After reading the article complete the article matrix. identifying…

UltraOxideGuanaco28After reading the article complete the article matrix. identifying…After reading the article complete the article matrix.identifying major theories which underpin the studyDescribe the purpose of the study and identify the author(s) research questions and hypothesesDescribe how the research questions were studied (e.g. type of research, methods used)A summary of the results including statisticsAn analysis of the methods used, the results that were found including any limitations or improvements that could have been made on this studyOvercontrol is a transdiagnostic cluster of characteristics associated with excessive inhibitory control [1]. This cluster of interrelated characteristics includes: cognitive and behavioural inflexibility, supressed emotional expression, perfectionism, heightened performance monitoring, increased threat sensitivity, and reduced reward processing [1, 2]. This is typically coupled with a reduced sense of social connection and increased isolation irrespective of the size of one’s social circle or frequency of social contact [1, 3, 4]. Overcontrol has been associated with a range of psychiatric diagnoses, including refractory depression [1, 4], restrictive eating disorders [3, 5] and obsessive-compulsive personality disorder [1], as well as paediatric anxiety disorders [2]. Overcontrol is hypothesised to result from the interaction of neurobiological, environmental and learning factors [1]. It can be expressed discreetly, and difficulties are not always overtly obvious when interacting with others. People with this cluster of traits describe experiencing high levels of negative emotions, whilst displaying an outwardly inhibited or sometimes overly agreeable facade. This can make overcontrol difficult to identify and target in treatments [1]. While psychological treatments are not expected to result in temperamental change, typically considered neurobiological and genetically based [6], new treatments can aim to support individuals to understand, identify and manage temperamental factors in more adaptive ways. Given the high rates of comorbidity [7-9], relapse [10-13], and treatment nonresponse [9, 14, 15] for individuals with the aforementioned cluster of diagnoses, treatments that target underlying transdiagnostic mechanisms and reconceptualise treatment targets to the management of broader temperamental and personality factors may help to improve outcomes and reduce relapse rates. Radically Open Dialectical Behaviour Therapy (RO DBT) is a new transdiagnostic treatment that targets maladaptive overcontrol [3]. It is provided over approximately 8 months and consists of a combination of weekly skills classes (groups) and weekly individual sessions. Treatment primarily focuses on improving social connection via the change mechanisms of a) reducing physical arousal associated with threat sensitivity, b) more open and genuine emotional expression and c) improved social signalling [1, 16]. Social signalling refers to the intended and unintended cues people constantly display to others. RO DBT posits that improved social signalling leads to the development of closer and more genuine social connections, which then leads to improved symptom management and reduction of psychological distress. There is now evidence that RO DBT is effective for treating refractory depression [4, 17, 18] and preliminary evidence for the treatment of adult eating disorders [19-21]. Despite these promising findings with adults, RO DBT is yet to be empirically tested with adolescents beyond its use in a day program setting for adolescents with eating disorders [22]. RO DBT was introduced as a new transdiagnostic treatment in partnership between two National and Specialist Child and Adolescent Mental Health Services (N&S CAMHS) services; the Maudsley Centre for Child and Adolescent Eating Disorders (MCCAED) and the Dialectical Behaviour Therapy (DBT) Service at the Maudsley Hospital in London. RO DBT was piloted in its original form from 2015 to 2016. Feedback from adolescents who received RO DBT during this early pilot testing period resulted in modifications of the original RO DBT materials to make them more developmentally sensitive and appropriate for an adolescent population. Structurally the treatment was shortened from 30 (120 min) down to 20 (90 min) weekly skills classes provided alongside weekly individual sessions (60 min). Some of the original RO DBT skills were simplified, combined and/or the language was changed to be more adolescent appropriate. Similarly, examples in the RO DBT materials were modified to be more relevant and relatable to this age group. Lastly, images, video clips and new activities were introduced to improve engagement with the materials and concepts. The structure and timing of the weekly individual sessions remained unchanged. This case series aimed to assess whether the adolescent adaptation of Radically Open Dialectical Behaviour Therapy (RO-A) leads to improvements in overcontrol characteristics, relationship quality, and psychiatric symptoms of depression and eating disorders. The study also explored whether any changes were consistent with the theoretical model of change proposed by the RO DBT treatment model that improvements in overcontrol are associated with improvements in psychiatric symptoms. This article reports the findings for the initial phase of evaluation of RO-A. Method Participants Adolescents (13-18 years old at baseline) in this study were referred from either the DBT service or MCCAED at the Maudsley Hospital. This case series reports on consecutive referrals between June 2017 and February 2020, the period in which the new adolescent adapted RO-A treatment programme was being delivered. All adolescents were screened for overcontrolled personality traits using the Assessing Styles of Coping Word-pair Checklist (ASC-WP) [1] followed by clinical interview assessing overcontrol factors such as risk aversion, perfectionism, emotional expressiveness, social connectedness, and rigid and rule governed behaviour. Adolescents referred from the DBT service were all initially referred to standard DBT for treatment of repeated episodes of self-harm and low mood. If, during the initial assessment with the service, overcontrol was identified using the ASW-WP screening tool and clinical interview, RO-A was offered rather than standard DBT. All adolescents referred from MCCAED were screened for overcontrolled using the same procedure (ASC-WP screen and clinical interview) if, after receiving family therapy for eating disorder (FT-ED), they continued to experience high levels of eating disorder behaviours and cognitions that interfered with daily functioning despite partial or full weight restoration. Persisting difficulties included, ongoing significant distress at mealtimes, significant cognitive rigidity and rules around food and eating, and/or significant social and education disruption due to these factors (e.g., missing school, struggling to socialise). Exclusion criteria for this RO-A case series included psychosis, medical instability (see Junior MARSIPAN guidelines [23]), high psychiatric risk requiring inpatient treatment (e.g. imminent suicidal risk), emotional undercontrol and/or previous experience of RO DBT. No minimum weight was required for inclusion. See Fig. 1 for study flowchart. Treatment intervention and model Treatment in this study is an adolescent adaptation (RO-A) of the original RO DBT model described by Lynch [16]. See above for more details on the modifications made. These changes were based on early feedback from adolescents that treatment length was too long and that materials were too adult focused. RO-A includes 20 weekly 90-min skills class and a weekly 60-min individual session. Skills classes focus on teaching new skills to manage maladaptive overcontrol and includes mindfulness practice, homework provision and review. Skills classes consist of between two to eight individuals in treatment working together with one or two facilitators depending on the group size. The skills class focusses on teaching a range of skills designed to help adolescents express emotions more freely, engage in new novel behaviours, increase spontaneity and playfulness, live more flexibly, learn from feedback, strengthen social and community connectedness, and activate social safety systems. Individual sessions focus on applying these skills in the adolescent’s daily life, monitoring social signalling and overt overcontrolled behaviours, linking these with internal experiences and value-based goals. This includes the use of diary cards, in-session role plays and the use of chain analyses. See treatment manual for further details of treatment aims and structure [1, 16]. All adolescents were initially contracted to attend one full round of skills classes (n = 20) after which treatment was reviewed. Actual treatment length was based on individual goals and symptom presentation. Once adolescents had reached their identified value-based goals treatment ended, regardless of the number of individual or skills classes they had attended. Additional individual sessions and/or skills classes was offered if adolescents were actively working towards their value-based goals and using treatment effectively. Treatment objectives RO-A aims to reduce maladaptive overcontrol by targeting emotional expressiveness, cognitive flexibility, and social signalling. Improved social functioning and social signalling is hypothesised to lead to improved social connection, psychiatric symptom improvement and more global improvements in functioning. Therapists All therapists involved in this study were employed by either the N&S CAMHS DBT service or MCCAED. RO DBT therapists represented the mix of professions present in both multidisciplinary teams, including clinical and counselling psychology, psychiatry, family therapy and nursing. All therapists attended 10-days of intensive RO DBT training delivered by approved RO DBT trainers, and attended weekly to fortnightly RO DBT consult with bi-monthly external supervision by a RO DBT approved supervisor. Ethics approval and consent to participate This study was approved by the South London and Maudsley (SLaM) CAMHS Service Evaluation and Audit Committee. As this study constitutes service evaluation or audit, NHS Research Ethics Committee approval was not required. SLaM CAMHS service evaluation and audit approval allows for analysis and publication of anonymised data extracted from case files without written consent from participants or carers. Outcome measures were administered as part of routine clinical care. All methods were performed in accordance with the stipulated guidelines and regulations. Data collection and outcome measures Outcome in this case series was measured as changes in overcontrol characteristics, relationship quality and psychiatric symptoms of depression and eating disorders. A range of self-report questionnaires were included that were selected to identify temperament, personality and coping factors associated with overcontrol in adolescents, as well as relationship quality and attachment. Validated adolescent measures were not available for the full range of overcontrol related factors as this is an emerging field. Adult measures were used in their absence. Symptoms of depression were also assessed using self-report measures to explore the relationship between changes in overcontrol factors and changes in psychiatric symptoms. Eating disorder symptoms were also assessed for those who reported eating concerns at assessment. Outcome measures were collected by clinical staff as part of routine clinical care. Measures for screening and assessing overcontrol characteristics The Assessing Styles of Coping Word-pair Checklist (ASC-WP) [1] was used as the initial screen for overcontrol. This 47-item self-report screening tool requires participants to choose one word from a pair of words that best describes them. Word pairs include one word that is more representative of over- and the other of undercontrol. The ASC-WP has not been validated with young people but was included due to an absence of any validated screening tools for overcontrol at the time of data collection. The Emotion Regulation Questionnaire (ERQ) [24] is a validated 10-item self-report measure used to examine emotional regulation strategies via two subscales: cognitive reappraisal and the suppression of emotional expression. Cognitive reappraisal strategies refer to when someone changes their cognitions in order to change their emotional experience (example item: “when I want to feel less negative emotions [such as sadness or anger], I change what I’m thinking about”). The expressive suppression subscale assesses how much someone inhibits the behavioural expression of their emotions to regulate themselves (example item: “when I am feeling negative emotions, I make sure not to express them”). Cognitive reappraisal strategies are typically considered adaptive and associated with low psychological distress, whereas expressive suppression is considered less adaptive and associated with psychological distress and alexithymia [25]. The ERQ has demonstrated good reliability and validity [24], good internal consistency [25], and has been used with adolescents [26]. Internal consistency in the current study was good for the Reappraisal subscale (baseline a = .92; discharge a = .88), and moderate for the Suppression subscale (baseline a = .77; discharge a = .79). The Negative Temperament subscale of the Schedule of Non-adaptive and Adaptive Personality for Youth (SNAPY-Y) [27] was included to assess level of maladaptive negative temperament and its stability across treatment. The subscale measures tendencies towards irritability, distress, fear, anger and sadness. The SNAPY has shown to be a valid measure of personality in adolescence that demonstrates good internal consistency, structural validity [27], and has available clinical norms [27, 28]. Internal consistency was moderate to good in the current study (baseline a = .78, discharge a = .81). The Five Factor Obsessive Compulsive Inventory – Short Form (FFOCI) [29, 30] is a 48-item self-report assessment of risk aversion, cognitive flexibility, perfectionism, workaholism and punctiliousness. The FFOCI has not been validated for children and adolescents, but in the absence of a validated measure of obsessivecompulsive personality traits in children and adolescence, was included in this study. The FFOCI has demonstrated good discriminant validity and internal consistency with an undergraduate university sample [30]. Internal consistency was variable in the current study and ranged from good to poor depending on the subscale (Risk Aversion baseline a = .68, discharge a = .61; Inflexibility baseline a = .59, discharge a = .81; Punctiliousness baseline a = .77, discharge a = .72; Perfectionism baseline a = .60, discharge a = .74; Workaholism baseline a = .86, discharge a = .89). Reward processing was assessed using the Temporal Experience of Pleasure (TEPS) [31]. The 18-item selfreport measure assesses two aspects of trait-based reward processing based on Klein’s [32] model of anhedonia. Anticipatory pleasure (TEPS-ANT; “wanting”), the first subscale, examines the motivation for and expectation of pleasure and reward responsivity. The second subscale, consummatory pleasure (TEPS-CON; “liking”), measures the appreciation of positive stimuli and openness to different experience in the moment. Anticipatory, as opposed to the consummatory, aspects of reward processing have been associated with motivation, reinforcement learning and reward-based decision-making [33]. The TEPS has not been validated with adolescents but has demonstrated good convergent and divergent validity, internal consistency and testretest reliability in undergraduate university samples [31]. Internal consistency within the current study was moderate to good (TEPS-ANT baseline a = .90, discharge a = .82; TEPS-CON baseline a = .69, discharge a = .84). Measures assessing relationships quality The Withdrawal subscale of the Youth Self-Report questionnaire (YSR-W) [34] is an 8-item self-report measure examining the degree of perceived social withdrawal and isolation. The YSR is a valid, reliable and frequently used measure to assess a range of problems in adolescents [34]. Internal consistency was moderate to good in the current study (baseline a = .79, discharge a = .86). The Social Connectedness Scale (SCS-R) [35] is a 20- item self-report measure used to assess connectedness that an individual feels in their social environment. Low scores are indicative of low levels of social connection. This measure shows good internal consistency and validity with an adult sample [35], however has not been validated with adolescents. Internal consistency was high in the current study (baseline a = .92, discharge a = .91). The Attachment Styles Questionnaire (ASQ) [36] was used to define attachment characteristics and the quality of parental relationships. The ASQ consists of 40-items partitioned into five subscales including relationship confidence, need for approval, discomfort with closeness, pre-occupation and relationships as secondary. The ASQ has been shown to be valid and reliable, with good internal consistency [36-38] and has been used with adults and adolescents [39]. Internal consistency ranged from good to poor in the current study, depending on the subscale (Confidence baseline a = .79, discharge a = .83; Discomfort baseline a = .86, discharge a = .84; Preoccupation baseline a = .70, discharge a = .70; Relationships as Secondary baseline a = .75, discharge a = .59; Need for Approval baseline a = .77, discharge a = .73). Diagnostic assessment and measures of mental health symptoms All adolescents in this case series completed the Development and Wellbeing Assessment (DAWBA) at assessment. The DAWBA is a widely used structured diagnostic assessment that generates DSM-5 [40] and ICD-10 [41] psychiatric diagnoses for two to 17-year olds [42]. It has been shown to be a valid diagnostic tool [43] and may be more suitable than the widely used Eating Disorder Examination (EDE) diagnostic interview [44] for diagnosing adolescents with an eating disorder [45]. The Moods and Feelings Questionnaire (MFQ) [46] consists of 33-items used to screen for symptoms of depression in children and young adults. Scores of 27 and higher indicate the presence of depression [47, 48]. The MFQ was provided to all adolescents at baseline and discharge, regardless of symptom presentation. It has been shown to have good validity, reliability and internal consistency with adolescents [49]. Internal consistency was good in the current study (baseline a = .92, discharge a = .91). Incidence of self-harm was collected at baseline and discharge using a single-item questions. Adolescents self-reported whether or not they had engaged in any self-harm in the preceding 2 weeks. The Eating Disorder Examination Questionnaire (EDE-Q, v6) was completed at baseline and discharge by those who reported eating concerns at assessment (n = 23). The EDE-Q is a 28-item measure with a total (global) score made up by four subscales: restraint, eating concerns, shape concerns and weight concerns. It has good internal consistency [50] and has been used previously with clinical [51] and community adolescent samples [52]. Internal consistency was moderate to good, depending on the subscale (Global Score baseline a = .79, discharge a = .83; Dietary Restraint baseline a = .86, discharge a = .84; Eating Concerns baseline a = .70, discharge a = .70; Shape Concerns baseline a = .75, discharge a = .59; Weight Concerns baseline a = .77, discharge a = .73). Percentage of median Body Mass Index (%mBMI) adjusting for age and gender (BMI/median BMI for age and gender × 100) was also recorded to assess changes in physical health for those who reported eating concerns. This is the recommended method for children and adolescents with anorexia nervosa [23]. In this study, any young person under 90%mBMI was classified as underweight, and under 85%mBMI as significantly underweight. Statistical analysis The Shapiro-Wilkes test was used to test the distribution of the data. Paired t-tests were used for normally distributed data and Wilcoxon signed-rank test for nonnormally distributed data to compare differences between baseline and discharge data. Cohen’s d was used to measure effect sizes for the paired t-tests (> 0.3 = small; > 0.5 = medium; > 0.7 = large). Non-parametric data effect size was estimated using r (> 0.1 = small; > 0.3 = medium, > 0.5 = large). McNamar’s test was used to compare rates of self-harm (present/absent) in the 2 weeks preceding assessment and the 2 weeks preceding discharge. Effect size was estimated using Cramer’s V. Internal consistency for each measure and subscale was assessed using Cronbach’s alpha. Pearson’s r correlations were conducted to explore the relationship between changes in overcontrol related factors and changes in symptoms of depression and eating disorders from baseline to discharge. Due to the exploratory nature and sample size, significance testing was not conducted, rather 95% confidence intervals are reported. All statistical analyses were performed using SPSS version 26. To examine potential sampling bias in missing data at discharge, analyses were conducted to compare those who had paired data (completed assessment measures at both baseline and discharge) to those who did not across key demographic and clinical factors. Results showed that there were no differences between those with paired data compared to those without with regard to age, referral team (MCCAED or DBT service), primary diagnostic category (eating, mood or anxiety disorder diagnosis), severity of mood symptoms (MFQ at baseline) or the presence of self-harm. For the subgroup referred with eating concerns there was also no difference in weight (%mBMI) or severity of eating disorder psychopathology (EDEQ Global score) at baseline. Further analysis was conducted to examine difference in treatment characteristics. There was no difference between those with paired data and those without with regard to duration of treatment (in weeks), the number of skills classes attended, or the number of individual sessions attended. Results Group characteristics Twenty-eight adolescents who met the case series inclusion criteria were offered RO-A between June 2017 and February 2020. Sixteen (57.1%) were referred from MCCAED and 12 (42.9%) from DBT. Demographic information is presented in Table 1. The majority were female (92.9%) and identified as White British (71.4%). One identified as transgender. Rates of major depressive disorder and eating disorders were both high (MDD = 78.6%; ED = 78.6%) for the group as a whole. Twentythree adolescents reported eating concerns at assessment. Of these, 22 met DSM-5 criteria for an eating disorder diagnosis. All but one (n = 21/22, 95.2%) had an eating disorder primarily characterised by restrictive eating (anorexia nervosa and atypical anorexia nervosa). Mean weight at the start of RO-A for the young people diagnosed with an eating disorder was 94.65%mBMI (sd = 6.63, range = 83.20-109.00). Three young people were underweight (< 90%mBMI), and one was significantly underweight (< 85%mBMI). Comorbidity was the norm, with 85.7% meeting criteria for two or more DSM-5 psychiatric diagnoses. All adolescents (100.0%) had received at least one type of psychological treatment prior to attending RO-A. Fourteen young people (2/16 MCCAED referrals, 12/12 DBT referrals) had engaged in treatment with general CAMH S prior to RO-A. Mean duration of CAMHS treatment was 22.71 months (sd = 15.23, range = 3-54 months), andTable 1 Patient characteristics (N = 28) Age range in years (mean) 13-18 (16.1) Gender distribution (%) 26 females (92.9%), 2 males (7.1%) Ethnicity - White British 20 (71.4%) - Black British 1 (3.6%) - British Indian 2 (7.1%) - Other 5 (17.9%) DSM-V Diagnoses - Eating disorder 22 (78.6%) - Anorexia nervosa (AN) 12 (42.9%) - Atypical anorexia nervosa (AN-A) 9 (32.1%) - Bulimia nervosa (BN) 1 (3.6%) - Major Depressive Disorder 22 (78.6%) - Anxiety disorder (> 1 diagnosed) 19 (67.9%) – Generalised Anxiety Disorder 17 (60.7%) – Social Phobia 12 (42.9%) – Separation Anxiety 1 (3.6%) – PTSD 1 (3.6%) – Panic Disorder 2 (7.1%) – Specific Phobia 2 (7.1%) ? Agoraphobia 1 (3.6%) – OCD 2 (7.1%) – Autism Spectrum Disorder 1 (3.6%) Number of diagnoses – 1 diagnosis 4 (14.3%) – 2 diagnoses 8 (28.6%) – 3 diagnoses 8 (28.6%) – 4 or more diagnoses 8 (28.6%) Previous treatment – FT-ED 20 (71.4%) – Systemic family therapy 1 (3.6) – CBT 13 (46.4%) – DBT 1 (3.6%) – Inpatient treatment 8 (28.6%) – 2 or more previous treatments 7 (25.0%) – No previous treatment 0 (0%)mostly consisted of cognitive behaviour therapy (CBT). For those referred to RO-A from MCCAED, the mean duration of treatment was 9.94 months (sd = 6.49, range = 3-29). All had received eating disorder focussed family therapy (FT-ED) and four had also received adjunctive CBT. See Table 1 for further details. Treatment characteristics Twenty-four (85.7%) completed RO-A treatment, defined as a) reaching their value-based goals agreed at assessment and b) agreement between the young person and team about readiness. The mean number of skills classes attended was 18.42 (sd = 6.40, range = 9-34) and individual sessions was 20.82 (sd = 8.27, range = 8-42). Six young people (21.4%) attended more than 20 skills classes (one complete round), and two (7.1%) attended more than 25 skills classes. Attendance at skills class was high (mean DNA rate = 1.79, sd = 2.08, range = 0-7, median = 1.5). The mean treatment duration was 34.26 weeks (sd = 11.04, range = 15-62). Four people (14.3%) were identified as treatment non-completers. Of these, three attended three or fewer skills classes, and one dropped out of treatment after 10 skills classes and nine individual sessions due to weight loss and was referred to more intensive day programme treatment. Outcomes in Overcontrol characteristics Descriptive and inferential statistics for characteristics of overcontrol are presented in Table 2. Suppression of emotional expression (ERQ-Suppression, d = -.72), cognitive inflexibility (FFOCI-inflexibility, d = 1.63) and the anticipatory aspects of reward processing (TEPS-ANT, d = .79) improved significantly from baseline to discharge with large effect sizes. Temperamental tendencies towards irritability, distress, fear, anger and sadness (negative temperament) did not significantly change from baseline to discharge (SNAP-Y Neg. Temp, d = .22). Descriptive and inferential statistics for measures assessing relationship quality are presented in Table 3. There was a significant increase in social connectedness (SCS-R, d = 1.03) and significant reduction in perceived withdrawal (YSR-W, d = .97) from baseline to discharge, both with large effect size. Within attachment relationships, confidence (ASQ-Confidence, d = 1.10) significantly increased, whereas discomfort (ASQ-Discomfort, d = .85) and avoidance (ASQ-Relationships as Secondary, d = 1.14) significantly reduced from baseline to discharge, all with large effect size. The need for approval and preoccupation within attachment relationships did not significantly change. Outcomes in psychiatric symptoms Symptoms of depression (MFQ) reduced significantly from baseline (mean = 47.47, sd = 11.4) to discharge (mean = 36.76, sd = 17.38; p = .03) with large effect size (d = .71). Those with eating disorder concerns at baseline reported a significant reduction in eating disorder symptoms (EDE-Q Global Score) with large effect size (meanbaseline = 3.8, sd = 1.55; meandischarge = 2.64, sd = 1.48, p = .04, d = 1.06). A significant reduction was also observed on all subscales of the EDE-Q; namely Dietary Restraint (meanbaseline = 3.42, sd = 1.84; meandischarge = 1.86, sd = 1.32, p = .006, d = 1.13), Eating Concerns (meanbaseline = 3.76, sd = 1.42; meandischarge = 2.60, sd = 1.60, p = .02, d = .86), Shape Concerns (meanbaseline = 4.64, sd = 1.64; meandischarge = 3.52, sd = 1.88, p = .04, d = .75), and Weight Concerns (meanbaseline = 4.04, sd = 1.63; meandischarge = 2.74, sd = 1.93, p = .04, d = .78). Weight did not significantly change between baseline (mean = 94.65%mBMI, sd = 6.63, range = 83.20-109.00) and discharge (mean = 96.90%mBMI, sd = 7.86, range = 83.00-109.00, p = .21). Exploration of paired data revealed that one adolescent who was underweight at baseline lost weight (treatment non-completer), whereas the other two who were underweight at assessment were above 90%mBMI at discharge. All others maintained or slightly gained weight during RO-A. Incidence of self-harm significantly reduced from baseline to discharge (p = .001, V = .39). Eighteen (64.3%) participants reported self-harm at assessment. Of these, five continued to report self-harm at discharge. No participant commenced self-harm during treatment. Table 2 Overcontrol characteristics at baseline and discharge Outcome measure (n paired) Baseline Discharge Sig Effect size Parametric Mean (SD) Mean (SD) ERQ-Reappraisal (n = 14) 17.67 (8.60) 17.80 (6.92) p = .96 d = .01 ERQ-Suppression (n = 15) 20.69 (4.00) 17.19 (5.17) p = .01* d = .72 TEPS-ANT (n = 16) 24.59 (10.82) 32.71 (9.80) p = .005** d = .79 TEPS-CON (n = 17) 29.78 (7.34) 31.00 (9.02) p = .50 d = .16 FFOCI-Risk Aversion (n = 16) 14.47 (2.83) 11.35 (2.57) p < .001** d = 1.17 FFOCI-Inflexibility (n = 16) 13.82 (2.83) 10.65 (3.06) p < .001** d = 1.63 FFOCI-Punctiliousness (n = 15) 14.25 (2.90) 13.44 (3.61) P = .35 d = .24 SNAP-Y-Neg. Temp. (n = 16) 33.76 (3.82) 34.71 (4.82) P = .38 d = .22 Non-parametric Median (IQR) Median (IQR) FFOCI-Perfectionism (n = 17) 16 (13.5-16) 16 (14-16) p = .26 r = .19 FFOCI-Workaholism (n = 16) 14 (12.25-14) 12.5 (7.25-12.5) p = .14 r-.26attachment at baseline and discharge Outcome measure (n paired) Baseline Mean (SD) Discharge Mean (SD) Sig Effect size SCS-R (n = 16) 50.65 (11.51) 68.00 (15.05) p = .001** d = 1.03 YSR-W (n = 17) 12.17 (3.15) 8.50 (3.60) P = .001** d = .97 ASQ-Confidence (n = 17) 16.06 (4.78) 22.17 (6.36) p < .001** d = 1.10 ASQ-Discomfort (n = 17) 52.28 (5.77) 48.06 (6.92) p = .002** d = .85 ASQ-Preoccupation (n = 17) 33.61 (5.26) 35.78 (5.63) p = .17 d = .34 ASQ-Relat. as Second. (n = 16) 23.18 (5.32) 16.82 (4.19) p < .001** d = 1.14 ASQ-Need for Approval (n = 17) 36.67 (4.34) 35.39 (4.05) p = .21 d = .31Correlation analysis See Table 4 for exploratory correlation analysis exploring the relationship between changes in overcontrol factors and changes in symptoms of depression and eating disorders. A reduction in symptoms of depression was strongly correlated with changes in the anticipatory aspects of reward processing (TEPS-ANT, r = -.66). Medium correlations were observed between changes in depression symptoms and changes in the suppression of emotional expression (ERQ-Suppression, r = .43) and cognitive reappraisal (ERQ-Reappraisal, r = -.45) aspects of emotion regulation. Changes in depressive symptoms were only weakly correlated with changes in level of risk aversion (FFOCI-Risk Aversion, r = .23). A reduction in symptoms of depression correlated strongly with increased social connectedness (SCS-R, r = -.57) and reduced social withdrawal (YSR-W, r = .69). Within attachment relationships, a reduction in symptoms of depression from baseline to discharge was strongly correlated with increased confidence (ASQ-Confidence, r = -.49), reduced discomfort (ASQ-Discomfort, r = .74), reduced preoccupation (ASQ-Preoccupation, r = .48) and reduced need for approval (ASQ-Need for approval, r = .68). Table 3 Relationship quality and attachment at baseline and discharge Outcome measure (n paired) Baseline Mean (SD) Discharge Mean (SD) Sig Effect size SCS-R (n = 16) 50.65 (11.51) 68.00 (15.05) p = .001** d = 1.03 YSR-W (n = 17) 12.17 (3.15) 8.50 (3.60) P = .001** d = .97 ASQ-Confidence (n = 17) 16.06 (4.78) 22.17 (6.36) p < .001** d = 1.10 ASQ-Discomfort (n = 17) 52.28 (5.77) 48.06 (6.92) p = .002** d = .85 ASQ-Preoccupation (n = 17) 33.61 (5.26) 35.78 (5.63) p = .17 d = .34 ASQ-Relat. as Second. (n = 16) 23.18 (5.32) 16.82 (4.19) p < .001** d = 1.14 ASQ-Need for Approval (n = 17) 36.67 (4.34) 35.39 (4.05) p = .21 d = .31 * = significant at p < 0.05 level; ** = significance at p < 0.01 level Abbreviations: SCS-R Social Connectedness Scale-Revised, YSR-W Youth Self Report-Withdrawal subscale, ASQ Attachment Style Questionnaire Table 4 Correlation analysis ex