How are families included in the treatment of adults affected by eating disorders? A scoping review

"I don't know how, if, it's ever going to end": narratives of caring for someone with an enduring eating disorder

BACKGROUND

Families and carers are pivotal in supporting loved ones experiencing eating disorders. This role can bring immense distress and burden, yet the experience of caring for someone with an enduring eating disorder has had minimal research focus. Thus, the purpose of this study is to give voice to carers empowering their stories to increase awareness and understanding, which could inform support to carers and consequently people with a lived and/or living experience of eating disorders.

METHODS

Semi-structured interviews were conducted with 9 carers supporting individuals who had been experiencing an eating disorder for 7 or more years. Data were collected and analysed using narrative inquiry approach.

RESULTS

Carers' narratives revealed feelings of guilt and personal failure; a profound sense of disillusion with current treatment approaches; and immense grief and anguish. As they negotiated a tenuous relationship with hope and the uncertainty of their loved one's future, carers spoke to a complex myriad of feelings of acceptance, letting go, and forging on.

CONCLUSION

Carers deserve to have their voices heard where they are too often silenced. Their narratives provide an urgent call for transformation in our treatments for eating disorders and further involvement of carers within the treatment journey, and their lived experience perspectives have great potential to guide this endeavour.

LEVEL OF EVIDENCE

Level V, qualitative interviews.

Orthorexia and Orthorexia Nervosa: A Comprehensive Examination of Prevalence, Risk Factors, Diagnosis, and Treatment

Orthorexia nervosa is an emerging and controversial eating disorder characterized by an obsessive preoccupation with healthy eating and an extreme fixation on food purity. Despite growing public interest in orthorexia, its classification as a distinct eating disorder remains a subject of ongoing debate in the mental health community. This paper comprehensively reviews the current literature on orthorexia nervosa, exploring the prevalence rates, risk factors, diagnosis, and treatment options. The paper offers an overview of orthorexia and its historical context and explores the challenges and considerations in diagnosing orthorexia and orthorexia nervosa. Specifically, the distinction between "orthorexia" and "orthorexia nervosa" is a debated issue in eating disorder research due to a lack of clear diagnostic criteria, making it challenging to accurately differentiate between an obsession with healthy eating and a more severe form with potential distress and impairment. Given the absence of formal diagnostic criteria, developing valid and reliable assessment tools is crucial to accurately identify and treat individuals experiencing these disorders. The paper's final section covers the existing treatment approaches for orthorexia nervosa. Overall, the paper highlights the complex and multifaceted nature of orthorexia nervosa. This review contributes to the ongoing discourse surrounding orthorexia and provides valuable insights for clinicians, researchers, and stakeholders in the mental health and eating disorders fields.

Perceptions of health professionals in providing care for people with anorexia nervosa and bulimia nervosa: a systematic review and meta-synthesis of qualitative studies

This study sought to synthesize and reinterpret findings from primary qualitative studies on the experience of health professionals in caring for people with anorexia nervosa and bulimia nervosa. We conducted a systematic review of the literature with the SPIDER search strategy assessing six databases. A meta-synthesis was performed with data from qualitative studies. Two independent reviewers screened and assessed the articles, extracted data from the articles and elaborated thematic synthesis. Nineteen articles met the inclusion/exclusion criteria. The meta-synthesis revealed three descriptive themes: Going outside the comfort zone: hard relational experiences of health professionals in providing care for people with anorexia nervosa and bulimia nervosa; Reflecting on treatment: relevance of discussion, communication, and flexibility in health professionals' work with anorexia nervosa and bulimia nervosa; and Dealing with ambivalences: experiences of health professionals with family members of people with anorexia nervosa and bulimia nervosa. We elaborated two analytical themes: Making work with eating disorders palatable: malleability necessary for health professionals in bonding with people with anorexia and bulimia nervosa and their families; and Leaving the professional comfort zone: transition from multi to interdisciplinary. Thus, mental health professionals who work with people diagnosed with anorexia and bulimia nervosa cope with hard emotional experiences that makes them feel out of their comfort zone, requiring flexibility to benefit a good therapeutic alliance, but there are still difficulties in promoting interdisciplinarity.

Involvement, depressive symptoms, and their associations with problems and unmet needs in caregivers of adult eating disorder patients

PURPOSE

This study aimed to examine the most important problems and needs caregivers of adult inpatients with eating disorders (EDs) are confronted with in their everyday lives. A further aim was to investigate the associations between problems, needs, involvement, and depression in carers.

METHODS

Fifty-five caregivers of inpatients with EDs (26 anorexia nervosa, 29 bulimia nervosa) completed the Carers' Needs Assessment, Beck Depression Inventory, and the Involvement Evaluation Questionnaire. The relationships between variables were tested via multiple linear regressions and mediation analyses.

RESULTS

The most frequent problem reported by caregivers was a lack of information about the course and treatment of the illness and consequent disappointment, whereas their most frequently reported needs were different forms of information and counselling. Problems, unmet needs, and worrying were especially high in parents compared to other caregivers. Involvement mediated significantly between problems (b = 0.26, BCa CI [0.03, 0.49]) as well as unmet needs (b = 0.32, BCa CI [0.03, 0.59]) of caregivers and their depressive symptoms.

CONCLUSION

Our findings underline the importance of including the problems and needs of caregivers of adult eating disorder patients in the planning of family and community interventions, to support their mental health.

LEVEL OF EVIDENCE

Level III: Evidence obtained from cohort or case-control analytic studies.

An investigation of the factor structure of a German version of the Eating Disorder Symptom Impact Scale (EDSIS) among parents of adolescents and young adults with anorexia nervosa

The aim of this study was to explore the factor structure, scale characteristics and convergent validity of a German version of the Eating Disorder Symptom Impact Scale (EDSIS). A total of 335 parents of adolescents and young adults with anorexia nervosa in inpatient or outpatient treatment completed the 24-item German translation of the EDSIS and other measures of caregiving burden and psychological distress. We tested a 4 vs. 6-factor model of the EDSIS using confirmatory factor analyses. The 6-factor model treating items as ordinal variables showed the best fit to the data (CFI = 0.949, RMSEA = 0.064). Strong invariance of this model was shown between the sample of mothers and fathers. Internal consistencies of the EDSIS scales were in the acceptable-to-good range. Bottom effects were observed for the 'Binge-Purge-Impacts' subscale only. Mothers had significantly higher EDSIS scores compared to fathers. The EDSIS total score and most of the subscores showed substantial positive correlations with caregivers' psychological distress, level of depression, anxiety and expressed emotion as well as negative associations with the level of perceived caregiving skills. The German version of the EDSIS is a useful tool to assess caregiving burden in mothers and fathers of patients with anorexia nervosa.

Management of eating disorders for people with higher weight: clinical practice guideline

INTRODUCTION

The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.

AIM

The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.

METHODS

The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.

RECOMMENDATIONS

Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.

CONCLUSIONS

This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.

Working with families of adults affected by eating disorders: uptake, key themes, and participant experiences of family involvement in outpatient treatment-as-usual

BACKGROUND

Eating disorders are associated with significant personal and family costs. Clinical guidelines recommend family members be involved and supported during care, but little has been reported regarding the preferences of adults around carer involvement in treatment. The necessary intensity of family work with adults is also unknown. A trial of a standardised brief family involvement method was conducted in an adult eating disorder service offering treatment-as-usual. Uptake and feasibility of implementing the approach as part of standard outpatient care and the preliminary impact on issues identified by adult patients and carers were evaluated.

METHODS

Eligible referrals at an adult eating disorders outpatient clinic were offered as needed family consultation to address presenting interpersonal problems identified by patients and their family members, and outcomes were evaluated 4 weeks later. Pre and post intervention surveys identified participant self-reported change in (i) problem frequency, (ii) distress and disruption caused, and (iii) confidence regarding presenting problems. Open text responses provided an overview of patient and carer goals for family involvement and revealed how the novel method impacted these areas as well as overall experience of, and feedback regarding, the brief family intervention.

RESULTS

Twenty-four female participants aged 18-53, and 22 carers participated in 31 consultations. Common concerns raised were eating disorder related interpersonal and communication issues. The focused sessions, offered on a one-at-a-time basis, showed preliminary effectiveness for reducing both patients and carer concerns. For example, adult patients reported that life interference from interpersonal problems was lower and confidence to deal with them was higher following family consultation. Carers also reported that frequency, level of worry, and life interference around presenting problems were lower after the structured family intervention.

CONCLUSIONS

Brief family consultation, with a single focus on issues identified by family members and adult patients, was a safe and feasible procedure with adults affected by eating disorders. Effective at meeting the needs of participants, the framework investigated in the current study may also be a useful direction for adult services to consider when looking to support families and meet recommendations for their routine involvement in the outpatient care.

TRIAL REGISTRATION

Australian Clinical Trials Register number: ACTRN12621000047897 (www.anzctr.org.au).

Anorexia and Young Womens' Personal Networks: Size, Structure, and Kinship

Anorexia is a serious threat to young women's wellbeing worldwide. The effectiveness of mental health intervention and treatment is often evaluated on the basis of changes in the personal networks; however, the development of such measures for young women with anorexia is constrained due to the lack of quantitative descriptions of their social networks. We aim to fill this substantial gap. In this paper, we identify the basic properties of these women's personal networks such as size, structure, and proportion of kin connections. The empirical analysis, using a concentric circles methodology, is based on 50 ego networks constructed on data drawn from interviews with Russian-speaking bloggers who have been diagnosed with anorexia and write about this condition. We conclude that young women with anorexia tend to support a limited number of social ties; they are prone to select women as alters, but do not have a preference to connect to their relatives. Further research is needed to elucidate whether these personal network characteristics are similar among women with anorexia who belong to different age, ethnic, cultural, and income groups.

Multi-family therapy for eating disorders: A systematic scoping review of the quantitative and qualitative findings

OBJECTIVE

This study reviewed the quantitative and qualitative evidence-base for multi-family therapy (MFT) for eating disorders regarding change in physical and psychological symptoms, broader individual and family factors, and the experience of treatment.

METHOD

A systematic scoping review was conducted. Four databases (PsycInfo, Medline, Embase, CENTRAL) and five grey literature databases were searched on 24th June 2021 for relevant peer-reviewed journal articles, book chapters, and dissertations. No beginning time-point was specified. Only papers that presented quantitative or qualitative data were included. No restrictions on age or diagnosis were imposed. Studies were first mapped by study design, participant age, and treatment setting, then narratively synthesized.

RESULTS

Outcomes for 714 people who received MFT across 27 studies (one mixed-method, 17 quantitative and nine qualitative) were synthesized. MFT is associated with improvements in eating disorder symptomatology and weight gain for those who are underweight. It is also associated with improvements in other individual and family factors including comorbidities, self-esteem, quality of life, and some aspects of the experience of caregiving, although these findings are more mixed. MFT is generally experienced as both helpful and challenging due to the content addressed and intensive group process.

DISCUSSION

MFT is associated with significant improvements in eating disorder symptoms across the lifespan and improvement in broader individual and family factors. The evidence base is small and studies are generally underpowered. Larger, higher-quality studies are needed, as is research investigating the unique contribution of MFT on outcomes, given it is typically an adjunctive treatment.

Promoviendo una Alimentación Saludable (PAS) results: Engaging Latino families in eating disorder treatment

Latinos/as are underrepresented in eating disorders clinical trials. This study compared results of a culturally adapted individual cognitive-behavioral treatment (CBT) for binge-spectrum eating disorders that included or excluded a family enhanced module (CBT + FE), in a proof-of-principle pilot study with a sample of Latina adults and one family member per patient. Twenty-five patients (M_age = 37 yrs) and 25 family members (M_age = 40 yrs) were randomized to CBT (n = 13) or CBT+ FE (n = 12). DSM-IV eating disorder diagnoses were: 48% (n = 12) bulimia nervosa, 28% (n = 7) binge-eating disorder, and 24% (n = 6) eating disorder not otherwise specified. Effect sizes favored CBT + FE on adherence and retention, and scores on treatment satisfaction and therapeutic alliance were high, indicating treatment acceptability. In spite of the hypothesis that family outcomes such as support, familism, cohesion, pride, family cultural conflict, burden, and marital satisfaction (in couples) would be superior in CBT + FE, the preliminary data were inconclusive and results were mixed. The hypothesis that eating disorder outcomes including global eating psychopathology, binge eating, and purging would improve in CBT + FE was not supported. There was some evidence that patients in CBT improved more particularly on binge eating, otherwise the groups had no differences. In conclusion, the results suggest that CBT + FE could enhance treatment adherence and retention, although this did not automatically translate to better family and symptom outcomes.