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.     

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.     

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.     

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.     

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.     

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.     

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.     

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).     

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.     

Overcoming destructive societal values in the treatment of anorexia nervosa: An intensive day treatment model

Sociocultural contributions to the development of anorexia nervosa are examined, and a treatment approach for counteracting these factors are presented. An intensive day treatment program serves as a prototype of such an approach, designed to help overcome the destructive effects of certain values prevalent in North America. This treatment program is outlined and evaluated. The program includes expressive therapies (art, dance, music, and drama), skill-focused activities (stress management, assertiveness training and nutrition programs) and a fitness/recreation program. Significant psychological changes in the participants were found on 10 of the 11 measures employed for evaluatio—the eight scales of the Eating Disorder Inventory, the two clinical scales of the Eysenck Personality Inventory, and the Self-Control Scale of the Reid-Ware Multidimensional Internal-External Scale. The value of such a program as one component of an overall treatment strategy is discussed.     

Multiple family therapy for anorexia nervosa: concepts, experiences and results

Multiple family therapy (MFT) is an increasingly popular treatment approach for adolescents suffering from anorexia nervosa and their families. This paper describes the ingredients and different phases of this treatment, and outlines its indications and contra‐indications. Relationship patterns in families containing anorectic teenagers are examined, with a special emphasis on identifying areas for change in family relationships. Results with regard to the overall acceptability of the approach are presented.     

Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa

This study examined the relationship between therapeutic alliance and primary symptom change (weight gain) during CBT for anorexia nervosa. The aims were threefold: (1) to establish the strength of the therapeutic alliance across the treatment, (2) to determine whether early therapeutic alliance is associated with the completion of CBT for this client group, and (3) to determine the direction of the relationship between therapeutic alliance and weight gain. Adult outpatients (N = 65) with a diagnosis of anorexia nervosa (or atypical anorexia nervosa) completed a measure of alliance at session six and at the end of treatment. Weight was recorded at the start of treatment, session six and at the end of treatment. The strength of the alliance was consistently high in the sample. However, early therapeutic alliance was not associated with either the likelihood of completing treatment or subsequent weight gain. In contrast, both early and later weight gain were associated with the strength of subsequent alliance. These findings indicate that it might be advisable to focus on techniques to drive weight gain rather than rely on the therapeutic alliance to bring about therapeutic change.     

Manipulating body representations with virtual reality: Clinical implications for anorexia nervosa

Anorexia nervosa patients exhibit distorted body-representations. Specifically, they represent their bodies as larger than reality. Given that this distortion likely exacerbates the condition, there is an obligation to further understand and, if possible, rectify it. In pursuit of this, experimental paradigms are needed which manipulate the spatial content of these representations. In this essay, I discuss how virtual reality technology that implements full-body variants of the rubber-hand illusion may prove useful in this regard, and I discuss some issues related to the clinical application of this method.