Interpersonal psychotherapy for anorexia nervosa

Emotional reactivity and eating disorder related attitudes in response to the trier social stress test: An experimental study in people with anorexia nervosa and with bulimia nervosa

BACKGROUND

In order to experimentally asses the role of socio-emotional problems in Eating Disorder (ED) psychopathology, we have measured affective states and ED-related attitudes in response to an acute psychosocial stress and their relationships with interpersonal sensitivity in people with Anorexia Nervosa (AN) and Bulimia Nervosa (BN).

METHODS

Twenty-one women with AN, 21 with BN and 27 healthy women underwent an acute psycho-social challenge, the Trier Social Stress Test. Anxiety feelings, hunger perception, amount of desired food and body dissatisfaction were measured throughout the experimental procedure. The relationships between these variables and with interpersonal sensitivity measures were explored through Pearson's correlation and mediation analyses.

RESULTS

Stress-induced anxiety was increased in people with EDs. People with AN showed reduced hunger perception, decreased desire for food and a negative association between anxiety feelings and desire for food. In people with EDs, baseline ineffectiveness predicted post-stress body dissatisfaction through the mediation of post-stress anxiety levels.

LIMITATIONS

The relatively low sample size and the lack of an experimental control condition are the main limitations of the study.

CONCLUSIONS

The present findings show, for the first time, the relationships between socio-emotional distress and ED-related attitudes in people with EDs, providing experimental support to the interpersonal model of EDs. This gives empirical evidence to treatments targeting interpersonal problems in EDs.

Teammate influences, psychological well-being, and athletes' eating and exercise psychopathology: A moderated mediation analysis

OBJECTIVE

Positive and negative influences from teammates (e.g., supportive teammate friendships, modelling of teammates' disordered eating) have been associated with athletes' eating/exercise psychopathology. However, research is yet to explore how an athlete's psychological well-being and gender may impact upon these relationships. This study aimed to explore whether psychological well-being mediates the relationship between teammate influences and eating/exercise psychopathology, and to determine whether gender moderates the significant mediation effects identified.

METHOD

Athletes (N = 195, mean age 18.35 years, n = 110 female, n = 81 lean sport athletes) completed a survey three times over an 8-month period exploring teammate influences, psychological well-being (self-esteem, anxiety, depression) and eating/exercise psychopathology. Mediation and moderated-mediation analyses were conducted.

RESULTS

Higher levels of anxiety significantly mediated the positive relationships between bulimia modelling and teammate pressure with eating and exercise psychopathology. Higher levels of depression significantly mediated the positive relationship between teammate pressure and body dissatisfaction, and the negative relationship between supportive friendships and body dissatisfaction. Higher levels of self-esteem mediated both inverse relationships between supportive friendships and a lower drive for thinness (fully) and body dissatisfaction (partially). Gender did not significantly moderate any mediation relationships.

DISCUSSION

Male and female athletes with poor psychological well-being (i.e., high levels of anxiety or depression) are more susceptible to negative teammate influences, while athletes with good psychological well-being (i.e., high self-esteem) reap the protective benefits of supportive teammate friendships. Understanding the circumstances under which teammates are influential is vital for the development of targeted intervention and prevention strategies to reduce athlete eating and exercise psychopathology.

Persistence of friendly and submissive interpersonal styles among those with binge-eating disorder: Comparisons with matched controls and outcomes after group therapy

Interpersonal problems play a prominent role in the development of binge-eating disorder (BED), so reducing their intensity may be a key focus of many psychological interventions. In recent years, several interpersonal treatments for BED were developed, which posit that binge eating arises to manage relational problems. However, few studies have evaluated the prototypical interpersonal problems, and no studies evaluated the longitudinal changes in interpersonal functioning after treatment within this population. We investigated the severity and prototypicality of interpersonal problems of 101 overweight women with BED from pre-group psychodynamic-interpersonal psychotherapy (GPIP) to 12 months post-GPIP. At baseline, we compared patients' interpersonal problems with two groups of matched controls (46 overweight and 49 normal weight women without a diagnosis of BED) and examined circular correlations between relational problems, depressive symptoms, and binge-eating frequency. Results showed that participants with BED had significantly higher levels of interpersonal problems compared with the matched control samples, with predominantly nonassertive and exploitable styles. Depressive symptoms were related to the presence of friendly-submissive interpersonal problems only among those with BED. Although the intensity of nonassertive interpersonal problems of patients with BED decreased post-group treatment, their profiles remained prototypically nonassertive and exploitable across all time points. Women with BED experience higher levels of interpersonal difficulties exemplified by an exploitable/nonassertive style that significantly improve but continue to prevail even after treatment. Clinicians might modify interventions to focus on increasing interpersonal skills and decreasing interpersonal dysfunctions among those with BED.

Interpersonal psychotherapy for depression

Interpersonal psychotherapy is an evidence-based therapy, originally developed to treat major depression. It is cited in numerous good practice guidelines. The biopsychosocial signs of depression are understood in the context of current social and interpersonal stressors, defined in terms of role transitions, disputes, bereavements and sensitivities. In therapy, the patient learns to understand the interactions between symptoms and interpersonal difficulties and the ways in which they are mutually reinforcing. Patients are helped to break this pattern and achieve a reduction in depressive symptoms and improvement in interpersonal functioning through improved communication, expression of affect and proactive engagement with the current interpersonal network. The therapeutic relationship is used as a tool for exploring and modelling external relationships. This article outlines the background to interpersonal psychotherapy, the process of therapy and the expansion of the evidence base.

Evidence-based clinical guidelines for eating disorders: international comparison

PURPOSE OF REVIEW

The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.

RECENT FINDINGS

Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines.

SUMMARY

Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.

Treatment of Eating Disorders in Women

This article reviews the most recent treatment literature for anorexia nervosa, bulimia nervosa, and binge eating disorder and serves as a guide for recommended readings and therapist resources. The primary focus is on empirically tested treatment modalities; for each of these approaches reviewed, the theoretical background, nature of the intervention, and existing empirical support are summarized. The article also presents less researched, albeit promising, approaches to eating disorder treatment, describing the rationale and available research. A focus on multicultural issues, including the paucity of eating disorder treatment research among participants of color, and suggestions for building research and enhancing treatment effectiveness with ethnic minority clients, is incorporated throughout. Recommendations concerning pressing research needs are made, and a summary of clinical recommendations for each disorder is formulated.

Does the interpersonal model apply across eating disorder diagnostic groups? A structural equation modeling approach

BACKGROUND

Interpersonal model has been validated with binge-eating disorder (BED), but it is not yet known if the model applies across a range of eating disorders (ED).

PURPOSE

The goal of this study was to investigate the validity of the interpersonal model in anorexia nervosa (restricting type; ANR and binge-eating/purge type; ANBP), bulimia nervosa (BN), BED, and eating disorder not otherwise specified (EDNOS).

PROCEDURE

Data from a cross-sectional sample of 1459 treatment-seeking women diagnosed with ANR, ANBP, BN, BED and EDNOS were examined for indirect effects of interpersonal problems on ED psychopathology mediated through negative affect.

RESULTS

Findings from structural equation modeling demonstrated the mediating role of negative affect in four of the five diagnostic groups. There were significant, medium to large (.239, .558), indirect effects in the ANR, BN, BED and EDNOS groups but not in the ANBP group. The results of the first reverse model of interpersonal problems as a mediator between negative affect and ED psychopathology were nonsignificant, suggesting the specificity of these hypothesized paths. However, in the second reverse model ED psychopathology was related to interpersonal problems indirectly through negative affect.

CONCLUSION

This is the first study to find support for the interpersonal model of ED in a clinical sample of women with diverse ED diagnoses, though there may be a reciprocal relationship between ED psychopathology and relationship problems through negative affect. Negative affect partially explains the relationship between interpersonal problems and ED psychopathology in women diagnosed with ANR, BN, BED and EDNOS. Interpersonal psychotherapies for ED may be addressing the underlying interpersonal-affective difficulties, thereby reducing ED psychopathology.

The association between interpersonal problems and treatment outcome in the eating disorders: A systematic review

OBJECTIVE

To review systematically the eating disorder literature in order to examine the association between pre-treatment interpersonal problems and treatment outcome in people diagnosed with an eating disorder.

METHODS

Six relevant databases were searched for studies in which interpersonal problems prior to treatment were examined in relation to treatment outcome in patients diagnosed with anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS).

RESULTS

Thirteen studies were identified (containing 764 AN, 707 BN and 48 EDNOS). The majority of studies indicated that interpersonal problems at the start of therapy were associated with a detrimental treatment outcome.

CONCLUSIONS

Individuals with a binge/purge-type of eating disorder may be particularly vulnerable to interpersonal issues and these issues may lead to poorer treatment recovery by reducing the individual's ability to engage in the treatment process on a functional level. The clinical and research implications are discussed.

Eating Psychopathology in Athletes and Nonathletes: The Effect of Situational and Dispositional Interpersonal Difficulties

In the current study, we had two aims. First, we investigated the associations between eating psychopathology, situational interpersonal difficulties, and dispositional interpersonal difficulties among athletes and nonathletes. Second, we examined the mediating role of self-critical perfectionism, self-esteem, and depression in these associations. A total of 152 athletes and 147 nonathletes completed self-report instruments pertaining to relationship quality with significant others, as well as social anxiety, loneliness, self-critical perfectionism, self-esteem, depression, and eating psychopathology. Social anxiety and loneliness were found to be the only significant independent predictors of eating psychopathology among both athletes and nonathletes. However, such associations were indirectly mediated through depression for athletes and through self-critical perfectionism, self-esteem, and depression for nonathletes. The findings of this study suggest that the psychosocial mechanisms involved in the eating psychopathology of athletes are relatively similar to that of nonathletes. Thus, it can be tentatively proposed that treatments and interventions that target reducing interpersonal conflicts currently available for the general population should also be offered to athletes.

Social insecurity in relation to orbitofrontal activity in patients with eating disorders: a near-infrared spectroscopy study

BACKGROUND

Functional neuroimaging techniques are widely used to elucidate changes in brain activity, and various questionnaires are used to investigate psychopathological features in patients with eating disorders (ED). It is well known that social skills and interpersonal difficulties are strongly associated with the psychopathology of patients with ED. However, few studies have examined the association between brain activity and social relationships in patients with ED, particularly in patients with extremely low body weight.

METHODS

In this study, 22-channel near-infrared spectroscopy was used to quantify regional hemodynamic changes during a letter fluency task (LFT) in 20 female patients with ED with a mean body mass index of 14.0 kg/m(2) and 31 female controls (CTLs). Symptoms were assessed using the Eating Disorder Inventory-2 and Beck Depression Inventory. We hypothesized that frontal activity in patients with ED would be lower than in CTLs and would show different correlations with psychopathological features compared with CTLs.

RESULTS

The LFT performance and score on the social insecurity subscale of the Eating Disorder Inventory-2 were significantly higher in the ED group than in the CTL group. The mean change in oxygenated hemoglobin (oxy-Hb) in bilateral frontal regions during the LFT was significantly smaller in the ED group than in the CTL group. Social insecurity score was positively correlated with the concentration of oxy-Hb in the bilateral orbitofrontal cortex in the ED group but not in the CTL group.

CONCLUSIONS

These results suggest that activity of the orbitofrontal cortex is associated with social insecurity and disturbed in patients with ED. Therefore, disturbed orbitofrontal cortex activity may underlie the lack of insight and social isolation that is characteristic of patients with ED.

The sorting test of the D-KEFS in current and weight restored anorexia nervosa patients

OBJECTIVE

Efforts have been made to characterize executive functions (EF) in anorexia nervosa (AN) both in the acute stage of the illness and after weight gain, yet many questions remain. The question of verbal versus visuo-perceptual stimuli in this regard has not been adequately addressed. The aim of this study is to further examine EF in women with past and present AN and to compare their performances in verbal and visual modalities with women who have never suffered from an eating disorder.

METHOD

Thirty-five underweight AN patients, 33 weight-restored patients symptom-free for at least 2 years, and 48 healthy female controls completed the Delis-Kaplan Executive Function System Sorting Test, so as to evaluate their EF.

RESULTS

No differences were observed between the scores of women with current and past AN. Both groups scored lower than controls on most test variables. However, while in the visuo-perceptual domain the performance of the AN groups was worse than that of controls, in the verbal domain they performed similarly to them.

DISCUSSION

Women with a past or present diagnosis of AN show difficulties in visuo-perceptual EF, whereas verbal EF seem to be preserved. There may be a dissociation between verbal and visuo-perceptual EF that persists after weight restoration.

The role of interpersonal functioning in the maintenance of eating psychopathology: a systematic review and testable model

This review aims to systematically evaluate the empirical literature relating to the interpersonal functioning of those with eating disorder psychopathology and presents a preliminary model to help the formulation of patients' problems. Following a thorough literature search, 35 papers were included in this systematic review. The vast majority of studies indicate a strong association between eating psychopathology and certain maladaptive personality traits. The origins of social anxiety and poor social support that have been described as maintaining eating disorders appear to differ according to diagnostic groups. Interpersonal difficulties in people with restrictive behaviors such as anorexia appear to be related to the avoidance of expressing feelings to others and to giving priority to other people's feeling over their own. While interpersonal difficulties in patients with bulimia nervosa appear to be more related to interpersonal distrust and negative interaction and conflict with others. These concepts are presented in a preliminary model of interpersonal functioning in the eating disorders.

The experience of pregnancy in women with a history of anorexia nervosa: An interpretive phenomenological analysis

BACKGROUND AND AIMS

To explore the experience of pregnancy for women who have a history of anorexia nervosa (AN), in relation to the impact of AN on pregnancy, and pregnancy on AN.

METHODS

Semi-structured interviews were conducted with six women with a history of AN. Data were analysed using Interpretive Phenomenological Analysis.

RESULTS

Four super-ordinate themes emerged: 'Effortful resistance of AN'; 'The unvalued self, valued other dialectic'; 'In new territory'; and 'Feeling distanced'.

CONCLUSIONS

Various factors motivated the women to try and change their AN behaviours. This was achieved with varying degrees of success. Attempts to manage AN cognitions and emotions were less successful, and this aspect of their illness persisted. Whilst the baby was viewed as worthy of nurturance, the self was not. Pregnancy represented an unfamiliar experience, and was a time of relative isolation and lack of psychological support. Findings are discussed in the context of theory, research and practice.

Interpersonal psychotherapy in child and adolescent mental health services

Over the past two decades, Interpersonal Psychotherapy (IPT) has shown itself to be one of only two evidence-based psychotherapies for the treatment of depression in adolescence-an age group where the prescribing of antidepressant medication is limited and where morbidity and recurrence are high. We review the literature on the development and research studies of the IPT model for depressed adolescent patients, as well as recent developments expanding its use to other cultures and different diagnostic areas. An overview is provided of the model in action, using a fictionalized case vignette. Finally, we consider the future of IPT for the treatment and prevention of affective disorders in the under 18 age group and in the context of other generations in vulnerable families.

Interpersonal psychotherapy: past, present and future

The authors briefly describe the origins, theory, and development of interpersonal psychotherapy: its roots in clinical outcome research, its spread from major depression to other psychiatric disorders and its increasing dissemination as an empirically validated clinical intervention included in treatment guidelines. They attempt to forecast research, organizational and training issues the growing interpersonal psychotherapy community may face in the future.

Emotional processing following recovery from anorexia nervosa

OBJECTIVE

Evidence suggests that poor emotional processing perpetuates anorexia nervosa (AN); however, emotional processing following recovery and interactions between aspects of processing remain unknown. This study examined beliefs about emotions, emotional tolerance and avoidance and emotion suppression to preserve relationships in recovered AN patients. It also explored whether beliefs about emotion are related to emotional avoidance.

DESIGN

A cross-sectional between-groups design was employed.

METHOD

Currently ill (n = 40), recovered AN patients (n = 24) and a sample of healthy controls (n = 48) completed measures of clinical and demographic background in addition to the Beliefs About Emotions, Distress Tolerance and Silencing the Self emotional processing questionnaires.

RESULTS

Recovered and healthy control groups were comparable (except for higher externalised self-perception in recovered participants) and both had better emotional processing than current AN patients. Beliefs about emotions correlated with level of emotional avoidance.

CONCLUSIONS

This study demonstrates functional levels of emotional processing following recovery from AN. It substantiates models proposing that maladaptive beliefs about emotions link to emotional avoidance and supports inclusion of these factors as treatment foci.

The long-term efficacy of three psychotherapies for anorexia nervosa: a randomized, controlled trial

OBJECTIVE

To evaluate the long-term efficacy of three psychotherapies for anorexia nervosa.

METHOD

Participants were women with broadly defined anorexia nervosa who had participated in a RCT comparing specialized psychotherapies (cognitive behavior therapy, CBT, and interpersonal psychotherapy, IPT) with a control condition (specialist supportive clinical management, SSCM), and attended long-term follow-up assessment (mean 6.7 years ± 1.2).

RESULTS

Forty three of the original sample of 56 women participated in long-term follow-up assessment (77%). No significant differences were found on any pre-selected primary, secondary or tertiary outcome measures among the three psychotherapies at long-term follow-up assessment. Significantly different patterns of recovery were identified for the psychotherapies across time on the primary global outcome measure. Although SSCM was associated with a more rapid response than IPT, by follow-up all three treatments were indistinguishable.

DISCUSSION

Potential implications for the timing of interventions to improve treatment response in anorexia nervosa are critically examined.

Application of the Transdiagnostic Cognitive-Behavioral Model of Eating Disorders to the Athletic Population

The purpose of this study was twofold: to explore the utility of components related to the transdiagnostic cognitive-behavioral model of eating disorders within an athletic population and to investigate the extent to which the model can be applied across gender, sport type, and performance standard to explain eating psychopathology. Five hundred and eighty-eight (N = 588) male and female British athletes completed a battery of self-report instruments related to eating psychopathology, interpersonal diffculties, perfectionism, self-esteem, and mood. Structural equation modeling revealed that eating psychopathology may arise from an interaction of interpersonal diffculties, low self-esteem, high levels of self-critical perfectionism, and depressive symptoms. Analysis further highlighted that the manner in which eating psychopathology may arise is invariant across athletes’ sport type and performance standard, but not across gender. The current findings suggest that the tested components of the transdiagnostic cognitive-behavioral model are pertinent and useful in explaining eating psychopathology among athletes.

Translating experimental neuroscience into treatment of eating disorders: two examples

Anorexia nervosa (AN) is a serious mental disorder with impaired functioning including not only the cognitive and socio-emotional but also physical domains. Improved treatments, especially for adults with AN, are urgently needed. The insights gained from basic research in experimental animal models and the advent of cognitive neuroscience have produced major advances in our understanding of the condition, but translating these into clinical research or practice remains a challenge. We describe here what the eating disorders field can gain from schizophrenia research in this area. We use the example of socio-emotional impairments in AN to describe the iterative process between basic research and intervention development for neurobiologically informed and based treatments for this condition and briefly touch on some other examples that stem from translational science.

The socio-emotional processing stream in Anorexia Nervosa

The significance of socio-emotional factors in development and maintenance of Anorexia Nervosa (AN) has been noted, but the literature is poorly integrated without clear models guiding research or treatment. This systematic review retrieved experimental studies of social-cognitive or affective processing in AN and categorised them using Ochsner's "Social-Emotional Processing Stream." Ochsner's "Processing Stream", based on healthy data, comprises five constructs: (1) acquisition of and (2) recognition and response to social-affective stimuli, (3) low-level and (4) high-level mental state inference and (5) context-sensitive emotion regulation. Thirty-seven experimental studies in Anorexia Nervosa were identified, mapping on to four of the five constructs (not Construct 3). A meta-analysis of nine affect recognition studies was conducted. AN patients demonstrated impairments in each of the four domains with preliminary reports that some difficulties are trait-like, and others ameliorate following recovery. Socio-emotional data was integrated with previous reports of neural abnormalities to generate an AN specific model of socio-emotional processing. Additional research is required for further definition and to translate experimental findings into clinical practice.

Interpersonal problems in eating disorders

OBJECTIVE

Eating disorders are often chronic in nature and lead to a number of problems among which interpersonal issues are suggested to be central. Although research has shown that individuals with disturbed patterns of eating consistently report problems in social interactions, this study is unique in assessing a range of interpersonal problems among patients with all types of eating disorders before and after intensive hospital-based treatment.

METHOD

A total of 208 patients receiving a primary diagnosis of restrictive anorexia nervosa, bulimia nervosa, or anorexia nervosa of the binge/purging-subtype were included in the study. Eating pathology, symptom severity, and interpersonal patterns were examined before and after treatment.

RESULTS

Patients with eating disorders exhibited a generally nonassertive, submissive interpersonal style, with anorexic patients of the binge/purging-subtype reporting more difficulties with social inhibition and nonaffiliation. These patterns were found to change over the course of treatment with interpersonal problems at intake predictive of greater binge severity at discharge. Furthermore, issues of dominance and social avoidance predicted outcome for specific subgroups of patients.

DISCUSSION

Results underscore the importance of interpersonal problems in eating disorders and suggest that interpersonal patterns remain a focus of treatment and future research.

Preventing excessive weight gain in adolescents: interpersonal psychotherapy for binge eating

The most prevalent disordered eating pattern described in overweight youth is loss of control (LOC) eating, during which individuals experience an inability to control the type or amount of food they consume. LOC eating is associated cross-sectionally with greater adiposity in children and adolescents and seems to predispose youth to gain weight or body fat above that expected during normal growth, thus likely contributing to obesity in susceptible individuals. No prior studies have examined whether LOC eating can be decreased by interventions in children or adolescents without full-syndrome eating disorders or whether programs reducing LOC eating prevent inappropriate weight gain attributable to LOC eating. Interpersonal psychotherapy, a form of therapy that was designed to treat depression and has been adapted for the treatment of eating disorders, has shown efficacy in reducing binge eating episodes and inducing weight stabilization among adults diagnosed with binge eating disorder. In this paper, we propose a theoretical model of excessive weight gain in adolescents at high risk for adult obesity who engage in LOC eating and associated overeating patterns. A rationale is provided for interpersonal psychotherapy as an intervention to slow the trajectory of weight gain in at-risk youth, with the aim of preventing or ameliorating obesity in adulthood.

Reliability and validity of communication skills questionnaire (CSQ)

A new and easy evaluation method of communication skills has been developed using the Communication Skills Questionnaire (CSQ), which can be self-administered or administered by family members and medical staff. The reliability and validity of this CSQ were evaluated. Eighty-seven patients with mental disorders and 100 normal controls participated in a self-rating evaluation of the CSQ, and 55 family members and four medical personnel also participated in objective rating. The CSQ contained 29 items and these items were divided into three categories: cooperative skills (17 items), assertive skills (six items) and general communication skills (six items, mainly non-verbal skills). Internal consistencies of all groups were between 0.91 and 0.97. Test-retest reliability values for patients, family members and medical staff were between 0.90 and 0.95. Interrater reliability of medical staff was 0.73. The total scores had a moderate positive correlation with Global Assessment of Functioning (GAF) score and doctor's impression of communication skill evaluated on a 10-point scale. The patient group had a lower CSQ score than that of controls and the score differences between controls and patients with schizophrenia, mood disorders or eating disorders were statistically significant. This questionnaire is a good psychometric method of evaluating the communication skills of patients.

Perceptions of parental communication orientation, perfectionism, and disordered eating behaviors of sons and daughters

This study investigated the influence of perceived parental communication orientation and individual perfectionism on late adolescent offspring's maladaptive eating behaviors using a nonclinical sample ( N=424). College students' perceptions of their communication patterns with parents, self- and parentally prescribed perfectionism, and perceptions of personal control were measured to explore possible associations among these variables and whether they, in combination, predicted maladaptive eating. Results revealed that 23% of the sample participated in maladaptive eating behaviors; in addition, a father-child conformity communication pattern and paternally prescribed perfectionism predicted maladaptive eating within this sample when controlling for individual factors such as offspring's perfectionism and perceived loss of personal control. These findings suggest that father-child communicative interaction that emphasizes conformity to high paternal standards may increase offspring's risk of developing maladaptive eating behaviors.

Exploring the psychopathology of anorexia nervosa: a Mahlerian standpoint

TOPIC

Anorexia nervosa is an eating disorder that extends beyond the well-known phenomenon of self-starvation to include dynamic psychological themes of autonomy and ego disturbances as well as self-regulation through eating disordered behaviors.

PURPOSE AND SOURCE

Exploration of these themes within Mahler's (1975) object relational framework provides the opportunity to examine the genesis of these themes during early psychological ego development and how they may characterize the development of the anorectic experience.

CONCLUSION

The Mahlerian perspective can provide psychiatric nursing with a psychoanalytical perspective outside of standard practice, thus promoting critical analysis and integration among the varying professions of psychiatry.

Adolescents with Anorexia Nervosa: Multiple Perspectives of Discharge Readiness

PROBLEM

Little is known about the conditions that must be in place to help adolescent patients and their families gain the confidence needed to continue recovery at home, following the adolescents' hospitalization for anorexia nervosa.

METHODS

Beliefs about discharge readiness were obtained through an open-ended questionnaire following the patients' first weekend pass home from an in-patient unit. The perceptions of patients, parents, and registered nurses were obtained using parallel versions of a questionnaire.

FINDINGS

An examination of the responses revealed four themes; medical stability, education, psychological changes, and community resource planning, that were common to all respondents, as well as themes specific to adolescents and to nurses.

CONCLUSIONS

The findings suggest that each group of respondents has unique discharge readiness needs and that registered nurses have an important role to play in helping patients and families make the transition home as successful as possible. Implications for nursing practice are highlighted.

Baseline personality characteristics of responders to 6-month psychotherapy in eating disorders: preliminary data

OBJECTIVE

The Karolinska Psychodynamic Profile (KAPP) was used for the assessment of the six-month outcome of Brief Adlerian Psychodynamic Psychotherapy (B-APP).

METHOD

Fifty-seven eating disordered women (28 with anorexia nervosa, 29 with bulimia nervosa), were included in the study. The sample was evaluated at baseline (time 0) and after six months (T6) with a clinical assessment and with Temperament and Character Inventory (TCI), Eating Disorder Inventory (EDI-2), State-Trait Anger Expression Inventory (STAXI), and KAPP.

RESULTS

Based on symptomatologic improvement, two sub-groups were obtained: responders (66.6%) and non-responders (33.3%). Significantly higher baseline scores emerged in the responders group on Ineffectiveness and Impulsivity (EDI-2) and on Harm Avoidance (TCI). Several KAPP items and areas improved in both groups at T6.

CONCLUSION

Multimodal treatment centered on B-APP lead to both a global clinical improvement and an improvement in several psychological and psychopathological features as assessed by EDI-2, STAXI and KAPP. The results suggest interesting clinical implications, though outcome predictors are quite weak.

Management of child and adolescent eating disorders: the current evidence base and future directions

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.

Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment

This paper is concerned with the psychopathological processes that account for the persistence of severe eating disorders. Two separate but interrelated lines of argument are developed. One is that the leading evidence-based theory of the maintenance of eating disorders, the cognitive behavioural theory of bulimia nervosa, should be extended in its focus to embrace four additional maintaining mechanisms. Specifically, we propose that in certain patients one or more of four additional maintaining processes interact with the core eating disorder maintaining mechanisms and that when this occurs it is an obstacle to change. The additional maintaining processes concern the influence of clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. The second line of argument is that in the case of eating disorders shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes. Accordingly, we suggest that common mechanisms are involved in the persistence of bulimia nervosa, anorexia nervosa and the atypical eating disorders. Together, these two lines of argument lead us to propose a new transdiagnostic theory of the maintenance of the full range of eating disorders, a theory which embraces a broader range of maintaining mechanisms than the current theory concerning bulimia nervosa. In the final sections of the paper we describe a transdiagnostic treatment derived from the new theory, and we consider in principle the broader relevance of transdiagnostic theories of maintenance.

Dropout from brief psychotherapy in anorexia nervosa

BACKGROUND

Dropout from psychotherapy is an important issue that has received little systematic attention. This study investigated the phenomenon of dropout from brief psychotherapy for anorexia nervosa (AN).

METHODS

99 outpatients suffering from AN of the restrictor type (n = 53) or binge/purging type (n = 46) were evaluated. Their clinical and personal characteristics were recorded, and body mass index was calculated for participants. They were administered the Eating Disorder Inventory-II (EDI-II), the State-Trait Anger Expression Inventory (STAXI) and the Temperament and Character Inventory (TCI).

RESULTS

Significant differences in some baseline psychopathologic (EDI-II, STAXI) and personality (TCI) variables emerged from the comparison between dropouts and completers. Patients who dropped out of the treatment showed higher levels of anger temperament, anger expression-in and expression-out and lower scores for the dimensions of character (low self-directedness and low cooperativeness). No differences were found between the two groups regarding sociodemographic and clinical variables.

CONCLUSIONS

Dropout from brief psychotherapy seems to be related to either psychopathologic or personality aspects, such as the tendency to repress anger, which is encountered also in psychosomatic disorders, and the presence of more compromised dimensions of character, typical of subjects with personality disorders. This study of dropout from brief psychotherapy in AN provided interesting results that will need further confirmation. Possible implications for treatment are addressed.

The development, evolution and philosophy of a clinical research unit

OBJECTIVE

To describe the development,evolution and philosophy of a clinical research unit.

METHOD

The 20-year history of clinical psychiatric research in Christchurch is described. The variety of influences which have impacted upon the studies undertaken is acknowledged,as are the personal histories of key staff.

CONCLUSIONS

Clinical research is potentially endangered. The maintenance and development of clinical research requires a mix of individual inquisitiveness and determination,local opportunity and political will. Despite a political desire for evidence-based medicine; most political policies and practices impede the development of new knowledge and the collection of new evidence.

Focus on psychiatry in New Zealand

New Zealand has been inhabited by the indigenous Maori people for more than 1000 years. The first European (Pakeha) to see the country, in 1642, was the Dutch explorer Abel Tasman. But the English explorer James Cook, who landed there in 1769, was responsible for New Zealand becoming part of the British Empire and, later, the British Commonwealth. In 1840 the Treaty of Waitangi was signed between Maori leaders and Lieutenant-Governor Hobson on behalf of the British Government. The three articles of the Treaty gave powers of Sovereignty to the Queen of England; guaranteed to the Maori Chiefs and tribes full, exclusive and undisturbed possession of their lands, estates, forests and fisheries; and extended to the Maori people Royal protection and all the rights and privileges of British subjects.

Individual psychotherapy for children and adolescents with an eating disorder from historical precedent toward evidence-based practice

This article reviews the place of individual therapy in the suite of treatment services required by children and adolescents with an eating disorder. Individual therapy is defined and traced from historical origins in psychoanalytic practice with later important modifications by Hilda Bruch and Arthur Crisp. More recent developments, based primarily on cognitive and learning theory are discussed, as is the timing of individual therapy with respect to illness stage and patient motivation. Evidence for therapy effectiveness is reviewed where possible. At present, treatment evidence in the pediatric mental health field must be inferred from adult research.

Psychiatric treatments: an exciting new century

At the beginning of the 1900s, effective psychiatric treatments were almost non-existent (Freud's discovery of the unconscious and his psychoanalysis based on this perhaps being the noteworthy exception). In many parts of the world a person with unusual behaviour was thought to be possessed by evil spirits. These demons were exorcised by such techniques as prayer, incantation, magic and the use of purgatives concocted from herbs. If these interventions were unsuccessful, more extreme measures were taken to ensure that the body would be an unpleasant dwelling place for the evil spirit. Flogging, starving, burning, and causing the person to bleed profusely were frequent forms of intervention (Atkinson et al, 1998).