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.     

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.     

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).     

Diurnal patterns of salivary cortisol and DHEA in adolescent anorexia nervosa

Although there is well-documented evidence for hyperactivity of hypothalamic-pituitary-adrenal (HPA) axis function in anorexia nervosa (AN), there has been little research into secretory patterns of salivary cortisol and dehydroepiandrosterone (DHEA) in this condition. The cortisol awakening response (CAR), a prominent and discrete feature of the cortisol cycle, has not been extensively explored in adolescent AN. Saliva samples were collected at awakening, 30?min and 12 h post-awakening on two consecutive weekdays from eight female adolescents with clinically diagnosed AN and 41 healthy control (HC) age-matched females. Adolescent AN patients had greater salivary cortisol and DHEA concentrations than HC girls at all points. Increased hormone secretion was unrelated to body mass index. However, despite hypersecretion of both hormones, the circadian pattern including the CAR paralleled that of the HC group. Findings from this preliminary study confirm dysregulation of HPA axis function in adolescent AN as evidenced by hypersecretion of both cortisol and DHEA, which share the common secretagogue adrenocorticotropic hormone. However, the parallel diurnal profiles for AN and HC participants, including the CAR, may indicate hypersecretion per se rather than differential regulation of the diurnal pattern of these two adrenal steroids in AN.     

Adolescent eating disorder: anorexia nervosa

Anorexia nervosa is an eating disorder observed with increasing frequency, especially among adolescent females. No consensus exists concerning the causes of the disorder. Social, psychosexual, family system, biological theories, and the regression hypothesis have been advanced to explain the phenomenon. The major characteristics are 25% loss of body weight, use of various means to lose weight, weight phobia, preoccupation with food, body image disturbances, as well as numerous associated medical conditions: bradycardia, hypotension, dehydration, hypothermia, electrolyte abnormalities, amenorrhea, metabolic changes, and abdominal distress. Anorexic adolescents resist treatment and may die if not cured. The following therapeutic modalities have been effective: hospitalization, and cognitive, behavioral, and family therapy. Some of the typical family patterns, early characteristics, social adjustment problems, and society's contribution to the disorder are presented.     

Cross-cultural issues in the treatment of intractable anorexia nervosa

This paper presents a case of intractable anorexia nervosa in a child burdened beyond her capabilities by unresolved conflicts in a parent. The dynamics will be assessed in the context of open systems theory of family function to suggest that the mother's conflicts, fixated at the time she left her native country, and her attempts to adapt to a new one, combined with other family members' failure to understand or appreciate the mother's cultural roots, interrupted the patient's normal maturation/development. The paper also presents a successful course of treatment of the binational anorexic girl, using a comprehensive inpatient program, emphasizing intensive family therapy with an open systems theory framework.The earlier version of this paper was presented at the Sixth World Congress of the International College of Psychosomatic Medicine, Montreal, Canada, September, 1981. Helpful comments by Regina Casper, M.D., helpful discussion by Kenneth Calestro, M.A., and support and encouragement by Katharine N. Dixon, M.D. are greatly appreciated.     

The Gnostic Syndrome: Anorexia nervosa

‘The Gnostic Syndrome’ discusses anorexia nervosa in terms of its poetics and in the context of a developmental object-relations theory. One case is used to illustrate the problems of therapy and the antecedents of the anorexia in childhood and adolescence. The paper forms an investigation into pre-moral states and the interaction of anorexia with character structure.     

The psychopathology of anorexia nervosa: A factor analytic investigation

To examine the psychopathology of anorexia nervosa, behavioral assessment measures sampling a wide range of relevant constructs were collected on 150 women diagnosed as having anorexia nervosa. The data were subjected to an exploratory factor analysis using maximum-likelihood estimation and oblique rotation. Five factors were extracted, which were titled Fasting and Restrictive Eating, Depression, Anxiety, and Negative Self-image, Bulimic Behaviors, Fear of Fatness/Body Image Disturbance, and Impulsive Behavior/Post-Traumatic Response. Discriminate function analysis suggested that, other than the bulimic behaviors factor, the Impulsive Behavior/Post-Traumatic Response factor best discriminated between bulimic and restrictor subtypes of anorexics. These data suggest that the underlying dimensions of anorexia nervosa are very similar to those of bulimia nervosa. The findings also have implications for the multidimensional assessment and treatment of anorexia nervosa as well as conceptual models of the disorder.     

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.     

Assessment of self and others during treatment for anorexia nervosa

Abstract

Repertory grids were used to compare a group of anorexic women (n = 12) with normal-weight (n = 12) and dieting (n = 10) control groups. Anorexics differed from both control groups in their perceptions of themselves and others. The constructs used were more meaningful to anorexics than to either control group. The way in which anorexics saw themselves differed from the way in which clinicians have indicated in the literature that they see their anorexic patients. Some constructs adopted a differential meaning and relevance for observer and observed when applied to the anorexic condition. The discrepancies between internally defined and externally imposed interpretations of construct meaning may help to explain why resistance to treatment and high relapse rates are encountered in anorexic women.     

A controlled trial of cognitive-behavioural and behavioural treatment of anorexia nervosa

This study was undertaken to investigate whether a cognitive-behavioural treatment procedure was superior to a standard behavioural treatment, in the outpatient therapy of patients with anorexia nervosa. The two treatments were also compared with a control treatment procedure consisting of routine outpatient management. Each group consisted of eight subjects. All the groups showed some improvement, but the findings did not provide support for the prediction that cognitive-behavioural treatment, designed specifically to manipulate both attitudes and behaviour, was superior to the other types of treatment. The implications of the findings are considered.     

Competence to make treatment decisions in anorexia nervosa: thinking processes and values

This paper explores the ethical and conceptual implications of the findings from an empirical study of decision-making capacity in anorexia nervosa. In the study, ten female patients aged 13 to 21 years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semi-structured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient participants were also tested using the MacCAT-T test of competence. This is a formalised, structured interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief self-administered questionnaires to assess their levels of psychopathology.The issues identified from the interviews are described under two headings: difficulties with thought processing, and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches or current standardised tests of competence.