"Knowing one's self" anorexic: implications for therapeutic practice

Eating disorders, disordered eating, and body image research in New Zealand: a scoping review

BACKGROUND

The prevention and treatment of eating disorders relies on an extensive body of research that includes various foci and methodologies. This scoping review identified relevant studies of eating disorders, body image, and disordered eating with New Zealand samples; charted the methodologies, sample characteristics, and findings reported; and identified several gaps that should be addressed by further research.

METHODS

Using scoping review methodology, two databases were searched for studies examining eating disorders, disordered eating, or body image with New Zealand samples. Snowball methods were further used to identify additional relevant articles that did not appear in initial searches. Two independent reviewers screened the titles and abstracts of 473 records. Full text assessment of the remaining 251 records resulted in 148 peer-reviewed articles being identified as eligible for the final review. A search of institutional databases yielded 106 Masters and Doctoral theses for assessment, with a total of 47 theses being identified as eligible for the final review. The included studies were classified by methodology, and the extracted information included the study foci, data collected, sample size, demographic information, and key findings.

RESULTS

The eligible studies examined a variety of eating disorder categories including binge-eating disorder, bulimia nervosa, and anorexia nervosa, in addition to disordered eating behaviours and body image in nonclinical or community samples. Methodologies included treatment trials, secondary analysis of existing datasets, non-treatment experimental interventions, cross-sectional observation, case-control studies, qualitative and mixed-methods studies, and case studies or series. Across all of the studies, questionnaire and interview data were most commonly utilised. A wide range of sample sizes were evident, and studies often reported all-female or mostly-female participants, with minimal inclusion of males and gender minorities. There was also an underrepresentation of minority ethnicities in many studies, highlighting the need for future research to increase diversity within samples.

CONCLUSION

This study provides a comprehensive and detailed overview of research into eating disorders and body image in New Zealand, while highlighting important considerations for both local and international research.

Bridging cognitive, phenomenological and psychodynamic approaches to eating disorders

Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for "objective" (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons' lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive-behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since "being anorexic" becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V.Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Paper 1: a systematic synthesis of narrative therapy treatment components for the treatment of eating disorders

BACKGROUND

There are presently a number of eating disorder treatment interventions that have a research-evidence base to support their effectiveness. However, rates of attrition and treatment outcomes demonstrate that there is no one-size fits all for the treatment of eating disorders. Narrative therapy is a promising, but under-researched, intervention for the treatment of eating disorders (EDs). The aim of this study was to conduct a narrative synthesis of the literature to explore the content and use of narrative therapy in the treatment of EDs.

METHOD

Data were extracted from 33 eligible included studies following systematic search of five data bases. Data included aims and objectives, sample characteristics, treatment details and components of narrative therapy, which informed the narrative synthesis. The study is reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Narrative therapy interventions for EDs consisted of several components including the narrative worldview; unpacking the problem story; finding, thickening the meaning and performance of stories hidden by the problem story; and safety considerations. A notable proportion of the extracted articles discussed components of unpacking problem stories, and finding and re-authoring openings (or unique outcomes) that were hidden by problematic stories. Relatively fewer papers discussed the processes by identity shifts were performed or lived out, including in the eating practices of those with a lived ED experience. Furthermore, few papers addressed how therapists established client safety within the narrative framework when working with EDs.

CONCLUSION

This narrative synthesis found that narrative practitioners utilise a variety of narrative therapy techniques in working with individuals with a lived ED experience. The current literature has emphasis on specific narrative therapy techniques used in ED treatments, with some aspects of the narrative worldview and safety considerations left undiscussed. Additional research is needed to explore how identity shifts in narrative therapy are performed and lead to measurable behavioural changes, and to consider how safety considerations can be established within the narrative worldview. There are a number of psychological therapies for eating disorders that have research evidence-base. These treatments, however, do not work for everyone as indicated by drop-out rates and eating disorders running a severe and enduring course for some people. Narrative therapy is a therapeutic intervention that has been reported as a promising intervention for people with an eating disorder. The focus of narrative therapy is to engage the person in finding identities hidden by problem-saturated identities and in the performance of these hidden identities. In this review, we have explored the use of narrative therapy for eating disorders to identify what aspects of this therapy are currently being used and which components are less referenced in the literature. Findings from this study support the need for further research into narrative therapy components in the treatment of eating disorders, particularly how hidden identities are performed and safety considerations are integrated into this therapeutic intervention.

Self-esteem as a catalyst for change in adolescent inpatients with anorexia nervosa: a pilot randomised controlled trial

PURPOSE

To determine the potential effectiveness of a six-session manualised self-esteem group using CBT approaches when given as an adjuvant to adolescent inpatients with Anorexia Nervosa (AN).

METHODS

Using a randomised controlled design, 50 girls aged 12-17 years with AN were assigned to either self-esteem group with treatment as usual (TAU) (n = 25) or TAU alone (n = 25). 50/78 (64%) consented to be randomised. Both groups completed self-report measures of self-esteem and eating disorder psychopathology at three time points to measure the potential effectiveness of the treatment. Qualitative feedback was collected to assess acceptability.

RESULTS

29 participants completed the study: 15 self-esteem group with TAU, 14 TAU alone. Self-esteem group participants had greater improvement in all outcomes than TAU participants at all time points, the difference in self-report self-esteem at T2 is 1.12 (95% CI - 1.44-3.69; effect size = 0.21). Similar small effect sizes were found for the eating disorder psychopathology measure following completion of the intervention but not at four-week follow-up. Favourable qualitative feedback was gained.

CONCLUSION

These findings demonstrate that the self-esteem group supplements an intensive treatment package which also addresses elements of low self-esteem. The self-esteem group was beneficial for addressing self-esteem and acted as a catalyst for change in eating disorder psychopathology. Positive qualitative feedback indicated the intervention was acceptable to users. Self-esteem group is a potential new adjuvant treatment for AN.

EMB RATING

Level 1.

'In an otherwise limitless world, I was sure of my limit.'† Experiencing Anorexia Nervosa: A phenomenological metasynthesis

Anorexia Nervosa (AN) has the highest mortality rate of the mental disorders, with still less than 50% of affected individuals achieving recovery. Recent calls to bring innovative, empirical research strategies to the understanding of illness and its core psychopathological features highlight the need to address significant paucity of efficacious treatment. The current study brings a phenomenological approach to this challenge, synthesizing lived experience phenomena as described by qualitative literature. Fifty-three studies published between the years 1998 and 2021 comprising a total of 1557 participants aged 12-66 suffering from AN or sub-threshold AN are included. Reciprocal and refutational analysis generated six key third-order constructs: "emotion experienced as overwhelming," "identity," "AN as a tool," "internal conflict relating to Anorexia," "interpersonal communication difficulties" and "corporeality." Twenty-six sub-themes were identified, the most common being fear, avoidance, AN as guardian/protector, and AN as intertwined with identity. Some themes associated with current treatment models such as low self-esteem, need for social approval and feelings of fatness were less common. We highlight the significant role of intense and confusing emotion in AN, which is both rooted in and engenders amplified fear and anxiety. Restrictive eating functions to numb these feelings and withdraw an individual from a chaotic and threatening world whilst providing a sense of self around which to build an illness identity. Results have implications for therapeutic practice and overly protective weight and shape focused medical treatment models, which may serve to reinforce the disease.

Anorexia nervosa: the diagnosis. A postmodern ethics contribution to the bioethics debate on involuntary treatment for anorexia nervosa

This paper argues that there is a relationship between understandings of anorexia nervosa (AN) and how the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. By positioning AN as a construct/discourse (hereinafter "AN: the diagnosis") several ethical issues are revealed. Firstly, "AN: the diagnosis" influences how the autonomy and competence of persons diagnosed with AN are understood by decision-makers in the treatment environment. Secondly, "AN: the diagnosis" impacts on how treatment and treatment efficacy are defined and the ethical justifiability of paternalism. Thirdly, "AN: the diagnosis" can limit the opportunity for persons with AN to construct an identity that casts them as a competent person. "AN: the diagnosis" can thus inherently affirm professional knowledge and values. Postmodern professional ethics can support professionals in managing these issues by highlighting the importance of taking responsibility for professional knowledge, values, and power and embracing moral uncertainty.

Assessment of anorexia nervosa: an overview of universal issues and contextual challenges

AIM

Anorexia Nervosa (AN) is a complex and clinically challenging syndrome. Intended for specialist audiences, this narrative review aims to summarise the available literature related to assessment in the adult patient context, synthesising both research evidence and clinical consensus guidelines.

METHOD

We provide a review of the available literature on specialist assessment of AN focusing on common trajectories into assessment, obstacles accessing assessment, common presenting issues and barriers to the assessment process, the necessary scope of assessment, and tools and techniques. It describes the further step of synthesising assessment information in ways that can inform resultant care plans.

RESULTS

In addition to assessment of core behaviours and diagnostic skills, considerations for the expert assessor include the functions of primary care, systemic and personal barriers, knowledge of current assessment tools and research pertaining to comorbid pathology in AN, assessing severity of illness, role of family at assessment, as well as medical, nutritional and compulsory elements of assessment.

CONCLUSION

Comprehensive assessment of AN in the current healthcare context still remains largely the remit of the specialist ED clinician. Assessment should remain an on-going process, paying particular attention to available empirical evidence, thereby reducing the gap between research and practice.

Identity and eating disorders (IDEA): a questionnaire evaluating identity and embodiment in eating disorder patients

BACKGROUND

In this paper we tested the hypothesis that persons with eating disorders (EDs) are affected by disturbances of the way they experience their own body (embodiment) and shape their personal identity, assuming that the various kinds of anomalies of eating behavior are consequences thereof.

SAMPLING AND METHODS

We developed and validated a new self-reported questionnaire named IDEA (IDentity and EAting disorders), which was administered to 147 ED patients and 187 healthy controls. Test-retest reliability, internal consistency, psychopathological correlates, and concurrent validity were evaluated. A factor analysis was performed to verify the distribution of items into subscales.

RESULTS

The questionnaire showed good test-retest reliability, and internal consistency. IDEA scores were specifically associated with ED psychopathology, and they did not show any correlation with sociodemographic and general clinical variables. Four factors were extracted, which were related to the following phenomena: 'feeling oneself only through the gaze of the other and defining oneself only through the evaluation of the other', 'feeling oneself only through objective measures', 'feeling extraneous from one's own body', and 'feeling oneself through starvation'.

CONCLUSIONS

IDEA represents a multidimensional, brief, versatile, easy-to-perform instrument for clinical evaluation, assessing abnormalities in lived corporeality, and of personal identity, which appeared to be specifically associated with the core features of ED psychopathology. The main limitations of the study are the cross-sectional design. Also, it is impossible to ascertain whether the domains we assessed are specific traits of patients with EDs, or state-related features. To answer this question, a longitudinal study is needed.

Expanding the concept of motivation to change: the content of patients' wish to recover from anorexia nervosa

OBJECTIVE

Motivational approaches to anorexia nervosa (AN) have mainly concerned motivational quality and quantity. We investigated the content of patients' wish to recover.

METHOD

Eighteen women, aged 18-39, with AN were interviewed in depth using a phenomenological study design. Interviews were tape-recorded, transcribed, and analyzed using the QSR-N*Vivo software program.

RESULTS

Four motivational content areas characterized informants' wishes to recover: "Sense of vitality" (e.g., joy, concentration, spontaneity, energy); "Sense of autonomy" (e.g., choosing to recover, new methods of mastery, self-determination); "Sense of insight" (e.g., awareness, seeing nuances, limitation of goals, self-knowledge); and "Negative consequences" (e.g., loss of future, costs to own children, feeling sick or thin, social costs, physical costs).

CONCLUSION

Our sample of AN patients' motivation to recover may be described using three dimensions: content, quality, and quantity, and may also include motives with no behavioral intention. Sustained therapeutic success may rest upon the therapist's ability to identify and ally with the patient's motives to recover.

Self-liking and self-competence: relationship to symptoms of anorexia nervosa

Self-esteem has been hypothesised to play a pivotal role in the development and treatment, and outcome of anorexia nervosa (AN). Though this relationship is typically investigated by considering self-esteem as a unitary construct, research suggests that this comprises of two related but distinct components of self-liking and self-competence. This study investigates the association between self-liking, self-competence, and symptomatology of AN through the course of a defined treatment episode in 77 women. Self-liking was significantly associated with laxative abuse. Self-competence was significantly associated with elevated ineffectiveness, perfectionism and interpersonal distrust. Although self-competence and eating disturbance severity significantly improved over the treatment episode, one in three participants reported a reduced self-like or self-competence. Changes in both self-competence and self-liking at the end of treatment was associated with changes in drive for thinness. Such findings have implications for treatment models concerned with improving self-esteem.

The meaning of self-starvation: qualitative study of patients' perception of anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) patients tend to place a positive value on their symptoms. Many clinicians believe that this plays a central role in maintaining the disorder. However, empirical research on how patients attribute meaning to their symptoms is lacking. This study aims at systematically exploring the meaning that the patients with AN attribute to their anorectic behavior.

METHOD

A qualitative, descriptive, phenomenological design was used. Eighteen women aged 20-34 with AN (DSM-IV) were interviewed with an informant-centered interview. The interviews were tape-recorded, verbatim transcribed, coded, and analyzed phenomenologically, using a QSR-N*Vivo software program.

RESULTS

The psychological meanings that the informants attributed to their anorectic behavior could be summarized in eight constructs: "Security" (feeling of stability and security), "Avoidance" (avoiding negative emotions), "Mental strength" (inner sense of mastery), "Self-confidence" (feeling acknowledged and worthy of compliments); "Identity" (achieving new identity), "Care" (eliciting care from others), "Communication" (communicating difficulties), and "Death" (wishing to starve oneself to death).

CONCLUSION

The eight constructs may have central functions in the maintenance of AN and should be regarded when patients' motivation and goals for treatment are assessed. Further study of the possible functions of the constructs in maintaining AN is warranted.

Can psychiatric terminology be translated into legal regulation? The anorexia nervosa example

OBJECTIVE

To explore the tension between the definition of mental illness in clinical psychiatry and its embodiment in legislation applied by tribunals reviewing decisions to treat.

METHOD

Severe anorexia nervosa is used as a case exemplar of the tension between the appropriate narrative to express the clinical imperative to treat and the law's focus on finer technical language which secures individual civil rights and liberties. Australian and international experience is reviewed.

RESULTS

The paper finds that the clinical and the legal narratives about how to 'define' mental illness do differ at the formal level of expression where they necessarily intersect in the setting of tribunal review of involuntary treatment decisions. However, in practice mental health admissions and tribunal reviews generally endorse the clinical applications of that more capacious and fluid terminology of clinical psychiatry.

CONCLUSIONS

While tribunal reviews of clinical decisions may occasionally require clinicians to participate in an unfamiliar legal dialogue about narrowly construed definitions of mental illness, tribunals apply more complex tests which are sensitive to clinical practice and good therapeutic objectives.

An international collaborative database: its use in predicting length of stay for inpatient treatment of anorexia nervosa

OBJECTIVE

We describe the establishment of an Australasian multisite research database for inpatient treatment of anorexia nervosa (AN). Using this database, the second aim of this study is to investigate the extent to which length of stay (LOS) in participating facilities could be predicted at admission from patient, clinical, and site variables.

METHOD

Standardized demographic and clinical data were collated for 213 admission episodes involving 154 participants over a 20 month period from five Australian and one New Zealand specialist treatment centres.

RESULTS

While nine variables significantly predicted LOS on univariate analysis, linear regression determined that only body mass index, and having had 2-3 previous admissions made significant independent contributions to LOS.

DISCUSSION

Multisite databases offer a viable means by which to conduct clinical research, particularly in regard to low prevalence disorders such as AN. Their additional advantage is that of involving front-line practitioners recruiting participants more likely to be representative of cases seen across treatment centres. At just under a fifth of the total variance predicted by the best-fit model, LOS in hospital remains an aspect of AN treatment difficult to predict, and future studies need to explore variables other than the obvious demographic or clinical issues at admission. The clinical and planning implications are discussed.