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Research Article | DOI: https://doi.org/10.31579/NPCP.2019/007
*Corresponding Author: Anna Rita Atti, Department of Biomedical and Neuromotor Sciences, Viale Pepoli 5, 40123, Bologna University, Bologna, Italy.
Citation: Rita Atti A , Bandini L, Valente S, Sighinolfi C, Mastellari T et al. (2019) Cognitive-Behavioral Therapy for Group Assertive Training in outpatients with Eating Disorders: an open label trial. Neural Plasticity Clinical Practice, 2(1): DOI: 10.31579/NPCP.2019/007.
Copyright: ©2019. Anna-Rita Atti. This is an open-access article distributed under the termsof the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 06 November 2019 | Accepted: 16 November 2019 | Published: 27 November 2019
Keywords: assertiveness; eating disorders; binge eating disorder; bulimia nervosa; cognitive behavioral therapy; CBT
Poor assertiveness is a hallmark of Eating Disorders (ED) and it might play a role in etiology and maintenance of ED symptoms. Forty outpatients with Bulimia Nervosa, Binge-Eating Disorder or Not Otherwise Specified ED underwent a 10-week session Cognitive-Behavioral group Therapy (CBT) for assertiveness. Patients were assessed at baseline and after one and three months from treatment beginning. Regression analyses were conducted to assess predictors of outcome. From baseline to month 3, the proportion of patients free of ED symptoms increased while severity of symptoms decreased. Discomfort related to assertiveness decreased while probability of engage in assertive behaviors increased. Some beneficial effects on emotional control were observed. Furthermore, level of general assertiveness achieved after treatment predicted improvements in ED symptoms and emotion regulation. In conclusion, results provide preliminary evidence for the role of CBT group assertive training as an effective intervention for ED patients.
People with a competent range of social skills have a variety of complementary abilities. The capacity to initiate and maintain a conversation, the adequate expression of one’s own feelings and opinions, the ability to deal with criticism in interpersonal situations and to defend one’s own rights and opinions in a respectful way of others’ rights, as a whole, are known as assertiveness [1]. Assertive people are able to recognize their own needs, to affirm themselves with good chance to achieve their own goals, while maintaining positive relationships with others. In other words, the adoption of assertive behaviors allows the understanding and the communication of emotions, feelings and opinions to other people in a balanced way, without assuming passive or aggressive behaviors [1]. Poor assertiveness is a feature of patients affected by Eating Disorders (ED), especially Bulimia Nervosa (BN) and Binge-Eating Disorders (BED) [2–4]. Indeed, besides abnormal eating patterns, people affected by ED show reduced ability to express feelings, low ability to understand others’ perspective [3], and a high self-directed hostility [5]. ED patients usually show difficulties in interpersonal relationships: interpersonal diffculties could be related to giving priority to other people emotions over their own feelings or to interpersonal distrust and conflicts with other people, considering at the same time the presence of specific personality characteristics that can be associated with ED, such as anxious-fearful traits, obsessive-compulsive or avoidant traits in AN and dramatic-erratic personality traits in BN and BED [6,7]. Due to poor assertiveness, they are likely to experience high levels of distress in human interactions [2,3]. Moreover, interpersonal difficulties are often associated with the occurrence of binge behaviors [8] and such difficulties, together with depressive and anxiety symptoms, might play a significant role in the etiology and maintenance of bulimic symptoms [9]. Raykos et al. [10] examined baseline interpersonal problems across eating disorder diagnoses and reported that more severe psychopathology was associated with significantly greater difficulty in socializing. Moreover, their findings showed that interpersonal problems such as difficult socializing and being assertive appeared to be unique risk factors for Eating Disorders.
With regards to treatment options for ED, besides the antidepressants fluoxetine which reduces binge behaviors in BN patients in the short term [11], the Cognitive Behavioral Therapy (CBT) represents the most effective therapy for BN and BED [12]. CBT for ED address not only ED symptoms but also other specific features such as mood intolerance, clinical perfectionism, low self-esteem or interpersonal difficulties [13]. Previous studies demonstrated the effectiveness of CBT on several outcomes, e.g. ED symptoms, psychosocial functioning and interpersonal problems: in particular, CBT techniques allow to address the overevaluation of shape and weight (core symptom in EDs), establishing a regular eating behavior and helping the patient engaging in the process of change. Furthermore, CBT training takes into consideration the interpersonal life area, evaluating the potential role of the patient’s relationships, which could favor the process of change or in contrast represent an obstacle to the healing process [4, 12-14]. Group and individual CBT for patients with Bulimia Nervosa revealed equivalent effects, though individual CBT seems to be more effective in maintaining abstinence from bulimic behaviors in the long term [15]. However, CBT is overall known to be effective in group settings as well [12,16].
As stated before, focusing on problematic interpersonal features associated with ED is a useful and powerful strategy to treat these conditions and obtain long-lasting amelioration of symptoms. An open trial of group CBT evaluating some interpersonal elements (such as assertiveness) in a sample of 29 patients, based on the work of Fairburn et al. [17] and Jones & Stone [18], showed an overall improvement in dimensional measures of bulimic attitudes and behaviors, in particular maintained at the 6-month follow-up. Moreover, statistically significant improvement in psychological functioning was evident for assertiveness [19]. Another open trial carried out on BN outpatients confirmed that a Combined Group CBT (CGCBT) with assertive training and self-esteem enhancement reduced binge-eating behaviors and improved social functioning [20].
Recently, authors have focused on exploring predictors of clinical outcome in ED [21–23] to target those variables that could improve ED symptoms, in order to enhance clinical interventions and protocols of care. From evidence, predictors of ED symptoms reduction were improvement in emotion regulation strategies [22], reduction in weight and shape concerns and reduction of depressed mood [21], concern over mistakes, perfectionism and mood intolerance [23]. To our knowledge, even though assertive trainings have been shown to improve ED symptoms in open trial studies [17–20], its specific role in predicting clinical improvement in ED symptoms and emotion regulation strategies has not been examined yet.
In the present study we delivered a CBT group training on assertiveness (not focused on specific eating disorder patterns) in order to improve ED symptoms (such as binge behaviors, unusual eating behaviors, disordered eating patterns etc.) and emotion regulation in outpatients with BN, BED, and other related disorders such as NOS eating disorder (EDNOS), and Night Eating Syndrome (NES). We evaluated the specific effect of the assertiveness module included in the CBT-Enhanced protocol treatment, as CBT-E can be considered a powerful treatment that can be used in outpatients with ED, as showed in previous studies. In fact, CBT-E allows to target perfectionism, to cope adequately with intense mood alterations (e.g. depression, anger and anxiety) and to work on low self-esteem and interpersonal difficulties. Especially for BN and BED, CBT techniques are considered as a first-line treatment [13-14, 24].
Furthermore, in order to assess predictors of outcomes, we expected: a) the general level of assertiveness achieved after intervention (3 months) to predict the severity of ED symptoms, over and above the severity of ED symptoms showed at baseline; b) the general level of assertiveness at 3 months to predict the ability of emotions regulation after treatment (3 months), over and above difficulties in emotion regulation strategies showed at baseline.
2.1. Participants
Patients were consecutively recruited among individuals referred for a psychiatric consultation from February 2012 until January 2014, to the Adult-Study and Assistance Unit for Eating Disorders of Bologna, Northern Italy. It is an Academic Outpatients Clinic specialised in the diagnosis and treatment of eating disorders in adult (≥18 years, Italian legal age); patients are followed regularly and consultations are held by a psychiatrist generally once a week, therefore the most severe cases are adressed in different and more intensive levels of care. Patients were asked to participate whether they met the following inclusion criteria (i) age ≥ 18 years, (ii) ability to provide an informed consent, and (iii) diagnosis of Bulimia Nervosa (BN), or Binge-eating Disorder (BED), or NOS Feeding or Eating Disorder (EDNOS), according to DSM-IV criteria (DSM-IV criteria were used for all patients to maintaint homogeneity in diagnosis, as the first patients were enrolled before DSM-V was published). Exclusion criteria were (i) current presence of psychotic symptoms, (ii) serious suicidal ideation, (iii) substance abuse, (iv) mental retardation, (v) poor understanding and difficulties in comprehension and speaking Italian, (vi) neurological disorders and/or severe or unstable medical conditions that could impair evaluations. An informed consent was signed by all participants at study’s enrollment. The study was approved by the local ethical committee (Comitato Etico Interaziendale Bologna-Imola - CE-BI, approval code: CE07OS09). Out of 45 patients meeting the inclusion criteria, 40 accepted to take part to the CBT group training on assertiveness. The remaining 5 subjects did not accept because they felt uncomfortable in filling out the psychometric tests.
2.2. Evaluations
The diagnostic evaluation was performed by the Mini International Neuropsychiatric Interview (MINI) [25], a semi structured clinical interview which was administered once at the baseline. Other psychometric evaluations were administered at baseline and after 1 and 3 months from treatment beginning. As group sessions were weekly, at 1-month follow-up participants had already attended 4 sessions, while the 3-months follow-up was performed two weeks after the end of the treatment. Therefore, evaluations were made at baseline, during the training (month 1) and after the training (month 3). Evaluations included the Bulimic Investigatory Test of Edinburgh (BITE) [26], the Scale of Interpersonal Behaviour (SIB) [27,28] and the Difficulties in Emotion Regulation Scale (DERS) [29,30].
The Bulimic Investigatory Test of Edinburgh (BITE) is a questionnaire containing 33 items measuring presence and severity of bulimic symptoms and it consists of two subscales: the symptomatology scale (30 items), which measures the level of symptoms present and the severity scale (3 items) that provides a severity index. This questionnaire has a high internal consistency (Cronbach’s alpha coefficient = 0.96). The BITE is a reliable and valid screening tool: when supported by a clinical evaluation it is suitable for a detailed definition of BN and BED [26]. The Italian version of BITE, as used in this trial, has proven good psychometric properties [31].
The Scale of Interpersonal Behaviour (SIB) questionnaire contains 50 items, 46 of which are classified into the following four categories of assertive responding: 1) Display of negative feelings (Negative assertion), 2) Expression of and dealing with personal limitations, 3) Initiating assertiveness, 4) Praising others and the ability to deal with compliments/praise of others (Positive assertion). In addition to these subscales, a fifth scale named General Assertiveness can be employed as an indication of a person's overall level of assertiveness across various situations and various types of assertive behaviour. The general (Overall) assertiveness score is obtained by summing all the 50 items. For each dimension, the SIB gives two types of information: the importance of discomfort (anxiety/distress) associated with attempts of self-assertion in specific social situations (Discomfort scale) and the probability of engaging in a specific assertive response (Frequency scale). The Italian version of the questionnaire [27] shows robust psychometric properties, reliability and internal consistency (Cronbach’s alpha coefficient = 0.84).
Difficulties in emotion regulation were measured by the Italian version of the Difficulties in Emotion Regulation Scale (DERS) [29,30]. The original 41 items covered six dimensions with good reliability (Cronbach’s alphas > 0.80), resulting in a 36-item questionnaire. The dimensions reflected (a) problems of accepting emotional responses (Non-Acceptance), (b) problems engaging in goal directed behavior (Goals), (c) difficulties with impulse control (Impulse) in response to upsetting emotions, (d) lack of awareness of emotions (Awareness), (e) limited access to emotion regulation strategies (Strategies) in response to distress and (f) lack of emotional clarity (Clarity). Although the factor structure of the Italian validation of the DERS [30] did not perfectly overlap with the original one, the overall and subscales' internal consistency was high (Cronbach’s alpha coefficient: 0.90).
Participants’ opinion and degree of satisfaction regarding the training received was evaluated with no objective tool or scale but during ordinary follow-up clinical interviews held by the referent physician of the clinic.
2.3. Experimental Treatment: Assertiveness Training
The participants underwent the CBT training in groups of about 7 people. The training consisted in 10-weeks group sessions: each session was 90 minutes long and it was held weekly by a trained cognitive-behavioral psychotherapist with previous experience in individual and group CBT treatment of ED (C.S.). The psychotherapist was blind to the participants’ clinical diagnosis and symptoms severity and was otherwise involved neither in the enrollment procedure nor in test administration. The following CBT techniques were used during the training sessions: psychoeducation, cognitive restructuring of distorted thinking, interpersonal skills training, role-playing and problem-solving [32].
Therefore, the ouctomes of the assertiveness activities were (1) to promote ad raise awereness of oneself and one’s interpersonal difficulties, (2) to deal with emotional conflicts, (3) to recognize one’s own behavioral style, (4) to achieve a balanced and constructive behavior without connotations of passivity and/or aggression, (5) to be able to effectively communicate with other people improving interpersonal skills, (6) to increase self-esteem and self-efficacy, thereby reducing the symptoms of anxiety related to discomfort in relationships.
All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975 and its most recent revision. The study was approved by the local ethical committee (Comitato Etico Interaziendale Bologna-Imola - CE-BI, approval code: CE07OS09).
2.4. Statistical Analysis
All statistical analyses were performed by SPSS for Windows, 17th version [33]. Simple linear analyses were performed by the Chi-sq test, the Student’s T-test and General linear model (GLM), within subjects contrast, depending on the nature of the variables. According to power calculation, with a significance level of 0.05, on a sample size of 40 patients we were able to detect medium-large effect size of w=0.45 in Chi-sq analysis (df=1), with a sufficient power of 0.80, and medium effect sizes of f=0.23 in GLM for Repeated Measures Model within subjects contrasts. In addition, in order to assess predictors of outcomes (severity of ED symptoms and emotional dysregulations) regression analyses were conducted.
3.1. Socio-Demographic Characteristics of the Study Population
The socio-demographic characteristics of the sample are summarized in table 1. As shown in Table 1, the experimental group was composed by 40 patients with ED; 97.5% of patients were Italian, while 87,5% were females. 80% of the patients sample was living in urban areas. Mean age of the experimental group was 47 years, with a baseline BMI of 35.3 Kg/m2. In the whole sample, 65% of patients suffered of BED, 17.5% of BN, 10% of EDNOS and 7.5% of NES. Five of 40 patients (12.5%) were subjected to bariatric surgery and 23 patients were receiving psychotropic drugs (57.5%).
A Standard Deviation
3.2. Psychometric Evaluations During CBT Group Therapy for Assertiveness
At the BITE, the proportion of patients without eating symptoms increased during and after the training from 10% (baseline), up to 35.9% (month 3). As shown in table 2A, between baseline and month 3 participants with highly severe symptoms decreased from 22.5% to 10.3%, even though a significant difference could be observed only considering the severity of symptoms after the first month of treatment (Chi-sq=4.48 df=1 p=0.034).
However, comparing patients who are free from symptoms with those reporting ED symptoms (unusual eating habits and highly disordered eating pattern together), a significant overall decrease could be detected in the number of patients reporting symptoms (Chi-sq=7.98 df=2 p=0.018), especially comparing subjects at baseline and at month 3 from treatment initiation (Chi-sq=7.87 df=1 p=0.005).
Findings show that, during the group CBT, the number of patients reporting ED symptoms decreased over time, while patients reporting no symptoms at the BITE increased. Specifically, 26% of the patients reporting ED symptoms at baseline had no more ED symptoms at the end of the treatment (3 months after treatment beginning). Similarly, as regards the severity of symptoms, the number of patients with clinically relevant or severe symptoms decreased over time, while the number of patients with no clinically relevant symptoms increased. Overall, 24% of the patients with clinically relevant symptoms at baseline showed symptoms that were no more clinically relevant at the BITE at the end of the training.
B missing info for 1 subject
Table 2B shows how Distress at the SIB diminished in 4 out of 5 dimensions (Negative Assertion, Expression of and dealing with personal limitations, Initiating Assertiveness, General Assertiveness) both after 1 month and after 3 months from treatment beginning. Similarly, the frequency of assertive behaviors increased. In particular, table 2B shows significant results for Negative Assertion (Discomfort and Frequency Scale), Initiating Assertiveness (Discomfort Scale) and Positive Assertion (Frequency Scale).At the DERS, Goals scale scores improved significantly between baseline and month 1 and such improvement was confirmed at month 3 (F-value=3.899 df=2 p=0.026). Awareness decreased as well across time, even if the result did not appear to be statistically significant.
missing info for 1 subject
3.3. Predictors of Outcomes (ED symptoms and emotional deregulation)
A logistic regression analysis was conducted to assess assertiveness as a predictor of improvement in ED symptoms. In the first step, the severity of bulimic symptoms showed at baseline (as designated by the overall score of BITE) was entered as an independent variable and was found to be a significant predictor of severity of bulimic symptoms assessed at 3 months (dependent variable). Subsequently, the overall level of assertiveness achieved after treatment (measured by the fifth scale of the SIB) score was added in the second step and was found to significantly account for bulimic symptoms, in addition to the variance explained by bulimic symptoms evaluated before treatment. A closer inspection of the final equation in the analysis revealed that both measures of bulimic symptoms at baseline and level of assertiveness achieved after treatment were significant predictors of severity of bulimic symptoms at 3 months.
In addition, a hierarchical linear regression analysis was conducted to assess assertiveness as predictor of improvement in emotion regulation strategies. In the first step, emotion dysregulation showed at baseline (as designated by the overall score of DERS) was entered as an independent variable and was found to be a significant predictor of emotion dysregulation at 3 months (dependent variable). Subsequently, the overall level of assertiveness achieved after treatment (measured by the fifth scale of the SIB) was added in the second step and was found to significantly account for emotion dysregulation at 3 months, in addition to the variance explained by emotion dysregulation assessed at baseline. A closer inspection of the final equation in the analysis revealed that both measures of emotion dysregulation at baseline and level of assertiveness achieved after treatment were significant predictors of improvements in emotion regulation strategies at 3 months.
3.4. Evaluations by Patients
Overall, the feedback of the participants about the assertiveness training was very positive: they all became more aware of their interpersonal difficulties and at the end of the treatment they were able to recognize how their difficulties could influence their ED symptoms and how to manage them.
Results provide preliminary evidence for the efficacy of the assertive training in reducing ED symptoms in patients affected by binge eating (BED), bulimia (BN) and related ED such as NOS eating disorders (EDNOS) and Night eating syndrome (NES). Moreover, it seems to improve specific dimensions of interpersonal and assertive behavior.
4.1. Effect of the Assertive CBT Group on Eating Disorder Symptoms
Our results are consistent with previous findings showing that unspecific training for assertive skills is as effective in reducing symptoms severity as specific interventions focused on symptoms of BN [34]. Furthermore, they are consistent with studies suggesting that the improvement of assertiveness correlates with a natural improvement of eating patterns, as found in girls and young women [35,36]: low assertiveness has been shown to be related to eating problems and interventions on both self-esteem and interpersonal difficulties have been shown to reduce disordered eating behaviors.
Since the intervention was specifically focused on assertiveness, the decreasing discomfort observed in the patients enrolled associated with assertive behaviors and the increasing probability to engage in assertive behaviors together with the improvement of symptoms, suggests the role of poor assertiveness as a potential risk factor for BN, BED and other related disorders [2–4].
4.2. Effect of the Assertive CBT Group on Assertiveness
According to our data, discomfort associated with assertive behaviors decreased at 3 months, though the probability of engaging in assertive behaviors did not change significantly overall.
The main change observed was related to discomfort associated with Negative assertion, i.e. displaying negative feelings in situations in which the individual have to request change in another person's annoying behaviour, have to stand up for his/her rights in a public situation, have to take initiative to resolve problems and to satisfy his/her needs or have to refuse requests.
Another interesting result for the patients’ interpersonal skills was observed on Initiating assertiveness, i.e. introducing oneself, starting a conversation with a stranger or a group of strangers and expressing one's own opinion. Discomfort decreased during and after the treatment, and the probability to engage in these assertive behaviors increased after the treatment. Discomfort and probability of Expression and dealing with personal limitation decreased and increased respectively after treatment.
Similar findings were obtained in several trials testing multidimensional interventions that included assertive training [19, 37–39].
4.3. Effect of the Assertive CBT Group on Emotion Regulation
Results show that even though our intervention was not strictly focused on emotion regulation skills, the assertive training had positive results on some dimensions of emotion regulation. Difficulties in emotion regulation have been associated with emotional eating in obese bariatric surgery candidates [40,41] and in people suffering from ED [42–45], in particular in Anorexia Nervosa [46,46–50], BED [51–54] and BN [46,52,55].
In the last decade, among novel treatments for ED, some approaches have been developed to specifically address emotion regulation, especially for BN and BED [56]. According to a recent review of the literature [57], dialectical behavior therapy (DBT), which specifically address emotion deregulation, is effective in addressing ED and their symptoms. However, improvement in emotion regulation capabilities as a driving element for ED symptoms reduction is not fully supported and the beneficial effects seem not to be maintained in the long term [58]. In our sample, training on assertiveness suggest improvement on some dimensions of the emotional control (Non-Acceptance and Goals scales scores in particular), contributing potentially to the reduction of symptoms severity and frequency in BN and BED patients.
4.4. Predictors of Outcomes
In our study we aimed at assessing the impact of assertiveness on clinical improvements, in particular ED symptoms and emotion deregulation. Findings have shown how the level of assertiveness achieved after treatment could predict a reduction in bulimic symptoms, emotion deregulation and severity (as showed for both BITE and DERS at baseline).
4.5. Limitations of the Study
Overall, the results of the present study should be taken in the light of some important limitations. Firstly, patients were already receiving a psychotherapeutic and/or psychopharmacological intervention. The effect of previous treatment may have influenced the group training results. However, this represents indeed what happens in routine clinical practice and increases the external validity of our study.
Nonetheless, even though all subjects were already under treatment, a positive effect of the assertiveness training could be observed on ED symptoms, suggesting that it may be an effective strategy to improve the standard individual psychological and/or pharmacological treatment.
Another limitation which may be partially explained by the point discussed above is the high percentage of patients that, at baseline, were classified as not having clinically relevant ED symptoms (10%) and/or not of clinically relevant severity (42.5%). Nevertheless, all the patients enrolled received a structured clinical diagnostic interview (MINI), beside the BITE assessment, to ensure the presence of a current ED: they were enrolled in the study only if satisfying criteria for a current ED were present.
The Italian version of the BITE has proven good psychometric properties and good sensitivity for BN, but it lacks accuracy in detecting some ED such as anorexia, NES and EDNOS. This might explain the inclusion of patients with no or not clinically relevant symptoms, due to the BITE use.
However, it remains one of the most consistent, valid and reliable questionnaires to detect altered eating behaviors.
Nevertheless, the specificity of our sample and the relative overall low severity of symptoms should be taken into account as a potential confounder, as well as a limitation for comparative purposes. Furthermore, the sample size was small (n=40) and we were able to detect only medium-large effects on the presence and the severity of symptoms before, during and after treatment, and medium effect sizes on continuous evaluations. This may explain the low statistical significance of the results obtained and the potential lack of detection of smaller effects. On the other hand, for the same reason, the results obtained may be considered clinically significant, even though the lack of correction for multiple testing may also increase the detection of false positive findings.
Furthermore, as we limited our assessment to 3 months after treatment beginning (the last observation (3rd month) was only 2-weeks after treatment ending) we are able to suggest that the assertiveness training is of some effectiveness for ED only in the short term. Longer follow-ups are needed to evaluate possible maintenance of the observed beneficial effects.
Finally, we point out that the present study is an open label trial therefore lacking a control group and that patients’ gender was not taken into account in the analysis. Results must be considered in the light of these limitations.
This study was carried out without funding.
We are grateful to all patients referring to our clinic for their constant collaboration and warm support. We are thankful to Diana Tassinari and for English revisions of the manuscript.
All the authors have no conflict of interest to declare.
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I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
