A systematic review of family caregiving in eating disorders

A qualitative study on the multi-level process of resilience development for adults recovering from eating disorders

BACKGROUND

Resilience research to date has been criticised for its consideration of resilience as a personal trait instead of a process, and for identifying individual factors related to resilience with no consideration of the ecological context. The overall aim of the current study was to explore the multi-level process through which adults recovering from EDs develop resilience, from the perspectives of clients and clinicians. The objective of this research was to outline the stages involved in the process of developing resilience, which might help to inform families and services in how best to support adults with EDs during their recovery.

METHOD

Thirty participants (15 clients; 15 clinicians) took part in semi-structured interviews, and responded to questions relating to factors associated with resilience. Using an inductive approach, data were analysed using reflexive thematic analysis.

RESULTS

The overarching theme which described the process of developing resilience was 'Bouncing back to being me', which involved three stages: 'Who am I without my ED?', 'My eating disorder does not define me', and 'I no longer need my eating disorder'. Twenty sub-themes were identified as being involved in this resilience process, thirteen of which required multi-level involvement.

CONCLUSION

This qualitative study provided a multi-level resilience framework for adults recovering from eating disorders, that is based on the experiences of adults with eating disorders and their treating clinicians. This framework provided empirical evidence that resilience is an ecological process involving an interaction between internal and external factors occurring between adults with eating disorder and their most immediate environments (i.e. family and social). Anorexia nervosa, bulimia nervosa and binge-eating disorder demonstrate high rates of symptom persistence across time and poor prognosis for a significant proportion of individuals affected by these disorders, including health complications and increased risk of mortality. Many researchers have attempted to explore how to improve recovery outcomes for this population. Eating disorder experts have emphasised the need to focus not only on the weight indicators and eating behaviours that sustain the eating disorder during recovery, but also on the psychological well-being of the person recovering. One way to achieve this is to focus on resilience, which was identified as a fundamental aspect of eating disorder recovery in previous research. This study conceptualises resilience as a dynamic process that is influenced not only at a personal level but also through the environment in which the person lives. This study gathered data from adults with eating disorders and their treating clinicians, to devise a framework for resilience development for adults recovering from eating disorders. The paper discussed ways in which these findings and the framework identified can be easily implemented in clinical practice to facilitate a better understanding of eating disorder resilience and to enhance recovery outcomes.

Moving online: young people and parents' experiences of adolescent eating disorder day programme treatment during the COVID-19 pandemic

BACKGROUND

This study examined the experiences of young people and their parents who attended an intensive day treatment programme for eating disorders online during the global COVID-19 pandemic.

METHODS

Online questionnaires were completed by 14 adolescents (12-18 years) and their parents (n = 19). The questionnaires included a mixture of rating questions (Likert scale) and free text responses. Free text responses were analysed using reflexive thematic analysis.

RESULTS

Three main themes were identified: 1) New discoveries, 2) Lost in translation and 3) The best of a bad situation. This study provides insight into the benefits and pitfalls of online treatment delivery in the adolescent day programme context, which has rapidly had to become part of the everyday therapeutic practice. Results indicate that there are advantages and disadvantages to this, and that parents and young people's views differed.

CONCLUSIONS

This study suggests that the increased accessibility provided by online working does not necessarily translate to increased connection. Given the importance of therapeutic alliance in treatment outcomes, this will be an important consideration for future developments of online intensive treatments.

The value of including families in the treatment of anorexia nervosa

The aim of this paper is to consider family and wider carer involvement in the treatment of anorexia nervosa, and how this can be used to add value to services. We discuss widely adopted interventions involving the family that have been manualised and studied in trials that have outcome measures that are of relevance to illness costs. The therapeutic targets of these interventions range from a focus on feeding to the wellbeing of the whole family. The theoretical models that underpin interventions involving the family/wider carers include both intra and interpersonal processes, with the exception of family-based therapy, which in its original form holds an agnostic stance towards aetiology. Although formal evaluation of the cost effectiveness of these interventions is minimal, there is evidence that involving the family can reduce bed use and improve the wellbeing of both patients and family members. Moreover, for the most part, these interventions are acceptable to patients and carers. Finally, we consider how these approaches can be disseminated and scaled up more widely into services.

Psychological distress and associated factors of the primary caregivers of offspring with eating disorder during the coronavirus disease 2019 pandemic

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) is a global pandemic and posed serious challenges in many countries. A number of studies before the COVID-19 pandemic have shown that the primary caregivers of the ED patients are subjected to great burden, psychological pressure, and serious emotional problems. This study aimed to investigate the psychological distress level of the primary caregivers of ED offspring during the COVID-19 pandemic.

METHODS

From March 6 to April 20, 2020, 378 questionnaires for primary caregivers of ED offspring and 1163 questionnaires for primary caregivers of healthy offspring were collected through an online crowdsourcing platform in mainland China. Valid questionnaires that met the criteria included 343 (90.74%) primary caregivers of ED offspring and 1085 (93.29%) primary caregivers of healthy offspring. Using Propensity Score Matching (PSM), 315 (83.33%) primary caregivers of ED offspring and 315 matched primary caregivers of healthy offspring were included in the statistical analysis. Depression, anxiety, perceived stress and social support were measured by Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Perceived Stress Scale-10 and Social Support Rating Scale, respectively.

RESULTS

The rates of depression and anxiety of the primary caregivers of ED offspring were 20.6 and 16.5%, which were significantly higher than those of primary caregivers of healthy offspring (4.1 and 2.2%), all P < 0.001. Regression analysis found that perceived stress, social support, previous or present mental illness, family conflicts during the COVID-19 pandemic had a significant impact on the severity of depression (P < 0.001, P = 0.002, P = 0.041, P = 0.014); Perceived stress, social support, family conflicts during the COVID-19 pandemic and years of education had a significant impact on the severity of anxiety (P < 0.001, P = 0.002, P = 0.002, P = 0.003).

CONCLUSIONS

During the COVID-19 pandemic, primary caregivers of ED offspring experienced more psychological distress than that of primary caregivers of healthy offspring. ED caregivers with high perceived stress may have higher levels of depression and anxiety. ED caregivers with high social support, no mental illness and no family conflicts may have lower levels of depression. ED caregivers with high social support, no family conflicts, and high years of education may have lower levels of anxiety.

Does a Skills Intervention for Parents Have a Positive Impact on Adolescents' Anorexia Nervosa Outcome? Answers from a Quasi-Randomised Feasibility Trial of SUCCEAT

Skills trainings for caregivers of patients with anorexia nervosa (AN) have been proven to be effective in improving caregiver skills and reducing caregivers’ psychopathology. The effects on patients, especially adolescents, are largely unknown. The aim of this study was to evaluate the effectiveness of a caregivers’ skills training program (Supporting Carers of Children and Adolescents with Eating Disorders in Austria, SUCCEAT, workshop or online version) on adolescents with AN delivered as workshops (WS) or online (ONL). Outcomes are Body-Mass-Index (BMI) percentile, eating psychopathology (Eating Disorder Examination, EDE), attitudinal and behavioural dimensions of eating disorders (Eating Disorder Inventory-2), motivation to change (AN Stages of Change Questionnaire), emotional and behavioural problems (Youth Self-Report) and quality of life (KINDL). All outcome variables significantly improved across both SUCCEAT groups (WS and ONL) and were sustained at 12-month follow-up. The online and workshop delivery of SUCCEAT were equally effective. Most effect sizes were in the medium-to-high range. Full or partial remission was observed in 72% (WS) and 87% (ONL) of patients. Caregiver skills trainings, either delivered as workshops or online modules, are highly recommended to complement treatment as usual.

The transition process between child and adolescent mental services and adult mental health services for patients with anorexia nervosa: a qualitative study of the parents' experiences

BACKGROUND

Patients with Anorexia Nervosa (AN) often experience the transition between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) as challenging. This period tends to have a negative influence on the continuity of care for the adolescents and represents a demanding and difficult period for the parents. To our knowledge, no previous study has explored the parents' experience with the transition from CAMHS to AMHS. Therefore, this qualitative study examines how parents experience the transition process from CAMHS to AMHS.

METHODS

In collaboration with a service user with carer experience, qualitative interviews were conducted with 10 parents who had experienced the transition from CAMHS to AMHS, some from outpatient care and others from both in- and outpatient mental care units in Norway. All had some experience with specialized eating disorder units. The interviews were analyzed with a Systematic Text Condensation (STC) approach. Service users' perspectives were involved in all steps of the research process.

RESULTS

Six categories represent the parents' experiences of the transition: (1) the discharge when the child turns 18 years old is sudden; (2) the lack of continuity is often followed by deterioration and relapses in the patient; (3) the lack of involvement and information causes distress; (4) knowledge - an important factor for developing a trusting relationship between parents` and clinicians`; (5) parents have overwhelming multifaceted responsibilities; and (6) parents need professional support.

CONCLUSION

Improving the transition by including parents and adolescents and preparing them for the transition period could ease parental caregiving distress and improve adolescents' compliance with treatment. Clinicians should increase their focus on the important role of parents in the transition process. The system should implement routines and guidelines to offer caregivers support and guidance during the transition process.

A peer interview qualitative study exploring support for carers of people with comorbid autism and eating disorders

BACKGROUND

Carers of people with eating disorders (EDs) are known to experience a lack of support, high levels of unmet needs and resulting distress. Specific support and interventions for carers may benefit both the carer, and their loved one with an ED. Individuals with co-occurring autism and EDs may present with additional needs and difficulties relating to their Autism Spectrum Condition (ASC) that impact their carers. However, there is a lack of research exploring whether carers of people with ASC and EDs have specific support needs, and what kinds of support may be most beneficial for this population.

METHODS

This study used a qualitative interview design, utilising peer interviews. Eleven carers participated in interviews about their experiences as a carer, and their views on existing support systems and potential improvements. As the study took place during the initial UK coronavirus lockdown, the impact of the lockdown also emerged as a topic during the interviews. Interviews were transcribed and analysed using thematic analysis.

RESULTS

Five themes were identified: challenges associated with co-occurring Autism and EDs, a lack of existing support for carers from healthcare services, the personal impact of caring for someone with both ASC and EDs, ideas for how carers can be best supported, and the impact of the coronavirus on carers.

CONCLUSIONS

Carers of loved ones with both ASC and EDs described the experience as having a significant personal impact on their lives, but also experienced a lack of support from healthcare services. There was a perception that caring for someone with both an ASC and EDs presents additional challenges compared to caring for someone with an ED only, and that this population therefore requires specialised support. Recommendations for possible support options, and for further research, are outlined.

Adding maintaining factors to developmental models of anorexia nervosa: An empirical examination in adolescents

OBJECTIVE

A biopsychosocial approach has been proposed to explain the pathogenesis of anorexia nervosa (AN), despite only a few of the existing etiological models having received empirical support. The aim of this study was to empirically investigate Herpertz-Dahlmann, Seitz, and Konrad (2011, https://doi.org/10.1007/s00406-011-0246-y)'s developmental model and to consider if interpersonal reactions to the illness might serve as maintaining factors following the model proposed by Treasure and Schmidt (2013, https://doi.org/10.1186/2050-2974-1-13) METHOD: One hundred adolescents and their families were participated in the study: 50 diagnosed with AN, paired by age and parents' socio-economic status with 50 adolescents without a pathology. Biological, psychological and familial variables were assessed using ten questionnaires and a blood analysis test. Additionally, structural equation modeling was conducted to assess two hypothetical models.

RESULTS

The fit of both models was good after the addition of two covariate parameters (e.g., Comparative Fit Index > 0.96 and Tucker-Lewis Index > 0.95). Premorbid traits were linked to body dissatisfaction and to the number of stressful life events; this in turn was linked to AN symptoms. Biological and familial consequences reinforced this pathology.

CONCLUSIONS

Our findings provide support for both models, suggesting that inter relationships between bio-psycho-familial variables can influence the course of AN during adolescence.

Association between the social support for mothers of patients with eating disorders, maternal mental health, and patient symptomatic severity: A cross-sectional study

BACKGROUND

Although caregivers of patients with eating disorders usually experience a heavy caregiving burden, the effects of social support on caregivers of patients with eating disorders are unknown. This study aimed to investigate how social support for mothers who are caregivers of patients with an eating disorder improves the mothers' mental status and, consequently, the symptoms and status of the patients.

METHODS

Fifty-seven pairs of participants were recruited from four family self-help groups and one university hospital in Japan. Recruitment was conducted from July 2017 to August 2018. Mothers were evaluated for social support using the Japanese version of the Social Provisions Scale-10 item (SPS-10), self-efficacy using the General Self-Efficacy Scale, loneliness using the University of California, Los Angeles Loneliness Scale, listening attitude using the Active Listening Attitude Scale, family functioning using the Family Assessment Device, depression symptoms using the Beck Depression Inventory (Second Edition), and psychological distress using the Kessler Psychological Distress Scale. Patients were evaluated for self-esteem using the Rosenberg Self-Esteem Scale, assertion using the Youth Assertion Scale, and their symptoms using the Eating Disorder Inventory. We divided the mothers and patients into two groups based on the mean score of the SPS-10 of mothers and compared the status of mothers and patients between the high- and low-scoring groups.

RESULTS

High social support for mothers of patients with eating disorders was significantly associated with lower scores for loneliness and depression of these mothers. We found no significant differences in any patient scores based on mothers' level of social support.

CONCLUSIONS

For patients with eating disorders, social support for a caregiver cannot be expected to improve their symptoms, but it may help prevent caregiver depression and loneliness.

Assessing Family Functioning Before and After an Integrated Multidisciplinary Family Treatment for Adolescents With Restrictive Eating Disorders

The present study presents an investigation of family functioning in the families of adolescents with severe restrictive eating disorders (REDs) assessed before and 6 months after a multidisciplinary family treatment program that combined psychodynamic psychotherapy, parental role intervention, and triadic or family-centered interventions. Nutritional counseling and neuropsychiatric monitoring of the overall treatment and care process were also provided. Family functioning was assessed using the clinical version of the Lausanne Trilogue Play (LTPc), a semi-structured procedure for observing family dynamics, previously validated for this patient population. The LTPc is divided into four phases. In phase 1, the mother interacts with the patient while the father assumes the role of observer. In phase 2, the father plans an activity with the patient while the mother observes. In phase 3, all the family members interact. Finally, in phase 4, the parents talk while the adolescent observes. A significant change emerged in family functioning after the treatment, but only for the interactive phase 2, when the father is required to interact with the daughter while the mother silently observes. The results of this study suggest that a relatively brief multidisciplinary treatment program may significantly improve family functioning in the families of patients diagnosed with severe REDs. Although appropriate clinical trials are needed to further test the efficacy of this treatment, the results also reinforce the concept that treatment programs targeting the individual patient and both the parents should be a first-line approach in adolescents with severe REDs.

Identifying Loss of Control Eating within Childhood Obesity: The Importance of Family Environment and Child Psychological Distress

This study aims to examine the differences in family environment, psychological distress, and disordered eating symptomatology between children classified by weight status with or without loss of control (LOC) eating and to test a model of the role of emotional regulation of LOC eating based on a dysfunctional family environment. A cross-sectional study was conducted among 239 families. The assessment measured family expressed emotion, family adaptability and cohesion, child levels of depression and anxiety, body esteem, and disordered eating attitudes. The assessment was carried out in primary care centers and primary schools. Child body mass index (BMI) was associated with higher expressed emotion, psychological distress, and disordered eating symptomatology. Children with obesity and LOC presented higher BMI, poorer body esteem, and more disordered eating attitudes than children without LOC. Children with overweight/obesity, both with or without LOC, exhibited higher psychological distress and emotional overinvolvement than normal-weight children. A partial mediation of depression or anxiety and disordered eating attitudes between expressed emotion and LOC was found. Findings support that children with overweight/obesity show more family and psychological distress. Body esteem issues and disordered eating attitudes could alert the presence of LOC in children with obesity. The function of LOC might be to cope with psychological distress that may appear in a dysfunctional family environment.

SPACE-ARFID: A pilot trial of a novel parent-based treatment for avoidant/restrictive food intake disorder

OBJECTIVE

This pilot trial aimed to assess the feasibility, acceptability, treatment-satisfaction, and preliminary efficacy of Supportive Parenting for Anxious Childhood Emotions adapted for avoidant/restrictive food intake disorder (SPACE-ARFID). SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits and aims to promote food-related flexibility.

METHOD

Parents of 15 children (ages 6-14 years) with ARFID participated in 12 weekly sessions of SPACE-ARFID. Feasibility and acceptability were assessed by calculating enrollment, attendance, attrition, and adverse events. Treatment-satisfaction was assessed with the Client Satisfaction Questionnaire (CSQ-8), administered posttreatment. ARFID symptom severity and impairment and family accommodation were assessed at baseline and posttreatment.

RESULTS

Of 17 eligible families, 15 (88.24%) elected to participate in the trial. Of the 15 participating families, all except for 1 (6.67%) completed all 12 weekly treatment sessions. Both parents and children rated the treatment as highly satisfactory. ARFID symptom severity and impairment as well as family accommodation were significantly reduced from pre- to posttreatment. Increases in food-related flexibility are described.

DISCUSSION

Findings provide preliminary evidence that SPACE-ARFID, a parent-based treatment that focuses on parental responses to the ARFID symptoms is feasible, acceptable, and satisfactory and produces improvement in clinical outcomes.

"If she had broken her leg she would not have waited in agony for 9 months": Caregiver's experiences of eating disorder treatment

This study aims to explore caregivers' experiences of eating disorder services and subsequent impacts on the caregiving burden and patient outcomes. Thematic analysis was employed to investigate qualitative data from a caregiver-targeted online survey run by BEAT, the UK's largest eating disorder charity. Six hundred and 16 caregivers completed the survey. Participants' experiences of eating disorder treatment were predominantly negative, characterised by three main themes: (a) Barriers to care: enduring obstacles caregivers face in accessing support for their loved ones, (b) Experiences of services: high levels of unmet needs for caregivers and patients alike, (c) Affected domains: the pervasive impact of caregiving, influenced by experiences of services. This study is the largest of its kind to explore caregivers' experiences of eating disorder treatment services and aims to give voice to this overlooked group within research. Notably, little has been done to address broader systemic challenges faced by caregivers in accessing support for loved ones. Results indicate these challenges may play a substantial role in shaping the caregiving burden, carer coping styles, and subsequent patient outcomes. Findings denote wider systemic issues and a lack of specificities of information and practical skills that could help prevent caregivers from experiencing the caregiving burden and subsequent consequences on eating disorder patient outcomes.

Caregiver accommodation in adolescents with avoidant/restrictive food intake disorder and anorexia nervosa: Relationships with distress, eating disorder psychopathology, and symptom change

OBJECTIVE

The role of family and caregiver accommodation is a well-defined maintenance factor for anxiety disorders and OCD. Family accommodation for patients with eating disorders is beginning to be described and characterized, but gaps in the literature remain. The current project compares levels of accommodation in families of those with anorexia nervosa (AN) to those with avoidant/restrictive food intake disorder (ARFID). It additionally establishes whether accommodation changes over the course of treatment and the extent to which these changes are related to changes in eating disorder pathology.

METHODS

A total of 39 adolescents with ARFID and 59 with AN presenting to a partial hospitalization program were included, with measures completed at intake and discharge.

RESULTS

Caregivers of adolescents with AN and those with ARFID reported similar levels of accommodation, with the exception of the Reassurance Seeking subscale of the Accommodation and Enabling Scale for Eating Disorders (AESED). Additionally, accommodation decreased significantly from intake to discharge for both patient groups. Intake AESED scores were also significantly related to caregiver distress, and changes in AESED scores were related to decreases in relevant eating disorder psychopathology for both groups.

CONCLUSIONS

The results of the current study highlight the importance of considering family accommodation for ARFID patients and point to the need for future research to capture changes in accommodation over the course of treatment in relation to the delivery of evidence-based interventions and subsequent changes in ED symptoms.

Effectiveness and influencing factors of online education for caregivers of patients with eating disorders during COVID-19 pandemic in China

Objective

The goals were twofold: To estimate the depression and anxiety levels among caregivers of patients with eating disorders (ED) in China during the COVID‐19 pandemic when compared with a control group, and to assess whether an online education program was effective in decreasing the anxiety and depression of the caregivers of patients with ED, and associated factors.

Method

Caregivers of patients with ED (n = 254) and a comparison group of non‐ED caregivers (N = 254) were recruited at baseline. Additionally, caregivers of patients with ED were invited into a free 4‐week online education program, with an additional online group as support. Depression and anxiety levels were assessed at baseline and after the intervention.

Results

Caregivers of patients with ED showed significantly higher levels of depression and anxiety than the comparison group of non‐ED caregivers. The online education program showed no significant effect on decreasing depression and anxiety levels of caregivers of patients with ED overall. Caregivers who had older loved ones and not living with them were more likely to decrease their depression levels. Caregivers of patients with longer illness duration were less likely to decrease their anxiety levels.

Discussion

These results showed that caregivers of ED patients suffered more serious psychological distress during the pandemic. A more structured and intensive online intervention with a limited number of participants might be required to address caregivers' distress in post‐COVID‐19 China.

The autism diagnostic observation schedule: Patterns in individuals with anorexia nervosa

OBJECTIVE

Studies have used the Autism Diagnostic Observation Schedule (the ADOS-2) in individuals with anorexia nervosa (AN), but the patterns of scores have not been assessed. We examined which subset of the ADOS-2 items best discriminate individuals with AN from healthy controls (HC), and assessed the potential clustering of AN participants based on different profiles of the ADOS-2 item scores.

METHOD

We combined datasets from two previous studies, and (a) compared mean ranks between young AN participants (N = 118) and HC (N = 42), (ii) replicated the item selection procedure of the existing ADOS-2 algorithm to assess sensitivity of items in the AN group, and (c) applied a two-step clustering analysis in the AN group (N = 149).

RESULTS

AN participants displayed significantly higher mean ranks than HC participants in five of 32 items. All five items are part of the existing ADOS-2 algorithm. We found two clusters of AN participants; one representing normal social behaviour, comprising 68% of the individuals with AN, and one representing less efficient social behaviour, comprising 32% of individuals with AN.

CONCLUSIONS

The items comprising the social affective cluster of the existing ADOS-2 algorithm are well suited to assess difficulties with social functioning in individuals with AN.

Exploring the ways in which COVID-19 and lockdown has affected the lives of adult patients with anorexia nervosa and their carers

Objective

This qualitative study explores the ways in which the coronavirus disease 2019 (COVID‐19) pandemic and associated lockdown measures have affected the lives of adult patients with anorexia nervosa (AN) and their carers.

Method

Semi‐structured interviews were conducted with patients with AN (n = 21) and carers (n = 28) from the start of UK Government imposed lockdown. Data related directly to the impact of lockdown and COVID‐19 were analysed using thematic analysis.

Results

Four broad themes were identified for patients and carers separately. Patients experienced: 1. reduced access to eating disorder (ED) services; 2. disruption to routine and activities in the community; 3. heightened psychological distress and ED symptoms; 4. increased attempts at self‐management in recovery. Carer themes included: 1. concern over provision of professional support for patients; 2. increased practical demands placed on carers in lockdown; 3. managing new challenges around patient wellbeing; 4. new opportunities.

Conclusions

Reduced access to ED services, loss of routine and heightened anxieties and ED symptoms resulting from COVID‐19 and lockdown measures presented challenges for patients and carers. Increased remote support by ED services enabled the continuation of treatment and self‐management resources and strategies promoted self‐efficacy in both groups.

Reduction of High Expressed Emotion and Treatment Outcomes in Anorexia Nervosa-Caregivers' and Adolescents' Perspective

High expressed emotion (EE) is common in caregivers of patients with anorexia nervosa (AN) and associated with poorer outcome for patients. In this study, we examined the prevalence of high EE in caregivers of adolescents with AN and analyzed predictors for EE using multivariate linear regression models. We further analyzed whether EE is reduced by the “Supporting Carers of Children and Adolescents with Eating Disorders in Austria” (SUCCEAT) intervention using general linear mixed models and whether a reduction of EE predicts patients’ outcomes. Caregivers were randomly allocated to the SUCCEAT workshop (N = 50) or online intervention (N = 50) and compared to a comparison group (N = 49). EE and patients’ outcomes were assessed at the baseline, post-intervention, and at the 12-month follow-up. Up to 47% of caregivers showed high EE. Lower caregiver skills, higher AN symptom impact, higher levels of depression and motivation to change in caregivers were significant predictors for high EE. EE significantly decreased in the SUCCEAT groups and the comparison group according to the caregivers’, but not the patients’ perspective. The level of reduction could partially predict subjective improvement and improvement in clinically assessed AN symptoms and body mass index of patients. Implementing interventions for caregivers addressing EE in the treatment of adolescents with AN is strongly recommended.

Childhood Avoidant/Restrictive Food Intake Disorder: Review of Treatments and a Novel Parent-Based Approach

Avoidant/Restrictive food intake disorder (ARFID) is characterized by dietary restrictions that are not based on weight or shape concerns but that result in marked interference in feeding, growth, or psychosocial functioning (American Psychiatric Association, 2013; Eddy et al., 2019). The aim of the current article was to review available reports of treatment for childhood ARFID published since its inclusion in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and to introduce a novel parent-based treatment for child ARFID through a case presentation. Empirical support for psychosocial treatments for child ARFID currently stems from two small-scale pilot randomized control trials, one pilot open trial, case reports, case series, and retrospective chart reviews. Treatment approaches for outpatient care generally apply family-based therapy, child-centered cognitive behavioral therapy, or parent-based behavioral approaches. SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits. SPACE-ARFID aims to promote flexibility and adjustment in food related situations. The treatment helps parents to systematically reduce family accommodation, or changes that they make to their own behavior to help their child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms.

Long-Term Efficacy of the Workshop Vs. Online SUCCEAT (Supporting Carers of Children and Adolescents with Eating Disorders) Intervention for Parents: A Quasi-Randomised Feasibility Trial

Interventions for main carers of adult patients with anorexia nervosa (AN) can reduce the caregiving burden and increase caregiver skills. However, the effectiveness and feasibility for carers of adolescent patients, the optimal form of the intervention and long-term outcomes are largely unknown. We evaluated the efficacy and feasibility of the "Supporting Carers of Children and Adolescents with Eating Disorders in Austria" (SUCCEAT) workshop vs. online intervention. Main caregivers (parents) of adolescent patients with AN were randomly allocated to a workshop (n = 50) or online version (n = 50). Participants were compared to a non-randomised comparison group (n = 49) receiving multi-family or systemic family therapy. Primary (General Health Questionnaire) and secondary outcomes were obtained at baseline, three-month and 12-month follow-up. Adherence was high for workshop and online participants (6.2 and 6.7 sessions completed out of 8). Intention-to-treat analyses revealed significant pre-post reductions in the primary outcome for the workshop (d = 0.87 (95%conficence interval (CI): 0.48; 1.26)) and online (d = 0.65 (95%CI: 0.31; 0.98)) intervention that were sustained at the 12-month follow-up. There was no significant group difference (p = 0.473). Parental psychopathology and burden decreased and caregiver skills increased in all groups; the improvement of caregiver skills was significantly higher in SUCCEAT participants than in the comparison group. Online interventions for parents of adolescents with AN were equally effective as workshops. The improvements remained stable over time.

A theoretical review of interpersonal emotion regulation in eating disorders: enhancing knowledge by bridging interpersonal and affective dysfunction

Individuals with eating disorders (EDs) frequently report interpersonal and affective dysfunction. A useful lens for uniting these ideas is through the framework of interpersonal emotion regulation (IER), which consists of the ways others assist a distressed individual and how this shapes his or her subsequent emotional, behavioral, and cognitive responses. In this theoretical review, we provide an overview of the rationale for exploring IER and review IER processes in this population using the framework of the Process Model of Emotion Regulation. Finally, we offer suggestions for next steps in conducting research. IER offers a parsimonious way to explore social and emotional constructs related to ED pathology and may provide potential targets for prevention and intervention in these difficult-to-treat disorders.

Focus on family functioning in anorexia nervosa: new perspectives using the Lausanne Trilogue Play

31 families of female adolescents affected by anorexia nervosa (AN) and 20 of girls with emotional and behavioral disorders participated in a semi-standardized videotaped game: the Lausanne Trilogue Play (LTPc). We aimed to clarify if there is a typical AN family profile and if the LTPc procedure could predict the risk of developing AN. We confirmed that AN families exhibit dysfunctional alliances. Particularly because of the difficulty of the three members to be available to the interaction at least with their body (participation) and to comply with the role expected at each stage of the game (organization). Moreover, these families show a significant worse functioning, especially regards to the mother-daughter phase of the game, in focal attention and affective contact functional levels, while in triadic and couple phases they present lower scores than comparison group in all functional levels. Furthermore, we found that LTPc may predict the possibility of belonging to a family with a daughter with AN rather than one whose daughter has a different disorder. Therefore, LTPc would allow clinicians foresee the risk of developing AN and tailoring the most suitable therapeutic intervention and finally see its effectiveness using LTPc for later follow-up video feedback sessions.

Psychological distress among carers and the moderating effects of social support

BACKGROUND

Carers provide both practical and emotional support and often play an important role in coordination of care for recipients. The demands of caring may lead to increased levels of stress for the carer, which can affect mental health and quality of life. This study examined the relationship between being a carer and psychological distress (assessed using the Kessler Psychological Distress Scale [K10]), and explored the moderating effect of social support in that relationship using a large sample.

METHODS

The study used data from the 45 and Up study, a large cohort study of individuals aged 45 years and over in New South Wales, Australia, and applied multiple regression methods and moderation analysis. The sample for the current study comprised 267,041 participants drawn from the baseline dataset, with valid data on the primary outcome (carer status).

RESULTS

The mean age of participants was 62.73 (±11.18) years, and 4.23% and 7.13% were identified as full-time and part-time carers, respectively. Compared to non-carers, full-time carers had K10 scores that were on average, higher by 1.87, while part-time carers' K10 scores were on average higher by 1.60 points. A perception of social support reduced the strength of the relationship between carer status and psychological distress by 40% for full-time carers and 60% for part-time carers.

CONCLUSIONS

The findings have important implications, for both prevention and treatment of psychological problems among carers. In terms of prevention, they suggest that public health campaigns focused on increasing awareness regarding the psychological burden faced by carers would be useful. In terms of intervention, potential treatments that focus on improving social support networks may be helpful. The results are particularly important in the current context of an ageing population in Australian and other developed countries, where caregiving is likely to play an increasing role in the care and support services.

Psychometric properties of the Spanish version of the Experience of Caregiving Inventory (ECI) among caregivers of individuals with an eating disorder

PURPOSE

The aim of this study was to examine the psychometric properties of the Spanish version of the Experience of Caregiving Inventory (ECI-S), which is designed to assess the caregiver's appraisal of the impact of caring for a relative with a serious mental illness.

METHODS

A cross-sectional study was conducted among 320 caregivers of a relative with an eating disorder to examine: (a) descriptive statistics; (b) internal consistency reliability; (c) the fit of the original ten-factor structure of the ECI through exploratory factor analysis, using a semi-confirmatory approach, for each subscale individually, and (d) concurrent validity. A total of 307 caregivers completed the scale.

RESULTS

Reliability of the ECI subscales scores was acceptable (α = 0.63-0.89). Results replicated the original ten-factor structure of the instrument. The concurrent validity was supported by correlations of the ECI-negative subscale with psychological distress (GHQ-12, 0.43), and with depression and anxiety (HADS, 0.48 and 0.49, respectively).

CONCLUSIONS

The Spanish version of the ECI (ECI-S) demonstrated good psychometric properties in terms of validity and reliability that were similar to the original version. It is an acceptable and valid instrument for assessing the impact on family members of caring for a relative with an eating disorder and can be recommended for use in clinical settings in Spain.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

Identifying psychosocial and familial correlates and the impact of the stressful life events in the onset of anorexia nervosa: Control-case study (ANOBAS): Psychosocial and familial correlates and stressful life events in AN

Anorexia nervosa (AN) is a multifactorial illness. Although several studies have determined which factors could predispose AN, few studies have determined which factors could precipitate it. What is more, it has been suggested that having experienced stressful life events (SLE) could be related to the onset of AN. The aim of this study was to explore specific psychosocial and familial correlates and the impact of SLE in the onset of AN. Following a case-control design, 40 adolescents diagnosed with AN were matched to three control groups, 40 healthy adolescents, 40 adolescents with affective disorders, 40 adolescents with asthma and their families by sex, age and socioeconomic status. Diagnostic interviews K-DSADS and questionnaires were used. The results empathised that no specific predisposing correlates were found for AN. Similarly, the increase of the amount of SLE prior to the onset is an overall characteristic for psychiatric disorders, which in AN it is only specifically related to psychological correlates, but no to cortisol. In terms of specific SLE, those related to interpersonal problems were frequent at the onset of AN. The results highlight the consequences of SLEs in the emotional well-being of the AN adolescents, that could be specific for this psychopathology.

Establishment of a multifamily therapy (MFT) service for young adults with a severe eating disorder - experience from 11 MFT groups, and from designing and implementing the model

BACKGROUND

Eating disorders are serious illnesses leading to a substantially lowered quality of life not only for the patient but also for their family. They are difficult to treat, and many patients fail to complete their treatment. At the Regional Centre for Eating Disorders (RESSP) at Nordland Hospital in Bodø, in the north of Norway, it was apparent that many young adult patients maintained an active, ongoing relationship with their family of origin, and that parents and others were often highly involved in their life and illness. It was therefore desirable to develop a treatment model involving family members; specifically a multifamily therapy (MFT) group programme.

METHODS

The aim was to establish an MFT service at RESSP for young adult patients suffering from severe eating disorders. This involved, (1) work preparatory to the establishment of the new service, (2) the development and implementation of a suitable MFT model, and (3) sharing the skills and knowledge gained from our experiences to other professionals in the field, and in other settings. This work of development and change can be understood as a process of innovation and is here described within the framework of implementation theory. The work took place in a clinically naturalistic context at the centre.

RESULTS

The MFT model description is based on experience during its development as well as its final form. The stages of this development process and of the changes made in order to establish the new service are described, together with its core components. To date, 68 patients and 198 family members have participated. Dropout rate has been 7.4% and the majority of patients have continued in treatment after completion of the MFT groups. BMI measurements show a significant weight-gain for those with an underweight at start. 32 other professionals have been trained in the model, and a similar service started in 3 other units.

CONCLUSION

The new model has been welcomed by patients and families alike. The MFT group programme has had a strikingly low dropout rate and a majority of patients have continued in treatment. BMI measurements show a significant weight-gain for those being underweight at start. Other therapists have been trained in the model, and similar services set up elsewhere. In order to document and increase the usefulness of the MFT treatment, a research project has been initiated to evaluate experience and outcomes both quantitatively and qualitatively.

Experiences of patients with anorexia nervosa during the transition from child and adolescent mental health services to adult mental health services

BACKGROUND

The transition between the Child and Adolescent Mental Health Services (CAMHS) and the Adult Mental Health Services (AMHS) is identified as an especially critical time for the continuity of care for patients with anorexia nervosa (AN). However, research on this topic is scarce. In the present study, we explore the patients' experiences of the transition between CAMHS and AMHS.

METHODS

A qualitative explorative study was carried out based on recorded interviews from one multi-step focus group and six individual interviews with patients who experienced the transition from CAMHS to AHMS in Norway. This study is service user-initiated, meaning service users were involved in all steps of the research process.

RESULTS

The adolescents' experiences are characterized by four overall themes regarding the transition process between CAMHS and AMHS: (1) "Being unprepared and alone in the transition process" describes how a lack of preparation for the transition between CAMHS and AMHS makes them feel alone and increases stress. (2) "It takes time to create a trusting relationship" describes how time influences patients' trust in therapists and motivation for treatment. (3) "We are not all the same" describes how adolescents develop differently but are not treated differently despite their diverse ability to be self-sufficient. (4) "How they see me and treat me affects my hope for the future" describes the interaction between adolescents and therapists.

CONCLUSIONS

Acknowledging the patients' needs during the transition period and considering their readiness for the transition is important. Taking into account the four dimensions described in the present study might improve the transition process and enhance the patients' self-sufficiency and maturity.

Living with someone with an eating disorder: factors affecting the caregivers' burden

We focused on carers of subjects suffering from eating disorders (ED), and studied the characteristics that mostly expose them to high levels of stress, anxiety, depression and expressed emotion, favoring the accommodation of the family system to the cared person. We administered the accommodation and enabling scale for eating disorders (AESED) questionnaire, the family questionnaire (FQ) and the depression, anxiety and stress scale (DASS-21) questionnaire to 97 carers of 62 ED patients, and investigated the carer's characteristics associated with the scores in the three questionnaires. A personal history of ED, being the primary carer, and caring for a person with a diagnosis of anorexia nervosa are the characteristics that contribute most to aggravate the carers' burden in terms of stress, anxiety, depression, accommodation and enabling. Our findings may help doctors to provide effective support to caregivers and eventually improve the treatment of subjects with ED.

Validation of a childhood eating disorder outcome scale

We developed and validated a childhood eating disorder outcome scale based on outcomes associated with body mass index standard deviation score (BMI-SDS). This prospective observational study included 131 children with eating disorders (aged 5-15 years). Participants' outcomes scales were completed at the first visit and at 1, 3, 6, and 12 months. The scale evaluated 12 outcomes: body weight change (BW), eating attitude (EA), fear of being fat (FF), body image distortion (BD), menstruation (ME), perceived physical condition (PC), attending school (AS), disease recognition by school (RS), family function (FA), disease recognition by parent (RP), social adaptation (SA), and relationships with friends (RF). Responses to all items were on a four-point Likert scale. Exploratory factor analysis was used to determine the number of factors based on the 12 outcomes. The relation between outcome scale scores and BMI-SDS over the 12-month follow-up period was analyzed. Two types of factors were extracted: disease-specific factors (EA, FF, BD) and biopsychosocial factors (BW, PC, AS, FA, SA, RF). Three items (ME, RS, RP) were excluded because they showed no significant loading effect. There was a significant negative correlation between the outcome scale and BMI-SDS, and changes in outcome scale scores from baseline to 12 months were significantly associated with improvement in BMI-SDS. We developed a childhood eating disorder outcome scale characterized by disease-specific and biopsychosocial factors. Biopsychosocial management combined with a therapeutic approach for disease-specific symptoms may support body weight recovery for children with eating disorders.

Efficacy of a brief group intervention for carers of individuals with eating disorders: A randomized control trial

OBJECTIVE

Interventions for carers of individuals with eating disorders are often time and resource intensive, which may be a barrier for service providers or attendees. This study aimed to evaluate the efficacy of a very brief, two-session psychoeducation and communication skills-based intervention for carers of individuals with eating disorders.

METHOD

Carers (N = 44) were randomized to attend two 2.5 hr sessions delivered 1 week apart or waitlist control. Carer burden, self-efficacy, skills, knowledge, expressed emotion (emotional overinvolvement and critical comments), distress (anxiety and depression), and accommodating and enabling behaviors were assessed at preintervention and postintervention and 1-month follow-up.

RESULTS

Carer burden, self-efficacy, skills, knowledge, and one component of expressed emotion (critical comments) improved significantly more in the treatment group compared to the waitlist. Changes in anxiety, depression, and accommodating and enabling behaviors did not significantly differ between groups.

DISCUSSION

These results demonstrated that substantial improvements can be made from a very brief carers' intervention. More intensive and targeted interventions might be required to address carers' emotional symptoms and to reduce accommodating and enabling behaviors.

Caregiving experience and expressed emotion among parents of adolescents suffering from anorexia nervosa following illness onset

The aim of this study was to better understand the relationship between parents' experience of caregiving and expressed emotion during the early stage of their child's eating disorder. Fifty mothers and 38 fathers of adolescents suffering from anorexia nervosa and hospitalized for the first time participated in this study. They completed the Experience of Caregiving Inventory, a measure of the negative and positive aspects of the caregiving experience, and the Family Questionnaire, which measured the different dimensions of expressed emotion, namely emotional over-involvement and critical comments. Results showed that caregiving experience is significantly and positively correlated to expressed emotion. Among the negative aspects of caregiving, sense of loss contributed most to emotional over-involvement, while difficult behaviours contributed most to critical comments. The results suggest that parents' perceptions of their child and child's future are strongly related to their tendency to be over-involved. The perception of disruptive behaviours in their child could be one of the principal triggers or exacerbating factors of parents' critical attitudes.

Family-based treatment for transition age youth: the role of expressed emotion and general family functioning

The aim of this study was to investigate changes in family functioning and parental expressed emotion (EE) in parents and transition age youth (18 to 25 years old) with Anorexia Nervosa participating in Family-Based Treatment for Transition Age Youth (FBT-TAY). Further, we examined whether perceived family functioning and EE were associated with changes in eating disorder behaviour and weight in participants at end-of-treatment and three months post-treatment. Generalized estimating equations revealed that changes in family functioning significantly improved from baseline to end-of-treatment (p = .0001), and baseline to three months post-treatment (p = .0001) in parents; and from baseline to end-of-treatment (p = .011), and baseline to three months post-treatment (p = .0001) in transition age youth. The level of parental EE did not differ significantly from baseline to end-of-treatment (p = .379), or baseline to three months post-treatment (p = .185). A series of Ordinary Least Square regression models demonstrated that changes in perceived family functioning and EE were not significantly associated with changes in eating disorder behaviour and weight restoration of transition age youth at end-of-treatment and three months post-treatment. Overall, perceptions of family functioning improved during the course of FBT-TAY, but EE did not.

Family-based Treatment of Eating Disorders: A Narrative Review

Eating disorders (EDs) are serious psychiatric illnesses that typically develop during adolescence or young adulthood, indicating that individuals with EDs may benefit from early intervention. Family-based treatment is the leading treatment of youth with anorexia nervosa, with increasing evidence of its efficacy for youth with bulimia nervosa. This review describes the role of family engagement within family-based treatment of EDs, followed by a summary of current empirically supported, family-based ED interventions. It concludes with discussion of the ways in which family interventions are expanding and adapting to improve the breadth and scope of ED treatment in adolescence and young adulthood.

User satisfaction with family-based inpatient treatment for adolescent anorexia nervosa: retrospective views of patients and parents

BACKGROUND

Research is scarce on patient and parent satisfaction with family-based treatment for adolescent anorexia nervosa (AN), especially family-based treatment adapted to inpatient settings. The purpose of this study was to describe and compare patient and parent satisfaction with an inpatient family-based treatment program for adolescent AN, and to investigate whether the level of satisfaction with treatment was associated with eating disorder outcome.

METHODS

Former patients and their parents were contacted approximately five years (4.5 ± 1.7, range: 1.3-7.0) after discharge from family-based inpatient treatment. Ninety-four participants (patients: n = 34, mothers: n = 40, fathers: n = 20) from 46/58 (79.3%) families took part in the study. Former patients and both parents completed treatment satisfaction questionnaires. Outcome at follow-up was assessed by the Eating Disorder Examination Questionnaire and body mass index (kg/m2).

RESULTS

Overall, mothers and fathers reported a high level of satisfaction with treatment, while the former patients' satisfaction was moderate. There were no significant differences between treatment satisfaction scores for mothers and fathers. However, the former patients' treatment satisfaction scores were significantly lower than the parents' scores on several of the items. Correlations between eating disorder outcome parameters and treatment satisfaction were small, except for fathers' satisfaction with treatment and weight outcome at follow-up.

DISCUSSION

Family-based treatment adapted to inpatient settings is a novel treatment approach for adolescents with AN that require hospitalization. Inclusion and empowerment of parents are considered crucial in outpatient family-based treatment, but may be just as important in inpatient programs. Mothers and fathers alike reported high levels of satisfaction with treatment, which may constitute an important factor in the success of family-based treatment.

CONCLUSION

Family-based inpatient treatment for adolescents with severe AN who have failed to respond to outpatient treatment seemed to be highly valued by parents and viewed by adolescents as acceptable. Parental satisfaction with their child's treatment is likely to be an important factor for treatment implementation and adherence both in outpatient and inpatient settings.

Supporting a friend, housemate or partner with mental health difficulties: The student experience

AIMS

When experiencing mental health difficulties, university students turn to their friends for support. This study assessed the consequences of caregiving among a university sample, identifying predictors of caregiving burden among students.

METHODS

A total of 79 students with experience of supporting a friend with mental health difficulties were recruited through a UK student mental health charity to complete an online survey. Alongside qualitative data, the online survey used the Experience of Caregiving Inventory and the Involvement Evaluation Questionnaire as measures of the consequences of caregiving.

RESULTS

Students supporting friends, housemates or partners were found to experience significant consequences of caregiving. Frequency of face-to-face contact and duration of illness predicted more negative consequences of caregiving, but these relationships were not straightforward. The presence and intensity of professional support did not influence the experience of caregiving.

CONCLUSIONS

The study suggests that the impact of supporting friends with mental health difficulties is not insubstantial for students. Broadening the network of informal social support may help improve the experience for students supporting a friend, but currently, contact with professional services appears to have a limited effect.

Family accommodation in psychopathology: A synthesized review

Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology, and to avoid or alleviate distress related to the disorder. Research on family accommodation has expanded greatly in the past few years. The aim of this study was to provide a synthesized review of recent findings on family accommodation in psychopathology. Electronic databases were searched for available, peer-reviewed, English language papers, published between September 2015 and March 2018, cross-referencing psychiatric disorders with accommodation and other family-related terms. Ninety-one papers were identified and reviewed, of which 69 were included. In obsessive-compulsive disorder and anxiety disorders family accommodation has been linked to symptom severity, functional impairment, caregiver burden, and poorer treatment outcomes. Several randomized controlled trials explored the efficacy of treatments aimed at reducing family accommodation. A growing number of studies have reported family accommodation in eating disorders where it is associated with greater symptom severity and caregiver burden. Family accommodation has also been studied in other disorders, including autism spectrum disorders, tic disorders, and posttraumatic stress disorder. Research on family accommodation in psychopathology is advancing steadily, expanding across disorders. The study highlights the importance of addressing family accommodation in the assessment and treatment of various disorders.

The adolescent onset anorexia nervosa study (ANABEL): Design and baseline results

The anorexia nervosa adolescent longitudinal biomarker assessment study (ANABEL) is a 2-year longitudinal study.

OBJECTIVE

Evaluate several clinical, biochemical, immunological, psychological, and family variables and their interactions in adolescent onset eating disorders (EDs) patients and their 2-year clinical and biological outcome. This article illustrates the framework and the methodology behind the research questions, as well as describing general features of the sample.

METHODS

A longitudinal study of 114 adolescents with EDs seeking treatment was performed. Only adolescents were selected during 4 years (2009-2013). The variables were collected at different times: baseline, 6, 12, 18, and 24 months of the start of treatment. Diagnoses were completed through the semi-structured Kiddie-Schedule for Affective Disorders and Schizophrenia interview.

RESULTS

At baseline, the mean age was 15.11 (SD = 1.36). The mean ED duration was 10 months (SD = 5.75). The mean body mass index was 16.1 (SD = 1.8). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis at baseline for restrictive anorexia nervosa was 69.6%, 17.4% for purgative anorexia nervosa, and 24.3% for other specified feeding disorder. At 12 months, 19.4% were in partial remission, whereas at 24 months, 13.8% had fully recovered and 29.2% had partially recovered.

CONCLUSIONS

There was an acceptable physical and psychopathological improvement during the first year of treatment, with recovery being more evident during the first 6 months.

Predictive factors for outcome in adolescents with anorexia nervosa: To what extent does parental Expressed Emotion play a role?

In studies on family therapy in Anorexia Nervosa, family relationships, as assessed by Expressed Emotion, have been associated with outcome. Our aim was to explore the contribution of Expressed Emotion as a predictor of 18-month outcome, above and beyond the usual predictive factors. Sixty adolescent girls suffering from Anorexia Nervosa and their parents were assessed at baseline and 18 months later. Levels of Expressed Emotion were evaluated in both parents with the Five-Minute Speech Sample. After controlling for treatment group and initial clinical status, high maternal Emotional Over-Involvement at baseline was significantly associated with better clinical state. More precisely, high maternal Emotional Over-Involvement was associated with higher nutritional status, lower eating disorder severity and fewer re-hospitalizations 18 months later. No associations were found with paternal levels of Expressed Emotion. Therefore, our study confirmed the importance of taking into account both maternal and paternal Expressed Emotion. Our results also underlined that high maternal Emotional Over-Involvement plays a positive role in the outcome of Anorexia Nervosa and needs to be explored further.

The Nature of Patient- and Family-Centred Care for Young Adults Living with Chronic Disease and their Family Members: A Systematic Review

BACKGROUND AND AIM

The published literature addressing the nature of patient- and family-centred care (PFCC) among young adults (16-25 years old) living with chronic disease and their family members is diverse. The aim of this systematic review was to collect and interpretatively synthesise this literature to generate a conceptual understanding of PFCC in this age group.

METHOD

From an initial pool of 10,615 papers, 51 were systematically identified as relevant to the research question and appraised using the Critical Appraisal Skills Programme tools. A total of 24 papers passed the quality appraisal and proceeded to a qualitative meta-synthesis.

RESULTS

The qualitative meta-synthesis revealed three major elements of PFCC relevant to young adults living with chronic disease and their family members: (1) patients and practitioners felt able to engage with each other on an emotional and social level; (2) patients and families felt empowered to be part of the care process; and (3) patients and families experienced care as effective at addressing their individual needs.

CONCLUSION

There is agreement among young adult patients and families about what constitutes PFCC in a chronic disease setting, independent of the aetiology of the pathological process. Patients and families also have strong feelings about how practitioners can achieve PFCC in practice. These findings have implications for the delivery of health services to young adults living with chronic disease and their family members.

Cost-effectiveness of the mobile application TCApp combined with face-to-face CBT treatment compared to face-to-face CBT treatment alone for patients with an eating disorder: study protocol of a multi-centre randomised controlled trial

BACKGROUND

The clinical utility of the existing apps for people with eating disorders (EDs) is not clear. The TCApp has been specifically developed for people with EDs, is based on the principles of Cognitive Behavioural Treatment (CBT) and allows a bidirectional link between the patient and the therapist. The objectives of the study are, first, to assess the clinical efficacy of a combined intervention for Eating Disorders (EDs) that includes an online intervention through the TCApp plus standard face-to-face CBT in comparison to standard face-to-face CBT alone, and second, to examine the cost-effectiveness of the TCApp and identify potential predicting, moderating and mediating variables that promote or hinder the implementation of the TCApp in ED units in Spain.

METHODS

The study methodology is that of a randomised controlled trial combining qualitative and quantitative methods, with a 6-month follow-up. Approximately 250 patients over 12 years old with a diagnosis of an ED from several ED units in Spain will be randomised to one of two different conditions. Participants, their caregivers, healthcare professionals and technical staff involved in the development and maintenance of the application will be assessed at baseline (T0), post-intervention (T1) and at 6 months follow-up (T2). Primary outcome measures will include ED symptomatology while secondary measures will include general psychopathology and quality of life for patients, quality of life and caregiving experience for family caregivers and adoption-related variables for all participants involved, such as perceived usability, user's satisfaction and technology acceptance. For the cost-effectiveness analysis, we will assess quality-adjusted life years (QALYs); total societal cost will be estimated using costs to patients and the health plan, and other related costs.

DISCUSSION

The study will provide an important advance in the treatment of EDs; in the long term, it is expected to improve the quality of patient care and the treatment efficacy and to reduce waiting lists as well as direct and indirect costs associated with the treatment of EDs in Spain.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03197519 ; registration date: June 23, 2017.

Experience of caregiving and coping strategies in caregivers of adolescents with an eating disorder: A comparative study

Caring for a relative with an eating disorder (ED) is associated with heightened psychological distress, which, according to a stress-coping model, may be influenced by coping and appraisal. However, limited quantitative studies have assessed coping in ED caregivers. This cross-sectional study aims to assess 1) the differences in coping between caregivers of three groups: patients with an ED, patients with a substance use disorder, and healthy teens, and 2) the patient and caregiver variables associated with coping and appraisal of the caregiving experience. A one-way MANOVA was significant for caregiver group for mothers, but not fathers. Mothers of both patient groups used more self-sufficient problem focused coping than mothers of healthy teens. Patient caregivers did not significantly differ from caregivers of healthy teens in their use of avoidance. Mothers used social support strategies more than fathers. A positive experience of caregiving was significantly associated with the use of approach-oriented coping in ED caregivers and a negative experience of caregiving was significantly associated with avoidance in ED mothers. Older ED caregivers were less likely to use avoidance. Future interventions could help ED caregivers to recognize their coping preferences and how to appropriately use these strategies when faced with illness-related stressors.

Family-based treatment for transition age youth: parental self-efficacy and caregiver accommodation

BACKGROUND

Family-Based Treatment (FBT) is the first line of care in paediatric treatment while adult programs focus on individualized models of care. Transition age youth (TAY) with Anorexia Nervosa (AN) are in a unique life stage and between systems of care. As such, they and their caregivers may benefit from specialized, developmentally tailored models of treatment.

METHODS

The primary purpose of this study was to assess if parental self-efficacy and caregiver accommodation changed in caregivers during the course of FBT-TAY for AN. The secondary aim was to determine if changes in parental self-efficacy and caregiver accommodation contributed to improvements in eating disorder behaviour and weight restoration in the transition age youth with AN. Twenty-six participants (ages 16-22) and 39 caregivers were recruited. Caregivers completed the Parents versus Anorexia Scale and Accommodation and Enabling Scale for Eating Disorders at baseline, end-of-treatment (EOT), and 3 months follow-up.

RESULTS

Unbalanced repeated measures designs for parental self-efficacy and caregiver accommodation towards illness behaviours were conducted using generalized estimation equations. Parental self-efficacy increased from baseline to EOT, although not significantly (p = .398). Parental self-efficacy significantly increased from baseline to 3 months post-treatment (p = .002). Caregiver accommodation towards the illness significantly decreased from baseline to EOT (p = 0.0001), but not from baseline to 3 months post-treatment (p = 1.000). Stepwise ordinary least squares regression estimates of eating disorder behaviour and weight restoration did not show that changes in parental-self efficacy and caregiver accommodation predict eating disorder behaviour or weight restoration at EOT or 3 months post-treatment.

CONCLUSIONS

Our findings demonstrate, albeit preliminary at this stage, that FBT-TAY promotes positive increases in parental self-efficacy and assists caregivers in decreasing their accommodation to illness behaviours for transition age youth with AN. However, changes in the parental factors did not influence changes in eating and weight in the transition age youth.

The relation between patient characteristics and their carers' use of a directive versus collaborative support stance

OBJECTIVES

Collaborative support provided by carers (family and friends) of individuals with eating disorders has been shown to be integral to patient motivation and clinical outcome. Little is known about factors that contribute to carers' use of collaborative, as opposed to directive, support stance. This exploratory research investigated associations between patient characteristics and carers' support beliefs and behaviors.

METHOD

Eating disorder patients (n = 72) completed measures of readiness for change, eating disorder, and psychiatric symptom severity, and interpersonal functioning. Their carers (n = 72) completed measures of collaborative and directive support.

RESULTS

Patient demographic variables, readiness for change, and psychiatric symptom severity were not associated with carer beliefs or behaviors. However, some patient interpersonal functioning scores were; higher Domineering/Controlling scores were associated with carers viewing directive support as more helpful, and with their use of more directive support behaviors. Higher Vindictive/Self-Centered and Intrusive/Needy scores in patients were also associated with carers viewing directive support as more helpful.

DISCUSSION

This exploratory study suggests that carers may be more prone to utilizing a directive, rather than a collaborative, support stance with patients experiencing higher levels of threat, anger, and hostility, and lower levels of safety, closeness, and trust.

The Science Behind the Academy for Eating Disorders' Nine Truths About Eating Disorders

OBJECTIVE

In 2015, the Academy for Eating Disorders collaborated with international patient, advocacy, and parent organizations to craft the 'Nine Truths About Eating Disorders'. This document has been translated into over 30 languages and has been distributed globally to replace outdated and erroneous stereotypes about eating disorders with factual information. In this paper, we review the state of the science supporting the 'Nine Truths'.

METHODS

The literature supporting each of the 'Nine Truths' was reviewed, summarized and richly annotated.

RESULTS

Most of the 'Nine Truths' arise from well-established foundations in the scientific literature. Additional evidence is required to further substantiate some of the assertions in the document. Future investigations are needed in all areas to deepen our understanding of eating disorders, their causes and their treatments.

CONCLUSIONS

The 'Nine Truths About Eating Disorders' is a guiding document to accelerate global dissemination of accurate and evidence-informed information about eating disorders. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

A controlled trial of a yoga-based prevention program targeting eating disorder risk factors among middle school females

This study investigates outcomes of a revised version of a yoga-based, eating disorder prevention program, targeting eating disorder risk factors, among fifth grade girls (i.e., Girls Growing in Wellness and Balance: Yoga and Life Skills to Empower [GGWB]). The program is designed to decrease eating disorder risk factors and bolster self-care and includes revisions not yet studied that extend the program to 14 weeks and enhance content addressing self-care. Efficacy was assessed using a controlled, repeated measures design. Results indicate that participation in the GGWB program significantly decreases drive for thinness and body dissatisfaction while significantly increasing self-care when compared to a control group. As expected, the program did not have significant effects on eating disordered behaviour likely due to low baseline rates among participants. Implications of findings as well as directions for future research on prevention are discussed.

Expressed Emotions and Depressive Symptoms in Caregivers of Adolescents with First-Onset Anorexia Nervosa-A Long-Term Investigation over 2.5 Years

OBJECTIVE

High levels of expressed emotions (EE) and depressive symptoms (DS) are often found in caregivers of patients with anorexia nervosa (AN). Both parameters are considered to influence AN symptoms of the patient.

METHODS

One hundred seventy adolescent women with AN and their caregivers were assessed at admission, discharge, at 1-year and 2.5-year follow up to evaluate AN symptoms of the patient and EE and DS of caregivers.

RESULTS

The EE and DS were elevated at admission and decreased during treatment, criticism (as part of EE) exhibited again at the 2.5-year follow up. Caregivers of more severely ill patients reported significantly greater levels of EE and DS. Mothers were more affected than fathers. EE and DS were interrelated.

CONCLUSION

Caregivers of adolescent AN patients suffer from elevated levels of EE and DS. Further studies are needed to examine whether therapeutic interventions to reduce caregivers' EE and DS might have a positive influence on treatment outcome. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.