Compulsive Eating Research Articles

Eating Compulsivity in Inpatients with Severe Obesity and the General Population: The Italian Version of the Measure of Eating Compulsivity (MEC10-IT)

This study aimed to validate and investigate the psychometric properties of the Italian version of the Measure of Eating Compulsivity-10 (MEC10-IT) in a sample of inpatients with severe obesity (Study 1), and to test the measurement invariance of the measure across non-clinical and clinical samples (Study 2). In the first study, a confirmatory factorial analysis (CFA) was conducted among 452 patients in order to confirm the factorial structure of the MEC10-IT. In the second study, the psychometric properties of the MEC10-IT were tested on 453 inpatients with severe obesity and a community sample of 311 participants. The CFA confirmed the factorial structure of the MEC10-IT among an Italian sample of adult inpatients with severe obesity (Study 1). The MEC10-IT was also demonstrated to be invariant between the clinical and the community sample and to possess good psychometric properties, as well as excellent screening abilities for classifying individuals with problematic eating behaviors (Study 2). In conclusion, the MEC10-IT could be considered as a valid and reliable tool for the assessment of compulsive eating in both non-clinical and clinical samples and represents a psychometrically sound measure for clinical and research purposes.

Pica: recognizing the presentation in primary dental care

Pica is an eating disorder characterized by compulsive eating of non-food items. It can present to dentists through patient medical histories, and also through causing atypical patterns of non-carious tooth surface loss. In highlighting two cases of pica presenting in general practice, we aim to raise awareness of this condition and its dental implications. CPD/Clinical Relevance: This article advises on how pica may present to a general dentist and gives advice on management.

ARIPIPRAZOLE INDUCED COMPULSIVE EATING DISORDER: A CASE REPORT

IntroductionAripiprazole is a newer atypical antipsychotic with a favorable side-effect profile, especially a low propensity to result in metabolic syndromes.It is effective at treating bipolar disorder, the positive symptoms of schizophrenia and has the potential to treat negative and cognitive symptoms.However, prior studies suggested that aripiprazole seem to be associated to a risk of inducing certain impulse control behaviors, such as uncontrollable gambling, hyper sexuality, as well as compulsive eating.ObjectivesWe proposed to assess the evidence for compulsive eating associated with the use of aripiprazole.MethodsWe report a rare case of new onset aripiprazole induced compulsive eating behavior in a patient with bipolar disorder. Then, we conducted a literature review using“PubMed” database and keywords “Aripiprazole”, “Impulse Control Behaviors”, “Compulsive Eating”.ResultsHe was a 21-year-old patient, diagnosed with bipolar 1 disorder. He was prescribed Aripiprazole, after a neuroleptic malignant syndrome induced by haloperidol (which was prescribed during the first episode psychosis).One month following the treatment initiation, the patient complained of eating excessively. He was not able to control his eating and gained 30 Kg over the period of 4 months. Metabolic assessment showed a hypercholesterolemia.ConclusionsAripiprazole is a promising novel antipsychotic in mental diseases. However current evidence associates compulsive behaviors like eating with the use of Aripiprazole, probably due to the drug affinity to 5-HT receptors. More studies are needed to confirm this rare side effect.Disclosure of InterestNone Declared

Pica in an Urban Environment

The practice of pica, the compulsive ingestion of nonfood substances over a sustained period of time, was studied in 553 African American women who were admitted to prenatal clinics in Washington, D.C. Dietary, biochemical, and psychosocial correlates of the pica practices of a subset of this urban population are presented in this paper. Geophagia, compulsive eating of clay or dirt, was not observed in these women; pagophagia, or the ingestion of large quantities of ice and freezer frost, was self reported in 8.1% of the women, who consumed 1/2 to 2 cups a day from 1 to 7 days per week. Serum ferritin concentrations of pica women were significantly lower during the second and third trimesters of pregnancy; the average values for three trimesters of pregnancy for both ferritin and mean corpuscular hemoglobin were significantly lower in pica women than their nonpica counterparts (P = 0.0001 and P = 0.017, respectively). Although not significantly different, the iron (66 vs. 84% RDA) and calcium (60 vs. 75% RDA) contents of the diets of pica women were less those of nonpica women. Gestational age, body length, and body weight were not different, but head circumferences of infants delivered to pica women who consumed freezer frost and/or ice were smaller than those of nonpica women (P = 0.012). The hypothesis is presented that pica in African American women may be a mediator of stress, acting through the immune system. The size of the social support network of pica women was significantly less than that of nonpica women.(ABSTRACT TRUNCATED AT 250 WORDS)

The risks of misclassifying addictive food substances as non-addictive.

The risks of misclassifying addictive food substances as non-addictive.

Prader-Willi syndrome: Symptoms and topiramate response in light of genetics.

Prader-Willi Syndrome (PWS) is a rare genetic condition, which affects one in 25,000 births and results in various phenotypes. It leads to a wide range of metabolic and endocrine disorders including growth delay, hypogonadism, narcolepsy, lack of satiety and compulsive eating, associated with mild to moderate cognitive impairment. Prognosis is especially determined by the complications of obesity (diabetes, cardiorespiratory diseases) and by severe behavioral disorders marked by impulsivity and compulsion. This heterogeneous clinical picture may lead to mis- or delayed diagnosis of comorbidities. Moreover, when diagnosis is made, treatment remains limited, with high interindividual differences in drug response. This may be due to the underlying genetic variability of the syndrome, which can involve several different genetic mutations, notably deletion or uniparental disomy (UPD) in a region of chromosome 15. Here, we propose to determine whether subjects with PWS differ for clinical phenotype and treatment response depending on the underlying genetic anomaly. We retrospectively included all 24 PWS patients who were referred to the Reference Center for Rare Psychiatric Disorders (GHU Paris Psychiatrie and Neurosciences) between November 2018 and July 2022, with either deletion (N = 8) or disomy (N = 16). The following socio-demographic and clinical characteristics were recorded: age, sex, psychiatric and non-psychiatric symptoms, the type of genetic defect, medication and treatment response to topiramate, which was evaluated in terms of eating compulsions and impulsive behaviors. We compared topiramate treatment doses and responses between PWS with deletion and those with disomy. Non-parametric tests were used with random permutations for p-value and bootstrap 95% confidence interval computations. First, we found that disomy was associated with a more severe clinical phenotype than deletion. Second, we observed that topiramate was less effective and less tolerated in disomy, compared to deletion. These results suggest that a pharmacogenomic-based approach may be relevant for the treatment of compulsions in PWS, thus highlighting the importance of personalized medicine for such complex heterogeneous disorders.

ASSOCIATION BETWEEN STRESS, EATING BEHAVIOUR AND THE RISK OF CARDIOVASCULAR DISEASES AMONG UNIVERSITY EMPLOYEES

Objective: The present study aimed to investigate the possible relationship between stress, eating behaviors and risk of cardiovascular diseases in employees of University, in western India.
 Method: 123 employees, aged between 20 to 60 years were randomly selected from the various departments of university. A cardiovascular risk assessment tool was developed to assess the cardiovascular risk in the participants. For the assessment of compulsive eating, Compulsive eating scale (CES) was used and to assess the level of psychological stress among study participants Stressful Situations Questionnaire (SSQ) was used. Anthropometric and biophysical measurements of the participants were also recorded.
 Results: 63% respondents had high stress, whereas compulsive eating was present in 56.9% respondents. Cardio vascular disease risk was associated with psychological stress (r = 0.214 and significance =0.01) and eating behaviors. (r =0.196 and significance = 0.030). Stress and eating behavior were also positively correlated with each other. (r =0.756 and significance = 0.000). Cardiovascular diseases was found to be significantly related with eating behaviors, psychological stress, BMI, waist hip ratio, age and high blood pressure (P<0.05).
 Conclusion: The present study demonstrates that the level of psychological stress and compulsive eating is high among university employees and that increases their risk for CVD. Obese employees tend to be in stressful situation that leads to compulsive eating.

Impulse-Control Disorders and Restless Leg Syndrome in Parkinson's Disease: Association or Coexistence.

Both Impulse-control disorders and related behaviours (ICD-RB) and restless leg syndrome (RLS) are relatively common in patients with Parkinson's disease, but little is known are they related or independent complications of dopaminergic therapy. The aim of this study was to determine the correlation between ICD-RBs and RLS and also, to determine the associated significant psycho-behavioural profile of RLS patients in presence of ICD-RBs. PD who visited neurology OPD were screened for the presence of addictive behaviors, alcohol and substance abuse, ICDs including Impulse control disorders not elsewhere classified with the help of a QUIP questionnaire. RLS was evaluated by diagnostic criteria set by the International RLS study group. To evaluate the association of RLS and ICDs, cohort was divided into groups of patients who had both ICD and RLS, ICD with no RLS, RLS with no ICD and no ICD or RLS. Among 122 PD patients who visited OPD, 95 eligible were included in the study. Out of these 95 patients, 51 (53.6%) had at least one ICD-RB and 18 (18.9%) had RLS. ICD-RB in decreasing order of frequency were compulsive medication (47.4%), compulsive eating (29.4%), compulsive buying (17.6%), gambling (11.7%), hypersexuality (3.9%), and others (29.8%). Among 18 patients with RLS, 12 (66.7%) were associated with at least one ICD-RB. The compulsive behaviours significantly associated with PD-RLS group were gambling (27.8%), followed by compulsive eating (44.2%). While comparing disease characteristics, PD-ICD/RLS patients had statistically significant disease duration (p 0.007) and higher LEDD (p 0.004). Other demographic and socioeconomic features did not reveal any differences between the groups. 11% of PwPD can have co-occurrence of RLS and ICD-RBs. Circadian fluctuation in levels of dopamine release on the background of hyper-dopaminergic state produces waves of crest and trough, which may be possible for this behavioral profile. Long-term dopaminergic treatment or degenerative process itself may be the cause leading to emergence of both RLS and ICD-RBs in PD patients.

Sugar Beverage Habitation Relieves Chronic Stress-Induced Anxiety-like Behavior but Elicits Compulsive Eating Phenotype via vLSGAD2 Neurons.

Chronically stressed individuals are reported to overconsume tasty, palatable foods like sucrose to blunt the psychological and physiological impacts of stress. Negative consequences of high-sugar intake on feeding behavior include increased metabolic disease burdens like obesity. However, the neural basis underlying long-term high-sugar intake-induced overeating during stress is not fully understood. To investigate this question, we used the two-bottle sucrose choice paradigm in mice exposed to chronic unpredictable mild stressors (CUMS) that mimic those of daily life stressors. After 21 days of CUMS paralleled by consecutive sucrose drinking, we explored anxiety-like behavior using the elevated plus maze and open field tests. The normal water-drinking stressed mice displayed more anxiety than the sucrose-drinking stressed mice. Although sucrose-drinking displayed anxiolytic effects, the sucrose-drinking mice exhibited binge eating (chow) and a compulsive eating phenotype. The sucrose-drinking mice also showed a significant body-weight gain compared to the water-drinking control mice during stress. We further found that c-Fos expression was significantly increased in the ventral part of the lateral septum (vLS) of the sucrose-treated stressed mice after compulsive eating. Pharmacogenetic activation of the vLS glutamate decarboxylase 2(GAD2) neurons maintained plain chow intake but induced a compulsive eating phenotype in the naïve GAD2-Cre mice when mice feeding was challenged by flash stimulus, mimicking the negative consequences of excessive sucrose drinking during chronic stress. Further, pharmacogenetic activation of the vLSGAD2 neurons aggravated anxiety of the stressed GAD2-Cre mice but did not alter the basal anxiety level of the naïve ones. These findings indicate the GABAergic neurons within the vLS may be a potential intervention target for anxiety comorbid eating disorders during stress.

Pica Syndrome Revealing Celiac Disease: A Case Report

Celiac disease is an autoimmune mediated chronic inflammatory enteropathy primarily affecting the small intestine, occurring in genetically predisposed individuals and caused by a permanent sensitivity to ingest gluten cereals. Pica is the compulsive eating of nonnutritive substances, and may be either a cause or a result of iron deficiency, with the latter being a possible presenting sign of Celiac Disease. We report the case of an 18-year-old female patient with history of depression and pica disorder. Laboratory investigations, serology testing and duodenal biopsy showed arguments of celiac disease with spectacular improvement noted after initiating the gluten free diet.

The risk of exercise addiction mediates the relationship between social media use and mental health indices among young Iranians

Exposure to social media can motivate some individuals’ desire to be thinner and to attain an ideal body shape. This may also motivate a minority of individuals to engage in extreme exercise. Moreover, both problematic social media use and problematic exercise can have detrimental effects on mental health. A community sample of Iranian adolescents (n = 562; mean age = 14.95 years [SD ± 1.70]; 62.5% female) and young adults (n = 745; mean age = 26.19 years [SD ± 7.42]; 60.5% female) participated in an online survey designed to evaluate the mediating role of exercise addiction in the relationship between problematic social media use and mental health consequences. Results indicated that 2.7% of adolescents and 4.4% of young adults were at risk for exercise addiction. After controlling for age, gender, body mass index (BMI), and educational attainment level, the results indicated that problematic social media use significantly predicted exercise addiction. Among both adolescents and adults, exercise addiction significantly mediated the association between problematic social media use and mental health consequences including psychological distress (β s = 0.06–0.12), insomnia (β s = 0.07–0.09), body image concern (β s = 0.19–0.10), and compulsive eating (β s = 0.06–0.07). Given that exercise addiction mediated the relationship between problematic social media use and mental health consequences, it is recommended that public health campaigns are needed for Iranian adolescents and young adults to raise their awareness about the potentially detrimental health consequences in relation to problematic social media use and exercise addiction. The findings suggest a need for an additional cross-cultural study examining the effect of social media on exercise addiction, in order to gain a more comprehensive understanding to help in terms of prevention and intervention for adolescents and emerging adults both in and outside of Iran.

Habitual behaviour associated with exposure to high-calorie diet is prevented by an orexin-receptor-1 antagonist

Habitual actions, which are associated with addictive behaviours, contribute to the loss of control of food seeking seen following exposure to calorie-dense foods in rats. Antagonism of orexin-receptor-1 (ORX-R1) has been shown to reduce a range of stimulus-driven feeding behaviours, but have yet to be implicated in the regulation of habitual actions. In the current study, male Long-Evans rats were given ‘binge-like’ access to high-calorie diet (HCD) or standard chow diet, and were subsequently trained to press a lever for food outcome. When lever responses were tested following outcome devaluation, chow-fed rats displayed goal-directed actions, whereas HCD-exposed rats displayed habitual actions. In study 1, it was shown that systemic administration of the ORX-R1 antagonist, SB-334867, prior to test restored goal-directed behaviour in HCD-exposed rats. In study 2, intra-nigral administration of SB-334867 similarly restored goal-directed behaviour, thereby implicating the substantia nigra as an important site for this effect. This study demonstrates that targeting ORX-R1 reduces habitual food seeking in male rats which may be important for understanding and treating compulsive feeding, obesity and binge eating disorder. This study also implicates the lateral hypothalamus, where ORX is produced, in mediating the expression of habits for the first time, and thus extends on the neurocircuits known to regulate habitual actions. Further investigation is required to determine whether the same effects are also seen in female rats, given that there are recognised sexual dimorphisms in feeding behaviour and a higher incidence of disordered eating in female than male populations.

Online vs Face-to-Face Administration of Impulse Control Disorder Questionnaires in Parkinson Disease: Does Method Matter?

Social desirability bias, the tendency to underreport undesirable behaviors, may be one reason patients with Parkinson disease (PD) underreport symptoms of impulse control disorders (ICDs). We compared rates of ICD endorsement on questionnaires administered face-to-face and online in 60 patients with mild-to-moderate idiopathic PD. Participants also completed a self-report measure of social desirability. We found a significantly higher prevalence of any ICD based on online (56.7%) vs in-person (33.3%) administration. Significantly higher endorsement of items related to hypersexuality in men and compulsive eating and buying in women were found with online administration. Social desirability bias was positively correlated with ICD symptom endorsement across all items and subscales. The results highlight the importance of social context/setting and the need for sensitivity and discretion when screening for ICD symptoms. Although a higher level of symptom endorsement does not necessarily imply a greater level of accuracy, more work is needed to determine which method of administration is most accurate for clinical and research practice.

Rapid Eye Movement Sleep Behavior Disorder in Parkinson's Disease: A Survey-Based Study.

To characterize Parkinson's disease (PD) symptoms based on the presence, onset time, and severity of rapid eye movement sleep behavior disorder (RBD) and their association with impulse control disorders (ICD). RBD is a frequent non-motor symptom in PD, usually described as prodromal. The severity of RBD according to the start time and its relationship with ICD in PD needs further clarification. A survey-based study was performed to determine the presence of RBD symptoms, their severity, and the temporal relationship with the PD onset. The survey included RBD1Q, the Mayo Sleep, and the RBDQ-HK questionnaires and questions about clinical characteristics, including ICD. Only PD patients with care partners spending night hours in the same room were included. 410 PD patients were included: 206 with RBD (50.2%) and 204 non-RBD (49.8%). The PD-RBD patients were younger and their daily levodopa dose was higher than the non-RBD group. Most of these patients developed RBD symptoms after the onset of clinical PD were younger at motor symptom onset and had higher scores in the hallucinations and psychosis subsection of MDS-UPDRS-I. RBD group had a more severe non-motor phenotype, including more ICD than those without RBD, mainly due to higher compulsive eating. In our study, most patients recognized RBD symptoms after the onset of the PD motor symptoms and the clinical features of PD with and without RBD were distinctive, supporting the hypothesis that PD-RBD might represent a variant pattern of neurodegeneration.

Altered Food Behavior and Cancer: A Systematic Review of the Literature.

There is evidence of an association between cancer and certain types of altered eating behaviors, including orthorexia, food cravings, and food addiction. Given the growing interest in the topic throughout the scientific community we conducted a systematic review to summarize current evidence on the development of altered food behavior, including food addiction and cancer. The Cochrane Collaboration and the Meta-analysis Of Observational Studies in Epidemiology guidelines were followed to perform this systematic review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to report the process and results. The structured literature search was conducted on 19 April 2022, on PubMed/Medline and Scopus, combining free-text terms and medical subject headings. A total of seven articles were included once the selection process was completed. Food craving has been associated with different types of cancer in adults and young patients, as well as with orthorexia; conversely, compulsive eating has only been explored in patients with prolactinoma treated with dopamine agonists. This systematic review explored a new area of research that warrants further investigation. More research is required to better understand the relationship between cancer and food behavior.

Treating Patients with Aripiprazol: A Safe Gamble?

IntroductionAripiprazole (ARI) is an atypical antipsychotic drug with D2 partial agonist properties, usually prescribed to treat mood disorders (major depression or bipolar disorder) and schizophrenic disorder (schizophrenia or schizoaffective disorder). Dopamine receptor agonists, as is ARI, have been implicated in some cases of impulse-control problems, such as gambling disorder (GD), increased spending, hypersexuality and compulsive eating.ObjectivesCurrently, it is hypothesized that aripiprazole may cause impulse-control problems because it can produce a hyperdopaminergic state in the mesolimbic pathway (reward system) through its predominant action on dopamine D3 receptors. We intend to do a non-systematic review of the scientific information regarding this subject.MethodsThe authors revised the published literature about this topic, selecting relevant articles, systematic reviews and case reports, with the topic words: “aripiprazol”, “gambling disorder” and “dopamine receptor” in scientific data base.ResultsOverall, a few cases of ARI-induced pathological gambling as well as ARI-induced hypersexuality have been reported. In one study it was verified that comorbid psychiatric and substance use disorders were common among those who have experienced GD or worsened GD after beginning ARI treatment. In another study, it was verified that the group of patients who reported this alleged side-effect were mostly young (mean age, 33.6 years), mostly men (88.2%) and most lived alone.ConclusionsAttributing to dopamine agonists the only factor that can explain the onset of GD is simplistic and dangerous. Many other potential risk factors, including individual vulnerability factors (temperament, genetics) as well as environmental factors, must be considered.DisclosureNo significant relationships.

Aripiprazol and Hypersexuality: when partial is to much

IntroductionA growing number of published cases has showed that hypersexual behavior may arise with treatment with second-generation antipsychotics, including aripiprazole and olanzapine. Aripiprazole is a second-generation antipsychotic commonly used to treat schizophrenia and bipolar disorder. It has a unique pharmacologic profile acting as a partial agonist of the dopamine D2 receptor, as a partial agonist at the 5-HT1A receptor, and as an antagonist at the 5-HT2A receptor. Literature shows that medication with partial dopaminergic agonistic activity can cause compulsive behaviors, such as pathological gambling, compulsive eating, compulsive shopping, and hypersexuality. Although it is difficult to predict who would develop these behaviors, the literature suggests that patients at a higher risk of developing impulsive behaviors include those with a personal or family history of obsessive-compulsive disorder, impulse control disorder, bipolar disorder, impulsive personality, alcoholism, drug abuse, or other addictive behaviors.ObjectivesHere, we present a case of a 32-year-old male who developed hypersexuality symptoms after receiving aripiprazole as treatment for bipolar disorder.MethodsWe have done a literature review using the MeSH terms Aripiprazole and hypersexuality in the “PubMed”.ResultsAfter switching Aripiprazole to Risperidone the hypersexuality symptoms started to decrease and got almost complete relief after 2 weeks.ConclusionsThis case highlights the rare hypersexuality side effect that can arise in patients receiving aripiprazole for bipolar disorder treatment. Clinicians should be aware of the increased risk of hypersexuality and other impulsive behaviors as they can significantly impair a patient’s daily functioning.DisclosureNo significant relationships.

Habenular nuclei linked with compulsion in alcoholism and obesity / Núcleos habenulares estão relacionados com compulsão no alcoolismo e obesidade

Alcoholism, also known as "alcohol dependence syndrome", is a disease that develops after repeated use of alcohol, typically associated with binge eating. Obesity is the result of a combination of genetic and environmental factors. Compulsive eating is not caused by hunger or pleasure, but as a defense mechanism that prevents feelings of loneliness, failure and abandonment. The aim of the present research, of bibliographic nature, will be to discuss the relation of the habenula with the mechanism of compulsion for the consumption of alcohol and food. As a methodology, searches will be carried out in databases, in the last 10 years, in Pubmed. The descriptors "habenula", "obesity", "alcoholism" and "compulsion" will be used in articles written in English, French and Spanish. Seeking to relate the neural pathways of the habenula, with disorders triggered by excessive alcohol consumption and eating disorders, concerning the anatomical and functional aspects and the pathways of dependence. To this end, the authors propose to understand this relationship from a neurological perspective, with an emphasis on mental health, encompassing a neurobiological and social view. It is expected, with this research, to collaborate with the development of a new alternative regarding the treatment of these diseases, considering the habenula as a reference. It is hoped, with this research, to collaborate with the development of a new alternative regarding the treatment of the complication, considering the habenula as a reference, in order to promote an improvement in the quality of life and health promotion of these patients. It is hoped, with this research, to collaborate with the development of a new alternative regarding the treatment of the complication, considering the habenula as a reference, in order to promote an improvement in the quality of life and health promotion of these patients.

Decreased excitability of leptin-sensitive anterior insula pyramidal neurons in a rat model of compulsive food demand

Compulsive eating is an overlapping construct with binge eating that shares many characteristics with substance use disorders. Compulsive eating may impact millions of Americans; presenting in some cases of binge eating disorders, overweight/obesity, and among individuals who have not yet been diagnosed with a recognized eating disorder. To study the behavioral and neurobiological underpinnings of compulsive eating, we employ a published rodent model using cyclic intermittent access to a palatable diet to develop a self-imposed binge-withdrawal cycle. Here, we further validated this model of compulsive eating in female Wistar rats, through the lens of behavioral economic analyses and observed heightened demand intensity, inelasticity and essential value as well as increased food-seeking during extinction. Using electrophysiological recordings in the anterior insular cortex, a region previously implicated in modulating compulsive-like eating in intermittent access models, we observed functional adaptations of pyramidal neurons. Within the same neurons, application of leptin led to further functional adaptations, suggesting a previously understudied, extrahypothalamic role of leptin in modulating feeding-related cortical circuits. Collectively, the findings suggest that leptin may modulate food-related motivation or decision-making via a plastic cortical circuit that is influenced by intermittent access to a preferred diet. These findings warrant further study of whether behavioral economics analysis of compulsive eating can impact disordered eating outcomes in humans and of the translational relevance of a leptin-sensitive anterior insular circuit implicated in these behaviors.

Contributions of discussion groups in the therapeutic education of bulimic disorders

Thetreatment of patients suffering from bulimic disorders requires a multidisciplinary approach combining a somatic approach and a psychiatric approach. The Maison des adolescents of the Cochin Hospital offers a therapeutic education program focused on the management of compulsive binge eating. Its modalities have been modified over the years in order to better adjust to the needs of these patients. Monthly discussion groups have been added to the individual interviews, and have been key points in structuring the treatment.