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.     

Developing a model of the treatment for eating disorder: Using neuroscience research to examine the how rather than the what of change

Treatments for eating disorders, in particular for people with anorexia nervosa, have often been adaptations of therapies designed for other conditions. Indeed, there is a move advocating the use of a transdiagnostic treatment approach in which general module based treatments are mixed together as needed rather than using a specific anorexia nervosa targeted strategy. The outcome of treatment is relatively poor, especially for those who for some reason do not have the benefit of an expert form of early intervention for anorexia nervosa. Technological advances in the neurosciences and genetics have radically altered how eating disorders and in particular anorexia nervosa have been conceptualised. In this paper we describe evidence that suggests that key aspects of the social information processing network both the cognitive and affective elements may be anomalous in people with anorexia nervosa. This has implications for models of treatment which can be tailored more directly to these causal and or maintaining factors. We describe the Maudsley method of working with adults with anorexia nervosa which has integrated these elements. This treatment approach includes working with the individual to develop a more flexible and holistic cognitive style with greater emotional intelligence. This is supplemented with work with the families to interrupt interactions that either accommodate to or aggravate the symptoms. Thus we are now in the position to understand and work to change how people with anorexia nervosa think and behave rather than focusing on what people think and say they do. Our prediction is that treatments that focus more directly on aetiology such as the intrapersonal and interpersonal maintaining factors will improve outcome.     

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.     

Family therapy and psychosomatic illness

The author suggests that clinical experience has developed to the point where the question can be asked, “Is a specific psychosomatic illness responsive to a specific type of family therapy?” Examples such as structural family therapy in childhood diabetes, asthma, pain, and anorexia nervosa; cognitive family therapy in adult chronic pain; and marital group behaviour modification in adult obesity, chronic pain, and myocardial infarction, are critically reviewed. The evidence suggests, but does not yet prove, that specific types of marital and family therapy may be effective in a few specific psychosomatic problems, a useful adjunctive therapy in some psychosomatic problems, and that family assessment is helpful in the management of all psychosomatic problems.     

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.     

SCHIZOPHRENIA AS DIALOGUE AT THE ENDS OF ITS TETHER: THE RELATIONSHIP OF DISRUPTIONS IN IDENTITY WITH POSITIVE AND NEGATIVE SYMPTOMS

Changes to definitions and theories of psychopathology result less from scientific advances and more from changes in social and cultural values. Herein, the historical and contemporary diversity in definitions and theories of anorexia nervosa is used to illustrate this point. First, we offer a discussion of diachronic diversity (diversity over time) and synchronic diversity (diversity at a given point in time) in conceptions and theories of psychopathology in general. Second, we elaborate a social constructionist perspective on psychopathology in general. Third, to illustrate this perspective, we provide a diachronic and synchronic analysis of definitions and theories of anorexia nervosa. Fourth, we discuss the implications of this analysis for clinical practice. We conclude that whatever view eventually prevails will depend not on which one is better at rooting out some hidden truth about anorexia nervosa but, rather, on which one is viewed as more compatible with evolving social and cultural standards, views, and norms regarding health and illness in general and self-starvation in particular.     

Concomitant group therapy with anorectics and their parents as a supplement to family therapy

A study was made of family therapy with anorexia nervosa patients in a child psychiatric outpatient department. Eight families referred in 1984 were offered group therapy and family therapy simultaneously, one group for patients with anorexia nervosa and one group for their parents. The participants of both groups reported that they had learned a lot from the experience but stated that they felt group therapy could not replace family therapy.     

神经性厌食症的家庭治疗--西方关于神经性厌食症心理治疗的新进展

弗洛伊德关于家庭和心理性别发展的论述给神经性厌食症的理解、分析与治疗带来了新的关注焦点,在其之后的学者将他的思想进一步继承和发展,创造出了以家庭为关注对象的且在当代得到广泛应用的系统家庭疗法,并将该疗法应用到了神经性厌食症的诊断与治疗中,取得了开创性的成果.     

Is manualized family‐based treatment for adolescent anorexia nervosa acceptable to patients? Patient satisfaction at the end of treatment

Patient satisfaction with treatment sheds light on the acceptability, disseminability and usefulness of treatments. This study aimed to assess the perspectives of families who completed treatment using a manual-driven family-based treatment for anorexia nervosa. We hypothesized that overall, manualized treatment would be viewed as acceptable and helpful, but that none the less, a proportion of patients would identify a wish for other types or additional therapy. A total of thirty-four families participated in the survey. Results suggest that patients and families viewed the treatment as highly effective and acceptable. However, approximately a quarter suggested that individual therapy, more family therapy, and focusing on other issues besides anorexia nervosa would improve treatment. These data suggest that a manual-driven family-based treatment for adolescents with anorexia nervosa is acceptable to adolescents and their parents, though modifications to include additional therapy and individual therapy might be considered in some cases.     

Locus of control,psychopathology, and weight gain in Juvenile anorexia nervosa

Based on a hypothesized disturbance in personal control and efficacy in anorexia nervosa, locus of control score infernale adolescents with anorexia nervosa was compared to scores obtained from depressed and conduct disorder controls, and to adolescent female standardization norms. Results indicated that (a) as a group, anorectics were significantly more internal than each of the controls; (b) anorectics scoring in a more external direction showed greater denial of illness, fear of weight change, impulse dyscontrol, rigidity of self-imposed controls, use of purgatives and diuretics, and body-image distortion; and (c) more internal anorectics evidenced more rapid weight gain during treatment. Findings were discussed in terms of the psychopathology of anorexia nervosa and the empirical literature relating locus of control to personality functioning and symptom alleviation.     

The role of body image and self‐perception in anorexia nervosa: the neuroimaging perspective

Anorexia nervosa is a severe psychiatric illness characterized by intense fear of gaining weight, relentless pursuit of thinness, deep concerns about food and a pervasive disturbance of body image. Functional magnetic resonance imaging tries to shed light on the neurobiological underpinnings of anorexia nervosa. This review aims to evaluate the empirical neuroimaging literature about self‐perception in anorexia nervosa. This narrative review summarizes a number of task‐based and resting‐state functional magnetic resonance imaging studies in anorexia nervosa about body image and self‐perception. The articles listed in references were searched using electronic databases (PubMed and Google Scholar) from 1990 to February 2016 using specific key words. All studies were reviewed with regard to their quality and eligibility for the review. Differences in brain activity were observed using body image perception and body size estimation tasks showing significant modifications in activity of specific brain areas (extrastriate body area, fusiform body area, inferior parietal lobule). Recent studies highlighted the role of emotions and self‐perception in anorexia nervosa and their neural substrate involving resting‐state networks and particularly frontal and posterior midline cortical structures within default mode network and insula. These findings open new horizons to understand the neural substrate of anorexia nervosa.     

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.     

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.     

'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.     

Conceptualising,designing and drafting a monthly multi-family therapy programme and manual for adolescents with anorexia nervosa

The written transmission of therapists' expertise in manuals is an important issue which is highlighted in the literature. Manuals are essential for research, training and therapeutic guidance. However, the conceptualisation, design and drafting of therapy manuals have received little attention. Our team conceptualised and designed a 10-monthly session multi-family therapy programme for adolescents suffering from anorexia nervosa. This paper presents the methodology used to evolve from training and theoretical models to designing a programme and drafting the accompanying manual. We then describe how our team reached a consensus regarding the role to be attributed to food-related symptoms in the programme. These arduous tasks were rewarded by fruitful discussions among team members, which led to a shared theory of treatment. The methodology presented here is drawn from both the experience of specialised teams and from that of families in providing care to adolescents with anorexia nervosa.     

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.     

Body images of patients with anorexia nervosa, bulimia nervosa and female control subjects: a comparison with male ideals of female attractiveness

Body images of female patients with anorexia nervosa and bulimia nervosa were assessed against females without eating disorders and compared with male ideals of female attractiveness. A computer program was applied to examine body images of 62 patients with anorexia nervosa, 45 patients with bulimia nervosa, and 40 female and 39 male control subjects. Body size overestimation was most distinct in the two patient groups. Self-ideal discrepancy was highest in bulimia nervosa. Estimation of the society's ideal female body in all three female groups did not differ from men's perception of the most attractive female body. Congruence of ideals of female attractiveness in patients, female, and male control subjects and described differences between patients and female controls support the theory that body image disturbance is a problem of processing self-referential information regarding body image rather than a problem of processing body image related information per se.     

Chronic Eating Disorders in Therapy: Clinical Stories Using Family Systems and Psychoanalytic Approaches

This paper presents three pieces of work, all focused around a person presenting with a long history of disordered eating patterns. One treatment was a couple therapy, one a family plus individual therapy and the third a purely individual therapy. The three different psychotherapies demonstrate an approach which uses psychoanalytic as well as family therapy thinking and techniques. The material is offered to show examples of the clinical practice within which individual and couple or family therapy constitute a range of psychotherapeutic responses to people and, in particular, to people with eating disorders. The context of the therapy is described in some detail as it accounts for many features of the treatments, for example, that they are justified within the institution by having been subject to empirical investigation. A metaphor, that of the medieval castle, is offered as an evocation of the experience of the person that is relevant in the practice of both individual and family therapy.     

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.