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Medicine 2.0'12 Boston (Full Paper of Conference Presentation) Virtual Worlds
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Original Paper
Virtual Reality for Enhancing the Cognitive Behavioral Treatment of Obesity With Binge Eating Disorder: Randomized Controlled Study With One-Year Follow-up
Gian Luca Cesa1,2, MSc, PsyD; Gian Mauro Manzoni3,4, PsyD, PhD (Psych); Monica Bacchetta1, PsyD, PhD (Psych); Gianluca Castelnuovo3,4, PsyD, PhD (Psych); Sara Conti1, MSc, PsyD; Andrea Gaggioli1,4, MSc, PhD (Psych); Fabrizia Mantovani5, MSc, PhD (Psych); Enrico Molinari3,4, MSc, PsyD; Georgina Cárdenas-López6, PhD; Giuseppe Riva1,4, MSc, PhD (Psych)
1Applied Technology for Neuro Psychology Lab, Istituto Auxologico Italiano, Verbania, Italy
2Centro Obesità e Nutrizione Clinica (CONC), Ospedale Privato Accreditato Villa Igea, Forlì (FC), Italy
3Psychology Research Laboratory, Ospedale San Giuseppe, Istituto Auxologico Italiano, Verbania, Italy
4Department of Psychology, Catholic University of Sacred Heart, Milan, Italy
5CESCOM-Centre for Research in Communication Sciences, University of Milan-Bicocca, Milan, Italy
6Laboratorio de Enseñanza Virtual y Ciberpsicología, Facultad de Psicología, Universidad Nacional Autónoma de México, México, Mexico
Psychology Research Laboratory
Ospedale San Giuseppe
Istituto Auxologico Italiano
Via Cadorna, 90
Piancavallo (VB)
Verbania, 28824
Phone: 39 323 514278
Fax: 39 323 514278
ABSTRACTBackground: Recent research identifies unhealthful weight-control behaviors (fasting, vomiting, or laxative abuse) induced by a negative experience of the body, as the common antecedents of both obesity and eating disorders. In particular, according to the allocentric lock hypothesis, individuals with obesity may be locked to an allocentric (observer view) negative memory of the body that is no longer updated by contrasting egocentric representations driven by perception. In other words, these patients may be locked to an allocentric negative representation of their body that their sensory inputs are no longer able to update even after a demanding diet and a significant weight loss.
Objective: To test the brief and long-term clinical efficacy of an enhanced cognitive-behavioral therapy including a virtual reality protocol aimed at unlocking the negative memory of the body (ECT) in morbidly obese patients with binge eating disorders (BED) compared with standard cognitive behavior therapy (CBT) and an inpatient multimodal treatment (IP) on weight loss, weight loss maintenance, BED remission, and body satisfaction improvement, including psychonutritional groups, a low-calorie diet (1200 kcal/day), and physical training.
Methods: 90 obese (BMI>40) female patients with BED upon referral to an obesity rehabilitation center were randomly assigned to conditions (31 to ECT, 30 to CBT, and 29 to IP). Before treatment completion, 24 patients discharged themselves from hospital (4 in ECT, 10 in CBT, and 10 in IP). The remaining 66 inpatients received either 15 sessions of ECT, 15 sessions of CBT, or no additional treatment over a 5-week usual care inpatient regimen (IP). ECT and CBT treatments were administered by 3 licensed psychotherapists, and patients were blinded to conditions. At start, upon completion of the inpatient treatment, and at 1-year follow-up, patients' weight, number of binge eating episodes during the previous month, and body satisfaction were assessed by self-report questionnaires and compared across conditions. 22 patients who received all sessions did not provide follow-up data (9 in ECT, 6 in CBT, and 7 in IP).
Results: Only ECT was effective at improving weight loss at 1-year follow-up. Conversely, control participants regained on average most of the weight they had lost during the inpatient program. Binge eating episodes decreased to zero during the inpatient program but were reported again in all the three groups at 1-year follow-up. However, a substantial regain was observed only in the group who received the inpatient program alone, while both ECT and CBT were successful in maintaining a low rate of monthly binge eating episodes.
Conclusions: Despite study limitations, findings support the hypothesis that the integration of a VR-based treatment, aimed at both unlocking the negative memory of the body and at modifying its behavioral and emotional correlates, may improve the long-term outcome of a treatment for obese BED patients. As expected, the VR-based treatment, in comparison with the standard CBT approach, was able to better prevent weight regain but not to better manage binge eating episodes.
Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 59019572; http://www.controlled-trials.com/ISRCTN59019572 (Archived by WebCite at http://www.webcitation.org/6GxHxAR2G)
(J Med Internet Res 2013;15(6):e113)
virtual reality; obesity; binge eating disorders; allocentric lock hypothesis
Binge Eating Disorder (BED) is proposed in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) as a new diagnostic category, requiring further research, within the spectrum of the category Eating Disorders Not Otherwise Specified (EDNOS). BED is characterized by eating a much larger amount of food than most people would consider normal in a discrete amount of time (2 hours). This is associated with a loss of control about what and how much is eaten, but without the compensatory behaviors (vomiting, use of laxatives) typical of bulimia nervosa [1]. On average, individuals suffering from BED have a high prevalence of psychiatric and medical comorbidities, as well as obesity [2]. In fact, BED may occur in up to 30% of extremely obese subjects seeking treatment at weight loss programs [3], and obesity may be observed in approximately 65-70% of people with BED [4]. Cognitive behavioral therapy (CBT) can be considered one of the better clinical approaches available to treat BED [5]. CBT has been shown to reduce binge days and episodes and to improve the psychological features of BED, such as measures of restraint, hunger, and disinhibition surrounding eating. However, CBT alone has not shown strong results in decreased weight and sustained weight reduction in the mid-term (3- and 6-month follow-ups) [2,5].
The rising prevalence of weight-related disorders and the lack of a clear solution are pushing eating disorder and obesity researchers to start collaborating across fields to address them. In particular, their effort is focused on the identification of risk factors that are shared between these weight-related disorders [6]. Apparently, unhealthful weight-control behaviors, such as fasting (going without eating for 24 hours for weight control), vomiting, or laxative abuse, are the common antecedents of both obesity and eating disorders [6-11]. For example, Neumark-Sztainer and colleagues [7] discussed the results of the Project EAT II (Eating Among Teens), a longitudinal study involving 2516 ethnically and socioeconomically diverse adolescents. They report that, 5 years later, the use of unhealthful weight-control behaviors increased the risk for binge eating with loss of control by a factor of six, for being overweight by a factor of three, and for extreme weight-control behaviors, such as the use of diet pills and self-induced vomiting by a factor between two and five. A similar result was found by Stice and colleagues [11]: in a different longitudinal study fasting was the best predictor for the future onset, 5 years later, of binge eating and bulimia nervosa. These data have an important clinical implication: the evidence that youths practicing unhealthful weight-control behaviors are at higher risk for obesity implies that prevention and treatment interventions should also focus on the causes of these behaviors. A study by Kostanski and Gullone [12] with a sample of 431 Australian pre-adolescent children (7-10 years) offers a possible interpretation: pre-adolescents as young as 7 years of age are unsatisfied with their body appearance and deliberately engage in restrictive eating behaviors. Moreover, a recent study [13] showed that in adolescents frequent self-weighing is associated with lower body satisfaction and higher rates of unhealthy and extreme weight control behaviors.
In particular, according to the allocentric lock hypothesis (ALH) [14,15], individuals with obesity and eating disorders may be locked to an allocentric (observer view) negative image schema [16] of their body that is no longer updated by contrasting egocentric representations driven by perception. In other words, these patients may be locked to a negative image of their body that perception is not able to update even after a demanding diet and a significant weight loss. In sum, they cannot win. Whatever they do to modify their real body, they will always be locked in a negative body perception that they hate. This situation usually has two effects: subjects either start more radical dietary restraint or, at the opposite end, decide to stop any form of food control and start "disinhibited" eating behaviors. The passage from a locked allocentric representation to eating or weight disorders may be explained by social influence: media and culture promote diet as the best way to improve body image satisfaction. However, the impossibility of improving body image, even after a demanding diet, locks the patient into an unsatisfying body experience.
Although the ALH is starting to be backed by research data with anorectic patients [17,18], we decided to include in a CBT approach a virtual reality (VR) protocol aimed both at unlocking the negative memory of the body [15] and at modifying its behavioral and emotional correlates within an inpatient, medically managed, intensive cognitive-behavioral BED treatment.
The purpose of this study is to evaluate the brief and long-term efficacy of the proposed approach (VR-enhanced CBT for obese inpatients with BED) in a randomized controlled trial. Outcome measures are weight, number of binge eating episodes during the previous month, and body satisfaction. We hypothesize that the VR-enhanced CBT (ECT) is more effective than standard CBT and a control condition in (1) maintaining and further improving weight loss, and (2) maintaining binge eating remission at 1-year follow-up after discharge from a multimodal medically managed inpatient program (IP). Furthermore, we hypothesize that ECT is more effective than standard CBT and a control condition in improving and maintaining body satisfaction.
The study was approved by the Ethical Committee of the Istituto Auxologico.
Participants and Procedures
This study was a randomized controlled trial (ISRCTN 59019572). In total, 124 consecutive patients seeking treatment at the Eating Disorder Unit of the Istituto Auxologico Italiano, Verbania, Italy, were seen for screening interviews for admission to the study. Criteria for participation included the following: (1) women aged 18-50 years, (2) who met DSM-IV-TR criteria for BED for at least 6 months prior to the beginning of the study, (3) no other concurrent severe psychiatric disturbance (psychosis, depression with suicidal risk, alcohol or drug abuse), (4) no concurrent involvement in other treatment for BED, including pharmacotherapy, (5) no concurrent medical condition not related to the disorder, and (6) written and informed consent to participate.
Of these, 34 either did not fulfill inclusion criteria or were excluded for other reasons (eg, time constraints). All patients meeting the inclusion criteria were then consecutively and randomly assigned to one of the three experimental conditions described below. The randomization scheme was generated by using a randomization website [19]. After allocation, 24 patients declined participation in the study (Figure 1). In total, 66 female patients (mean age 31.79±7.9 years, mean weight 106.6±17.7 kg, mean height 162±7 cm, mean BMI 40.5±5.2) entered the treatment phase (Figure 1; a detailed description of the inclusion criteria is included in the CONSORT-ehealth form available in Multimedia Appendix 1). The sample characteristics are shown in Table 1. Baseline comparisons among the three groups showed a difference only in marital status. Percentages of married patients were significantly higher in the IP group and, to a lesser extent, in the ECT group than in the CBT group.
The VR-enhanced CBT and traditional CBT (see below for treatment details) were administered by 2 licensed clinical psychologists and 1 licensed psychotherapist under the supervision of a senior licensed psychotherapist. The 3 therapists were randomized to the two treatment conditions.
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|Table 1. Baseline characteristics.
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|Figure 1. Clinical trial flowchart.
The Integrated Multimodal Medically Managed Inpatient Program
The integrated multimodal medically managed inpatient program (IP) was the common treatment condition for all the participants. It consisted of hospital-based living for a duration of 6 weeks. Inpatients received medical, nutritional, physical, and psychological care. In particular, they maintained a low-calorie diet (tailored to patients' needs), entered weekly nutritional groups held by dieticians, received psychological support both in individual and group settings, and undertook physical training. Participants who were allocated to this condition were considered "controls" and did not enter the following treatments.
Cognitive Behavior Therapy
During the inpatient program, participants allocated to this condition received 15 additional cognitive behavior therapy (CBT) sessions over 5 weeks. Therapists followed a detailed manual that outlined the contents of each session. This manual was based on the CBT approach described by Fairburn and colleagues [20,21] and by Ricca and colleagues [22]. It was developed during a year of intensive pilot work and adapted to the inpatient setting. In particular, after the first inpatient week, participants entered 5 weekly group sessions and 10 biweekly individual sessions. The first 8 individual sessions were structured according to Stage 1 of the CBT manual for binge eating. They focused on an overview of the goals of the treatment program, the use of self-monitoring records to identify high-risk situations that might trigger binge eating, support in normalizing eating patterns, and the identification of behavioral strategies for coping with high-risk situations for binge eating. The final 2 individual sessions focused on the maintenance of improvement and on relapse prevention.
The group sessions were structured according to Stage 2 of the CBT manual for binge eating. They focused on problem-solving strategies and cognitive interventions targeting concerns about body weight and shape and problematic eating. After hospital discharge, continuity of care and support through telecommunication devices (email, chat, and telephone as preferred) were offered to each patient. Contacts were not scheduled and were dependent on patients' needs.
VR-Enhanced Cognitive Behavior Therapy
Like the CBT condition, participants allocated to VR-enhanced cognitive behavior therapy (ECT) received 15 additional sessions over 5 weeks. After the inpatients' first week, participants entered 5 weekly group sessions similar to the CBT ones (focused on concerns about body weight and shape and problematic eating) and 10 biweekly VR sessions. ECT treatment was based on a detailed protocol describing the contents of each of the 15 sessions [23,24]. For the virtual reality sessions, NeuroVR open-source software was used [25-27]. NeuroVR includes 14 virtual environments used by the therapist during a 60-minute session with the patient (see Figure 2). The environments present critical situations related to the maintaining/relapse mechanisms (Home, Supermarket, Pub, Restaurant, Swimming Pool, Beach, Gymnasium) and two body image comparison areas. Through the VR experience, patients practiced both eating/emotional/relational management and general decision-making and problem-solving skills. By directly practicing these skills within the VR environment, patients were helped in developing specific strategies for avoiding and/or coping with triggering situations.
The first session was used to assess any stimuli that could elicit abnormal eating behavior. Specifically, the attention was focused on a patient's concerns about food, eating, shape, and weight. The next 14 sessions were used to assess and modify the following.
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|Figure 2. A screenshot of the NeuroVR 2 open-source software.
Expectations and Emotions Related to Food and Weight (Functional Analysis)
The therapist helped patients to recognize why they eat and what they need to either avoid or cope with the specific emotional/behavioral triggers. This was achieved by integrating different cognitive-behavioral methods: Countering, Alternative Interpretation, Label Shifting, and Deactivating the Illness Belief.
Strategies Used to Cope With Difficult Interpersonal and Potential Maintenance Situations
The patient practiced old behaviors and tested new ones. This was achieved both by using the Temptation Exposure with Response Prevention [28,29] (skills training) and by working on these three empowering dimensions [30]: perceived control, perceived competence, and goal internalization (fostering the motivation).
Body Experience of the Subject
To do this, the virtual environment integrates the therapeutic methods used by Butter & Cash [31] and Wooley & Wooley [32] with the body image rescripting protocol based on ALH (see Table 2) [15,33].
In particular, we used the virtual environment in the same way as guided imagery [34] is used in the cognitive and visual/motorial approach.
After hospital discharge, continuity of care and support through telecommunication devices (email, chat, and telephone as preferred) were offered also to patients allocated to this condition. As in the previously described condition, contacts were not scheduled and were dependent on patients' needs.
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|Table 2. The VR body image rescripting protocol (adapted from Riva, 2011).
Assessments were obtained 1 week after the start of the inpatient program, at the last week, and at 1-year follow-up (by postal mail). Height was measured with a stadiometer, and weight was assessed with the participant in lightweight clothing with shoes removed, on a balance beam scale. A single question extracted from the EDI-Symptom Checklist [35] was administered at each time-point to assess the number of binge eating episodes (with binge eating defined as the consumption of unusually large amounts of food with a subjective sense of loss of control during the last month). Data at follow-up were self-reported. The following self-report questionnaires were also administered 1 week after the start of the inpatient program, at the last week, and at 1-year follow-up (by postal mail):
- The Italian version [36] of the Body Satisfaction Scale (BSS) [37]: The scale consists of a list of 16 body parts, half involving the head (above the neck) and the other half involving the body (below the head). The subjects rate their satisfaction with each of these body parts on a 7-point scale: the higher the rating, the more dissatisfied the individual.
- The Italian version [38] of the Body Image Avoidance Questionnaire (BIAQ) [39]: The BIAQ is a 19-item self-report questionnaire on avoidance of situations that provoke concern about physical appearance, such as avoidance of tight-fitting clothes, social outings, and physical intimacy. In particular, the questionnaire measures the avoidance behaviors and grooming habits associated with negative body image.
- Contour Drawing Rating Scale (CDRS) [40]: This is a set of 9 male and female figures with precisely graduated increments between adjacent size. In this test, subjects rate the figures based on the following instructional protocol: (a) current size and (b) ideal size. The difference between the ratings is called the "self-ideal discrepancy score" and is considered to represent the individual's dissatisfaction.
Statistical Analysis
A power calculation was done to evaluate the possibility of detecting statistically significant differences both between the groups (independent measures) and within groups (repeated measures). Given the low/medium statistical power due to the relatively small number of participants, the non-normality of several distributions and the unbalanced groups, we decided to use the exact methods with Monte Carlo approximation: a series of nonparametric statistical algorithms that enable researchers to make reliable inferences when data are sparse, heavily tied or unbalanced, not normally distributed, or fail to meet any of the underlying assumptions necessary for reliable results using the standard asymptotic method [41]. The exact methods with Monte Carlo approximation used for comparisons are the Kruskal-Wallis test with post hoc analysis [42] for independent measures, the Wilcoxon rank-sum test for repeated measures, and Chi-square for categorical variables, with alpha=0.5, two-tailed. Weight data were analyzed with an intention-to-treat (ITT) analysis with nonresponders at follow-up assumed to have regained 0.3 kg per month—an assumption already used in previous studies [43,44]. Also, missing data in number of binge eating episodes during the previous month were replaced with baseline values carried forward (BCF), assuming that nonresponders had worsened. Differently, missing data at follow-up in the BSS, BIAQ, and CDRS questionnaires were not imputed because we had no assumption about the missing process. Odds ratios with confidence intervals were also calculated with respect to the percentage maintaining or improving the weight loss at follow-up for ECT and CBT treatment conditions in comparison with the inpatient program alone. Data were analyzed using SPSS 16.0.
Inpatient Treatment Analysis
Outcome data were available for all the participants at the end of treatment. Weight significantly decreased in all the three conditions (ECT: -6.17 kg, CI -7 to -5.3, P<.001; CBT: -7.1 kg, CI -7.9 to -6.2, P<.001; IP: -6.6 kg, CI -8.1 to -5.2, P<.001) without any significant differences between them (Table 3). This was an expected result because all the participants underwent the same 6-week medically managed inpatient treatment including a low-calorie diet and physical training (30 minutes of walking two times a week as a minimum). For the same reason, the number of binge eating episodes decreased to zero in all the three groups (Figure 3).
Body satisfaction (BSS and CDRS) significantly improved in all the groups too, with no difference across them, while body image concerns (BIAQ-Total) significantly improved only in the ECT condition. This result probably means that experiencing a medically managed inpatient treatment helped in accepting one's own body and in decreasing dissatisfaction towards it, but only the treatment enhanced by VR exposure was effective in improving body satisfaction in relation to typical avoidance situations (Table 3).
Follow-up Analysis
One year follow-up data were available for 66.6% (n=44) of the participants who initially entered and completed the treatment phase. Drop-out rates were similar for each group. Patients who did not respond to the follow-up call were not interviewed about their reasons for not attending the final assessments. Differences between those who did and did not respond were tested for all the variables at baseline and at the end of treatment. Statistically significant differences were found only in median numbers of baseline binge eating episodes (12 responders, 16 non-responders). With respect to the two treatment conditions, responders were only those patients who had at least one telepsychological session through telecommunication devices with the clinical psychologist or psychotherapist to whom they had been initially assigned for treatment.
ITT analysis of weight and BMI outcomes after 1-year follow-up show a different picture in comparison with the previous results (Table 3). First, statistically significant weight and BMI increases were observed in the IP group (from 105 kg to 109.3 kg; P<.001), while no statistically significant weight and BMI changes were found between the end of the inpatient treatment and the 1-year follow-up in CBT and ECT groups. In addition, statistically significant differences in weight and BMI median scores at follow-up were found across the three groups in favor of ECT (Table 4). In fact, only ECT was effective in further improving weight loss at 1-year follow-up.
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|Table 3. Means, standard deviations, and medians for BSS, CDRS, and BIAQ-Total at entry to the study and upon completion of the inpatient program.
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|Figure 3. Monthly mean number of binge eating episodes at baseline, at the end of the inpatient treatment and at 1-year follow-up (dropouts at follow-up are assumed to have regained the baseline score).
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|Table 4. Means, standard deviations, and medians for weight and BMI at entry of the study, upon completion of the inpatient program, and at 1-year follow-up by group.
With respect to percentages of weight and BMI reductions at 1-year follow-up from baseline, almost significant differences emerged between the three groups (P=.052 for both) in favor of ECT and CBT (Figure 4). Post hoc comparisons showed a significant difference between ECT and IP (P=.027). Furthermore, ECT was significantly better after 1-year follow-up in improving or maintaining weight loss after treatment than IP alone. The percentages of participants who succeeded in weight maintenance or in further loss was 44.4% in ECT versus 10.5% in IP (OR 6.8, 95% CI 1.3-35.4, P=.014). Also CBT was significantly better after 1-year follow-up in improving or maintaining weight loss than IP alone, with 40% of participants being successful (OR 5.7, 95% CI 1.09-31.5, P=.035). With respect to the 5% weight loss criterion (from baseline), ITT analyses did not detect any statistically significant difference across groups, even if percentages show a trend in favor of ECT (ECT 55.6%, CBT 50%, and IP 31.6%).
Monthly number of binge eating episodes significantly increased from zero in all three groups at 1-year follow-up. ITT analysis with BCF found no statistically significant difference between the groups in follow-up median scores (Figure 3). This was largely due to the relatively great number of nonresponders we handled, assigning them the baseline scores. We decided to impute missing data in order to preserve statistical power, and we used BCF because we assumed that nonresponders had worsened.
Given that drop-out rates were not different among the three groups, we also ran a sensitivity analysis by excluding patients who did not answer the follow-up call. Results were not dissimilar and depicted the same picture we observed with imputed data.
Follow-up analyses were not performed on BSS, BIAQ, and CDRS scores because missing data were not imputed and a responders-only analysis was unfeasible due to the critical lack of information. Statistical power would have been insufficient to detect even large differences across groups and the risk of type II error would have been quite inflated.
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|Figure 4. Median percent weight reduction at the end of the inpatient treatment and at 1-year follow-up (dropouts at follow-up are assumed to have regained 3.6 kg, 0.3 per month).
We presented a randomized controlled clinical trial testing and comparing a new VR-enhanced CBT approach with standard CBT for the treatment of obese individuals with BED. Starting from the ALH [14]—suggesting that individuals with obesity may be locked to an allocentric (observer view) negative memory of the body that is no longer updated by contrasting egocentric representations driven by perception—we decided to include in the standard CBT approach to BED patients a VR-based protocol aimed at both unlocking the negative memory of the body and modifying its behavioral and emotional correlates.
We tested the efficacy of the VR-enhanced CBT on 66 female obese (BMI>40) patients with BED referred to a 6-week medically managed inpatient program (IP). Participants were randomly divided in three groups: IP (control condition), IP+CBT (15 additional sessions of group and individual CBT sessions), and IP+ECT (15 additional sessions of CBT group and VR individual sessions). We found that the inpatient program was effective in reducing weight in a sample of obese patients with BED in a relatively brief period (6 weeks) and independently from the added CBT and ECT treatments. This was a largely expected result given the highly controlled environment in which patients attended the multimodal program. The VR-enhanced CBT (ECT) delivered during the inpatient program showed to be effective in the long term. In fact, ECT proved superior to the inpatient program alone in preventing weight regain and in further improving the weight loss after 1-year follow-up. Also, standard CBT was more effective than the inpatient program alone in preventing weight regain. However, follow-up scores with nonresponders assumed to have regained 3.6 kg (0.3 per month) show a significant difference in favor of ECT. Indeed, only ECT was effective in further improving weight loss at 1-year follow-up. On the contrary, control participants regained on average most of the weight they had lost during the inpatient program.
Binge eating episodes decreased to zero during the inpatient program (because of the same reasons explained for weight reduction) but were reported again in all three groups at 1-year follow-up. However, in the ITT analysis with BCF, a substantial regain was observed only in the group who received the inpatient program alone, while both ECT and CBT were successful in maintaining a low rate of monthly binge eating episodes (Figure 3).
Some study limitations deserve attention. The first and most important one is the medium-high rate of nonresponders (33.4%); thus, our follow-up results have to be considered with caution. In order to preserve the ITT principle and statistical power, we handled missing data by imputation, assuming that patients who did not provide data at 1-year follow-up had worsened. With respect to weight, we imputed data according to a plausible empirical rule already used in previous studies [43,44], while missing data in a number of binge eating episodes were handled by an imputation method (BCF) that deserves more critical consideration [45]. Second, the CBT treatment used in this study is a reduced (6-week) version of the Oxford outpatient protocol [20,21]. Obviously, major changes have been made to the original 44-week format, so we cannot compare our results with ones obtained in studies that implemented the original protocol. Third, no other psychosocial variable was measured beyond body image satisfaction. As a reviewer suggested, measures of emotional and social functioning would have added further information on the efficacy of the ECT treatment. We agree and hope that future studies on this novel VR-enhanced treatment will include further measures of psychological, emotional, and social variables that can act as outcomes as well as mediators or moderators of treatment efficacy.
The rising prevalence of weight-related disorders and the lack of a clear solution are pushing eating disorder and obesity researchers to collaborate. In particular, their efforts have identified a critical risk factor: unhealthful weight-control behaviors, such as fasting, vomiting, or laxative abuse, are the common antecedents of both obesity and binge eating. But why do these subjects decide to start such radical weight-control behaviors? The answer underlined both by clinical practice and by research studies is simple: because subjects do not like their bodies.
Given the importance of body image satisfaction for the quality of life of these patients, these findings argue for the potential benefits of treatment strategies for improving body satisfaction. Unfortunately, this vision is not shared by the existing treatment protocols. As noted by Rosen 15 years ago, only a third of cognitive-behavioral treatments assessed in his review addressed body image specifically [46]. The situation still has not changed very much. And when it happens, the focus is more on shape concerns and over-evaluation than on the experience and perception of a fat body [47].
Recently the ALH [14,15] offered a clear link between a negative body image and the etiology of obesity and eating disorders, ie, patients may be locked to an allocentric (observer view) negative image schema of their body that is not updated by contrasting egocentric representations driven by perception. In other words, they cannot win: whatever they do to modify their real body, they will always be present in a virtual body that they hate. This situation has usually two effects: subjects either start more radical dietary restraint or, the opposite, they decide to stop any form of food control and start "disinhibited" eating behaviors.
In this study, we tested a modified CBT approach that included a VR-based treatment to target this issue. VR can be considered an "embodied technology" for its effects on body perceptions [48]. On one side, different authors showed that is possible to use VR both to induce illusory perceptions, eg, a fake limb [49], by altering the normal association between touch and its visual correlate. It is even possible to generate a body transfer illusion [50]: Slater and colleagues substituted the experience of male subjects' own bodies with a life-sized virtual human female body. On the other side, it is also possible to use VR to improve body image [51,52], even in patients with eating disorders [23,53,54] or obesity [55,56]
Despite the study limitations discussed above, findings support the hypothesis that the integration of a VR-based treatment, aimed at both unlocking the negative memory of the body and at modifying its behavioral and emotional correlates, may improve the long-term outcome of a treatment for obese BED patients. This result is in line with the recent review [57] about the use of VR for the treatment of body image in eating disorders. The authors concluded their paper with the following words: "VR-based therapies seem to be especially suitable for improving body image both in ED patients and in subclinical samples…All these studies showed significantly greater improvement in measures related with body image when the VR component was added." (p. 9). The ALH discussed in this paper may be a possible explanation for this result. However, due to the integrated structure of the VR intervention and to the assessment tools used in the trial, we are not able to verify a possible direct effect of the proposed treatment on the allocentric lock (only indirect through a better body satisfaction). So, future studies are needed to further explore and verify this specific hypothesis.
As expected, the VR-based treatment, in comparison with the standard CBT approach, was able to better prevent weight regain but not to better manage binge eating episodes. This is because both CBT and ECT shared the same protocol on problem-solving strategies and cognitive interventions targeting problematic eating.
Future research should focus on using meta-analysis techniques in order to test the real strength of effects found in the clinical studies, and on conducting more controlled studies comparing VR-based treatments with traditional ones. To reach this goal, the "Laboratorio de Enseñanza Virtual y Ciberpsicología" at the School of Psychology of the Universidad Nacional Autonoma de Mexico, in cooperation with the Obesity Unit of the Medica Sur Hospital in Mexico City, have recently started a controlled clinical trial [58,59].
The present work was supported by the Commission of the European Communities (CEC), through its IST program (Project VEPSY Updated and Project INTREPID) and by the Italian MIUR FIRB program (Project IVT2010).
Conflicts of Interest
None declared.
Multimedia Appendix 1
CONSORT-EHEALTH checklist V1.6.2 [59].[PDF File (Adobe PDF File), 987KB]
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- Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later? J Am Diet Assoc 2006 Apr;106(4):559-568. [CrossRef] [Medline]
- Neumark-Sztainer D. Preventing obesity and eating disorders in adolescents: what can health care providers do? J Adolesc Health 2009 Mar;44(3):206-213. [CrossRef] [Medline]
- Johnston JM. Eating disorders and childhood obesity: who are the real gluttons? CMAJ 2004 Dec 7;171(12):1459-1460 [FREE Full text] [CrossRef] [Medline]
- Stice E, Presnell K, Shaw H, Rohde P. Psychological and behavioral risk factors for obesity onset in adolescent girls: a prospective study. J Consult Clin Psychol 2005 Apr;73(2):195-202. [CrossRef] [Medline]
- Stice E, Davis K, Miller NP, Marti CN. Fasting increases risk for onset of binge eating and bulimic pathology: a 5-year prospective study. J Abnorm Psychol 2008 Nov;117(4):941-946 [FREE Full text] [CrossRef] [Medline]
- Kostanski M, Gullone E. Dieting and body image in the child's world: conceptualization and behavior. J Genet Psychol 1999 Dec;160(4):488-499. [CrossRef] [Medline]
- Friend S, Bauer KW, Madden TC, Neumark-Sztainer D. Self-weighing among adolescents: associations with body mass index, body satisfaction, weight control behaviors, and binge eating. J Acad Nutr Diet 2012 Jan;112(1):99-103 [FREE Full text] [CrossRef] [Medline]
- Riva G. Neuroscience and eating disorders: the allocentric lock hypothesis. Med Hypotheses 2012 Feb;78(2):254-257. [CrossRef] [Medline]
- Riva G. The key to unlocking the virtual body: virtual reality in the treatment of obesity and eating disorders. J Diabetes Sci Technol 2011 Mar;5(2):283-292 [FREE Full text] [Medline]
- Dodge E, Lakoff G. Image schemas: From linguistic analysis to neural grounding. In: Hampe B, editor. From perception to meaning: image schemas in cognitive linguistics. Berlin: Walter de Gruyter; 2005:57-91.
- Riva G, Gaudio S. Allocentric lock in anorexia nervosa: new evidences from neuroimaging studies. Med Hypotheses 2012 Jul;79(1):113-117. [CrossRef] [Medline]
- Gaudio S, Riva G. Body Image Disturbances in Anorexia: The link between functional connectivity alterations and reference frames. Biological Psychiatry 2013 May;73(9):e25-e21. [CrossRef]
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- Fairburn CG. Overcoming binge eating. New York: Guilford Press; 1995.
- Fairburn CG, Wilson GT. Cognitive-behavioral therapy for binge eating and bulimia nervosa: A comprehensive treatment manual. In: Binge eating: nature, assessment, and treatment. New York: Guilford Press; 1993.
- Ricca V, Mannucci E, Zucchi T, Rotella CM, Faravelli C. Cognitive-behavioural therapy for bulimia nervosa and binge eating disorder. A review. Psychother Psychosom 2000;69(6):287-295. [Medline]
- Riva G, Bacchetta M, Baruffi M, Rinaldi S, Vincelli F, Molinari E. Virtual reality-based experiential cognitive treatment of obesity and binge-eating disorders. Clinical Psychology and Psychotherapy 2000;7:209-219.
- Riva G, Bacchetta M, Cesa G, Conti S, Molinari E. Virtual Reality and Telemedicine Based Experiential Cognitive Therapy: Rationale and Clinical Protocol. In: Riva G, Galimberti C, editors. Towards CyberPsychology: Mind, Cognition and Society in the Internet Age. Amsterdam: IOS Press; 2001:273-308.
- Riva G, Gaggioli A, Villani D, Preziosa A, Morganti F, Corsi R, et al. NeuroVR: an open source virtual reality platform for clinical psychology and behavioral neurosciences. Stud Health Technol Inform 2007;125:394-399. [Medline]
- Riva G, Gaggioli A, Grassi A, Raspelli S, Cipresso P, Pallavicini F, et al. NeuroVR 2--a free virtual reality platform for the assessment and treatment in behavioral health care. Stud Health Technol Inform 2011;163:493-495. [Medline]
- Riva G, Carelli L, Gaggioli A, Gorini A, Vigna C, Corsi R, et al. NeuroVR 1.5 - a free virtual reality platform for the assessment and treatment in clinical psychology and neuroscience. Stud Health Technol Inform 2009;142:268-270. [Medline]
- Schlundt DG, Johnson WG. Eating disorders: assessment and treatment. Boston: Allyn and Bacon; 1990.
- Riva G. Virtual Reality vs. Virtual Body: The use of virtual environments in the treatment of body experience disturbances. CyberPsychology & Behavior 1998;1:129-137.
- Menon ST. Psychological Empowerment: Definition, Measurement, and Validation. Canadian Journal of Behavioural Science 1999;31:161-164.
- Butters JW, Cash TF. Cognitive-behavioral treatment of women's body-image dissatisfaction. J Consult Clin Psychol 1987 Dec;55(6):889-897. [Medline]
- Garner DM, Garfinkel PE. Intensive out-patient and residential treatment for bulimia. In: Handbook of treatment for eating disorders. New York: Guilford Press; 1997.
- Smucker MR, Dancu C, Foa EB, Niederee JL. Imagery rescripting: A new treatment for survivors of childhood sexual abuse suffering from posttraumatic stress. Journal of Cognitive Psychotherapy 1995;9:3-17.
- Leuner H. Guided affective imagery (GAI). A method of intensive psychotherapy. Am J Psychother 1969 Jan;23(1):4-21. [Medline]
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- Riva G, Molinari E. Factor structure of the Italian version of the Body Satisfaction Scale: a multisample analysis. Percept Mot Skills 1998 Jun;86(3 Pt 1):1083-1088. [Medline]
- Slade PD, Dewey ME, Newton T, Brodie D, Kiemle G. Development of the Body Satisfaction Scale (BSS). Psychology and Health 1990;4:213-226.
- Riva G, Molinari E. Replicated factor analysis of the Italian Version of the Body Image Avoidance Questionnaire. Percept Mot Skills 1998 Jun;86(3 Pt 1):1071-1074. [Medline]
- Rosen JC, Srebnik D, Saltzberg E, Wendt S. Development of a Body Image Questionnaire. Psychological Assessment 1991;1:32-37.
- Thompson MA, Gray JJ. Development and validation of a new body-image assessment scale. J Pers Assess 1995 Apr;64(2):258-269. [CrossRef] [Medline]
- IBM. SPSS User Manual: Exact Tests. Chicago, IL: SPSS Inc; 2000.
- Siegel S, Castellan NJ, Jr N. Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill; 1988.
- Wadden TA, Berkowitz RI, Womble LG, Sarwer DB, Phelan S, Cato RK, et al. Randomized trial of lifestyle modification and pharmacotherapy for obesity. N Engl J Med 2005 Nov 17;353(20):2111-2120. [CrossRef] [Medline]
- Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL. A self-regulation program for maintenance of weight loss. N Engl J Med 2006 Oct 12;355(15):1563-1571. [CrossRef] [Medline]
- Salim A, Mackinnon A, Christensen H, Griffiths K. Comparison of data analysis strategies for intent-to-treat analysis in pre-test-post-test designs with substantial dropout rates. Psychiatry Res 2008 Sep 30;160(3):335-345. [CrossRef] [Medline]
- Rosen JC. Body image assessment and treatment in controlled studies of eating disorders. International Journal of Eating Disorders 1996;19:341-343.
- Fairburn CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008.
- Spagnolli A, Gamberini L. A Place for Presence. Understanding the Human Involvement in Mediated Interactive Environments. PsychNology Journal 2005;3:6-15 [FREE Full text] [WebCite Cache]
- Slater M, Perez-Marcos D, Ehrsson HH, Sanchez-Vives MV. Inducing illusory ownership of a virtual body. Front Neurosci 2009 Sep;3(2):214-220 [FREE Full text] [CrossRef] [Medline]
- Slater M, Spanlang B, Sanchez-Vives MV, Blanke O. First person experience of body transfer in virtual reality. PLoS One 2010;5(5):e10564 [FREE Full text] [CrossRef] [Medline]
- Riva G. Modifications of body-image induced by virtual reality. Percept Mot Skills 1998 Feb;86(1):163-170. [Medline]
- Riva G. Virtual environment for body-image modification: Virtual reality system for the treatment of body image disturbances. Computers in Human Behavior 1998;14:477-490.
- Riva G, Bacchetta M, Cesa G, Conti S, Molinari E. Six-month follow-up of in-patient experiential cognitive therapy for binge eating disorders. Cyberpsychol Behav 2003 Jun;6(3):251-258. [CrossRef] [Medline]
- Riva G, Bacchetta M, Baruffi M, Rinaldi S, Molinari E. Virtual reality based experiential cognitive treatment of anorexia nervosa. J Behav Ther Exp Psychiatry 1999 Sep;30(3):221-230. [Medline]
- Riva G, Bacchetta M, Cesa G, Conti S, Castelnuovo G, Mantovani F, et al. Is severe obesity a form of addiction? Rationale, clinical approach, and controlled clinical trial. Cyberpsychol Behav 2006 Aug;9(4):457-479. [CrossRef] [Medline]
- Riva G, Bacchetta M, Baruffi M, Rinaldi S, Vincelli F, Molinari E. Virtual reality based Experiential Cognitive Treatment of obesity and binge-eating disorders. Clinical Psychology and Psychotherapy 2000;7:209-219.
- Ferrer-García M, Gutiérrez-Maldonado J. The use of virtual reality in the study, assessment, and treatment of body image in eating disorders and nonclinical samples: a review of the literature. Body Image 2012 Jan;9(1):1-11. [CrossRef] [Medline]
- Riva G, Cárdenas-López G, Duran X, Torres-Villalobos GM, Gaggioli A. Virtual reality in the treatment of body image disturbances after bariatric surgery: a clinical case. Stud Health Technol Inform 2012;181:278-282. [Medline]
- Eysenbach G, CONSORT-EHEALTH Group. CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res 2011;13(4):e126 [FREE Full text] [CrossRef] [Medline]
|ALH: allocentric lock hypothesis
|BCF: baseline values carried forward
|BED: binge eating disorders
|BIAQ: Body Image Avoidance Questionnaire
|BSS: Body Satisfaction Scale
|CBT: cognitive behavioral therapy
|CDRS: Contour Drawing Rating Scale
|ECT: VR-enhanced cognitive behavior therapy
|IP: integrated multimodal medically managed inpatient program
|ITT: intention-to-treat
|VR: virtual reality
|Edited by G Eysenbach; submitted 15.11.12; peer-reviewed by V Cardi, J Guiterrez, P Bordnick, A Tal; comments to author 22.01.13; revised version received 13.03.13; accepted 12.04.13; published 12.06.13
Please cite as:
Cesa GL, Manzoni GM, Bacchetta M, Castelnuovo G, Conti S, Gaggioli A, Mantovani F, Molinari E, Cárdenas-López G, Riva G
Virtual Reality for Enhancing the Cognitive Behavioral Treatment of Obesity With Binge Eating Disorder: Randomized Controlled Study With One-Year Follow-up
J Med Internet Res 2013;15(6):e113
URL: http://www.jmir.org/2013/6/e113/
doi: 10.2196/jmir.2441
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Copyright©Gian Luca Cesa, Gian Mauro Manzoni, Monica Bacchetta, Gianluca Castelnuovo, Sara Conti, Andrea Gaggioli, Fabrizia Mantovani, Enrico Molinari, Georgina Cárdenas-López, Giuseppe Riva. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 12.06.2013.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.


text:
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subset: commoncrawl


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We hate to start our articles off with well-worn clichs, but Honda's Type R is a modern day classic. Honda's Type R label represents the pinnacle of factory-bred race engineering, and only the company's fastest and best drivers' cars get the right to wear the badge. Americans got their first taste of the R when the Acura Integra Type R hit showrooms back in 1997. Though that original R is now 10 years old, it is still considered to be one of the best performance cars ever built.
Anyone that is even remotely into cars has coveted a car with a Type R badge at one time or another. But as the R was produced in very limited numbers, only a select few people got to see one on the streets, let alone drive one. This scarcity only made people want to drive a Type R even more, resulting in a flood of homemade Type Rs.
At first, most of these homemade Type Rs were, to be blunt, crap. People just slapped a Type R badge on whatever car they were driving and hoped that the R's cred would somehow magically make their Accord, Prelude, Mustang or "VTEC" Celica the fastest thing on the streets. Thankfully this concept of sticker tuning seems to have died, but the people's desire to build a Type R for themselves has not. And these days, people are building cars that are actually true to what that R stands for. Take, for instance, the 1992 Honda Civic you see here. Unable to score a true Civic Type R (as they were never sold here and all), its owner, Kelvin Hernandez, set about turning his EG into a ride worthy of the R badge.
With Type R motors still rarer than a sober Britney sighting, Kelvin picked up a B18C1 out of an Integra GS-R. This motor is no slouch in stock trim, but Kelvin knew that it was capable of so much more. Displacement has been bumped up to 2.0 liters, and the block has been blueprinted, balanced and stuffed with goodies like CP dome pistons and Golden Eagle connecting rods. Up top, the head was treated to a three-angle valve job and Buddy Club Stage 4 cams--controlled by Skunk2 cam gears--work their bumpstick magic on the Supertech double valve springs and titanium retainers.
All the usual bolt-ons are present and accounted for: an AEM cold air intake, Sparks Racing 4-2-1 header and MagnaFlow exhaust keep the B18 breathing right. Fuel duties are handled by an AEM fuel regulator and fuel rail, Precision 440cc injectors and a Walbro 255 lph fuel pump. Igniting this enhanced mixture of air and fuel is an amped up and amplified ignition system comprised of an MSD 6 AL Blaster 2 coil and NGK plugs and wires. A 2000 Civic Si transmission--packed with goodies like a Type R LSD and a Tilton single disc street clutch--gets this engine's power to the ground via a set of Integra Type R axles.
As powerful as this Civic's engine may be, Type Rs aren't known for their power; they're known more for their handling prowess. To give this Civic R-like handling capabilities, Kelvin slapped on a set of Omni Power coilovers. For wheels, Kelvin felt that sticking with OEM Honda parts was best, so after giving his Civic a 5-lug conversion, he hooked his car up with a set of 15-inch gunmetal rims (right off a U.S.-spec Integra Type R) and wrapped them in sticky Bridgestone Potenza rubber.
The Type R goodness extends to this Civic's cabin, too. Hardcore Honda heads will immediately recognize the U.S.-spec Type R seats in the front, and we're sure that the JDM otaku out there are now making pointing gestures toward the JDM Type R steering wheel. While these two items would be enough for most people, Kelvin went one step further and added the U.S.-spec Type R gauge cluster and head unit. But that's not all: even more JDM bling has been added in the form of a Japan-spec defroster switch, coin tray, amber clock and climate control. The only non-Honda bits in this Civic's cockpit are the AEM wide band gauge and Auto Meter oil pressure gauge.


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The Free-Spirited Style Icon Performs a High Voltage Solo
Stripped down to lingerie by Bordelle and DKNY, Brazilian model Alice Dellal lets loose on her Premier drum kit in an exclusive edit of Matthew Donaldson's ground shaking new short. The heiress is known for championing the punk undercut and vamping for labels such as Agent Provocateur and Burberry, but she's also on percussion for female rock quartet Thrush Metal, which features fellow models Emma Chitty and Laura Fraser and socialite Isabella Ramsey. The film is the latest installment of stylist Aurelia Donaldson's series for The Telegraph, which explores the off-duty talents of models. Dellal, who counts Mick Jagger and Mario Testino as godparents, indulged us in some preferential treatment.
Gstaad or Gold Coast?
Gold Coast.
Full Metal Jacket or Pretty in Pink?
Pretty in Pink.
Jake and Dinos or Jak and Jil?
Jake and Dinos.
Leather or lace?
Rotten or Depp?
Cayless (Sullivan).
"I Touch Myself" or "Can't Touch This"?
"Can't Touch This."
Late nights or early mornings?
Early mornings.
Corvette or Cortina?
Levi's or Lagerfeld?
Corsets or cut-offs?
Mikimoto or De Beers?
Jones (Dominic).
Kumomotos or Kobe beef?
Kobe Beef.
Raccoon eyes or red lips?
Raccoon eyes.
Black magic or white lies?
White lies.


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The only suggestion I would make would be to cut the amount of rice in half. Otherwise the curry flavor is too mellow and my family really likes flavorful food.
Indian Baked Chicken Pockets
More From Southern Living Cooking School
- 1 cup basmati rice
- 1 tablespoon curry powder
- 1 tablespoon vegetable oil
- 1/3 cup finely chopped onion
- 1 tablespoon lemon juice
- 1 cup chopped cooked chicken
- 1 teaspoon salt
- 1/4 teaspoon pepper
- 1 (17.3-ounce) package frozen puff pastry sheets, thawed
- 1 large egg
- 2 tablespoons water
- 1 (9-ounce) jar mango chutney
- 1. Prepare basmati rice according to package directions.
- 2. Cook curry powder in a medium skillet over medium heat about 30 seconds or until fragrant. Add oil, and cook, stirring constantly, 1 minute. Add onion, and sauté 1 minute. Stir in lemon juice. Add rice, chicken, salt, and pepper; cook 1 minute.
- 3. Roll one pastry sheet into a 12-inch square on a lightly floured surface. Cut pastry into 9 (4-inch) squares.
- 4. Stir together egg and 2 tablespoons water; lightly brush edges of pastry squares with mixture.
- 5. Place 2 tablespoons rice mixture on each square, and fold over to form a triangle. Press edges to seal. Repeat procedure with remaining pastry and filling. Brush tops with remaining egg mixture, and place on a baking sheet.
- 6. Bake at 400º for 20 minutes or until golden brown. Serve warm with chutney.
- INDIAN PARTY POCKETS: Stir 1/3 cup golden raisins, 1/4 cup chopped almonds, and 3 tablespoons chopped cilantro into prepared chicken mixture, and proceed as directed. For a creamy dipping sauce, stir 1 cup plain yogurt, 1 tablespoon chopped cilantro, and 1/4 teaspoon each of curry powder, ground red pepper, salt, and pepper into the mango chutney.
- NOTE: To make smaller appetizers, cut each pastry sheet into 16 (3-inch) squares, top with about 1 tablespoon rice mixture, and proceed as directed.
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Indian Baked Chicken Pockets Recipe at a Glance
- COURSE: Appetizers, Hors d'Oeuvres
- CONVENIENCE: Entertaining
- CUISINE: Indian
- MAIN INGREDIENT: Poultry
- COOKING METHOD: Bake
- OCCASION: Autumn, Winter
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Home » News » Education
Absences of West High ex-principal unexplained
Former Manchester West Principal Mary Ellen McGorry speaks during a special naturalization ceremony at the high school last May. (UNION LEADER FILE)
Manchester school officials released the cumulative work days of McGorry for the past two years upon request of the New Hampshire Union Leader. However, school officials would not specify which days she was absent, nor would they discuss whether her absences had anything to do with an expensive investigation into McGorry and her subsequent resignation.
Under the terms of the union agreement governing principals, high school principals are required to work 226 days a year.
McGorry worked only 182 days during the 2011-12 school year, the last full year she worked for the district. She worked 233 days the previous year, seven days more than required.
"There were some legitimate reasons for her absences from school, and we did provide additional administrative support during that time frame," Superintendent Tom Brennan said this week.
West Side school board member John Avard said he remembers McGorry being off the job for health reasons, but he doesn't know the particulars or even what year that was.
"Regardless of the industry you're in, people have personnel issues that arise," Avard said. "There's various circumstances that do arise. As long as they're justifiable, we have to work with people."
McGorry was placed on paid leave shortly after the 2012-13 school year began. In January, she resigned the position she had held since 2007, although she will be paid until the end of the current school year. Her resignation followed a lengthy investigation, and school officials have refused to divulge the findings of the probe, citing personnel policies and law.
Her principal certification remains valid, according to the New Hampshire Department of Education.
Brennan said a principal can be out of work for various reasons, including illness and medical or family leave. School officials denied right-to-know requests by the New Hampshire Union Leader for the date of each day McGorry worked, the hours worked and reasons submitted when she didn't work.
"Providing this much detail would allow the public to discover sensitive personal and confidential information about these employees, such as their health status and private family matters," Brennan wrote in response to a Union Leader request.
"We believe that the public's interest to know his sensitive information does not override the privacy interest of the employees involved," he wrote.
McGorry's lawyer, Andru Volinsky, said he did not know about the absences.
"I probably wouldn't answer (why) if I knew," Volinsky said.
Brennan said school district policy calls for a replacement to step in if a building principal is going to be off the job for five days or more. A recent change to the policy requires the school board to be apprised of the absence, but Brennan said he's not sure if that provision was in effect last year.
Principals receive 1½ sick days for each month they are on the job. Under the terms of the principal union agreement, McGorry could not accumulate more than 15 days in a given year and 120 days throughout her time on the job.
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"Silence will save me from being wrong (and foolish), but it will also deprive me of the possibility of being right." -- Igor Stravinsky
Saturday, August 14, 2010
Theory and History
2 comments:
I bet he neglects the upside of the slave trade, too.ReplyDelete
I don't see the point of your remark, Bob. Certainly, an analysis of the slave trade that implied no one economically benefited from it would be somewhat lacking, wouldn't it? And this inflation arose through 'market forces' -- at least on the European end of things -- as Spanish gold and silver from the New World poured into the European economy. It COULD have been the case that the New World was empty when the Spaniards arrived, and they discovered unhomesteaded gold and silver. The inflation than would be a pure market phenomenon -- and aren't those all benign?ReplyDelete


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Central Okanagan News
Kaleden man injured in snowy crash
About 4 p.m., West Kelowna RCMP received a report of a head-on collision on Highway 97 at North Beach Road.
Apparently a Ford flat-deck truck was northbound on the highway when it lost control in slushy and slippery conditions.
The truck spun twice and crossed all oncoming lanes.
A southbound Pontiac Grand Prix travelling in the curb lane impacted the side of the truck, causing the truck to overturn onto its side before both vehicles came to a rest in the ditch.
The driver of the truck was not overtly injured but the driver of the Pontiac suffered serious but non-life threatening injuries and was transported to hospital by BC Ambulance Service paramedics.
No charges have yet been laid.
Road conditions appeared to be a contributing factor in the crash.
Read more Central Okanagan articles
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Review: LittleBigPlanet Karting is about much more than just racing
At it's core, LittleBigPlanet Karting is no different than any other kart racing game. You pick a track, or in this case a planet, and race against AI controlled opponents or other players. Of course, that's not what LittleBigPlanet is about; it's about so much more than just that. LittleBigPlanet has always been based on the concept of Play, Create, Share, and it's this... Read More


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Concrete Floor Finishes, Floor Stripping and Floor Refinishing
Polished Concrete is a revolutionary permanent process for concrete floor restoration. New concrete or worn out concrete is mechanically resurfaced, chemically hardened and polished to a permanent glossy, marble- like finish. The result is an aesthetically pleasing one of a kind work of art. The finished product provides less maintenance, an amazing mirror like finish and a permanent solution to your concrete floors.
Why Polished Concrete?
• Cost effective
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• Permanent Process
• Longer life than any other floor covering
• Environmentally Friendly/ Green Product
• Air quality is improved
• Slip resistance in compliance with NFSI
• Tire Streaks are history
• Dust Free Process
• Scratch resistant
• Stain Resistant
• Lower 10 year life cycle cost
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Contact us 1.877.550.3366 for a complimentary demonstration on the worst area of your floor. We suggest allowing us to demonstrate on a heavy traffic area so you may observe the amazing results that can be transformed with polished concrete. Click here for demonstration information.


text:
Nike Wants You To Join The Club
I'm a runner, so most of my workouts happen outside. On the rare occasion I actually do step inside a gym (this month's snow has been brutal on my en plein air regimen), I'm completely confounded. I stare at the rows of weight machines with a mixture of confusion and fear, and after 15 minutes of fumbling I usually give up without exerting myself at all. But thanks to wonders of modern technology, there is another way for chest press-phobes like me. Last night I had my first date with a virtual trainer, specifically Nike's new Training Club App.
With U.S. Soccer team goalie Hope Solo on hand to talk shop (Solo is on the injured reserve right now, but will be back in the net soon), the brand invited a group of beauty editors to a raw warehouse space on the West Side to try out its latest, pocket-sized revolution. Once imported to your iPhone or iTouch, the application flashes four customizable fitness options to Get Lean, Get Toned, Get Strong, or Get Focused. You pick your goals, level of fitness, and preferred workout (cardio, weights, circuit training) and it puts together a 30-45 minute routine with step-by-step instructions and demonstrations. Full disclosure: Even though the workout was created entirely by the program and couldn't have been easier to follow—it was actually projected onto the wall as a visual guide—I was psyched that Nike trainer Marie Purvis was there to help navigate. As previously mentioned, my aversion to indoor exercise mandates a lot of hand-holding. For those of you used to the gym, however, the virtual trainer that comes standard with the free download should be plenty motivational. Think of it as a way to kick-start your New Year's resolution without shelling out to shape up.—Elizabeth Cohen
Photo: Evan Agostini / AP Photo


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Happy birthday @ryanbangko , :) from all the way in Oz!
This pic was taken back in January when both "Ang Utol Kong Hoodlum" and Ryan's show were filming at the same place. He decided to drop by our set, kasi wala lang, he felt like it. Haha. Hope you had a blast of a day Ryan! You deserve happiness as you definitely give us all the joy you exert on Showtime!


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Editor's note: Mayor-Elect Matt Little was inaugurated and given the oath of office on Jan. 10. The following is the speech he prepared and read at the event. Minnesota Chief Justice Lorie Skjerven Gildea administered the oath to Little.
Thank you, Madame Chief Justice, Mr. City Administrator, City Council Members, and, most of all, my family and supporters.
I am honored and humbled to accept the oath of office as Mayor of Lakeville. And before I begin, I want to take a moment to thank Mayor Bellows and Councilmember Laurie Rieb for their dedicated years of service to our city. I know both of them will stay involved with Lakeville, and I look forward to working with them in the future.
Being elected to public office anywhere, in any position, is a remarkable responsibility, but to be elected mayor of my own hometown is a special privilege that energizes and motivates me.
I think most of us carry our hometowns with us in our hearts, and in our mind's eye we hold an idealized vision of that American icon: the town square. Now, I know we don't have an actual town square here in Lakeville and I'm not proposing that we build one. In fact, very few towns are built that way now days, but the idea of the town square is woven deep into the fabric of our country. So, in an essential way: Lakeville does have a town square, we've created it, in our minds and our hearts To some people that may seem like empty nostalgia, but it's pretty important to me… because even though Lakeville has become a big city, I still want to be a small town mayor.
In my mind's eye, when I look around Lakeville's figurative town square, I see a place filled with small businesses and local owners. I see TR's barbershop over there the Ben Franklin on the other side, and Mainstreet Café up a little way on Holyoke. Holyoke is our main street, of course.
I also see churches anchoring the town square, holding community dinners and reaching out to people in need. And, right around here I see City Hall; over there the Fire Station and the Police Station, where you can stop by and pet Zeus and Tank, our town's neighborhood police dogs. Just a short walk away is the Library, the Post Office and the school buildings surrounded by playgrounds and baseball fields.
Naturally, in the center of our town square, is a park; and for us, it's Pioneer Plaza where we can read about and gain inspiration from leaders of our past. The park is the center because it's where people come together… for celebrations or picnics or just to talk, or maybe to talk about how we can make our town even better.
You see, in our ideal town square, every organization, every person, has a job to do and role to play, in the right balance; at the right times. So it's not about extremes or ideology; it's not "all or nothing," "my way or no way." And when we disagree, which we will and we should, then we'll work it out. We'll get a cup of coffee at the Cafe or sit down in the Park (when it's warmer) and we'll talk it out. Because that's how we've always done it in our town square. People in Lakeville, like most Americans, are practical, we're reasonable, we like to get things done.
Now, at about this time in the speech, if I were you, I'd be thinking that Matt's getting pretty sentimental in his old age. But our town square doesn't have to be stuck in the past. We can build a virtual town square; where we watch council meetings online, discuss critical budget items on Twitter, and on Facebook we can talk trash about Eden Prairie football.
Of course, I don't mean we stop talking face-to-face, person-to-person. That's the heart of what makes our town square great. Besides we can do both. We'll still talk in the checkout lines at Cub; meet our neighbors at barbeques during national night out, and trade Pan-O-Prog stories over breakfast at the Buckboard. By blending both approaches, we can keep our town square alive and well in 2013. We can bring Norman Rockwell into the 21st Century.
And that's important, because I believe in Lakeville's past and Lakeville's future. We can grow a bigger and better city, without losing our small town heart. To do that, the people in our town square need to work together to solve problems. Fortunately, we share a broad consensus about that future and everyone has a part to play. Everyone has a role in creating jobs and increasing economic growth. Everyone has a role in ensuring that we have a safer and stronger community. And each of us has a role in making sure that city hall is responsive, efficient, and effective.
If we all work together, we WILL build a better Lakeville. And as Mayor, I look forward to working with our city council, city staff, and most importantly, all of you, to make this vision of Lakeville's 21st Century Town Square, a reality. In the last 28 years Lakeville has gone from a town of around 20,000 people to a vibrant city of over 56,000. So you could say, in a way, that Lakeville, like it's mayor, is all grown up. In fact, Lakeville and I have grown up together. But even though Lakeville's a big city now, it is still my profound honor to serve as your small town mayor.
Thank you,
Matt Little


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Media: "Opheliac" by Emily Autum, a Corpse Bride amv.
Mood: restless. That time of the year again. Time to move
I'm not a n00b so back the ********] off please.
I believe in Honor and Integrity.
I'm Literate, not a Nazis.
Don't push your [strike]God religion on me.
why yes I do in fact miss the days when gaia wasn't a spam can.
Who ever's trying to hack my account can just stop now. My big items aren't even on this account anymore.
I live through Creation
I bellydance. Can't get more awesome then that.
I'm in love with my Inari. He is my fox-face and my partner in crime.
All about Kitty (the Char) in the infamous words of Queen
"She keeps Moet et Chandon
In a pretty cabinet
'Let them eat cake' she says
Just like Marie Antoinette
A built-in remedy
For Khrushchev and Kennedy
At anytime an invitation
You can't decline
Caviar and cigarettes
Well versed in etiquette
Extraordinarily nice
She's a Killer Queen
Gunpowder, guillotine
Dynamite with a laser beam
Guaranteed to blow your mind
Recommended at the price
Insatiable an appetite
Wanna try?
To avoid complications
She never kept the same address
In conversation
She spoke just like a baroness
Met a man from China
Went down to Geisha Minah
Then again incidentally
If you're that way inclined
Perfume came naturally from Paris
for god she couldn't care less
Fastidious and precise
Drop of a hat she's as willing as
Playful as a p***y cat
Then momentarily out of action
Temporarily out of gas
To absolutely drive you wild, wild
She's out to get you
Recommended at the price
Insatiable an appetite
Wanna try?
You wanna try"
Viewing 12 of 97 friends
KittyKat's JournalThe Life Death Rebirth and trials of Kitty as you know her . . .
Journal and Profile of Kitty
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.::Life is a Cabaret Ol' Chum::.
"Be my Life"
"Be my Life"


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Excerpt from The Hole in Our Holiness by Kevin DeYoung
One of the reasons why I think Christians get tired of hearing about the law is because they never hear why they should obey the law. The imperatives hit us like a ton of study Bibles because we aren't given any motivation for keeping God's commands. Everything boils down to, "God said it, so do it." Or on the opposite end of the spectrum, some Christians make it sound like gratitude is the only legitimate motivation for obedience: "Look at everything Christ has done for you. Now be thankful and let the good works flow." These are both true motivations for holiness, but they aren't the only ones.
Jesus is the Great Physician, and like any good doctor he writes different prescriptions for different illnesses. The gospel is always the remedy for the guilt of sin, but when it comes to overcoming the presence of sin, Jesus has many doses at his disposal. He knows that personalities and sins and situations all vary. Jesus is not like a high school athletic trainer who tells everyone to "ice it and take a couple ibuprofen." He's not some quack doctor who always prescribes bloodletting. "High cholesterol? Here's a leach. Overactive bladder? I got a leach for that. Gout? A couple leaches will take the edge off."
The good news is that the Bible is a big, diverse, wise book, and in it you can find a variety of prescriptions to encourage obedience to God's commands.
Here are just some of the ways in which the Bible motivates us to pursue holiness:
- Duty. "The end of the matter; all has been heard. Fear God and keep his commandments, for this is the whole duty of man" (Eccles. 12:13).
- God knows all and sees all. "For God will bring every deed into judgment, with every secret thing, whether good or evil" (Eccles. 12:14).
- It's right. "Children, obey your parents in the Lord, for this is right" (Eph. 6:1)
- It's for our good. "Be careful to obey all these words that I command you, that it may go well with you and with your children after you forever, when you do what is good and right in the sight of the Lord your God." (Deut. 12:28).
- God's example. "Be kind to one another, tenderhearted, forgiving one another, as God in Christ forgave you" (Eph. 4:32).
- Christ's example. "And walk in love, as Christ loved us and gave himself up for us, a fragrant offering and sacrifice to God" (Eph. 5:2).
- Assurance. "Therefore, brothers, be all the more diligent to confirm your calling and election, for if you practice these qualities you will never fall" (2 Pet. 1:10).
- Being effective as a Christian. "For if these qualities are yours and are increasing, they keep you from being ineffective or unfruitful in the knowledge of our Lord Jesus Christ" (2 Pet. 1:8).
- Jesus' return. "Since all these things are thus to be dissolved, what sort of people ought you to be in lives of holiness and godliness, waiting for and hastening the coming of the day of God, because of which the heavens will be set on fire and dissolved, and the heavenly bodies will melt as they burn!" (2 Pet. 3:11–12).
- The world is not our home. "Beloved, I urge you as sojourners and exiles to abstain from the passions of the flesh, which wage war against your soul" (1 Pet. 2:11)
This list could easily be tripled. God doesn't command obedience "just cuz." He gives us dozens of specific reasons to be holy. God can prescribe many different medicines for motivation. If you're struggling with pornography, he might call to mind your identity in Christ or admonish you that the sexually immoral will not inherit the kingdom of God. If you are fighting pride, God might assure you that he gives grace to the humble or remind you that you follow a crucified Messiah. He can highlight your adoption, justification, reconciliation, or union with Christ. God can stir you up to love and good deeds with warnings and promises, with love and fear, with positive or negative examples. He can remind you of who you are, or who you were, or who you are becoming. God can appeal to your good, the good of others, or his own glory. You could probably find a hundred biblical reasons to be holy. And the sooner we explore and apply those reasons, the more equipped we'll be to fight sin, the more eager to make every effort to be more like Christ, and the more ready to say with the apostle John, "his commandments are not burdensome" (1 John 5:3).
Learn more about The Hole in Our Holiness by Kevin DeYoung.


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i am overpowered by the love that is inside me. i always have been. sometimes I have been able to use it to great effect, and other times I have been terrified by it to the point of total paralysis.
i've been reading break the night by elizabeth murray. it's a good book so far. i love reading biographies. if i made a list of all the biographies i've read, it would fill this blog. i read them to remind myself that everyone has specific struggles throughout life, and often they are worse then my own. i find it fascinating and encouraging to learn how someone survives and prospers under difficult circumstances.
that said, i just fully realized last night that if a story is close to what i experienced as a child, it will start bringing back memories. things that are floating in my mind that i chose not to focus on because they tend to stop me cold. i remember being very young, and when my father would come home from work, he and my mother would lock themselves in their bedroom to get high. i did not know the reason when i was a kid. my mother admitted it to me later on, although she is never specific on what they were using at that time. my sister and my older half-sister and i would spend the time drawing pictures in the kitchen. i remember sneaking down the hallway and sliding the pictures under the door.
i was always taken care of. always fed, always had clean clothes, never neglected, never sexually abused. i got all the little girl toys i wanted, really. i did, however, get shit kicked out of me on a fairly regular basis. i learned how to hide my bruises when i went to school. but we won't get into that too much here.
these experiences do not define who i am, but i wouldn't be me without them. i contradict myself because i contain multitudes (walt whitman). at the top of the list of things that i am, number one would have to be survivor. if you have lived through a shitty childhood, you build up a resilience. at the bottom of your mind, you know no matter what happens, you will find a way out.
everyday is a choice.
i need to leave. in the history of people who need to escape situations, i am in one of the top 5 scenarios.
i keep fighting this inclination to get sucked in. his capability to make me feel vulnerable is unreal. i don't want to have to worry if i hurt his feelings, just as much as i don't want to be in a position where mine are hurt. last week he demanded to know what was wrong with me, just because i didn't respond in a certain way to him. today he acted upset after i made a (joking) comment about his tendency to yell when he talks. i actually worried about this. i don't what that is, but i don't fucking want it. since day 1, i have tried to maintain distance. i should have never given him an inch last year. that was my first mistake. when i took his arm and told him that i liked him. i was a goddamn moron.
i am sick of it. even when we are getting along wonderfully, it makes me feel slightly ill. there should be boundaries. there should be no feelings involved at any time. no telling me that he misses me. no mentioning "love" or my "little heart." i get along with everybody, but it is as a casual acquaintance. the truth is, this is only temporary.
i just need to leave. other than the bullshit with him, there are about 4 other reasons to just get the fuck out of dodge. i just need to be gone.
"you tend sometimes to overvalue the gifts of the mind, and as a result you may betray your own needs and lose contact not only with what is right for you personally, but with what is right for others as well.
because you look at the general pattern, you are liable to miss essential needs in yourself which may vary from one situation to another. your emotional nature is powerful, raw, and extremely sensitive; and it may periodically throw you into depressed moods, fits of inexplicable irritability or anger, or feelings of loneliness and melancholy which you are unable to analyse or explain.
and you may also overlook another dimension of the realm of the heart which you fear so much: those mystical feelings of longing for letting go and experiencing a more infinite cosmos of love and serenity. personal love and mystical longing lie close together within you, and if you can find the courage to balance your powerful mental abilities with a greater openness to your own humanity, you will find that intimate relationship opens doors of a deeper and more profound kind - not just love of one person, but love of people and of life itself.
you have built a carefully controlled, detached and tolerant personality, and are adept at understanding another's perspective. but this outer surface is very fragile, and you must expend a considerable amount of energy preserving such a front when your real feelings are bubbling away underneath.
your assessment of your emotional life may be a distorted and overly negative one, and perhaps the parental values in which you were brought up have contributed to your harsh judgement on anything within you which is less than perfect or ideal. you will in the long run be far happier and more fulfilled if you can allow others to see and experience your great emotional sensitivity and depth."
"as good as this feels, you know where it goes."
"no. you're wrong. what feels so good is not knowing where it goes."
"how do i talk to you so you hear me? like a child? like a nut? like everything's fine? what's the secret? because i need you to hear me."
"i hear everything."
"then hear this: you need help. before this gets too far, you need help."
"i awoke from The Sickness at the age of forty-five, calm and sane, and in reasonably good health except for a weakened liver and the look of borrowed flesh common to all who survive The Sickness…"
william s. burroughs
(my brother relapsed. i am so fucking angry and sad at the same time. i want to smash things.)
today was not great.
"i think we are well advised to keep on nodding terms with the people we used to be, whether we find them attractive company or not. otherwise they turn up unannounced and surprise us, come hammering on the mind's door at 4 a.m. of a bad night and demand to know who deserted them, betrayed them, who is going to make amends. we forget all too soon the things we thought we could never forget."
joan didion
the employee of the month deal will be announced tomorrow. the prize will be tickets to a baseball game, hockey, or zoo tickets, or perhaps gift cards.
i do not care what the prize is, i want that shit and i will be bone crushingly disappointed if it goes to anyone else.
i am normally not a competitive person. but i have been killing myself at this job for the past 3 months. my sleep pattern has gotten all sorts of fucked up. i have little free time. tomorrow i will be there to at least 9 p.m., then come back in at 6 a.m. saturday morning.
besides the obvious self-esteem issues here, i also really want to win to stick it to at least 3 people.
this post makes me seem like such an asshole, but it's 100 degrees here and i'm exhausted.
listening to p.j. harvey takes me back. way back, i listened to stories from the city, stories from the sea at least a few times a day. (it actually wasn't that long ago - it just feels like it.) i was in love with that album.
i'd sit outside smoking, on my break, with my CD PLAYER, and it would change my mood completely. music has always been a way to escape. those were also the days i worked with brett, who would randomly come and sit outside with me. for the longest time, i had no idea that he liked me.
he had told me he used to smoke (which turned out to be a lie). so i would think he was trying to bum a cig. i'd offer him one, and he'd turn it down. brett was a cool guy, but a little awkward. he was at least 6 foot and thin. he got into this habit of shoving me at times - really hard, i would go stumbling and tripping across the room. then there were the gentle headlocks. dude would manhandle me. in a goofy way. it was only after he came back from some vacation that i figured him out.
he had this big dark ring on his finger, and i commented on it. he immediately took it off, "i got it from mexico. you can have it." i was amazed and tried to give it back, but he wouldn't take it back. and then i finally realized that i was kind of dumb. i was just starting to see the hippie, who was a friend of brett's, too.
i ended up being even dumber and followed that disaster to the end. brett, of course, heard about this pretty quick. he didn't really talk to me too much after that.
the point of this story is: sometimes i'm a liar (a boy has given me a ring), and sometimes i'm the one who hurts someone else.
summing up - i can't listen to pj harvey without a heavy tinge of sadness. also, i'm kind of a bitch at times.
i have to wake up at 4:40 to go into work tomorrow.
i am tired just thinking about it.
sweet fancy moses, give me strength.
what is with people getting engaged lately? every time i hear about these going on, my immediate thought is, 'what, were your parents happy or something?'
i know i will never get married. some people say this in a frivolous or rebellious manner, thinking they are being cool or different. or sad sacks. i simply know for a fact that i will never have a ring on my finger. it just won't happen. sometimes the truth of this makes me sad, but at the same time, i never expected anything different in my life.
my parents marriage scarred me for life. once you've seen how miserable someone can become from another person that they feel chained to, you're set for life. i mean, we had police at the door more than once. there was violence and hell on earth. no, my friend, you will not be dreaming of walking down the aisle. you want to be able to make a neat escape should the time come.
i am just not the wife type, clearly, with the laundry list of emotional problems, and all the poor decision making skills.
things that are supposed last forever terrify me. and yet, i feel alone.