptability of a novel, targeted psychological therapy for AN (Maudsley Model of Anorexia Nervosa Treatment for Adults; MANTRA) compared with Specialist Supportive Clinical Management (SSCM).METHODOne hundred forty-two outpatients with broadly defined AN (body mass index [BMI] ≤ 18.5 kg/m²) were randomly allocated to receive 20 to 30 weekly sessions (depending on clinical severity) plus add-ons (4 follow-up sessions, optional sessions with dietician and with carers) of MANTRA (n = 72) or SSCM (n = 70). Assessments were administered blind to treatment condition at baseline, 6 months, and 12 months after randomization. The primary outcome was BMI at 12 months. Secondary outcomes included eating disorders symptomatology, other psychopathology, neuro-cognitive and social cognition, and acceptability. Additional service utilization was also assessed. Outcomes were analyzed using linear mixed models.RESULTSBoth treatments resulted in significant improvements in BMI and reductions in eating disorders symptomatology, distress levels, and clinical impairment over time, with no statistically significant difference between groups at either 6 or 12 months. Improvements in neuro-cognitive and social-cognitive measures over time were less consistent. One SSCM patient died. Compared with SSCM, MANTRA patients rated their treatment as significantly more acceptable and credible at 12 months. There was no significant difference between groups in additional service consumption.CONCLUSIONSBoth treatments appear to have value as first-line outpatient interventions for patients with broadly defined AN. Longer term outcomes remain to be evaluated.