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.     

‘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.     

'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.     

NEED,GREED AND ENVY IN ANOREXIA NERVOSA AND THE CHALLENGE THEY PRESENT

For as long as man has been on this earth, envy and greed have performed a duet of destruction. Indeed, these terrifyingly complimentary emotions have been at the root of the worlds' great conflicts and can be seen featuring as a point of origin in what are euphemistically referred to as ‘crimes of passion’. In biblical accounts, both were sighted amongst the seven deadly sins. An impressively awesome curriculum vitae indeed.

In this paper I should like to explore the role of envy and greed in the formation of anorexia nervosa, where it would appear that the destructive nature of this powerful duo have been turned inwards against the body itself. Analytical theorists make much of the difficulties evoked by the Oedipal situation. These particular theories are explored at length and applied to anorexia nervosa. In attempting to understand how this painful stage of development impacts upon this client group, the difficulties posed and the coping strategies employed to alleviate them are both examined.

A further avenue discussed is the particular challenge anorexia nervosa sufferers pose to those of us who would seek to engage them in therapy. Anorectic difficulties in engaging and accepting therapy are explored and understanding is sought as to how we might begin to make progress with this most intractable of illnesses. I would like to illustrate these issues by utilizing my experiences of working clinically with a client suffering from an enduring eating disorder.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

From eating disorders to women's situations: Extending the boundaries of psychological inquiry

This paper seeks to extend feminist critiques of the prevalent psychiatric approaches to the eating disorders. It also includes a critique of feminists' writings that make assumptions similar to, and hence suffer from some of the same theoretical weaknesses as, the prevalent clinical literature. The main purpose is to contribute to the development of a social-historical approach to the study of the relentless pursuit of thinness among women. The social-historical approach is contrasted with individualistic psychological, family systems and multidimensional accounts of anorexia nervosa and bulimia. Potential directions suggested by feminist and social-historical analyses of the relentless pursuit of thinness among women are briefly described.     

MMPI-A in the inpatient assessment of adolescents with eating disorders.

The MMPI-A (Butcher et al., 1992), like the older MMPI (Hathaway & McKinley, 1983), distinguishes between anorexia and bulimia. In this study, 245 adolescent girls diagnosed with anorexia, bulimia, or eating disorder not otherwise specified completed the MMPI-A. Multivariate analyses revealed significant differences between anorexia and bulimia on the MMPI-A's validity, clinical, content, and supplementary scales, particularly suggesting multiple impulse control problems among bulimic patients. However, profiles were also more homogeneous across eating disorder groups than in studies using the older MMPI, with high points involving some combination of Scales 1, 2, 3, and 0 for two thirds of the patients in this study. Implications are considered for understanding the common and differential psychopathology of eating disorders.     

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.     

Nature against nurture: calcification in the right thalamus in a young man with anorexia nervosa and obsessive-compulsive personality disorder

This report describes the case of a young man with a large calcification in the right thalamus that was first diagnosed at 9 years of age. Case history reveals specific eating rituals and other obsessive-compulsive personality traits during the patient's childhood and adolescence, fulfilling diagnostic criteria of obsessive-compulsive personality disorder. After a critical life event the patient develops anorexia nervosa. We suggest that our case and further literature provide evidence for an involvement of specific thalamic structures, such as the dorsomedial nucleus, in the development of anorexia nervosa. Furthermore, the treatment of the patient by a combined psychotherapeutic and pharmacotherapeutic approach is described. We focus on the beneficial effect of the atypical antipsychotic olanzapine, which can induce weight gain by an increase of leptin levels.     

The severity and status of eating disorder NOS: implications for DSM-V

"Eating disorder NOS" is the most common eating disorder encountered in outpatient settings yet it has been neglected. The aim of this study was to describe the characteristics of eating disorder NOS, establish its severity, and determine whether its high relative prevalence might be due to the inclusion of cases closely resembling anorexia nervosa or bulimia nervosa. One hundred and seventy consecutive patients with an eating disorder were assessed using standardised instruments. Operational DSM-IV diagnoses were made and eating disorder NOS cases were compared with bulimia nervosa cases. Diagnostic criteria were then adjusted to determine the impact on the prevalence of eating disorder NOS. Cases of eating disorder NOS comprised 60.0% of the sample. These cases closely resembled the cases of bulimia nervosa in the nature, duration and severity of their psychopathology. Few could be reclassified as cases of anorexia nervosa or bulimia nervosa. The findings indicate that eating disorder NOS is common, severe and persistent. Most cases are "mixed" in character and not subthreshold forms of anorexia nervosa or bulimia nervosa. It is proposed that in DSM-V the clinical state (or states) currently embraced by the diagnosis eating disorder NOS be reclassified as one or more specific forms of eating disorder.     

Young people's theories of anorexia nervosa and obesity

One hundred and forty-seven participants completed a 108-item questionnaire, based on that used by Fumham and Hume-Wright in 1992 aournal of Clinical Psychology, 48, 20-36) that looked at their beliefs about the causes and cures of anorexia neruosa and obesity. The four parts of the questionnaire were individually factor analysed and an intevretable factor structure emerged for each. while age and knowing someone with anorexia neruosa or obesity did not correlate with the factors obtained, sex, actual body size, estimated body size and having experience of an eating disorder were found to correlate significantly with a number of factors. Factors of cause and cure were not correlated regarding anorexia neruosa, but were for obesity. Several correlations within cause and cure, across both disorders, were also significant. The implications of these jindings and how they relate to the theories described in the Introduction are considered in the Discussion.     

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.     

焦虑障碍的系统式家庭治疗

焦虑障碍是最常见的心理障碍之一.其具有症状重、病程慢、复发率高、社会功能明显缺损等特点,给个人、家庭和社会造成了巨大的负担.家庭环境因素在焦虑障碍的发病、转归和预后方面都起到重要作用.本文介绍了国内外关于焦虑障碍患者家庭特点和家庭互动模式的研究结果.系统式家庭治疗作为一种家庭治疗模式,具有其独特的治疗理念和方法,国内外研究结果表明系统式家庭治疗用于焦虑障碍具有良好疗效.今后,还应该运用更加多元化的研究方法探讨中国焦虑症家庭动力学特点和家庭功能,并采用更加严格的随机对照设计,进一步证实系统式家庭治疗对焦虑障碍的治疗效果.     

The Role of the Family in Childhood Obsessive–Compulsive Disorder

While obsessive–compulsive disorder is widely recognized to have a strong genetic component, psychosocial factors are also acknowledged to be important. The primary focus of this paper is on familial factors associated with OCD in children and adolescents. It explores the family context as a possible risk factor in the development and maintenance of the disorder, including parental modeling, expressed emotion, parenting style, and family accommodation of the child's symptoms. The involvement of the family in the treatment of the disorder is also reviewed. Finally, future directions for research investigating familial factors in childhood OCD are presented.     

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.     

Do eating disorder voice characteristics predict treatment outcomes in anorexia nervosa? A pilot study

Individuals with anorexia nervosa often describe experiencing an internal “voice” of their disorder, which previous research has associated with multiple dimensions of eating pathology. This pilot study examined whether eating disorder measures use invoice characteristics at the outset of outpatient therapy predicted changes in disordered eating over the course of treatment. Participants were 14 individuals meeting ICD-10 criteria for anorexia nervosa. Participants completed measures relating to the severity of disordered eating and voice-related characteristics (perceived voice power and metacognitive appraisals about its nature) at the start and end of therapy. Results indicated that the perceived power of the eating disorder was reduced over the course of outpatient therapy, although its other characteristics remained stable. Greater levels of voice power, omnipotence and benevolence at the outset of therapy were related to greater improvements in eating attitudes. No voice-related characteristics were associated with changes in weight. These findings suggest that voice-related appraisals do not obstruct the effectiveness of outpatient therapies for anorexia nervosa. Further studies are needed to ratify these preliminary findings.     

Female Adolescents with Eating Disorders,Parental Psychopathological Risk and Family Functioning

Epidemiological studies on adolescents with eating disorders demonstrate a high prevalence of disordered eating behaviors, with a higher prevalence of eating disorders among girls. Several studies have recently demonstrated an association between female adolescents’ eating disorders, parental psychopathological risk, and an impaired family functioning with poor quality of the relationships among family members. On the basis of these premises, we conducted a cross-sectional study initially recruiting 243 families of female adolescents affected by anorexia nervosa (Group A), bulimia nervosa (Group B), and binge eating disorder (Group C) (average age 14–17) to assess their psychological profile (SCL90-R), specific representations of their family functioning (FACES-IV), and the possible effect of adolescents’ psychological profiles and parents’ psychopathological risk on family functioning. Our results indicate that adolescents and parents in Groups A, B, and C show an unequivocal psychopathological profile; in particular, adolescents with anorexia present the most severe psychopathological risk. Further, our results show that adolescents and their parents differ in their perception of their family functioning. More specifically, adolescents with anorexia perceive their family as highly disengaged, poorly interwoven, and rigid, in addition cohesion and communication qualities are perceived as low. Interestingly, parental psychopathological risk predicts adolescents’ specific perception of their family functioning. These findings may guide clinical interventions as they suggest that distinct maternal psychopathological symptoms can be associated with a variety of clinical configurations in their offspring, whereas paternal psychopathological risk may be present in adolescents suffering from all forms of eating disorders.     

Adolescence, sexual conflict, and anorexia nervosa

Anorexia nervosa is a life-threatening mental disorder. As many as one out of every 250 girls between the ages of 12 and 18 may develop anorexia nervosa. The high incidence of the disorder among adolescent girls suggests that developmental sexual pressure inherent in adolescence may be associated with the onset of the disease. The symptoms of anorexia nervosa appear with the onset of puberty and the development of the secondary sex characteristics. Symptom formation is related to the following developmental issues: physiological changes (menstruation and breast development) and psychological changes (body image and sexual identity).