Cognitive-behavioral Framework Research Articles

The Psychological Experience and Intervention in Post-Acute COVID-19 Inpatients.

PurposeCOVID-19 patients faced first-hand the life-threatening consequences of the disease, oftentimes involving prolonged hospitalization in isolation from family and friends. This study aimed at describing the psychological intervention to address the psychological difficulties and issues encountered by the hospitalized post-acute COVID-19 patients in a rehabilitation setting.Patients and MethodsPatients’ demographics, medical diagnosis, and neuro-psychological information were collected from March 2nd to May 12th, 2020. The main psychological issues and intervention strategies were collected.ResultsA total of 181 patients were hospitalized during this period. Among them, the 47.5% underwent psychological assessment (N=86; age: 74.58±13.39; 54.7% females). The most common psychological issues were acute stress disorders (18.6%), anxious and demoralization symptoms (26.7%), depression (10.5%%), and troublesome grief (8.1%). Once recovered from COVID-19, many patients were discharged home (38.4%), some received further rehabilitation in non-COVID-19 wards (41.9%), mostly due to pre-existent diseases (72.2%) rather than to COVID-19 complications (27.8%).ConclusionA great number of the hospitalized post-acute COVID-19 patients showed psychological issues requiring psychological intervention, the most common were anxiety, demoralization, acute stress, depression, and grief. The proposed psychological treatment for hospitalized COVID-19 patients was conducted in a Cognitive Behavioral framework. In particular, during the COVID-19 pandemic, psychological intervention is an important part of rehabilitation in the post-acute phase of the illness to reduce distress symptoms and improve psychological health.

COVID-19 Pandemic: Demographic Predictors of Self-Isolation or Self-Quarantine and Impact of Isolation and Quarantine on Perceived Stress, Anxiety, and Depression.

Introduction: With the sudden onset and global dispersal of the SARS-CoV-2 virus, many nations including Canada attempted to reduce spread of the resultant COVID-19 syndrome with self-isolation and quarantine, while seeking a cure or vaccine for this disease. Understanding impacts of self-isolation and self-quarantine on stress, anxiety, and depression will help us to mitigate these issues through appropriate development of mental health services.Methods: The sample was drawn from individuals who self-subscribed to Text4Hope, a service that delivers text messages based on a cognitive behavioral therapy framework. Text4Hope was developed to support Albertans during the COVID-19 pandemic. Subscribers were asked for demographic information and if they had to self-isolate or self-quarantine during the pandemic via a survey link. Mental health was assessed using the validated instruments: Perceived Stress Scale (PSS), Generalized Anxiety Disorder-7 item scale (GAD-7), and the Patient Health Questionnaire-9 (PHQ-9). Descriptive statistics and Chi-Square test results were derived using Statistical Package for Social Sciences (SPSS) version-26.Results: 6,041 of 32,805 Text4Hope subscribers (18.4%) completed the survey. Of these respondents, 19.2% had self-isolated or self-quarantined in Alberta as of March 31, 2020 during the COVID-19 pandemic. Post-hoc analysis using adjusted residuals suggested that individuals aged 60 years of age or older, and retirees had a higher likelihood of self-isolation or self-quarantine, compared to respondents with other age or employment characteristics. One-week prevalence rates for self-reported measures of moderate to high stress, likely Generalized Anxiety Disorder (GAD), and likely Major Depressive Disorder (MDD) were 84.9, 46.7, and 41.4%, respectively. Respondents who had to self-isolate or self-quarantine during the COVID-19 pandemic were significantly more likely to present with moderate to high stress, significant anxiety symptomatology, and significant depressive symptomatology.Conclusions: Older age and employment status were significantly associated with the likelihood of self-isolation or self-quarantine. We found elevated self-reported levels of anxiety and depression associated with self-reported COVID-19 pandemic-related self-isolation and self-quarantine activity. These findings have mental health implications both during and after the pandemic and demonstrate the need for greater focus on psychological complications of self-isolation and self-quarantine, and development of optimal ways to manage these pandemic consequences.

Manipulating Alcohol Expectancies in Social Anxiety: A Focus on Beliefs About Losing Control

Social anxiety is associated with increased and decreased alcohol use. Alcohol expectancies may help explain these inconsistencies. For example, a fear of losing control in front of others could motivate avoidance of alcohol. Similarly, cognitive models propose that individuals with elevated social anxiety believe they are at risk of behaving inappropriately and embarrassing themselves, indicating that beliefs about losing control over one’s behaviour may be involved in social anxiety. This experiment aimed to manipulate negative alcohol expectancies about losing control to assess their impact on symptoms and processes associated with social anxiety. Ninety-three undergraduate participants (i.e., non-clinical sample) were randomly assigned to an alcohol, placebo, or control condition and were ‘informed’ that alcohol makes people lose control over their actions/speech. They then completed a ‘getting to know you’ task. Participants in the placebo and alcohol (versus control) conditions experienced greater anxiety before and during the task and engaged in more post-event processing 24 h later. However, the physiological effects of alcohol influenced results: participants in the alcohol (versus placebo) condition experienced lower anticipatory anxiety, perceived themselves as making a better first impression, and demonstrated a lower reliance on safety behaviour. Although this experiment used a non-clinical sample, beliefs about losing control may be important to consider when conceptualizing social anxiety and treating associated symptoms from a cognitive-behavioural framework.

Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain.

A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability. Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability. It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.

14-OR: Piloting a Video-Based Telehealth Intervention to Reduce Distress and Depression in Parents of Schoolagers with Type 1 Diabetes (T1D)

Parents of school-agers (5-12 years) with T1D play an important role in their child’s T1D management and may be vulnerable to T1D distress and depressive symptoms. We present pilot data from a new group-based video telehealth intervention to reduce depressive symptoms and distress in parents of youth with T1D. Currently, 40 families enrolled in the Cognitive Adaptations to Reduce Emotional Stress (CARES) intervention and 27 completed treatment (both parents participated from two families for N=29; Age = 41.1±6.7 years; Child age = 10.1±1.5 years, 48% girls). CARES uses a cognitive behavioral framework to help parents identify maladaptive thoughts and promote healthy coping through behavioral activation and mindfulness. Parents participated in weekly CARES sessions via a HIPAA-compliant video-based telehealth platform. We measured feasibility and acceptability of 12-session and 8-session versions of the CARES intervention. We used paired t-tests to assess preliminary efficacy based on pre- and post-intervention changes in parent T1D-Distress (PAID-PR) and depressive symptoms (CESD-R), and exploratory changes in child HbA1c. Parents attended 89% of the 12-version sessions (N=14) and 84% of the 8-version sessions (N=15), suggesting adequate feasibility. Parents reported satisfaction with CARES across both versions. In the 12-session version, parents noted significant reductions in CESD-R scores (p=0.046) and T1D-Distress (immediate, p=0.007; theory, p=0.004), whereas in the 8-session version parents only noted reductions in T1D-Distress (immediate, p=0.018; theory, p=0.024). For both the 12- and 8-session versions, we found no difference in child HbA1c (p=0.497 and p=0.146, respectively). Our preliminary data suggest feasibility and efficacy for using video-based telehealth to deliver a group-based intervention to reduce parent distress, but only our 12-session version achieved a significant reduction in parent depression. Disclosure S.R. Patton: None. A.M. Marker: None. A. Monzon: None. E. Nelson: None. M.A. Clements: Consultant; Self; Glooko, Inc. Other Relationship; Self; Glooko, Inc. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK100779)

Emotional response to testing positive for human papillomavirus at cervical cancer screening: a mixed method systematic review with meta-analysis

ABSTRACT Tens-of-millions of women every year test positive for human papillomavirus (HPV) at routine cervical screening. We performed a mixed-methods systematic review using a results-based convergent design to provide the first comprehensive overview of emotional response to testing positive for HPV (HPV+). We mapped our findings using the cognitive behavioural framework. Six electronic databases were searched from inception to 09-Nov-2019 and 33 papers were included. Random-effects meta-analyses revealed that HPV+ women with abnormal or normal cytology displayed higher short-term anxiety than those with normal results (MD on State-Trait Anxiety Inventory = 7.6, 95% CI: 4.59–10.60 and MD = 6.33, CI: 1.31–11.35, respectively); there were no long-term differences. Psychological distress (general/sexual/test-specific) was higher in HPV+ women with abnormal cytology in the short-term and long-term (SMD = 0.68, CI: 0.32–1.03 and SMD = 0.42, CI: 0.05–0.80, respectively). Testing HPV+ was also related to disgust/shame, surprise and fear about cancer. Broadly, adverse response related to eight cognitive constructs (low control, confusion, cancer-related concerns, relationship concerns, sexual concerns, uncertainty, stigma, low trust) and six behavioural constructs (relationship problems, social impact, non-disclosure of results, idiosyncratic prevention, indirect clinical interaction, changes to sexual practice). Almost exclusive use of observational and qualitative designs limited inferences of causality and conclusions regarding clinical significance.

Strategies to Promote Social Connections Among Older Adults During “Social Distancing” Restrictions

Older age and medical comorbidity are factors associated with more severe illness and risk of death due to COVID-19 infection. Social distancing is an important public health strategy for controlling the spread of the virus and minimizing its impact on the older adult population. It comes at a cost, however. Loneliness is associated with myriad adverse health outcomes, one of which is impaired immune functioning, which adds even greater risk for coronavirus infection, complications and death. Older adults, therefore, are at compound risk, making effective management of loneliness and social isolation in our older patients a high priority target for preventive intervention. In this paper, the authors describe a cognitive-behavioral framework for social connectedness, including evidence-informed strategies clinicians can use to help patients develop a "Connections Plan" to stay connected and promote their social, mental, and physical health during "social distancing" restrictions. This set of strategies can be provided during brief (30 minute) telephone sessions and is analogous to creating a "Safety Plan" for suicide risk. The approach is illustrated with three case examples.

Mobile Apps for the Management of Comorbid Overweight/Obesity and Depression/Anxiety: A Systematic Review.

Objective This review aimed at searching for scientific literature on mobile apps for the management of comorbid overweight/obesity and depression/anxiety and providing a brief and comprehensive summary of their main features, targeted groups, and relevant results. Methods A bibliographical search was performed in Pubmed, PsycNet, Web of Science, ResearchGate, and Lilacs databases. The terms “obesity” and “overweight” were introduced in combination with “anxiety” and “depression” and “mobile app (application),” “smartphone app (application),” “android app (applicattion),” “iOS app (application),” “mobile health app (application),” and “mHealth app (application).” Results The initial search eliciting 204 citations was reduced to 7 relevant papers (4 original articles, 1 brief communication, and 2 study protocols). All publications were from the last five years, most were produced by research teams from the United States. All had adult samples, and interventions mostly followed a cognitive behavioral framework. Regarding mobile apps, five studies only used one to monitor weight and physical activity, one study to provide therapy to improve psychological wellness, and one study to monitor cognitions and emotions. No mobile app was found for the simultaneous management of overweight/obesity and depression/anxiety. Conclusions The prevalence and costs related to overweight/obesity and depression/anxiety are significant and likely to increase. Very often these conditions overlap; thus, it would be recommendable to treat their comorbidity simultaneously. Nevertheless, no mobile app has been designed for this purpose, which would help to reduce service provision costs and make treatment more easily accessible for patients.

The relations between YouTube addiction, social anxiety and parasocial relationships with YouTubers: A moderated-mediation model based on a cognitive-behavioral framework

YouTube is a popular video-sharing platform where viewers can watch videos made by media performers called YouTubers. YouTube is a social media site conducive to the development of parasocial relationships, which consists in asymmetrical relationships between media users and media performers. The aim of this study is to identify the determinants of YouTube addiction by examining the relationships between social anxiety, parasocial relationships with YouTubers and YouTube addiction based on a cognitive-behavioral theoretical framework. Data from 932 participants were collected through an online survey. Multiple regression analyses and structural equation modeling using a bootstrap procedure reveal that 1) social anxiety and 2) parasocial relationships with YouTubers are predictors of YouTube addiction, 3) social anxiety is a predictor of parasocial relationships, 4) social anxiety moderates the relation between parasocial relationships and YouTube addiction, 5) parasocial relationships mediate the relation between social anxiety and YouTube addiction and 6) social anxiety also moderates this mediated effect. The proposed moderated-mediation model of YouTube addiction fits well the data. The findings of this study contribute to the literature on the parasocial compensation hypothesis while providing useful information for prevention and intervention for YouTube addiction and social anxiety disorder.

Return-to-Player Percentage in Gaming Machines: Impact of Informative Materials on Player Understanding.

The addictive potential of electronic gaming machines (EGMs) is currently explained within a cognitive-behavioural framework. This framework explains that various erroneous cognitions regarding players' likelihood of winning contribute to persistent EGM gambling behaviour. Related to these cognitions is the pervasive misunderstanding among players regarding the operation of EGMs. However, little research has focussed specifically on player understanding of the theoretical proportion returned to players over the lifetime of a machine; return to player percentage. This study aimed to investigate the extent to which players understand the concept return to player percentage presented in different educative formats. A sample of 112 university students were randomly allocated to one of four conditions pertaining to a different mode of information delivery; infographic, vignette, brochure, or mandated legislation (control). Participants completed post-intervention measures to determine changes in knowledge. As predicted, participants exhibited a lack of understanding of the concept of return to player at baseline. However, contrary to predictions, exposure to any of the experimental conditions did not result in a greater understanding of return to player than controls. The study findings emphasise the difficulty individuals have in understanding complex concepts related to return to player percentages when presented in current formats and content. Treatment and responsible gambling policies need to adopt strategies to effectively improve knowledge of this aspect of the structural characteristics of gaming machines.

ACT vs CBT: an Exercise in Idiosyncratic Language

Since the development of acceptance and commitment therapy as a therapy model, there has been much debate about the similarities and differences between it and ‘second wave’ cognitive-behavioural practices (i.e. cognitive therapy, rational emotive behaviour therapy). This article builds on these discussions, discussing the underlying theoretical constructs relevant to the philosophy and practice of ACT and ‘second wave’ CBT models. Ultimately, this results in the conclusion that there are more similarities than differences between the two. Many of the espoused differences between them appear to be due to the implicit versus explicit attentional foci of the different models, and due to the development of idiosyncratic language by the different authors. As a result, it would appear that there is more to be gained by bringing these models together, to solidify the cognitive-behavioural framework and its application to therapy.

Cognitive, Behavioral, and Situational Influences on Relapse to Smoking After Group Treatment for Tobacco Dependence.

Socioeconomic disparities in treatment failure rates for evidence-based tobacco dependence treatment are well-established. Adapted cognitive behavioral treatments are extensively tailored to meet the needs of lower socioeconomic status (SES) smokers and dramatically improve early treatment success, but there is little understanding of why treatment failure occurs after a longer period of abstinence than with standard treatment, why early treatment success is not sustained, and why long-term treatment failure rates are no different from standard treatments. We sought to understand the causes of treatment failure from the perspective of diverse participants who relapsed after receiving standard or adapted treatment in a randomized control trial. We used a qualitative approach and a cognitive-behavioral framework to examine themes in responses to a semi-structured post-relapse telephone interview. The primary causes of relapse were familiar (i.e., habit, stress, unanticipated precipitating events). The adapted treatment appeared to improve the management of habits and stress short-term, but did not adequately prepare respondents for unanticipated events. Respondents reported that they would have benefited from continued support. New therapeutic targets might include innovative methods to reduce long-term treatment failure by delivering extended relapse prevention interventions to support early treatment success.Trial Registration: Clinicaltrials.gov NCT02785536.

Succumb to habit: Behavioral evidence for overreliance on habit learning in Internet addicts

Studies of Internet addiction (IA) under the cognitive-behavioral framework have suggested that IA derived from the excessive expectation of positive outcomes, which was a goal-directed behavioral progress. However, according to the dual-system account under the framework of associative learning theory, IA should be considered as a transition process from goal-directed to habit-based. It can be explained in terms of aberrant learning processes, where Internet addicts apparently succumb to habit with decreased sensitivity to reward devaluation. To test this hypothesis, we implemented an instrumental learning paradigm to investigate the difference of reliance on habit between Internet addicts and non-addicts. A total of 21 Internet addicts and 23 normal control subjects were trained in the first experimental phase and learned to associate stimuli with rewarding outcomes by pressing correct keys. In the subsequent outcome devaluation test and in the stimulus-response (S-R) habit test, subjects were required to adjust responses to changes in the value of current outcomes. Results revealed that (1) all subjects were able to gradually acquire the correct behavioral responses in the training phase, however, (2) extensive training rendered Internet addicts less sensitive to outcome devaluation in the outcome devaluation test, and (3) Internet addicts insisted on responding to previous stimuli in the S-R habit test, regardless of whether their responses were rewarded. Thus, we conclude that Internet addicts have an enhanced propensity to develop stimulus-driven habits and overly rely on it, leading to the failures to adjust behavior during goal reevaluation.

Psychosocial Interventions for Mental Illness among LGBTQIA Youth: A PRISMA-Based Systematic Review

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual (LGBTQIA) youth experience a unique range of psychosocial stressors often culminating in poor mental health outcomes. A systematic review of trials that evaluated psychosocial interventions for LGBTQIA youth aged 12–25 was undertaken to evaluate the effect of treatment components and participant-related variables on treatment outcome. The results suggest that creating safe, accepting places, discussion of shared experiences, and using a cognitive behavioural or attachment-based family therapy framework significantly decreased depression, sexual minority stress, anxiety and drug and alcohol use, and enhanced participant approval. LGBTQIA youth had poorer baseline mental health than non-LGBTQIA youth and experienced greater improvements. Further experimental research is needed to define effective treatment components and relevant individual factors to maximise treatment efficacy.

Identifying the "Therapy Targets" for Treating the Negative Symptoms of Psychosis Using Cognitive Behavioral Therapy.

The division of psychotic symptoms into positive and negative categories has largely divided the research on them. While the research on positive symptoms of psychosis has rapidly developed over the last three decades, the literature on negative symptoms has noticeably lagged behind. Negative symptoms have likely been ignored in the treatment literature because they were previously thought to remit following the treatment of positive symptoms. Recent evidence does not consistently support this theory and indicates that the different manifestations of negative symptoms require distinct approaches to treatment. The current review provides a re-evaluation of the theoretical literature on negative symptoms to inform and identify "treatment targets" to reduce them. The "treatment targets" are then translated into intervention strategies using a cognitive behavioral framework. A review of the empirical literature on cognitive behavior therapy for treating negative symptoms is then offered along with a critical discussion of where cognitive behavior therapy stands compared to other interventions and what research is still needed.

Towards a Cognitive-Behavioral Understanding of Assertiveness: Effects of Cognition and Distress on Different Expressions of Assertive Behavior

Assertiveness, as the ability to adequately express oneself while maintaining social gains, can be applied to various social contexts and concomitant social demands, but the cognitive and emotional correlates underlying assertive behaviour in diverse social events has not been considered. We tested a cognitive-behavioral framework for understanding the self-reported enactment of diverse types of assertive behaviours (i.e., displaying negative and positive feelings, expressing and managing personal limitations, and taking initiative), using a sample of 679 adolescents (mean age = 16.68, 261 boys) and a model generation approach to structural equation modelling. Cognition directly predicted lower distress and more frequent assertive behavior; also, cognition indirectly predicted assertive behavior through distress. Interpersonal management was the most salient cognitive theme predicting various types of assertive behaviors, alongside feeling less distressed when displaying negative feelings. Evidence was found for cognitive-behavioral theories being a valid approach to understanding assertiveness and sustaining insights for efficacious assertive training.

Imagery-Focused Cognitive Therapy (ImCT) for Mood Instability and Anxiety in a Small Sample of Patients with Bipolar Disorder: a Pilot Clinical Audit.

Despite the global impact of bipolar disorder (BD), treatment success is limited. Challenges include syndromal and subsyndromal mood instability, comorbid anxiety, and uncertainty around mechanisms to target. The Oxford Mood Action Psychology Programme (OxMAPP) offered a novel approach within a cognitive behavioural framework, via mental imagery-focused cognitive therapy (ImCT). This clinical audit evaluated referral rates, clinical outcomes and patient satisfaction with the OxMAPP service. Eleven outpatients with BD received ImCT in addition to standard psychiatric care. Mood data were collected weekly from 6 months pre-treatment to 6 months post-treatment via routine mood monitoring. Anxiety was measured weekly from start of treatment until 1 month post-treatment. Patient feedback was provided via questionnaire. Referral and treatment uptake rates indicated acceptability to referrers and patients. From pre- to post-treatment, there was (i) a significant reduction in the duration of depressive episode relapses, and (ii) a non-significant trend towards a reduction in the number of episodes, with small to medium effect size. There was a large effect size for the reduction in weekly anxiety symptoms from assessment to 1 month follow-up. Patient feedback indicated high levels of satisfaction with ImCT, and underscored the importance of the mental imagery focus. This clinical audit provides preliminary evidence that ImCT can help improve depressive and anxiety symptoms in BD as part of integrated clinical care, with high patient satisfaction and acceptability. Formal assessment designs are needed to further test the feasibility and efficacy of the new ImCT treatment on anxiety and mood instability.

Adult ADHD: Psychosocial Treatment Components andEfficacy Status

Psychosocial treatments for attention-deficit/hyperactivity disorder (ADHD) in adults and emerging adults have developed to address core symptoms of ADHD (hyperactivity, impulsivity, and inattention) and associated functional impairments. These psychosocial treatments have been developed to enhance the effect of medication treatments. Evidence-based psychosocial treatments teach patients skills in organization, time management, and planning by using a cognitive-behavioral framework. The latest version of these programs also teaches mindfulness skills, so patients learn to think critically before acting impulsively. Cognitive components to address maladaptive thoughts found in ADHD and associated patterns found in comorbid anxiety and depression facilitate mental health. Research indicates that these skill-based programs lead to significant changes including reductions in core symptoms, improved executive functioning, and reduced functional impairments. This article reviews the findings from meta-analyses and details treatment targets and treatment components contained in efficacious interventions. [ Psychiatr Ann. 2018;48(7):333–337.]

Learning to feel tired: A learning trajectory towards chronic fatigue

Chronic fatigue complaints are frequently reported in the general population and fatigue ranks among the most commonly reported symptoms in chronic disease. In contrast to its high prevalence and impact on quality of life, relatively little is understood about the etiology of chronic fatigue. We present a cognitive-behavioral framework, the ‘ALT+F’ model, that conceptualizes fatigue from an associative learning perspective, and we will evaluate the current evidence for this position. Central to this framework is the notion that interoceptive and exteroceptive stimuli can become associated with the fatigue experience. Consequently, these stimuli may acquire the capacity to elicit fatigue as well as anticipatory fear-related avoidance behavior. We will argue that associative learning processes may contribute to the development of chronic fatigue, fear of fatigue, avoidance of fatigue and activity, and eventually, functional disability. The extent to which associative learning processes give rise to chronic fatigue and fear-related avoidance behavior may depend on a number of risk factors, including perceptual-cognitive biases, sensitization, fatigue catastrophizing, and excessive generalization. The presented framework offers a new window on treatment and intervention options for chronic fatigue.

Addressing Weight Suppression to Improve Treatment Outcome for Bulimia Nervosa

Cognitive behavioral therapy (CBT) is regarded as the gold-standard treatment for bulimia nervosa (BN), yet despite impressive empirical support for its effectiveness, over 50% of patients fail to achieve abstinence from binge eating and purging by the end of treatment. One factor that may contribute to reduced efficacy rates in CBT is weight suppression (WS; the difference between a person's highest weight ever at their adult height and current weight). A growing body of research indicates that WS in patients with BN may have a clinically significant effect on symptomatology and prognosis. However, the current cognitive behavioral framework for BN does not explicitly acknowledge the role of WS in the onset or maintenance of BN symptoms and does not provide guidance for clinicians on how to address WS during treatment. The relationship between WS, biological pressure to regain lost weight, and the maintenance of BN symptoms suggest that current cognitive behavioral models of BN may be improved by considering the role of WS and exploring needed treatment modifications. Indeed, a reconceptualization of existing models may offer insight into potential strategies that can be used to reduce the susceptibility to treatment dropout, nonresponse, and relapse. It is therefore necessary to consider whether, and how, clinicians' consideration of WS during case conceptualization and treatment planning could serve to improve CBT outcomes. The current review explores ways in which high WS could contribute to poor CBT outcomes, provides preliminary clinical recommendations for incorporating WS into existing cognitive behavioral treatments based on extant data and clinical wisdom, and proposes suggestions for future research needed in this domain.