Reluctance to recover in anorexia nervosa

Readiness and Personality Disorders: Considering Patients' Readiness for Change and Our System's Readiness for Patients

ABSTRACT

The culture around personality disorder treatment has changed drastically in the past generation. While once perceived as effectively untreatable, there are now numerous evidence-based treatment approaches for personality disorders (especially borderline personality disorder). The questions, however, of who should be matched to which treatment approach, and when, remain largely unanswered. In other areas of psychiatry, particularly substance use disorders and eating disorders, assessing patient treatment readiness is viewed as indispensable for treatment planning. Despite this, relatively little research has been done with respect to readiness and personality disorder treatment. In this article, we propose multiple explanations for why this may be the case, relating to both the unique features of personality disorders and the current cultural landscape around their treatment. While patients with personality disorders often face cruel stigmatization, and much more work needs to be done to expand access to care (i.e., our system's readiness for patients), even gold-standard treatment options are unlikely to work if a patient is not ready for treatment. Further study of readiness in the context of personality disorders could help more effectively match patients to the right treatment, at the right time. Such research could also aid development of strategies to enhance patient readiness.

An exploration of patient experiences of transitioning to a remote day programme following inpatient treatment in an adult eating disorder service

WHAT IS KNOWN ON THE SUBJECT?: Traditionally, treatment for eating disorders (EDs) has been provided on an inpatient or outpatient basis, but more recently other levels of treatment provision to include, day care (DC) and community outreach programmes, have been developed. There is limited research exploring the experience of patients who have transitioned from inpatient ED treatment to a remote DC treatment. This lack of knowledge can impact mental health nurses' understanding of what that experience is like for patients and hence may influence the efficacy of collaboration and inclusion between patients and nurses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This research addresses this dearth of knowledge and adds to our understanding of patients' experiences of attending a remote DC programme following a period of inpatient treatment for an ED. This is an important study for nurses and other mental health professionals working with people in ED treatment, as it highlights the specific challenges and anxieties of transitioning from inpatient to a remote DC programme and the individualized supports advisable during this process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research provides a basis on which nurses can understand and address the challenges experienced by patients after transitioning to a less intensive supportive ED programme. The understanding of these experiences will enhance the therapeutic alliance between the nurse and patient, which will in turn support the patient in increasing agency as they progress through their recovery. This research provides a foundation on which to develop specific supports that need to be in place to help patients manage the anxieties they experience as they transition to a less intense and remote treatment. Findings from these lived experiences can be used to support the development of similar DC programmes for EDs in other settings.

ABSTRACT

INTRODUCTION: Day care (DC) treatment for people with an eating disorder (ED) provides for an easier transition from hospital to home, along with a treatment milieu where patients can maintain occupational and social functioning and allow for the transfer of newly acquired skills to everyday life.

AIM

To explore patients' experiences of attending a remote day programme following intense inpatient treatment in an adult ED service.

METHOD

A qualitative descriptive methodology informed the study. In-depth semi-structured interviews were conducted with 10 consenting patients. A thematic analysis framework was used to guide the process of data analysis.

RESULTS

Three themes reflected participants' experiences: 'Moving On: Preparing for Change', 'Navigating a New Support System' and 'Increasing Agency'.

DISCUSSION

An underlying issue for participants was an ongoing but changing experience of anxiety. While anticipatory anxiety is evident in preparing for discharge, this is replaced with a real-time anxiety as they endeavour to negotiate an effective support network.

IMPLICATIONS FOR PRACTICE

The findings from this study provide a basis on which mental health nurses can develop timely and effective treatment and support systems with patients who are transitioning from a high support inpatient ED programme to a less intensive ED remote DC programme.

Apps targeting anorexia nervosa in young people: a systematic review of active ingredients

Evaluating the presence of behavior change techniques (BCTs) in mHealth apps could be used to better understand what "active ingredients" contribute to outcomes. Despite the early onset of Anorexia Nervosa (AN) and the increasing use of mobile apps to seek mental healthcare among young people, BCTs underpinning mHealth apps targeting AN have never been systematically examined. This review systematically identified and analyzed BCTs underpinning apps targeted at reducing AN in young people in an attempt to understand their active components. Apps were searched and screened in Apple Store and Google Play. Six apps that met the inclusion criteria and were coded by trained researchers against the BCT Taxonomy V1. Overall, 22 of 93 possible BCTs were identified. The most common were "Information about health consequences," "Social support (unspecified)," and "Information about antecedents". Identified BCTs suggested potential overlaps with traditional clinical treatments for AN, such as cognitive behavioral therapy and family-based therapy. Further investigation is required to evaluate the apps' usability and effectiveness.

A preliminary exploration of experiences of integrating the body in the self in two women with anorexia nervosa in view of phenomenological conceptualisations

BACKGROUND

People with anorexia nervosa often present with confusions around bodily sensations and difficulties in experiencing their body as a place of their own. Many existing models understand anorexia nervosa as a disorder of behaviour and thoughts about eating and body size, and treatments typically focus on modifying thoughts and psychological processes. They leave aside the subject as she experiences the body from a first-person perspective. Inspired by phenomenology and the embodied mind thesis, this explorative study examines in depth the experiences of individuals with anorexia nervosa as they engage in Norwegian psychomotor physiotherapy. Through release of bodily tension and restricted breathing, this method aims to help subjects tune into the body and accept that difficult experiences, relationships and feelings are also bodily.

METHODS

Qualitative in-depth interviews were conducted with two women who had been attending Norwegian psychomotor physiotherapy for more than two years. Thematic analysis was used to identify, analyse and interpret themes within the data.

RESULTS

Three main overarching themes that structure the subjects' experiences were identified: the meaning of the therapeutic relationship, changes in bodily connectedness and ways of moving, and improved ability to articulate and reflect on feelings.

CONCLUSION

The subjects described a greater tendency to experience the body in the self and as a place of their own, a more flexible and vital body, and an increased capacity to identify, express and make sense of feelings. These changes enriched their interactions with the social world. Feeling acknowledged and accepted by the therapist throughout the process was essential. The study illustrates how difficult experiences, thoughts and feelings can, over time, manifest in the body as withheld breathing and diverse bodily constraints affecting both self- and body awareness. The study endorses the phenomenological concepts that our experiences of the self and the world are essentially bodily, and emphasizes the importance of the first-person perspective when investigating the contribution of the body to the self and to our interactions with the social world. Physio- and body awareness therapies that help patients relate to, understand and integrate bodily experiences may complement other treatment approaches and help patients with anorexia proceed with the recovery process. Having anorexia nervosa involve changes in the way one experiences the body. The condition has been linked to confusions around bodily sensations and reduced experience of the body as an integrated place of their own. The purpose of this study was to gain a richer understanding of bodily experiences in subjects with anorexia nervosa having attended a specialized physiotherapy approach. In depth interviews were conducted with two women who had anorexia nervosa and who had engaged in Norwegian Psychomotor Physiotherapy for more than two years. Three themes that structure the subjects' experiences were identified: the meaning of the therapeutic relationship, changes in bodily connectedness and ways of moving, and improved ability to articulate and reflect on feelings. The subjects described a greater tendency to experience the body in the self and as a place of their own, a more flexible and vital body, and an increased capacity to identify, express and make sense of feelings. Feeling acknowledged and accepted by the therapist throughout the process was essential. The study illustrates how difficult experiences, thoughts and feelings can manifest in the body as withheld breathing and diverse bodily constraints affecting both self- and body awareness in people with anorexia nervosa.

Different pathways, same goals: A large-scale qualitative study of autistic and non-autistic patient-generated definitions of recovery from an eating disorder

BACKGROUND

Definitions of recovery from an eating disorder (ED) have generally been formulated around clinical conceptualisations, rather than based on the views of patients. This paper therefore asked those with lived experience of ED for their own definitions of recovery.

METHOD

Data were collected as part of an online study looking at EDs, autism and relationships. About 173 participants identified as recovered from ED and gave free-response definitions of recovery. Responses were subject to thematic analysis.

RESULTS

Seven major themes were identified: Weight restoration, lack of ED behaviours, thoughts and behaviours, cognitions, emotional responses, getting on with life, and ongoing challenges.

CONCLUSIONS

Many definitions of recovery given by those who have lived experience of ED echoed those used by clinicians and researchers. There were also points of divergence around the ongoing challenges of recovery. Our findings highlight the need for continuing support post-weight restoration to facilitate the successful long-term recovery for those with ED.

Experiencing eight psychotherapy approaches devoted to eating disorders in a single-day workshop increases insight and motivation to engage in care: a pilot study

PURPOSE

For patients with eating disorders (EDs), early engagement in care is usually considered a positive prognostic factor. The aim of the study was to investigate how a single-day intervention devoted to early, brief, experiential exposure to a variety of psychotherapy approaches might support commitment to change and the decision to engage in care in patients with EDs.

METHODS

One hundred and sixty-nine adult outpatients newly diagnosed with an ED took part in a single-day workshop for groups of up to ten patients, where they experienced eight psychotherapeutic approaches. Motivation to change care and level of insight were assessed at baseline and 10 days after the intervention.

RESULTS

Motivation and commitment to take active steps toward change (expressed by the "Committed Action" composite score) significantly improved after the intervention (p < 0.001), and a significant number of patients specifically moved from "contemplation" to "action" stage (p < 0.001). The improvement of motivation to change was significantly associated with an increase in insight capacity (p < 0.001), and this increase was observed for almost all related dimensions such as recognition of illness or awareness of need for psychological treatment.

CONCLUSION

A single-day session devoted to experiencing a range of group psychotherapies increased patients' insight and motivation to actively engage in care. To confirm potential longer-term benefits of this intervention, further studies are needed to explore the contribution of each approach and process specifically involved in patients' increased motivation for care, as well as the clinical characteristics of patients associated with better outcomes.

LEVEL OF EVIDENCE

V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Females with Eating Disorders and Urinary Incontinence: A Psychoanalytic Perspective

Eating disorders (EDs) are complicated mental illnesses with significant treatment resistance and dropout rates. For successful treatment, it is important for clinicians to better understand the patients’ narrative and their lived experiences. A thorough psychodynamic understanding of patients’ childhood attachment and primary relationships, personality traits and mental processes is, therefore, crucial for managing patients with ED. Interestingly, several studies have observed an association between functional urinary symptoms and individuals with ED. EDs such as anorexia nervosa are associated with an increased risk of all urinary symptoms, and functional incontinence was also more common in extreme female athletes with low energy availability and with disordered eating. There is, however, a dearth of literature describing this relationship, and the underlying mechanisms remain remote. In this paper, we present a psychoanalytic approach to the presence of urinary symptoms in females with EDs. We hypothesize that these symptoms are tied to specific traits or characteristics of ED patients, namely the overarching need for control, a pathological strive for perfection and the self-denial of basic bodily urges. This is discussed in relation to psychopathological processes, development and personality factors commonly seen in patients with ED.

Compliance and resistance to treatment in an Italian residential Centre for eating disorders

The dominant biomedical model perceives eating disorders as mental disorders and its 'sufferers' as people who need to be healed. It follows that people diagnosed with an eating disorder are pressured to accept medical and psychological care due to the moral obligations that are associated with the sick role, as delineated by Parsons. This, however, does not necessarily imply that they are willing to heal. By analysing compliance and resistance to treatment in an Italian residential Centre for eating disorders, this paper suggests that patients may accept medical care in order to achieve objectives other than those for which power is exerted over them. By complying with treatment, patients may in fact attempt to (re)become anorexic or escape from their everyday environment and problems. It is therefore argued that biomedical power can be subverted from within through the adoption of what De Certeau defines as tactics.

Adaptation and Implementation of an Intervention Programme on Spanish Carers and Adolescent Patients With an Eating Disorder: Study Protocol of a Randomized Controlled Trial

Introduction: One of the major problems with inpatient treatment of adolescent girls with an eating disorder (ED) is that the strategies learned during their hospital stay are not easily applied or maintained in their daily lives, and this has been related to high rates of relapse and readmission. The ECHOMANTRA programme was developed to optimize outcomes during and following inpatient or day-patient treatment. ECHOMANTRA is based on interventions for carers (Experienced Carers Helping Others, ECHO) and patients (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) and is developed from the cognitive interpersonal model of anorexia (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013). This study aims to describe the study protocol of a randomized controlled trial (RCT) for evaluating the efficacy of an adaptation of a novel intervention for patients and carers (ECHOMANTRA) to be implemented as an add-on to treatment-as-usual (TAU).

Method: In a multi−center pilot RCT, 80 female adolescent patients with a DSM-5 diagnosis of an ED and their carers will be invited to participate in the study. They will then be randomized to receive either the ECHOMANTRA intervention as an add-on to TAU or TAU alone. A repeated measures design will be conducted across four time points. Primary outcomes will be patient psychological well-being and eating disorder symptoms, and secondary outcomes will include body mass index, obsessive-compulsive symptoms, perfectionism, motivation to change and psychosocial adjustment. For carers, outcome variables will include psychological well-being, expressed emotion, accommodation and enabling behaviors, burden, and care skills.

Discussion: The results from this trial will establish the effectiveness of ECHOMANTRA and may reveal whether and to what extent this novel intervention can optimize outcomes during and following inpatient treatment. This study will also provide the adaptation of the ECHOMANTRA in the Spanish context for inpatient/day-care treatment.

Women's perspectives toward their nutritional counseling for eating disorders: a qualitative internet-based study in Israel

Nutritional counseling is a central part of eating disorder (ED) treatment. However, the nature of this treatment has not yet been described from women's perspectives. We conducted two studies exploring views of women regarding their ED nutritional counseling. In the first study, we used content analysis to reveal practices that registered dietitians (RDs) use in ED treatment. In the second study, we used phenomenological analysis to explore the nature of the client-dietitian collaboration. Data included 1,897 posts and 8,673 responses from 414 distinct female users, retrieved from a moderated ED Internet community website in Israel. Content analysis demonstrated six practices used by RDs: meal planning, weight monitoring, health assessment/consultation, establishing rapports, food logs, joint eating. Phenomenological analysis produced four positions demonstrating client-dietitian collaborations: "Silent dialogue," "Cancelation and deception," "Tough love," "Containment." Findings revealed women's efforts to continue treatment despite their ambivalence about goals and recovery, and RDs' efforts to help women, despite the women's ambivalence, to move forward toward recovery.

Patients' Experiences and Perceptions of Recovering from Anorexia Nervosa While Having Contact with Psychiatric Care: A Literature Review and Narrative Synthesis of Qualitative Studies

Anorexia nervosa (AN) is a serious disease which is difficult to treat. Little is known about the recovery from AN, and therefore, this review's aim was to review and synthesise patients' experiences and perceptions of what is meaningful for recovery from anorexia nervosa while having contact with psychiatric care. Cinahl, PubMed, and PsycINFO were systematically searched, and 24 studies met the inclusion criteria and were included in the review. Three themes were identified: Being in a trustful and secure care relationship, Finding oneself again, and Being in an engaging and personal treatment. Efforts supporting staff learning and person-centred care should be emphasised and researched further.

Interviewing anorexia: How do individuals given a diagnosis of anorexia nervosa experience Voice Dialogue with their eating disorder voice? A qualitative analysis

A proportion of individuals given an eating disorder diagnosis describe the experience of an eating disorder 'voice' (EDV). However, methods for working with this experience are currently lacking. Voice Dialogue (Stone & Stone, 1989) involves direct communication between a facilitator and parts of the self to increase awareness, understanding, and separation from inner voices. Adapted forms of this method have shown promise in working with voices in psychosis. This study aimed to explore the experience and acceptability of Voice Dialogue amongst individuals with anorexia nervosa who experience an EDV. Nine women participated in a semistructured interview following a single Voice Dialogue session. Interview transcripts were analysed using interpretative phenomenological analysis (IPA). Three overarching themes were identified as follows: (i) "separating from the EDV"; (ii) "better understanding of the EDV"; and (iii) "hopeful, motivated, and afraid of recovery". The majority of participants found Voice Dialogue acceptable and helpful for exploring their EDV. Whilst preliminary, the results suggest that Voice Dialogue has potential in terms of helping individuals establish a more constructive relationship with their EDV and motivating change. Further research is needed to build upon these findings. Implications for addressing the EDV using voice-focused interventions are explored.

Meaning in Life Mediates Between Emotional Deregulation and Eating Disorders Psychopathology: A Research From the Meaning-Making Model of Eating Disorders

Emotional dysregulation, age, gender, and obesity are transdiagnostic risk factors for the development and maintenance of eating disorders (EDs). Previous studies found that patients with ED had less meaning in life than the non-clinical population, and that meaning in life acted as a buffer in the course of ED; however, to the data, there are no studies about the mediator role of meaning in life in association between the emotional dysregulation and the ED psychopathology.

Objective: To analyze the mediating role of meaning in life in the relationship between emotional dysregulation and the ED psychopathology in three samples with diverse risk factors for ED.

Method: Sample 1, n = 153 undergraduate young women; sample 2, n = 122 participants with obesity; and sample 3, n = 292 participants with ED. Multiple mediation analysis was performed.

Results: Sample 1: meaning in life showed a mediation effect between emotional dysregulation and the ED psychopathology (direct effect β = 0.390, p < 0.05) (indirect effect β = 0.227, p < 0.05), body satisfaction (direct effect β = −0.017, p < 0.05) (indirect effect β = −0.013, p < 0.01), and depression symptoms (direct effect β = 1.112, p < 0.001) (indirect effect β = 0.414, p < 0.001); sample 2: meaning in life showed a mediation effect between emotional dysregulation and binge eating and purging behaviors (direct effect β = 0.194, p < 0.01) (indirect effect β = 0.054, p < 0.05) and depression symptoms (direct effect β = 0.357, p < 0.001) (indirect effect β = 0.063, p < 0.05); sample 3: meaning in life showed a mediation effect between emotional dysregulation and the ED psychopathology (direct effect β = 0.884, p < 0.001) (indirect effect β = 0.252, p < 0.007), body satisfaction (direct effect β = −0.033, p < 0.05) (indirect effect β = −0.021, p < 0.001), borderline symptoms (direct effect β = 0.040, p < 0.001) (indirect effect β = 0.025, p < 0.001), and hopelessness (direct effect β = 0.211, p < 0.001) (indirect effect β = 0.087, p < 0.001).

Conclusions: These studies suggest the importance of considering meaning in life as a variable in the onset and maintenance of ED.

An innovative approach for the assessment of mood disturbances in patients with eating disorders

OBJECTIVE

Assessment of mood in eating disorders (EDs) has important clinical implications, but the current standard psychiatric classification (DSM-5) has limitations. The aim of the current study is to broaden the evaluation of depressive symptomatology by providing a comprehensive and innovative assessment approach in EDs through instruments that capture clinical phenomena of demoralization, subclinical distress, and psychological well-being.

METHODS

Seventy-nine patients who met diagnostic criteria for EDs of the Diagnostic and Statistical Manual of Mental Disorders - Fifth edition (DSM-5) were evaluated for depressive symptoms through Paykel's Clinical Interview for Depression, the Structured Clinical Interview for DSM-5 for major depressive episode and persistent depressive disorder, and the Diagnostic Criteria for Psychosomatic Research (DCPR) interview for demoralization. Further, self-report inventories encompassing psychological well-being and distress were used.

RESULTS

Guilt, abnormal reactivity to social environment, and depressed mood were the most common depressive symptoms in the sample. DSM-defined depressive disorders were found in 55.7% of patients. The DCPR-demoralization criteria identified an additional 20.3% of the sample that would have been undetected with DSM criteria. Both DSM and DCPR diagnostic categories were associated with compromised psychological well-being and distress. Demoralization, unlike depression, was not associated with the severity of ED symptomatology.

CONCLUSION

The findings indicate that a standard psychiatric approach, DSM-5-based, captures only a narrow part of the spectrum of mood disturbances affecting patients with EDs. A broadened clinimetric assessment unravels the presence of demoralization and yields clinical distinctions that may entail prognostic and therapeutic differences among patients who would be otherwise simply labeled as depressed.

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.

Residual eating disorder symptoms and clinical features in remitted and recovered eating disorder patients: A systematic review with meta-analysis

OBJECTIVE

In psychiatry, the presence of residual symptoms after treatment is linked to the definitions of remission and recovery. To identify the presence of residual eating disorder (ED) symptoms and associated non-ED clinical features in remitted and recovered EDs, the current systematic review with meta-analysis was performed.

METHOD

A systematic review was conducted on residual ED symptoms and non-ED clinical features including comorbid psychopathology, neurophysiological functioning, cognitive functioning, and quality of life in ED patients considered remitted or recovered. To examine residual ED symptoms, meta-analyses were performed while considering age, study quality, remission, and recovery criteria strictness as moderators. Sensitivity, publication bias, and heterogeneity analyses were also conducted.

RESULTS

The 64 studies selected for the systematic review underscored the presence of residual ED symptoms in anorexia nervosa (AN) and bulimia nervosa (BN), and impairments and deficits in the additional features examined. From the 64 studies, 31 were selected regarding residual ED symptoms in AN for meta-analysis. Large effect sizes indicated that remitted/recovered AN patients reported significantly lower body mass index (Hedges' g = -0.62[-0.77, -0.46]) and significantly greater symptomatology in terms of ED examination-questionnaire (Hedges'g = 0.86 [0.48,1.23]) and ED inventory (Hedges' g = 0.94[0.64,1.24]) than healthy controls, independently of remission and recovery criteria strictness, age, and study quality.

DISCUSSION

The presence of residual ED symptoms in AN is quantitatively supported, whereas the presence of residual ED symptoms in BN should be further investigated. Data on binge-eating disorder are missing. Future research should use consistent, multicomponent, and standardized comparable indicators of recovery.

Significados do Abandono do Tratamento para Pacientes com Transtornos Alimentares

Resumo Este estudo teve por objetivo compreender os significados do abandono do tratamento para pacientes com transtornos alimentares (TA), acompanhados em um serviço especializado. Trata-se de uma pesquisa descritivo-exploratória e transversal, com delineamento qualitativo. Participaram deste estudo seis mulheres com idades entre 19 e 37 anos, solteiras, profissionalmente ativas e com diagnóstico de TA. Foram realizadas entrevistas individuais, cujo conteúdo audiogravado foi posteriormente submetido à análise de conteúdo temática. Os motivos do abandono incluíram questionamentos relativos ao protocolo de tratamento, à equipe terapêutica, além de questões pessoais. Os aspectos multifatoriais envolvidos na dinâmica do abandono do tratamento indicam a necessidade de maior capacitação dos profissionais de saúde, especialmente no que concerne ao estabelecimento da aliança terapêutica e acolhimento empático para incrementar a adesão do paciente ao plano terapêutico. O conhecimento dos fatores apontados como desencadeadores de abandono pode contribuir para identificar precocemente indivíduos em risco e implementar medidas terapêuticas que resultem em melhor prognóstico.

Turning the Corner: A Comparison of Collegiate Athletes’ and Non-Athletes’ Turning Points in Eating Disorder Recovery

The purpose of this qualitative study was to identify turning points in eating disorder recovery in collegiate female athletes compared to non-athletes. The sample included 12 varsity athletes and 17 non-athlete college students who previously met criteria for Anorexia Nervosa (AN; n = 17); Bulimia Nervosa (BN; n = 3); Binge Eating Disorder (n = 1); or both AN and BN (n = 8). Participants completed individual interviews and responses were analyzed inductively. There was some commonality in the athletes’ and non-athletes’ experiences. For example, the most frequent turning point for both groups was Insight/Self Realization. Regarding the next three most frequent turning points, athletes reported Sport Performance, Confrontation, and Support/Concern from Others, whereas non-athletes reported Professional Treatment, Hitting a Low, and Support/Concern from Others. This study contributes to the sparse literature on competitive athletes’ recovery. Results indicated that athletes’ turning points differed from non-athletes; therefore, findings are discussed concerning athlete-specific treatment recommendations and suggestions for coaches.

Subjective incompetence as a predictor of treatment outcomes in eating disorder outpatients

Eating disorder (ED) patients are frequently characterized by feelings of inefficacy. The aims of the present study were to investigate subjective incompetence and whether its early modification in therapy is associated with treatment response in terms of both psychological distress and well-being. Sixty female ED outpatients undergoing cognitive-behaviorally-based treatment integrated with nutritional rehabilitation were evaluated using: Subjective Incompetence Scale (SIS), Eating Attitudes Test (EAT), Beck Depression Inventory (BDI-II), and Psychological Well-being Scales (PWB). Repeated measures analysis of variance to test changes in variables and hierarchical regression analyses to test the predictive role of SIS were conducted. Significant improvements in SIS, and in distress measures (EAT, BDI-II) and well-being (PWB) were observed by mid-treatment. Early SIS reductions in patients significantly predicted reductions in EAT-food and bulimic preoccupations, EAT-oral control and EAT-dietary restraint scores, independently of initial depressive symptomatology and illness severity. Gains in three PWB dimensions (environmental mastery, purpose in life, self-acceptance) were also predicted by changes in subjective incompetence. Treatment response might be enhanced by targeting more specifically persistent feelings of incompetence associated with ED symptomatology and compromised psychological well-being dimensions. Such paucities in positive functioning are central themes in EDs and if left untreated might represent obstacles to recovery.

Temporal Processing of Joyful and Disgusting Food Pictures by Women With an Eating Disorder

The present study used the presentation of food pictures and judgements about their duration to assess the emotions elicited by food in women suffering from an eating disorder (ED). Twenty-three women diagnosed with an ED, namely anorexia (AN) or bulimia nervosa (BN), and 23 healthy controls (HC) completed a temporal bisection task and a duration discrimination task. Intervals were marked with emotionally pre-rated pictures of joyful and disgusting food, and pictures of neutral objects. The results showed that, in the bisection task, AN women overestimated the duration of food pictures in comparison to neutral ones. Also, compared to participants with BN, they perceived the duration of joyful food pictures as longer, and tended to overestimate the duration of the disgusting ones. These effects on perceived duration suggest that AN women experienced an intense reaction of fear when they were confronted to food pictures. More precisely, by having elevated the arousal level and activated the defensive system, food pictures seemed to have speeded up the rhythm of the AN participants’ internal clock, which led to an overestimation of images’ duration. In addition, the results revealed that, in both tasks, ED women presented a lower temporal sensitivity than HC, which was related to their ED symptomatology (i.e., BMI, restraint and concern) and, particularly, to their weaker cognitive abilities in terms of attention, processing speed and working memory. Considered all together, the findings of the present experiment highlight the role of fear and anxiety in the manifestations of AN and point out the importance of considering non-temporal factors in the interpretation of time perception performance.

Are recovery stories helpful for women with eating disorders? A pilot study and commentary on future research

BACKGROUND

Anecdotally it is well known that eating disorder memoirs are popular with people with anorexia nervosa and recovery stories are readily available online. However, no research to date has empirically explored whether such stories are helpful for current sufferers. The aim of the current pilot study was to explore the efficacy of recovery narratives as a means of improving motivation and self-efficacy and to qualitatively explore patient perspectives of such stories.

METHOD

Fifty-seven women with anorexia nervosa and subclinical anorexia nervosa participated in this online study. Participants were randomised to either receive recovery stories or to a wait-list control group. After completing baseline measures, participants read five stories about recovery, and completed post-intervention measures two weeks later.

RESULTS

The quantitative results indicated that reading stories of recovery had no effect on motivation and self-efficacy over a two-week period. In contrast, the qualitative results showed that the stories generated thoughts about the possibility of recovery and the majority indicated they would recommend them to others.

CONCLUSIONS

This study adds to a growing body of research exploring the integration of voices of lived experience into treatment approaches. Future research should focus on 1) identifying for whom and at which stage of illness recovery stories might be helpful; 2) the mechanism via which they might operate; and 3) the most helpful way of presenting such stories.

Exploring the perceived usefulness of practical food groups in day treatment for individuals with eating disorders

BACKGROUND/AIM

Recovery from eating disorders is a challenging process. Emerging literature suggests that occupational therapists may provide a useful contribution in delivering purposeful eating-related interventions as a potential treatment to support sustained cognitive and behavioural changes for individuals with eating disorders. This study aimed to evaluate participants' perceptions of the contribution of occupational therapy practical food groups (food based outings and cooking groups) in supporting their functional recovery.

METHODS

Individuals attended practical food groups as part of standard treatment at an outpatient eating disorders day program. Ninety-nine participants completed questionnaires at discharge and up to three follow-up points (6, 12 and 24 months). Questions related to practical food groups were analysed, exploring participants' experiences and perceived usefulness of groups using rating-scale and open-ended questions. Open-ended responses were analysed using thematic analysis. Descriptive statistics were calculated for responses to rating-scale questions.

RESULTS

At discharge, participants rated the importance and usefulness of practical food groups as high (4.73 and 4.43 on 5-point scales, respectively), but tended to rate their enjoyment of the groups lower (3.50 on a 5-point scale). Some skill transfer was typically reported by participants at discharge (3.92 on a 5-point scale). One core theme, 'success through participation', emerged from qualitative comments. Six subthemes were also identified: helpful components of practical food groups; perceived benefit of exposure; impact of applying cognitive and behavioural skills; challenges affecting participation; facilitating adaptation; and influence of eating disorders on challenging feared foods.

CONCLUSION

This study highlights that participation in practical food groups was perceived as useful in assisting individuals to improve eating behaviours and, in some circumstances, transfer these skills into their lives outside of day program. Results suggest that occupational therapists may have an important contribution in delivering these interventions to support recovery and facilitate application of adaptive coping strategies.

The Egosyntonic Nature of Anorexia: An Impediment to Recovery in Anorexia Nervosa Treatment

A serious problem faced by clinicians treating anorexia nervosa is the egosyntonic nature of the illness, wherein individuals with anorexia nervosa value their disorder, thereby hindering motivation for recovery and engagement with treatment. The objective of this review article is to elucidate the nature of egosyntonicity in anorexia nervosa, reviewing both qualitative and quantitative research pertaining to this topic, and, importantly, to present methods to overcome this impediment to recovery in anorexia nervosa treatment. The authors elucidate functions of anorexia nervosa for patients, both within psychological and social spheres, as well as highlight the detrimental effect of egosyntonicity in terms of illness severity and motivation for recovery. The final part of the paper contains suggestions as to methods of bypassing pitfalls linked with the influence of the egosyntonic nature of anorexia nervosa within a treatment setting, as well as an examination of three current treatments (enhanced cognitive-behavioral therapy for eating disorders, Maudsley Model of Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management) in terms of the degree to which they target egosyntonicity.

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.

Feelings and perceptions of women recovering from anorexia nervosa regarding their eating behavior

Abstract: According to the phenomenological approach, observing a phenomenon through the perspective of those who lived it may be necessary to acquire fully comprehension of it. Therefore, to fully understand the eating behavior during anorexia nervosa and during its recovery, this study investigated individual perceptions and feelings of three women recovering from anorexia nervosa. This study is characterized as a qualitative research with phenomenological approach. The data were collected through interviews and analyzed following steps proposed by phenomenology researchers. During the anorexia nervosa experience, food restriction and irregular meal patterns were observed. Controlling food intake was associated with happiness. Guilt, anguish, sadness, fear and anger were associated with eating, and food was considered a villain. An obsessive thinking about food and a paradox between liking to eat and not wanting to eat were also observed. During recovery, it is important to have a more flexible eating behavior without negative feelings regarding food; however, feelings of guilty and fear were still detected. Perceptions about contact with nutritionists revealed the use of ineffective strategies. Although similarities were found in all reports, every woman had their own particular and singular experience. Rescuing their memories and experiences through their speech was important to fully understand and comprehend these personal experiences, and this complete understanding may enable health professionals to act more efficiently in the treatment of this complex phenomenon.

Intolerance of Uncertainty in eating disorders: An update on the field

Pathological fear and anxiety regarding food, eating, weight and body shape are at the core of eating disorder (ED) psychopathology. To manage anxiety, patients develop complicated repertoires of ritualistic and repetitive behaviours, which can lead to total functional impairment. Yet the cognitive processes underlying anxiety, fear, and anxiety-driven behaviours in EDs remain poorly understood. Intolerance of Uncertainty (IU) is defined as a tendency to react negatively on an emotional, cognitive, and behavioural level to uncertain situations and events. There is substantial evidence that IU is a transdiagnostic process that contributes to the maintenance of anxiety disorders; however, IU may also be relevant to the understanding and treatment of EDs. The current review summarises the growing literature examining IU in relation to ED symptoms, including restriction, bingeing, purging, ritualised behaviours, reassurance-seeking and body checking. Extending from the obsessive-compulsive disorder (OCD) and anxiety disorder literature, we propose that IU provides a novel theoretical and clinical framework from which to understand the anxiety, fixation with rules and rituals, and the cognitively rigid profile that is characteristic of ED presentations. We conclude with suggestions for future research, and discuss IU as a potential treatment target for core features of EDs and comorbid symptoms.

Adolescent and young adult women's opinions of common eating disorder prevention messages

We examined young women's opinions of five common eating disorder (ED) prevention themes in terms of persuasiveness and impact on behavioral intentions. Video-taped prevention themes were rated by female adolescents and young adults (ages 13-25) with and without eating disorders. Overall, younger participants found the prevention messages less persuasive than older participants. Controlling for age, clinical participants found the messages to be less persuasive than did non-clinical participants. Clinical participants reported no change in their behavioral intentions after watching the videos, whereas non-clinical participants reported a lower intention to diet and make body comparisons after viewing the messages. Presenter ratings (attractiveness, credibility, thinness) also positively predicted individuals' opinions of the messages. The findings suggest that younger adolescents and women who already display signs of disordered eating may be hard to persuade through ED prevention messages, and further research is needed to improve their impact among these groups.

Four Pathways to Anorexia Nervosa: Patients' Perspective on the Emergence of AN

INTRODUCTION

Studies show that patients' perception of their illness has a direct influence both on their utilization of health services and their adherence to treatment plans. This may be particularly relevant to the treatment of Anorexia Nervosa (AN). Previous studies on AN have typically explored single psycho-social factors that patients with AN relate to the emergence of their illness. There is a need for more coherent systematic descriptions of the complexity of the patients' narratives about how their illness emerged. In this study, we sought to identify common components in the participants' narratives. By identifying different combinations of these components in the narratives, we sought to describe differences in patients' perceived pathways to AN.

METHODS

Participants were 36 women aged 18-51 years who had been treated for AN within the past 2 years at five clinical institutions in Norway. Semi-open qualitative interviews were conducted, tape-recorded, transcribed and analysed using grounded theory techniques.

RESULTS

We identified the following four distinct perceived pathways into AN: 'The Avoidant', 'The Achiever', 'The Transformer' and 'The Punisher'. The pathways could be regarded as four different projects for mastering life's challenges.

DISCUSSION

Our results suggest that there seem to be at least four pathways into AN. This indicates that a common array of symptoms might cover very different psychological dynamics. These might need to be treated therapeutically in different ways and should probably be taken into account during the refinement of diagnostic tools. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Although patients with AN might present similar symptoms, patients' perspectives on the emergence of their problems indicate that a common array of symptoms cover a variety of subjective psychological dynamics. From the experienced patient's stance, there are at least four distinct pathways to the emergence of AN. Attempts to master the challenges of life were found to be a common denominator in the emergence of AN. Recognition and integration of the patient's understanding of her or his problems should be given high priority in treatment of AN.

Nurses' Establishment of Health Promoting Relationships: A Descriptive Synthesis of Anorexia Nervosa Research

Qualitative values that address personal and interpersonal dimensions are often overlooked in research that examines mental well-being among young patients with anorexia nervosa. The aim of this review was to identify and describe factors that promote and impede the relationships between nurses and the children, adolescents and young adults who are diagnosed with anorexia nervosa and also to explore and describe how those relationships benefit the patients' processes toward increased health and well-being. A descriptive literature synthesis was conducted following the four steps as described by Evans. The three databases CINAHL, PsycINFO and PubMed were used to search for qualitative articles. Fourteen articles met the criteria for inclusion and were analysed. Key findings were identified, and categories and themes were formulated and compared across the studies. Four themes are presented in the results: (1) The essentials in a relationship; (2) The person at the centre; (3) The nurses' attitudes; and (4) Knowledge. In addition to the contribution to the knowledge of how anorexia is manifested, our findings demonstrate the necessity for nurses to be person-centred in their relationships with patients and to have attitudes characterised by presence, genuine commitment and motivation. Nurses are more likely to convey a sense of trust and safety when they communicate with openness and honesty. Our review suggests that the motivation for patients to adhere to treatment is likely to increase when nurses approach patients with these characteristics and attitudes. We argue that the findings are relevant for nurses in their everyday practices.

#Proana: Pro-Eating Disorder Socialization on Twitter

PURPOSE

Pro-eating disorder (ED) online movements support engagement with ED lifestyles and are associated with negative health consequences for adolescents with EDs. Twitter is a popular social media site among adolescents that provides a unique setting for Pro-ED content to be publicly exchanged. The purpose of this study was to investigate Pro-ED Twitter profiles' references to EDs and how their social connections (followers) reference EDs.

METHODS

A purposeful sample of 45 Pro-ED profiles was selected from Twitter. Profile information, all tweets, and a random sample of 100 of their followers' profile information were collected for content analysis using the Twitter Application Programming Interface. A codebook based on ED screening guidelines was applied to evaluate ED references. For each Pro-ED profile, proportion of tweets with ED references and proportion of followers with ED references in their own profile were evaluated.

RESULTS

In total, our 45 Pro-ED profiles generated 4,245 tweets for analysis. A median of 36.4% of profiles' tweets contained ED references. Pro-ED profiles had a median of 173 followers, and a median of 44.5% of followers had ED references. Pro-ED profiles with more tweets with ED references also tended to have more followers with ED references (β = .37, p < .01).

CONCLUSIONS

Findings suggest that profiles which self-identify as Pro-ED express disordered eating patterns through tweets and have an audience of followers, many of whom also reference ED in their own profiles. ED socialization on Twitter might provide social support, but in the Pro-ED context this activity might also reinforce an ED identity.

The Effects of Stigma on Recovery Attitudes in People With Anorexia Nervosa in Intensive Treatment

Self-stigma in individuals with anorexia nervosa (AN) may affect engagement in intensive treatment. The objective of this study was to test a Model of Self-Stigma to identify the influence of public stigma, internalized stigma, self-esteem, and self-efficacy on recovery attitudes in individuals in inpatient treatment for AN. Using a cross-sectional design, 36 female participants with AN completed questionnaires during the first week of intensive inpatient treatment. Better attitude towards recovery was positively correlated with higher self-esteem and self-efficacy and negatively correlated with greater internalized stigma and perceptions of others devaluing families of individuals with AN. Together, these factors accounted for 63% of the variance in recovery attitudes. Findings demonstrate the adverse effects perceived stigma towards families, self-stigma, and self-esteem have on recovery attitudes in individuals with AN. Clinical interventions are needed to challenge internalized stigma and bolster self-esteem to enhance individuals' recovery efforts.

Predictors of Positive Treatment Outcome in People With Anorexia Nervosa Treated in a Specialized Inpatient Unit: The Role of Early Response to Treatment

OBJECTIVE

To investigate factors which predict positive treatment outcome in inpatients with anorexia nervosa (AN), particularly the role of early treatment response.

METHOD

102 patients entering specialist inpatient treatment were assessed for eating disorder history, psychopathology, and motivation to change. Predictive factors assessed were: early treatment response defined as weight increase of at least 0.5-1 kg/week during the first 6 weeks of treatment (n=87), admission body mass index (BMI), onset age, chronicity, motivation to change, diagnosis, and previous hospitalization for AN. Positive treatment outcome was defined as achieving a BMI of 17.5 kg/m(2) within an individual time frame.

RESULTS

Logistic regression indicated that patients were 18 times more likely to reach positive treatment outcome if they met the National Institute for Health and Care Excellence weight guidelines within the first 6 weeks of hospitalization. Higher admission BMI was also found to predict positive treatment outcome.

DISCUSSION

Higher entry BMI and early weight gain predict positive treatment outcome in individuals receiving specialist AN inpatient treatment. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

'Feelings stronger than reason': conflicting experiences of exercise in women with anorexia nervosa

BACKGROUND

Individuals with anorexia nervosa frequently feel ambivalent about treatment and weight restoration, and drop out and relapse rates in treatment are high. Increased insight into the function of the eating disorder is considered essential for achieving long-lasting, meaningful change. However, research investigating the functions of anorexia nervosa tends to focus on the role of the disease per se. Distinctions are rarely made across features. In particular, the subjective experience, understanding and sense making of the engagement in compulsive exercise in individuals with anorexia nervosa has received little attention. By using a qualitative methodological approach, this paper aims to expand on prior findings by examining how patients with anorexia nervosa understand and make sense of the experience of exercise in the context of their lives and treatment programme.

METHODS

Semi-structured interviews were conducted with six females, four of whom were former athletes. Transcripts were subjected to interpretative phenomenological analysis (IPA).

RESULTS

Two overarching themes emerged in the analysis of the larger study of which this paper is a part; 'paradoxical functions of exercise' and 'diverging experiences of exercise'. Diverging experiences of exercise is the focus of this paper. Firstly, in spite of being severely underweight and suffering from exhaustion, as well as having a clear awareness of the associated negative health effects, participants were engaged in a continuous cycle of rigorous and excessive exercise, which consumed extensive amounts of time and energy. Secondly, the results demonstrate how exercise routines negatively control and interfere with the participants' involvement in the social world. Thirdly, the manner in which participants speak about their exercise reveals their wording to be characterized by efforts to downplay the extent of their actual immersion in exercise. Issues of control and ambivalence about treatment and recovery can be considered potential triggers for the participants' engagement with exercise. Implicit meanings are elaborated upon and discussed in relation to existing literature.

CONCLUSIONS

The material provides increased insight into the multi-layered meanings of exercise for individuals with anorexia nervosa. It also suggests alternatives to current ways of understanding and approaching exercise that may enable this issue to be addressed in a more meaningful way in therapy. Qualitative approaches can make a valuable contribution to furthering such understanding.

Does compulsive behavior in Anorexia Nervosa resemble an addiction? A qualitative investigation

The characteristic relentless self-starvation behavior seen in Anorexia Nervosa (AN) has been described as evidence of compulsivity, with increasing suggestion of parallels with addictive behavior. This study used a thematic qualitative analysis to investigate the parallels between compulsive behavior in AN and Substance Use Disorders (SUD). Forty individuals currently suffering from AN completed an online questionnaire reflecting on their experience of compulsive behavior in AN. Eight main themes emerged from thematic qualitative analysis; compulsivity as central to AN, impaired control, escalating compulsions, emotional triggers, negative reactions, detrimental continuation of behavior, functional impairment, and role in recovery. These results suggested that individuals with AN view the compulsive nature of their behavior as central to the maintenance of their disorder, and as a significant barrier to recovery. The themes that emerged also showed parallels with the DSM-V criteria for SUDs, mapping onto the four groups of criteria (impaired control, social impairment, risky use of substance, pharmacological criteria). These results emphasize the need for further research to explore the possible parallels in behavioral and neural underpinnings of compulsivity in AN and SUDs, which may inform novel treatment avenues for AN.

The Effect of Eating Disorder Memoirs in Individuals With Self-Identified Eating Pathologies

As part of a larger, mixed-methods study, we posted an invitation to participate in a study on the effects of reading eating disorder memoirs on the website of an organization that provides support for people with eating disorders. Twenty-four women completed the questionnaire. Qualitative analysis of their responses indicated a recovery continuum, whereby the direction of memoir influence seemed to depend on an individual's recovery stage and motivation to recover. Individuals who reported that they were exposed to memoirs before, or during, their illness reported experiencing negative consequences including making unfavorable social comparisons, along with emulation and triggering of disordered behaviors, whereas those who reported being exposed when in recovery reported more positive outcomes including hope, validation, and social support. Findings have implications for the use of personal accounts as a means of facilitating patient recovery in eating disorder treatment settings. Future research should test the influence of memoirs using a larger eating disorder sample, and across different recovery stages.

Motivation to change and perceptions of the admission process with respect to outcome in adolescent anorexia nervosa

BACKGROUND

In patients with anorexia nervosa (AN), there is evidence that readiness to change is an important predictor of outcome with respect to weight gain and improvement in eating disorder psychopathology. In particular, young patients are characterized by a low level of motivation for recovery and perceive more coercion at hospitalization. Thus, a better understanding of the variables that influence readiness to change and perception of the admission process in adolescent AN may help to support patients in initiating change and staying motivated for treatment.

METHODS

In 40 adolescent patients diagnosed with AN according to DSM-IV criteria, we assessed in a prospective clinical cohort study the motivation to change using the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) at admission to inpatient treatment, in week 9 after admission and at discharge. Additional variables were assessed, including depressive symptoms (Beck Depression Inventory, BDI), eating disorder-specific psychopathology (Eating Disorder Inventory, EDI-2), body mass index (BMI) and the percentage of expected body weight (%EBW). The patients' perceptions of the admission process and their perceived need for hospitalization were assessed using a self-report scale developed by Guarda et al. (2007).

RESULTS

Younger patients perceived more coercion than older patients did. Low %EBW and more severe eating disorder-specific psychopathology were associated with a greater perceived need for hospitalization. Moreover, low %EBW at admission and a longer duration of illness were accompanied by a greater motivation to change at admission, whereas more severe eating disorder psychopathology was associated with a low motivation to change. The motivation to change increased significantly between admission and discharge. Patients with a greater motivation to change at admission exhibited a higher weekly weight gain during treatment but did not show better outcome in eating disorder-specific psychopathology and depression.

CONCLUSIONS

Motivation to change is an important predictor of short-term outcome with respect to weight gain trajectory during treatment of adolescent AN. As patients with a higher BMI at admission and those with more severe eating disorder-specific symptoms seem to be less motivated to change, the crucial issue of motivation to change should be addressed with these patients during the therapeutic process.

The Relationship between Alexithymia and Intolerance of Uncertainty in Anorexia Nervosa

BACKGROUND

Alexithymia and intolerance of uncertainty (IU) are relevant factors in social and emotional processing abilities in anorexia nervosa (AN) eventually rendering emotional coping difficult. However, the link potentially existing in AN between IU and alexithymia has been so far understudied.

SAMPLING AND METHODS

Sixty-one patients affected by AN and 59 healthy controls (HC) were enrolled and assessed for study purposes. All participants completed the following self-report questionnaires: Intolerance of Uncertainty Scale, State Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI) and Toronto Alexithymia Scale.

RESULTS

IU and alexithymia were greater in patients with AN when compared to HC. Moreover, in both AN and HC groups, IU and alexithymia significantly correlated with each other as well as with anxiety (STAI score) and depression (BDI score). No correlations were found between alexithymia and age. Patients' duration of illness was negatively correlated with two alexithymia subscales. After adjusting for anxiety, depression, body mass index and duration of illness (for AN), the correlation between IU and alexithymia remained significant.

CONCLUSIONS

In addition to confirming previous findings on marked levels of IU and alexithymia in AN, this study showed for the first time a correlation between IU and alexithymia in both AN and HC. Moreover, this result remained significant after controlling for a number of clinical variables. Taken together, these findings may have useful clinical implications for the treatment of AN sufferers. © 2015 S. Karger AG, Basel.

The process of help-seeking in anorexia nervosa: patients' perspective of first contact with health services

In this study we explored circumstances, reflections, and reactions to first treatment contact in 34 women (aged 18-51) diagnosed with anorexia nervosa (AN) (DSM-IV). Using methods from grounded theory we identified how the meeting came about, what motivated the patients, and how they reacted to the conversation. The results suggest that (a) health care professionals need to demonstrate effective professional communication skills and proficient knowledge about eating disorders in early contacts; (b) treatment goals other than recovery from AN should be explored; and

Between difference and belonging: configuring self and others in inpatient treatment for eating disorders

Dedicated inpatient care for eating disorders has profound impact on patients' embodied practices and lived realities. Analyses of inpatients' accounts have shown that participants endorse complex and conflicting attitudes toward their experiences in eating disorders wards, yet the apparent ambivalence that characterizes inpatient experiences has not been subject to critical examination. This paper examines the narrated experiences of 13 participants (12 women and one man; age 18–38 years at first interview) with past or present anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified, who had been hospitalized in an inpatient eating disorders ward for adults in central Israel. The interviews, which took place in 2005–2006, and again in 2011, were part of a larger longitudinal study exploring the subjective experiences of eating disorders and recovery among Israeli adults. Employing qualitative analysis, this study finds that the participants' accounts were concerned with dynamics of difference and belonging, as they played out in various aspects of inpatient care, including diagnosis, treatment, relationships with fellow patients and staff, and everyday life in hospital. Notably, participants simultaneously defined themselves as connected to, but also distinct from, the eating disordered others who formed their reference group at the ward. Through negotiating a protectively ambivalent positioning, participants recognized their eating disordered identities and connected with others on the ward, while also asserting their non-disordered individuality and distancing themselves from the potential dangers posed by ‘excessive’ belonging. The paper suggests that this ambivalent positioning can usefully be understood through the anthropological concept of liminality: being both a part of and apart from one's community.

Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa

AIM

The literature on clinical characteristics associated with premature termination of treatment (PTT) is beset with conflicting and non-replicated findings. This study explores clinical characteristics potentially associated with PTT in a randomised controlled outpatient psychotherapy trial for anorexia nervosa (AN).

METHODS

Participants were 56 women aged 17-40 years with spectrum AN. The completer group (n = 35) included those completing at least 15/20 planned sessions with the remainder of the sample comprising the PTT group (n = 21). Variables examined included demographic factors, psychosocial functioning, psychiatric history, lifetime comorbidity, temperament and eating disorder characteristics. Logistic regression was used to examine significant variables. A Kaplan-Meier survival curve was used to illustrate time taken to PTT.

RESULTS

The mean number of sessions in the PTT group was 8.1. Lower self-transcendence scores on the Temperament and Character Inventory were associated with PTT.

CONCLUSIONS

Recognising and addressing personality factors have the potential to enhance retention in treatment.

"Doing the impossible": the process of recovery from chronic anorexia nervosa

In this study, we aimed to explore the process of recovery over time from the perspective of those who had fully recovered from chronic anorexia nervosa (AN), using stringent recovery criteria. Eight women, assessed as fully recovered from chronic AN, told their story of the process of recovery. Data were analyzed using the qualitative method, narrative inquiry. Recovery was identified as a long and complex process that spanned four phases: from being unable or unready to change, to experiencing a tipping point where motivation increased and changed in quality, allowing the women to take action against the AN and finally allowing them to reflect and rehabilitate. Results provide a framework for understanding this complex process. Findings suggest that full recovery from chronic AN is possible and emphasize the importance of hope, motivation, self-efficacy, and support from others in the recovery process.

Pre-treatment predictors of attrition in a randomised controlled trial of psychological therapy for severe and enduring anorexia nervosa

BACKGROUND

Attrition is common in the treatment of anorexia nervosa and its causes are complex and incompletely understood. In particular, its relationship with adaptive function and motivational stage of change has been little studied. This study aimed to (1) investigate and (2) compare the strength of associations between adaptive function, stage of change and other previously found factors such as illness sub-type and treatment attrition in women with severe and enduring anorexia nervosa (SE-AN).

METHODS

Participants were 63 adult women with SE-AN of at least 7 years duration who were enrolled in a multi-site randomized controlled trial conducted from July 2007 through June 2011. Treatment comprised 30 outpatient visits over 8 months of either Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN) or Specialist Supportive Clinical Management (SSCM) both of which were modified for severe and enduring illness. Assessments were done at baseline, end of treatment, and 6 and 12 month post treatment follow-up. Demographic variables, duration of illness, specific and generic health related quality of life (QoL), eating disorder (ED) and mood disorder symptoms, social adjustment, body mass index (BMI), and motivation for change were assessed with interview and self-report questionnaires. Treatment attrition was defined as leaving therapy after either premature termination according to trial protocol or self-instigated discharge. Binary logistic regression was used to investigate relative strength of associations.

RESULTS

Those who did not complete treatment were significantly more likely to have the purging sub-type of anorexia nervosa and poorer ED related QoL. There were no significant differences between attrition and which therapy was received, educational level, and global ED psychopathology, stage of change, BMI, social adjustment, duration of illness or level of depression. The strongest predictors on multivariable analysis were ED QoL and AN-purging subtype.

CONCLUSION

This study supported previous findings of associations between attrition and purging subtype. Furthermore, we found associations between a potentially important cycle of attrition, and poorer EDQoL, which has not been previously reported. Contrary to expectations we did not find an association with BMI, severity of ED symptoms, low level of motivation to change ED features, or level of education.

Prediction of weight increase in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious psychiatric disorder with high mortality rates a poor outcome and no empirically supported treatment of choice for adults. Weight increase is essential for recovery from AN why research exploring important contributors is crucial.

AIMS

The current study examined the importance of motivation to change eating behaviour, treatment expectations and experiences, eating disorder symptomatology, self-image and treatment alliance for predicting weight increase.

METHODS

Female patients (n = 89) between 18 and 46 years of age with AN were assessed pre-treatment and at 6- and 36-month follow-ups with interviews and self-report questionnaires. At the 6-month follow-up the response rates differed from n = 58 (65%) to 66 (74%), and at the 36-month follow-up the response rates differed from n = 71 (80%) to 82 (92%).

RESULTS

At treatment start, expressed motivation to change eating habits, social insecurity and self-neglect were predictors of weight increase from 0 to 6 months, while duration, the time from onset to entering treatment, body dissatisfaction and interoceptive awareness were predictors of weight increase from 0 to 36 months.

CONCLUSIONS

In designing treatment for adult patients with AN, it is essential to include multifaceted interventions addressed to patients' motivation to change, social relations, negative self-image and body dissatisfaction in order to achieve weight increase. Early detection and thereby short duration is an additional important factor that contributes to weight increase.