Anorexia Nervosa: The Hospital's Role in Family Treatment

When an anorexia nervosa patient requires hospitalization for her ¹ 1 We will use the pronoun “her” to refer to anorexic patients since the overwhelming majority are female. Our discussion will focus mainly on younger adolescent girls who are still living with their families.
medical condition, the treatment team faces the problem of integrating the individual focus of inpatient care with the systems focus of family therapy. In this paper we propose a family-systems model of hospitalization, the aim of which is to facilitate such integration. The model draws on current theories of anorexia nervosa, as well as general concepts from psychodynamic, developmental, and family systems theories. The major hypothesis of the model is that all members of the anorexic family are developmentally arrested in the area of separation-individuation. On this assumption, we propose that the entire treatment team (including medical professionals and therapists) needs to function as “parents” to the anorexic family in much the same way that two cotherapists become parental figures in family therapy. Specifically, the team needs to provide those parenting responses that facilitate the family's individuation process.     

The robustness of communication of emotion via facial expression: Emotion recognition from photographs with deteriorated pictorial quality

This study

1 The studies reported here were conducted within the TELEMED project which is funded by the European Community within the RACE program.

examines whether the recognition of emotion from facial expressions is impaired by deterioration of spatial resolution, contrast resolution, and picture size. Eighty judges rated 65 stimuli under 11 conditions: Undistorted, reduced spatial resolution (three steps), reduced contrast resolution (three steps), reduced picture size (three steps), and a very ‘hard’ condition combining the severest spatial and contrast resolution. Variation in picture quality was achieved by using a digital video recorder. Recognition rate and intensity ratings were not significantly affected by variations in contrast resolution or picture size. The only significant reduction of recognition rate and intensity ratings resulted from reduction in spatial resolution, but only with the largest deterioration in such resolution. Results are discussed with respect to the fundamental importance of facial expressions in interaction and communication, and with respect to applications, such as tele-conferencing systems.     

Smoking attenuates regular aerobic exercise benefits to episodic free recall immediately following strenuous physical activity

The present study was designed to evaluate the extent to which free recall performance is influenced by competing demands on physiological resources dependent on blood‐oxygen levels. Fifty‐six healthy young adults (mean age=20 years) were allocated to groups (n_1–4=14) according to their level of exercise (more than 6 h aerobic exercise per wk, or sedentary 1

1 Here sedentary refers to individuals with no regular exercise routines

.) and smoking (more than 10 cigarettes per day, or none) behaviour. Participants performed two free recall tasks, one under normal physically inactive conditions and the other immediately following strenuous physical exertion (a step‐up test for 2 min). We predicted that recall would suffer following strenuous physical activity among smoking aerobic exercisers. We reasoned this would be due to the oxygen‐carrying capacity of the blood being compromised in this group by higher levels of smoking‐related carbon monoxide in the blood stream. The results supported this prediction. We interpret our findings according to a resource model of cognitive function, mediated by physiological mechanisms. Copyright © 2004 John Wiley & Sons, Ltd.     

Other than obedient: Girls' constructions of doctors and treatment regimes for anorexia nervosa

This paper examines how teenage girls diagnosed with and being treated for anorexia nervosa in hospital construct their anorexia, their identity as patients, medical authority and their doctors. In‐depth interviews were conducted with 25 adolescent girls in two large, metropolitan hospitals in Australia. Using a discourse analytic approach informed by poststructural theory, we elucidate how girls perform as patients, contest the authoritative position of doctors and deploy popular, taken‐for‐granted discourses of femininity to resist treatment regimes and the construction of themselves by others as ‘anorexic’ and ‘sick’. Our analysis indicates that medical discourses in the hospital do not necessarily define or delimit girls' constructions of themselves, of anorexia, treatment or their relationships with doctors. The paper argues that understanding and validating girls' perspectives is essential in building and maintaining a therapeutic alliance in hospitals. We conclude by discussing how insights from poststructural analysis can assist in improving hospital practice. Copyright © 2009 John Wiley & Sons, Ltd.     

Organization of the narrative components in autobiographical speech of anorexic adolescents: A statistical and non-linear dynamical analysis

Family theories of anorexia nervosa point out that patients’ autobiographic speech may reflect internalized family interactions. Our study characterizes the statistical distribution and temporal organization of the narrative components describing personal relationships in anorexic and control subjects. Semantic components related to personal interactions were encoded from life narratives of 14 adolescent girls with anorexia nervosa (restrictive type) and of 13 matched healthy adolescent girls. Speech analysis was performed using both statistical methods and non-linear time-series analysis. Static indices showed an over-representation of family relations and an under-representation of love relations in anorexic patients. Dynamical indices showed the independence between relational systems in anorexic patients. Dynamical analysis reveals that interactional patterns are internalized through the temporal organization of autobiographical speech. Moreover, these results support the existence of a specific temporal organization in anorexic adolescents’ life narratives which express the internalization of stationary family patterns and indicate relative inability to disengage from active previous relational patterns and to create new ones.     

Body Poly-texts: Discourses of the Anorexic Body

It is now increasingly acknowledged that anorexia nervosa is a ‘culture-bound syndrome’ which must be understood within the context of an increasing idealization of female thinness and a high prevalence of dieting and body dissatisfaction, particularly amongst women and girls. Whilst this socioculturally-oriented perspective is important, it is also simplistic to conceptualize anorexia simply as a ‘slimmer's disease’. The ways in which contemporary Western culture is imbricated in anorexia are both complex and multiple. This paper uses a discourse-analytic approach, informed by feminist Foucauldian theory, to examine some of the multiple and often conflicting meanings and discursive constructions of the (female) anorexic body. The paper is based on a series of interviews conducted with 23 women (21 diagnosed as anorexic and 2 self-diagnosed). The analysis focuses on the explication of two discourses: a romantic discourse and a discourse of Cartesian dualism evidenced in the interviews. By contrasting the very different ways in which these two discourses constitute the anorexic body, this paper aims to provide thereby a socioculturally contextualized and gender-oriented account of the multiple discursive constructions of ‘anorexia nervosa’ and ‘anorexic’ bodies. Implications for psychotherapeutic interventions are discussed.     

Inside the experience of anorexia nervosa: A narrative thematic analysis

Aim: This study considers the question of whether inpatient admission for anorexia nervosa was a therapeutic experience for two women with chronic anorexia nervosa. The question of whether inpatient admission for anorexia nervosa can be therapeutic is not answerable through existing research evidence. Method: The women were interviewed about their experience of having anorexia, its impact on their lives and the treatment they received. The interviews involved learning about the women's experiences by listening to their stories rather than asking them direct questions about what has been therapeutic about their treatment. Analysis: Their narratives were used to develop understanding grounded in experience and were analysed using a narrative thematic analysis. Ideas, themes and connections were noted but not coded as found in some forms of thematic analysis. Discussion: Consideration is given to the therapeutic qualities of the treatments the women received and the place of therapeutic inpatient admission. The central theme of this research was ‘relationships’ which indicates the use of therapeutic approaches that emphasise the importance of the therapeutic relationship in the treatment of chronic anorexia nervosa. It is suggested that psychodynamic and attachment theories should be used to inform overall treatment models. Some important issues for service provision and areas for further research are identified.     

‘It's like there are two people in my head’: A phenomenological exploration of anorexia nervosa and its relationship to the self

This study explores the lived experience of anorexia nervosa from the perspective of those who use pro-recovery websites for eating disorders. Fourteen people participated in an online focus group or an e-interview. Data were analysed using interpretative phenomenological analysis. Participants described their disorder as a functional tool for avoiding and coping with negative emotions, changing their identity and obtaining control. A central theme was the experience of an ‘anorexic voice’ with both demonic and friendly qualities. This voice felt like an external entity that criticised individuals and sometimes dominated their sense of self, particularly as anorexia nervosa got worse. Applying dialogical theory suggests a new model of anorexia nervosa, where the anorexic voice is a self-critical position, which disagrees with and attempts to dominate the more rational self. It is suggested that to move on from anorexia nervosa, the individual needs to address his/her anorexic voice and develop a new dominant position that accepts and values his/her sense of self.     

Evidenzbasierte Psychotherapie der Panikst?rung mit und ohne Agoraphobie

From the evidence reported in the recent guidelines [Heinrichs et al. (2009) Evidenzbasierte Leitlinie zur Psychotherapie der Panikst?rung mit und ohne Agoraphobie. Hogrefe, G?ttingen] the following conclusions can be drawn with respect to the treatment of panic disorder with or without agoraphobia, as well as for agoraphobia without panic disorder:

1. Every psychotherapy should be preceded by suitable diagnostics and a case formulation.
2. The effectiveness of every psychotherapy should be evaluated with well established measures.
3. For the treatment of panic disorder without agoraphobia, cognitive behavioral treatment (CBT) and applied relaxation have been shown to be effective (evidence grade 1).
4. For panic disorder with agoraphobia, CBT, combination treatment (CBT plus medication), as well as panic-focused psychodynamic psychotherapy in the outpatient setting have shown short-term effectiveness (evidence grade 1). Longer lasting effects have been documented for CBT (evidence grade 1).
5. For agoraphobia without panic disorder, CBT with a focus on situational exposure can be recommended (evidence grade 1).

     

'It's like there are two people in my head': a phenomenological exploration of anorexia nervosa and its relationship to the self

This study explores the lived experience of anorexia nervosa from the perspective of those who use pro-recovery websites for eating disorders. Fourteen people participated in an online focus group or an e-interview. Data were analysed using interpretative phenomenological analysis. Participants described their disorder as a functional tool for avoiding and coping with negative emotions, changing their identity and obtaining control. A central theme was the experience of an 'anorexic voice' with both demonic and friendly qualities. This voice felt like an external entity that criticised individuals and sometimes dominated their sense of self, particularly as anorexia nervosa got worse. Applying dialogical theory suggests a new model of anorexia nervosa, where the anorexic voice is a self-critical position, which disagrees with and attempts to dominate the more rational self. It is suggested that to move on from anorexia nervosa, the individual needs to address his/her anorexic voice and develop a new dominant position that accepts and values his/her sense of self.     

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.     

A study of temperament and personality in anorexia and bulimia nervosa

Although temperament and personality traits could influence the development and course of eating disorders, only a few studies examined the similarities and differences in personality between anorexia and bulimia nervosa. We compared 72 patients with DSM-IV eating disorders and 30 healthy controls. Dimensions of personality and personality disorders were evaluated with the Eysenck's EPQ, Cloninger's TCI, and the SCID-II questionnaires. The rates of impulsivity and clinical features were evaluated using specific rating scales. A comorbid personality disorder was found in 61.8% of patients with eating disorder. Avoidant personality disorder appeared was relatively common in anorexia nervosa restricting type; borderline personality disorder was most frequent in bulimia nervosa and the binge eating-purging type of anorexia nervosa. From a dimensional perspective, anorexic patients presented high scores in the dimension of persistence. Higher harm avoidance and impulsivity was found in bulimic patients. The overall eating disorders group presented high scores in neuroticism and low scores in self-directedness. Eating disorder patients have heterogeneous features of temperament and personality traits. Cluster C personality disorders seem more common in anorexia nervosa restricting type and impulsive personality features are associated with bulimic symptoms. Impulsivity seems to be a key aspect of temperament of bulimic patients, whereas anorexic symptoms are linked to persistent temperament traits.     

Is anorexia nervosa a neuropsychological disease?

Evidence for central nervous system, and more particularly cortical, etiology of anorexia nervosa is reviewed. Topics covered are neuropsychiatric comorbidity, inheritance patterns, the neurobiology of body-image disturbance and of the eating function, perinatal and alcoholic insult to the brain, neurochemical and neuroelectric disturbance, anatomic and metabolic brain imaging, and neuropsychological impairment. It is concluded that there is indeed an important neuropsychological etiological dimension to anorexia nervosa. The profile most frequently associated with anorexia nervosa is right posterior hypometabolism, followed by right anterior hypermetabolism, both associated with right-sided abnormal electroencephalogram spiking. It is also proposed that bulimia consists of a positive neurological subtype and that restricting anorexia represents a negative neurological subtype. Priorities for further research into anorexia nervosa are specified to include twin adoption studies, brain electrical topography studies, postmortem histological studies, and experimentally inspired neuropsychological studies.     

Establishing appropriate symptomatic control groups for the eating disorders

Two symptomatic control groups for the eating disorders were defined using high and low scores on the Dietary Restraint and Disinhibition scales of the Three Factor Eating Questionnaire. Clinical subjects diagnosed with anorexia and bulimia nervosa were compared with these symptomatic control groups using measures of body weight, bulimic symptoms, and anorexic symptoms. In comparison to the high-Restraint/low-Disinhibition group, anorexic subjects scored higher on measures of eating disorder symptoms but not on Restraint and Disinhibition. The high-Restraint/high-Disinhibition group differed from bulimia nervosa subjects on measures of eating disorder symptoms but did not differ on Restraint and Disinhibition. The results suggested that a control group defined by high Restraint and low Disinhibition formed an appropriate control group for anorexia nervosa. For bulimia nervosa, the most appropriate control group was defined by high Restraint and high Disinhibition.     

II. Symposium für Empirische Forschung in der Forensischen Psychiatrie, Psychologie und Psychotherapie am 25. und 26. Oktober 2012 in Hamburg

The Second Symposium for Empirical Research in Forensic Psychiatry, Psychology and Psychotherapy was held on 25th–26th of October 2012 in Hamburg. The symposium offers young scientists in the field the opportunity to present their research studies. In total 15 papers were presented at the symposium which will be briefly described in this article. The following four topics were discussed:

1. Innovative measurement tools for violent and sexual offenders,
2. Risk assessment tools for violent and sexual offenders,
3. Physiological and neuropsychological assessment of violent and sexual offenders,
4. Treatment approaches for violent and sexual offenders.

The conference is organized annually either by the University Medical Center Hamburg-Eppendorf (Institute for Sex Research and Forensic Psychiatry), the Saarland University Medical Center (Institute for Forensic Psychology and Psychiatry) or the Asklepios Medical Center Göttingen (Ludwig-Meyer-Institute for Forensic Psychiatry and Psychotherapy). The best three research presentations are honoured with the Ludwig Meyer Award of the Asklepios Psychiatry Niedersachsen GmbH, the Eberhard Schorsch Award of the German Society for Sex Research and the Hermann Witter Award of the Southwest German Academy of Forensic Psychiatry. The proceedings of the conference are expected to be published in autumn 2013 by the Wissenschaftliche Verlagsgesellschaft Berlin.     

Cognitive process-based subtypes of developmental coordination disorder (DCD)

The purpose of the study was to identify the cognitive subtypes demonstrated by children with developmental coordination disorder (DCD) using the Planning-Attention-Simultaneous-Successive Processing (PASS) theory and the Cognitive Assessment System (D-N CAS). Participants were 108 children aged 5- and 6-years old, 54 with DCD and 54 without DCD, all attending typical kindergartens. They were examined on 31 cognitive-motor variables. Hierarchical-agglomerative and iterative partitioning cluster analyses including 9 motor and 7 cognitive variables revealed the following six subtypes:

• oC1 = children at risk (having considerable difficulty with jumping and minor difficulty with manual dexterity and simultaneous coding);
• oC2 = children on the mean (all cognitive-motor scores close to the mean);
• oC3 = free from cognitive-motor problems (all scores above average);
• oC4 = manual dexterity, planning and simultaneous coding difficulties;
• oC5 = manual dexterity, dynamic balance, and planning difficulties;
• oC6 = generalized cognitive-motor dysfunction (all scores considerably below average).

It is well known that DCD is a heterogeneous condition. However, whenever cognitive processes were lower than average, cognitive-motor relationship was evident in subgroups C1, C4, C5 and C6. Early identification of task-specific cognitive-motor difficulties may be essential for early educational intervention practices in order to anticipate and improve learning, academic and performing difficulties.     

Working with Research Integrity—Guidance for Research Performing Organisations: The Bonn PRINTEGER Statement

This document presents the Bonn PRINTEGER Consensus Statement: Working with Research Integrity—Guidance for research performing organisations. The aim of the statement is to complement existing instruments by focusing specifically on institutional responsibilities for strengthening integrity. It takes into account the daily challenges and organisational contexts of most researchers. The statement intends to make research integrity challenges recognisable from the work-floor perspective, providing concrete advice on organisational measures to strengthen integrity. The statement, which was concluded February 7th 2018, provides guidance on the following key issues:

1. § 1.
   Providing information about research integrity
    
2. § 2.
   Providing education, training and mentoring
    
3. § 3.
   Strengthening a research integrity culture
    
4. § 4.
   Facilitating open dialogue
    
5. § 5.
   Wise incentive management
    
6. § 6.
   Implementing quality assurance procedures
    
7. § 7.
   Improving the work environment and work satisfaction
    
8. § 8.
   Increasing transparency of misconduct cases
    
9. § 9.
   Opening up research
    
10. § 10.
    Implementing safe and effective whistle-blowing channels
     
11. § 11.
    Protecting the alleged perpetrators
     
12. § 12.
    Establishing a research integrity committee and appointing an ombudsperson
     
13. § 13.
    Making explicit the applicable standards for research integrity
     

     

Presupposition and the a priori

This paper argues for and explores the implications of the following epistemological principle for knowability a priori (with ‘ $\mathcal{K}_\mathcal{A}$ ’ abbreviating ‘it is knowable a priori that’).

(AK) For all ?, ψ such that ? semantically presupposes ψ: if $\mathcal{K}_\mathcal{A}\phi, \,\mathcal{K}_\mathcal{A}\psi .$

Well-known arguments for the contingent a priori and a priori knowledge of logical truth founder when the semantic presuppositions of the putative items of knowledge are made explicit. Likewise, certain kinds of analytic truth turn out to carry semantic presuppositions that make them ineligible as items of a priori knowledge. On a happier note, I argue that (AK) offers an appealing, theory-neutral explanation of the a posteriori character of certain necessary identities, as well as an interesting rationalization for a commonplace linguistic maneuver in philosophical work on the a priori.     

Psychometric features related to the acute phase and final outcome of anorexia nervosa

The MMPI responses of a poor and good final outcome group from a follow-up study of anorexia nervosa were compared with responses of a group of anorexic patients in the acute phase. The poor outcome group produced elevated scores in the psychopathological range except on scales 4, 5 and 9. No elevations occurred in the good outcome group and the MMPI thus discriminated significantly between different kinds of final outcome of anorexia nervosa. The profile of the patients in the acute phase at time of testing was not significantly different from the poor outcome group profile. In order to improve the predictive validity of the MMPI related to anorexia nervosa, the paper points to possible directions for further research.