Family Therapy with Families of Holocaust Survivors

This is a clinical review of 7 families of Holocaust survivors who presented for treatment because of problems with an adolescent of the third generation. In 3 cases the problem was anorexia, and the remaining 4 had various clinical presentations, mostly related to separation-individuation issues. A common thread in the narratives that unfolded was that the trauma of the grandparent/survivors had been transmitted across subsequent generations to exercise significant influence on the children and grandchildren. Often, a more recent death or separation crisis had been the catalyst for these difficulties or a trigger that activated the Holocaust trauma. An outline of the therapeutic intervention is presented; it was based on a combination of systemic, structural, strategic, and psychodynamic approaches. It is suggested that open acknowledgment of the transgenerational issues played a critical role in moving families toward a more differentiated outcome.     

La terapia de conducta en el tratamiento de la anorexia nerviosa ¿eficaz o peligrosa?

RESUMEN

Por el peligro físico que supone y los delicados matices de sus alteraciones, la anorexia nerviosa constituye un verdadero reto para los procedimientos tradicionales en la práctica clínica. El uso reciente de técnicas de terapia de conducta se ha visto también contestado por su supuesta peligrosidad para las personas que padecen esta importante alteración. En este artículo se revisan los principios fundamentales que sustentan este tipo de terapia y sus implicaciones en la salud del enfermo. Al final del artículo se presenta un breve estudio de casos tratados con terapia conductual.     

Do in-vivo behaviors predict early response in family-based treatment for anorexia nervosa?

The aim of the study is to explore whether identified parental and patient behaviors observed in the first few sessions of family-based treatment (FBT) predict early response (weight gain of 1.8 kg by session four) to treatment. Therapy film recordings from 21 adolescent participants recruited into the FBT arm of a multi-site randomized clinical trial were coded for the presence of behaviors (length of observed behavior divided by length of session recording) in the first, second and fourth sessions. Behaviors that differed between early responders and non-early responders on univariate analysis were entered into discriminant class analyses. Participants with fewer negative verbal behaviors in the first session and were away from table during the meal session less had the greatest rates of early response. Parents who made fewer critical statements and who did not repeatedly present food during the meal session had children who had the greatest rates of early response. In-vivo behaviors in early sessions of FBT may predict early response to FBT. Adaptations to address participant resistance and to decrease the numbers of critical comments made by parents while encouraging their children to eat might improve early response to FBT.     

The effect on a child of a mother who though physically present was emotionally unavailable

In this paper I put forward a hypothesis on a particular psycho-sexual determinant of anorexia nervosa in adolescent girls. I begin with an overview of existing literature which examines anorexia from psychiatric, demographic, medical, historical and psychoanalytic viewpoints. Drawing on the theories of Freud, Klein, Winnicott and Bion, and building on previous thinking, I posit a specific disturbance in the psychic development of the adolescent girl. I suggest that this amounts to her rebellion against the psychic onset of her future maternal capacities for reverie and containment. I link this disturbance to a pathological mother-daughter relationship and illustrate my hypothesis with a clinical account of intensive, long-term work with an adolescent girl. The high motivation and vivid dream material of this patient make for a particularly rewarding study.     

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.     

Anorexia nerviosa: La eficacia de la terapia de conducta

RESUMEN

Dos artículos criticados sobre el tratamiento conductual de la anorexia nerviosa publicados por la Dra. Bruch (1976), en los que afirma que el peso ganado por ese procedimiento se pierde rápidamente y que esta ganancia de peso no se acompaña de otros cambios positivos, se compara con la revisión de varios artículos en los que se utilizó la terapia de conducta en este trastorno. Las críticas de Bruch no son apoyadas por los datos. Se observa la existencia de pruebas empíricas que apoyan la idea de que la terapia de conducta es el tratamiento de elección en la anorexia. A pesar de los grandes conocimientos de la autora en el área de los trastornos de comida y sus numerosas publicaciones, su crítica es muy pobre, especialmente en los que se refiere a datos controlados. En este estudio se intenta probar los supuestos planteados por la Dra. Bruch comparando sus críticas con los tratamientos conductuales de anorexia que se han publicado.     

Childhood anxiety associated with low BMI in women with Anorexia Nervosa

Objective

Extremely low body mass index (BMI) values are associated with increased risk for death and poor long-term prognosis in individuals with anorexia nervosa (AN). The present study explores childhood personality characteristics that could be associated with the ability to attain an extremely low BMI.

Methods

Participants were 326 women from the Genetics of Anorexia Nervosa (GAN) Study who completed the Structured Interview for Anorexia Nervosa and Bulimic Syndromes and whose mother completed the Child Behavioral Checklist and/or Revised Dimensions of Temperament Survey.

Results

Children who were described as having greater fear or anxiety by their mothers attained lower BMIs during AN (p < 0.02). Path analysis in the GAN and a validation sample, Price Foundation Anorexia Nervosa Trios Study, confirmed the relation between early childhood anxiety, caloric restriction, qualitative food item restriction, excessive exercise, and low BMI. Path analysis also confirmed a relation between childhood anxiety and caloric restriction, which mediated the relation between childhood anxiety and low BMI in the GAN sample only.

Conclusion

Fearful or anxious behavior as a child was associated with the attainment of low BMI in AN and childhood anxiety was associated with caloric restriction. Measures of anxiety and factors associated with anxiety-proneness in childhood may index children at risk for restrictive behaviors and extremely low BMIs in AN.     

Is amenorrhea a clinically useful criterion for the diagnosis of anorexia nervosa?

Aim of the study was to evaluate the clinical characteristics and the treatment outcome of underweight patients with eating disorder (ED) not otherwise specified without amenorrhea (EDNOS-WA), compared with classical anorexia nervosa (AN) cases. Seventy-three consecutive female patients (57 AN, and 16 EDNOS-WA) were evaluated before and after a 20-week cognitive behaviour inpatient treatment (CBT-I). Assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and the Temperament and Character Inventory (TCI). At logistic regression analysis, amenorrhea was only predicted by baseline BMI and intense exercise, not by psychopathological variables. Response to CBT-I was good and similar between groups, without differences in the dropout rate or time-to-dropout. Our data lend support to the hypothesis that the criterion “amenorrhea” is of no clinical utility in the diagnosis and treatment of AN and could be removed in the forthcoming DSM-V proposal.     

An Exploratory Evaluation of the Family Meal Intervention for Adolescent Anorexia Nervosa

Although weight restoration is a crucial factor in the recovery of anorexia nervosa (AN), there is scarce evidence regarding which components of treatment promote it. In this paper, the author reports on an effort to utilize research methods in her own practice, with the goal of evaluating if the family meal intervention (FMI) had a positive effect on increasing weight gain or on improving other general outcome measures. Twenty‐three AN adolescents aged 12–20 years were randomly assigned to two forms of outpatient family therapy (with [FTFM] and without [FT]) using the FMI, and treated for a 6‐month duration. Their outcome was compared at the end of treatment (EOT) and at a 6‐month posttreatment follow‐up (FU). The main outcome measure was weight recovery; secondary outcome measures were the Morgan Russell Global Assessment Schedule (MRHAS), amenorrhea, general psychological symptoms, and eating disorder symptoms. The majority of the patients in both groups improved significantly at EOT, and these changes were sustained through FU. Given its primarily clinical nature, findings of this investigation project preclude any conclusion. Although the FMI did not appear to convey specific benefits in causing weight gain, clinical observation suggests the value of a flexible stance in implementation of the FMI for the severely undernourished patient with greater psychopathology.     

Primärprävention bei Essstörungen

Zusammenfassung Essstörungen gelten als schwer therapierbar. Mit einer Mortalitätsrate von 5–16% ist Magersucht die schwerste psychosomatische Erkrankung bei Mädchen und jungen Frauen. In den letzten Jahren wurde daher verstärkt versucht, der Entstehung von Essstörungen durch präventive Maßnahmen entgegenzuwirken. Der Schwerpunkt liegt hierbei auf der Primärprävention im Rahmen von Schulprojekten. Hierfür liegen bereits ermutigende Wirkungs- und Qualitätsnachweise vor. Entsprechende Projekte stehen im Zentrum der vorliegenden Übersichtsarbeit. Diese stellt keinen Anspruch auf vollständige Darstellung, sondern ist ein Versuch der Systematisierung unterschiedlicher Herangehensweisen und soll durch die kurze Beschreibung möglichst prototypischer und evaluierter Beispiele einen Einblick in die derzeitige Praxis der Primärprävention von Essstörungen geben. Quellen der Übersicht sind die Datenbank der Bundeszentrale für gesundheitliche Aufklärung (BZgA), Veröffentlichungen in Fachzeitschriften sowie Internetauftritte. Da Art, Umfang und Umsetzung der Präventionsprogramme sehr von politischen Bedingungen und Voraussetzungen innerhalb des Gesundheits- und Bildungssystems abhängen, bleibt die Übersicht auf Programme aus dem deutschen Sprachraum beschränkt.