The Contribution of Shame to Eating Disorder Treatment Outcomes in a Community Mental Health Clinic.

OBJECTIVE: Shame is a powerful self-conscious emotion that is often experienced by individuals with eating disorders (EDs). While the association between EDs and shame is well-established, there is limited research investigating the contribution of pre-treatment shame to clinical outcomes. METHOD: Participants (N = 273) received outpatient cognitive-behavioral therapy for eating disorders (CBT-ED). We investigated pre-treatment shame as a predictor of dropout and as a moderator of change in ED psychopathology and clinical impairment from pre-treatment to post-treatment. We also explored the potentially moderating roles of body mass index, ED diagnostic category, and co-occurring anxiety and depression diagnoses. RESULTS: Shame improved substantially (d = 1.28) despite not being explicitly targeted in treatment. Pre-treatment shame did not predict treatment dropout. Individuals high in shame started and ended treatment with higher ED symptoms and impairment than those with low shame. The contribution of pre-treatment shame on the degree of change in symptoms/impairment depended critically on whether analyses controlled for pre-treatment symptoms/impairment. When those were controlled, high pre-treatment shame was associated with substantially less improvement in ED symptoms and impairment. There was some evidence that ED diagnosis and co-occurring depressive diagnoses may moderate the relationship between shame and treatment outcome. Changes in shame were positively associated with changes in ED symptoms and clinical impairment. DISCUSSION: A high level of shame at pre-treatment is not a contraindication for CBT-ED as good therapeutic outcomes can be achieved. However, outcomes may be enhanced among individuals high in shame by offering adjunctive interventions that explicitly target shame.

Validation of the Interpersonal Relationships in Eating Disorders (IR-ED) Scale in an Eating Disorder Sample.

OBJECTIVE: Interpersonal problems have been identified as a plausible mechanism underlying the onset and maintenance of eating disorders. The Interpersonal Relationships in Eating Disorders (IR-ED) scale is the first eating disorders-specific measure of interpersonal problems, which was developed in a nonclinical sample. The aims of the current study were to (a) confirm the factor structure of the IR-ED within a large clinical sample, (b) investigate measurement invariance of the IR-ED across nonclinical and clinical samples, (c) examine the convergent validity of the IR-ED using a generic measure of interpersonal problems, and (d) investigate the incremental clinical utility of the IR-ED in uniquely predicting eating disorder symptomatology. METHOD: Treatment-seeking individuals (N = 437) completed the IR-ED at their initial assessment appointment at a specialist eating disorder outpatient service. RESULTS: A multiple-group confirmatory factor analysis supported an invariant bifactor structure comprising a general interpersonal problems factor and two group factors-Avoidance of Body Evaluation and Food-Related Interpersonal Tension. Convergent validity was demonstrated by a large, statistically significant correlation with a generic measure of interpersonal problems (r = 0.62, p < 0.001). A series of structural equation models further revealed unique incremental predictive utility of the IR-ED for eating disorder symptomatology. DISCUSSION: The IR-ED has strong psychometric properties and may prove beneficial in the assessment, formulation, and treatment of eating-specific interpersonal problems among patients with eating disorders.

Opportunities lost? Rates and predictors of attrition in an eating disorders outpatient service.

OBJECTIVE: To examine rates and predictors of attrition from referral through to treatment completion in an outpatient public psychology service's eating disorder program in Perth, Western Australia. METHOD: The proportion (number) of clients (N = 671; mean age = 23.8 years) transitioning between stages of pre-treatment and treatment was identified. Associations between demographic, treatment and clinical variables and attrition were investigated using logistic regression. RESULTS: Only 34% (n = 230) of referred patients started treatment and 16% (n = 107) completed treatment. Referral acceptance was correlated with provisional diagnoses that meet the service's inclusion criteria, and attendance at an initial assessment was correlated with younger age. Treatment commencement was correlated with the presence of a co-occurring depressive or anxiety disorder, and no previous suicide attempts. Completing a full course of treatment was correlated with no previous hospitalisation for psychiatric issues, no previous suicide attempts, a history of psychiatric medication use, and treatment with family-based therapy. DISCUSSION: High rates of attrition were found from referral to treatment completion. A suggested framework for defining the different stages of attrition is proposed to allow for consistency of attrition reporting across the mental health field. Future studies are needed to identify why clients disengage following referral, assessment, and treatment commencement, to inform strategies to engage and sustain engagement and to optimise outcomes.

Short-term effects of the "I Spy Feelings" program on emotion regulation in 5- to 6-year-old children.

Introduction: Mental health difficulties in early childhood can have a debilitating and ongoing impact throughout an individual's life; emotion regulation can serve as a protective factor. Therefore, evidence-based prevention programs that teach children effective skills and strategies for emotion regulation are needed. Methods: As part of the Aussie Optimism pilot study evaluating the "I Spy Feelings" program, this study aims to assess the short-term effects of the program on emotion regulation in pre-primary aged children after 2 months via a longitudinal cluster randomized controlled trial. Participants included parents (N = 73) of 5- to 6-year-old children attending four different Catholic primary schools. Children from two of the schools were allocated to the intervention group where they participated in the program (N = 33), while children from the other two schools were allocated to the control group where they did not (N = 40). At each time point, all parents completed abridged Children's Emotional Management Scales measuring how well parents believe their child is able to cope with anger, sadness and worry. Results: A significant intervention effect 2 months after intervention was found for the outcome of anger coping such that parents whose children were in the intervention group reported significantly greater improvement in their children's ability to cope with anger compared to parents whose children were in the control group. No significant effect was found for the outcome of sadness, and results for the worry subscale were inconclusive due to unacceptable internal consistency. Discussion: The present study provides insight into the benefit of programs designed to enhance the emotion regulation skills of very young children. Further follow-up is needed to assess whether the "I Spy Feelings" program has lasting effects.

The relationship between clinical perfectionism and nonsuicidal self-injury: The roles of experiential avoidance, self-esteem, and locus of control.

OBJECTIVES: Perfectionism is linked to nonsuicidal self-injury (NSSI). Individuals with elevated perfectionism tend to avoid undesirable emotions and experience lower self-esteem, which are associated with NSSI. However, it is unclear if these mechanisms explain the link between clinical perfectionism and NSSI, and if locus of control is involved. We aimed to explore whether experiential avoidance and self-esteem would mediate the relationship between clinical perfectionism and NSSI, and if locus of control would moderate links between clinical perfectionism and both experiential avoidance and self-esteem. METHOD: As part of a larger study, 514 Australian university students (Mage = 21.15 years, SD = 2.40; 73.5% female) completed an online survey of NSSI, clinical perfectionism, experiential avoidance, self-esteem, and locus of control. RESULTS: Clinical perfectionism was associated with NSSI history, but not with recent NSSI or past year NSSI frequency. Lower self-esteem, but not experiential avoidance, mediated links between clinical perfectionism and NSSI history, recent NSSI, and NSSI frequency. More external locus of control was associated with NSSI, experiential avoidance, and lower self-esteem, but locus of control did not moderate pathways between clinical perfectionism and experiential avoidance or self-esteem. CONCLUSION: University students reporting elevated clinical perfectionism may have a tendency to experience lower self-esteem which is associated with NSSI history, recency, and severity.

An experimental investigation of biased attention in non-suicidal self-injury: The effects of perfectionism and emotional valence on attentional engagement and disengagement.

BACKGROUND AND OBJECTIVES: Theoretical models of non-suicidal self-injury (NSSI) propose that individuals who self-injure may find their attention more strongly captured by negative emotion, and that this intensifies distress which leads to episodes of NSSI. Elevated perfectionism is associated with NSSI, and when an individual is highly perfectionistic, a focus on perceived flaws/failures may increase risk of NSSI. We explored how history of NSSI and trait perfectionism are associated with different types of attention bias (engagement vs. disengagement) to stimuli that differ in emotional valence (negative vs positive) and perfectionism relevance (relevant vs irrelevant). METHODS: Undergraduate university students (N = 242) completed measures of NSSI, perfectionism, and a modified dot-probe task to measure attentional engagement with and disengagement from both positive and negative stimuli. RESULTS: There were interactions between NSSI and perfectionism in attention biases. Amongst individuals who engage in NSSI, those with elevated trait perfectionism exhibit speeded responding to and disengagement from emotional stimuli (both positive and negative). Furthermore, individuals with a history of NSSI and elevated perfectionism were slower to respond to positive stimuli, and faster to negative stimuli. LIMITATIONS: This experiment was cross-sectional in design so does not provide information about temporal ordering of these relationships, and given the use of a community sample, would benefit from replication in clinical samples. CONCLUSIONS: These findings lend support to the emerging idea that biased attention plays a role in how perfectionism is associated with NSSI. Future studies should replicate these findings using other behavioural paradigms and diverse samples.

Cognitive-emotional networks in students with and without a history of non-suicidal self-injury.

BACKGROUND: Contemporary models of non-suicidal self-injury (NSSI) suggest that emotional vulnerabilities, negative self-schemas, and beliefs about NSSI work together to differentiate students who self-injure from those who do not. However, it is unclear how these mechanisms are differentially related among students with and without a history of NSSI. Considering this, we used a network analysis approach to explore how students with and without a history of NSSI vary in processing their emotional experiences in relation to their self-concepts and beliefs about NSSI. METHOD: A sample of 480 university students (Mage = 21.18, SD = 2.43; 73.5 % female) completed self-report measures about their perceived emotional experiences (e.g., emotional reactivity, emotion regulation difficulties), self-concepts (e.g., self-esteem, self-efficacy), and NSSI. RESULTS: A network comparison test revealed that students with a history of NSSI perceived themselves to have difficulties regulating particularly intense, unwanted negative emotions. In light of this, students with a history of NSSI expected some benefits of NSSI (e.g., emotion regulation) regardless of potential barriers (e.g., pain). Conversely, for students without a history of NSSI, expecting NSSI to have aversive outcomes was tied to expecting NSSI to have few benefits. LIMITATIONS: The cross-sectional design limits inferences to be made about the network structures. CONCLUSIONS: Students with and without a history of NSSI appear to differ in their cognitive processing of negative emotions and strategies used to deal with these emotions.

Modeling pathways to non-suicidal self-injury: The roles of perfectionism, negative affect, rumination, and attention control.

OBJECTIVE: Using the Emotional Cascade Model as a theoretical framework, this study tested whether the relationship between perfectionism and non-suicidal self-injury (NSSI) operates through rumination and negative affect. Additionally, we tested whether the associations between perfectionism and both rumination and negative affect are moderated by attention control. METHODS: Using a correlational cross-sectional design, adults aged 18-25 with (N = 197) and without (N = 271) a history of NSSI completed measures of perfectionism, rumination, negative affect, attention control, and NSSI. RESULTS: Perfectionism was directly associated with increased odds of NSSI, and indirectly associated with odds of NSSI through rumination and negative affect. The relationship between perfectionism and rumination was moderated by attention focusing, such that the relationship was stronger for individuals who were higher in attention focusing. CONCLUSION: Integrating perfectionism and attention with existing models of NSSI may improve understanding of the factors contributing to NSSI and offers insights into future clinical directions.

Measurement Invariance of Perfectionism Measures in Students with and without a History of Non-Suicidal Self-Injury.

Perfectionism is a transdiagnostic process which may be implicated in the onset and maintenance of non-suicidal self-injury. No study has evaluated whether reported differences in perfectionism between individuals with and without a history of self-injury represent genuine group differences or measurement artefacts. The present study reports an investigation of the measurement invariance of two common scales of perfectionism, the Frost Multidimensional Perfectionism Scale-Brief (FMPS-Brief) and the Clinical Perfectionism Questionnaire (CPQ), among university students (Mage = 20.48, SDage = 2.22, 75.3% female, 22.8% male) with and without a history of self-injury (total n = 711). Results revealed full residual error invariance for the two-factor model of FMPS-Brief, while the bifactor model of the FMPS-Brief and the two-factor model of the CPQ demonstrated partial metric invariance. Accounting for partial metric invariance, the bifactor model of the FMPS-Brief also demonstrated partial residual error invariance. The current findings suggest that observed differences using the FMPS-Brief reflect genuine differences in perfectionism between individuals with and without a history of self-injury. Further, while researchers using the bi-factor model can have confidence that the general factor can adequately assess group differences, differential item functioning should be considered if using the strivings and concerns factors. Finally, in the current data, the CPQ did not perform as expected in baseline model fit and future research should replicate assessments of measurement invariance in this measure.

Guided Internet-delivered cognitive behaviour therapy for perfectionism in a non-clinical sample of adolescents: A study protocol for a randomised controlled trial.

BACKGROUND: Perfectionism is elevated across a range of psychopathologies and has been shown to impede treatment outcomes. There is also evidence suggesting elevated perfectionism may contribute to the onset and maintenance of non-suicidal self-injury. There is a growing body of evidence suggesting that Internet-delivered cognitive-behavioural therapy for perfectionism reduces perfectionism and symptoms of psychological disorders and that reductions are maintained at 3-month and 6-month follow-up. There may also be reductions in non-suicidal self-injury, although no study has investigated this potential benefit. Given that associations between perfectionism and psychopathology are observed across both adults and adolescents, the need for the development of interventions targeting adolescents is essential for early intervention and prevention. METHODS: The present study will employ a randomised controlled trial to examine the efficacy of 8-week guided Internet-delivered cognitive-behavioural therapy for perfectionism in adolescents compared to a waitlist control group. The primary outcome is perfectionism, and secondary outcomes include symptoms of psychological disorders, well-being, and non-suicidal self-injury. Outcomes will be assessed at pre-intervention, post-intervention, 1-month follow-up, 3-month follow-up, and 6-month follow-up. A minimum of 240 participants will be recruited online through social media, Australian universities, and schools across Australia. Generalised linear mixed models will be used to test for changes in outcomes between the intervention group and the waitlist control. DISCUSSION: The outcomes of this trial will contribute to the literature on perfectionism and psychopathology in adolescents, as well as the efficacy of guided Internet-delivered interventions for adolescents. TRIAL REGISTRATION: The trial was registered on the 20th of June 2019 at the Australia New Zealand Clinical Trials Registry (ACTRN12619000881134). TRIAL STATUS: This is protocol version 1.0. Participant recruitment began on 31 July 2019 and is still actively running with an anticipated completion date in the fourth quarter of 2020.

Attention biases in perfectionism: Biased disengagement of attention from emotionally negative stimuli.

BACKGROUND AND OBJECTIVES: Perfectionism is associated with the development and maintenance of several psychological disorders. Consequently, efforts to better understand perfectionism have potential transdiagnostic impact. One mechanism proposed to underlie perfectionism is an attention bias towards information signalling threats to perfectionism whereby people with elevated perfectionism selectively attend to threatening stimuli. METHOD: The present study assessed whether two core dimensions of perfectionism, perfectionistic strivings and perfectionistic concerns, are characterised by a threat-related attention bias, and whether this bias was characterised by attention being more rapidly captured by the stimuli (engagement bias), or of greater difficulty to disengage attention (disengagement bias). Participants (N = 108) completed measures of perfectionistic strivings and concerns, and symptoms of psychological distress before completing a modified dot-probe task to measure attention biases. Attention bias index scores were calculated across three factors: engagement bias vs disengagement bias, perfectionism relevant vs irrelevant stimuli, and negative vs positive emotional stimuli. RESULTS: Overall, perfectionistic concerns were associated with a disengagement bias for negative stimuli, regardless of whether stimuli were perfectionism relevant or not. No other significant main or interaction effects were observed. LIMITATIONS: The study was cross-sectional in design, and no temporal or causal inferences could be made. Additionally, participants were from a community sample and therefore replication is required in clinical populations. CONCLUSION: These findings demonstrate that individuals higher in perfectionistic concerns experience difficulty withdrawing their attention from emotionally negative stimuli. These findings contribute new information to our theoretical understandings of perfectionism and provide support for the cognitive-behavioural model of perfectionism.