Possible differences in family patterns in anorexia nervosa and bulimia nervosa

This paper examines the interactions in three families, one where the daughter had anorexia nervosa and two where the daughters had bulimia nervosa, and proposes some differences in the families’ patterns of enmeshment. It is hypothesized that these may be linked to differences in the development of the mother—child relationship. Implications for the choice of therapeutic strategies are discussed.     

Determinants of adolescent obesity: a comparison with anorexia nervosa

This report investigates childhood and adolescent obesity through a comparison with anorexia nervosa, an eating disorder typically associated with the opposite end of the eating behavior spectrum. Many similarities in the etiologies of the two conditions are discussed, particularly with regard to the influence of family interactional patterns. More specifically, it appears that the families of both anorexics and the obese are characterized by overprotectiveness and enmeshment, resulting in a poor sense of identity and effectiveness. Such children, usually compliant and dependent in childhood, misuse the eating function in an attempt to assert their independence and gain control of their lives in adolescence. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), anorexia nervosa, but not obesity, meets the definition of an eating disorder. Although it appears that DSM-III-R is accurate in not classifying obesity as an eating disorder, it is important to keep the etiological similarities of the two conditions in mind when treating obesity.     

Executive functioning in adolescent anorexia nervosa: Neuropsychology versus self- and parental-report

There is limited research concerning the relationship between neuropsychological assessment and self-report of executive functioning in adolescent anorexia nervosa (AN); available studies demonstrate only low to moderate correlations. Therefore, this study examines the association between neuropsychological test performance and self-report in AN. Forty adolescent inpatients with AN completed an extensive neuropsychological assessment, including set-shifting, central coherence, and questionnaires assessing executive functioning in daily life (BRIEF-SR). Their parents filled out an analog version (BRIEF-PF). Statistical analyses revealed low to medium positive and negative correlations between neuropsychological measures and BRIEF subscales. Similarly, self- and parental ratings were only slightly positively correlated, with patients scoring significantly higher than their parents on two subscales. The results support previous findings of modest correlations between self-report and performance-based testing and emphasize the importance of a multiple format assessment of executive functioning in adolescent AN.     

The Peter Pan Syndrome: Inpatient treatment of adolescent anorexia nervosa

Specific strategies designed for intervening in family, hospital, community, and school systems are discussed as crucial components in the treatment of adolescent anorexia nervosa. It is suggested that all these systems inadvertently collude in the “Peter Pan Syndrome”: maintaining the adolescent-identified patient in a latency age role in order to protect mother from depression and the family in its entirety from an “empty nest” developmental crisis. When strategic and structural alterations occurred within the above mentioned systems while the child was hospitalized and after discharge, the anorectic symptom was alleviated.     

The Peter Pan Syndrome: Inpatient treatment of adolescent anorexia nervosa

Specific strategies designed for intervening in family, hospital, community, and school systems are discussed as crucial components in the treatment of adolescent anorexia nervosa. It is suggested that all these systems inadvertently collude in the “Peter Pan Syndrome”: maintaining the adolescent-identified patient in a latency age role in order to protect mother from depression and the family in its entirety from an “empty nest” developmental crisis. When strategic and structural alterations occurred within the above mentioned systems while the child was hospitalized and after discharge, the anorectic symptom was alleviated.     

Moderators and mediators of remission in family-based treatment and adolescent focused therapy for anorexia nervosa

Few of the limited randomized controlled trails (RCTs) for adolescent anorexia nervosa (AN) have explored the effects of moderators and mediators on outcome. This study aimed to identify treatment moderators and mediators of remission at end of treatment (EOT) and 6- and 12-month follow-up (FU) for adolescents with AN (N = 121) who participated in a multi-center RCT of family-based treatment (FBT) and individual adolescent focused therapy (AFT). Mixed effects modeling were utilized and included all available outcome data at all time points. Remission was defined as ≥ 95% IBW plus within 1 SD of the Eating Disorder Examination (EDE) norms. Eating related obsessionality (Yale-Brown-Cornell Eating Disorder Total Scale) and eating disorder specific psychopathology (EDE-Global) emerged as moderators at EOT. Subjects with higher baseline scores on these measures benefited more from FBT than AFT. AN type emerged as a moderator at FU with binge-eating/purging type responding less well than restricting type. No mediators of treatment outcome were identified. Prior hospitalization, older age and duration of illness were identified as non-specific predictors of outcome. Taken together, these results indicate that patients with more severe eating related psychopathology have better outcomes in a behaviorally targeted family treatment (FBT) than an individually focused approach (AFT).     

Daily and trait rumination: diurnal cortisol patterns in adolescent girls

Rumination is a maladaptive form of emotion regulation associated with psychopathology. Research with adults suggests that rumination covaries with diurnal cortisol rhythms, yet this has not been examined among adolescents. Here, we examine the day-to-day covariation between rumination and cortisol, and explore whether trait rumination is associated with alterations in diurnal cortisol rhythms among adolescent girls. Participants (N?=?122) provided saliva samples 3 times per day over 3 days, along with daily reports of stress and rumination, questionnaires assessing trait rumination related to peer stress, and diagnostic interviews assessing depression and anxiety. Greater rumination than usual during the day was associated with lower cortisol awakening responses the following morning, but this effect was not significant after accounting for wake time and an objective measure of adherence to the saliva sampling protocol. Trait rumination was associated with lower average cortisol levels at waking and flatter diurnal slopes, accounting for wake time, protocol compliance, and other factors. These patterns may help to explain why rumination is related to the development of psychopathology.     

Differences between diurnal patterns of salivary cortisol and dehydroepiandrosterone in healthy female adolescents

The adrenal hormones cortisol and dehydroepiandrosterone (DHEA) share a common secretagogue: adrenocorticotropic hormone; however, secretion of these hormones can be dissociated suggesting subtle individual regulation at the level of the adrenal gland. We examined differences in the diurnal patterns of cortisol and DHEA secretion in healthy adolescent girls, with the aim of informing the possibility of exploiting these differences to aid interpretation of data from clinical populations in which these patterns can become dysregulated. Fifty-six healthy females aged 10-18 years provided saliva samples at 0 and 30 min (morning samples) and 12 h post-awakening on 2 consecutive weekdays. For morning salivary cortisol in relation to morning DHEA concentrations, correlational analysis revealed only a trend (p = 0.054). Similarly, the association between evening cortisol and DHEA was characterised as a trend (p = 0.084). Mean morning DHEA concentrations showed more day-to-day consistency than equivalent cortisol samples (r = 0.829 for DHEA and 0.468 for cortisol; z = 3.487, p < 0.0005). Unlike the cortisol pattern, characterised by a marked awakening response (cortisol awakening response, CAR), a significant rise in DHEA concentration post-awakening was not evident. Finally, there was a strong association between morning and evening concentrations of DHEA, not found for cortisol. The study shows differences in cortisol and DHEA secretion in the post-awakening period and informs work that seeks to examine correlates of dysregulated hypothalamic-pituitary-adrenal axis function. Parallel examination of both hormones enables enhanced interpretation of aberrant patterns of the CAR, i.e. an exploration of whether dysregulation affects both hormones (reflecting overall steroidogenic capacity) or cortisol alone (CAR-specific mechanisms).     

Action monitoring and perfectionism in anorexia nervosa

To study action monitoring in anorexia nervosa, behavioral and EEG measures were obtained in underweight anorexia nervosa patients (n=17) and matched healthy controls (n=19) while performing a speeded choice-reaction task. Our main measures of interest were questionnaire outcomes, reaction times, error rates, and the error-related negativity ERP component. Questionnaire and behavioral results indicated increased perfectionism in patients with anorexia nervosa. In line with their perfectionism and controlled response style patients made significantly less errors than controls. However, when controlling for this difference in error rates, the EEG results demonstrated a reduced error-related negativity in the patient group. These seemingly contradictory outcomes of improved performance and reduced error monitoring are discussed in relation with indications of anterior cingulate cortex hypoactivity in anorexia nervosa patients.     

Psychological aspects of anorexia nervosa

Research on anorexia nervosa (AN), its etiology and treatment, and the results of outcome studies are reviewed. Early studies focused on psychodynamic aspects of AN whereas recently the brain's neurotransmitters and hypothalamic area, particularly, having been investigated as contributing to symptoms of AN. No treatment is successful for all AN patients. Recovery is slow and is often resisted. Diet, psychotherapy, and drugs have sometimes alleviated symptoms for some AN patients but the root cause and the best treatment have eluded a century of research.     

Predisposition factors in anorexia nervosa.

Since its first recognition, a number of researchers have endeavored to link anorexia nervosa to underlying pathology. For example, in the past, attempts were made to associate anorexia with such psychiatric disturbances as schizophrenia, anxiety disorders, and obsessive-compulsive and antisocial personality disorders. Most recent efforts have focused on the possible link between anorexia nervosa and affective disorders. This article reviews the literature concerned with investigating psychiatric disturbances and genetic variables hypothesized as predisposing factors in the etiology of anorexia nervosa. Particular emphasis is given to research which discusses the association between anorexia nervosa and depression. Psychopharmacological evidence and family genetics studies are reviewed. Suggestions for future research are also made.     

Perceived-competence deficit in anorexia nervosa.

Anorexia nervosa patients are portrayed as competent and accomplished and yet they feel ineffective and diffident. The assessment of this aspect of their self-esteem presents methodological problems. The Interests and Abilities Questionnaire was designed to measure interests and perceived abilities in typical adolescent activities. The disparity between interests and perceived abilities--perceived-competence deficit (PCD)--was hypothesized to be characteristic of anorexics. Three groups of females, aged 14 to 24, were studied: 13 anorexic inpatients, 13 psychiatric inpatients without an eating disorder but of similar severity of illness, and 48 nonclinical subjects. Similar to the nonclinical controls, anorexics were interested in a variety of activities; similar to control patients, anorexics rated their abilities lower than nonclinical subjects. In PCD, anorexics scored significantly higher than both control groups; this difference was not related to level of depression.     

The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa

There is growing empirical evidence that family therapy is an effective treatment for anorexia nervosa, particularly in adolescence. This is in spite of the fact that the theoretical model from which most of the empirically based treatments are derived appears flawed. This paper provides a brief overview of the research evidence from treatment studies and studies of family functioning. It suggests that the main limitation of earlier theoretical models is their focus on aetiology rather than on an understanding of how families become organized around a potentially life-threatening problem. An alternative conceptual model is presented, and its application to family therapy and multiple-family therapy for adolescent anorexia nervosa is described. The treatment approach focuses on enhancing the families' own adaptive mechanism and mobilizing family strengths.     

Quantitative evidence for distinct cognitive impairment in anorexia nervosa and bulimia nervosa

It is generally agreed that at least some aspects of abnormal eating behaviour is indeed due in part to disordered cognition. The accumulated literature illustrates cognitive impairment in patients with anorexia nervosa (AN) and bulimia nervosa (BN). Yet beyond being inconsistent, these independent studies also do not reveal the magnitude of impairment within and across studies and fail to give due consideration to the magnitude of impairment so as to understand the severity and breadth of impairment and/or differences in cognitive profiles between patients with AN and BN. Hence, the present review on the subject sought to articulate the magnitude of cognitive impairment in patients with AN and BN by quantitatively synthesizing the existing literature using meta-analytic methodology. The results demonstrate modest evidence of cognitive impairment specific to AN and BN that is related to body mass index in AN in terms of its severity, and is differentially impaired between disorders. Together, these results suggest that disturbed cognition is figural in the presentation of eating disorders and may serve to play an integral role in its cause and maintenance. Implications of these findings with respects to future research are discussed.