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Rienecke RD, Trotter X, Jenkins PE. A systematic review of eating disorders and family functioning. Clin Psychol Rev 2024; 112:102462. [PMID: 38941693 DOI: 10.1016/j.cpr.2024.102462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 06/19/2024] [Accepted: 06/19/2024] [Indexed: 06/30/2024]
Abstract
The purpose of the current review was to address four questions: 1) Are there differences in family functioning or family environment among patients with different eating disorder (ED) diagnoses? 2) Are there differences in the perception of family functioning or family environment among different family members? 3) Is family functioning or family environment related to ED symptomatology? 4) Does family functioning or family environment change as a result of ED treatment? and 4a) If so, does this impact ED treatment outcome? Although most studies found no differences among ED diagnostic groups, those that did generally found worse family functioning among those with binge/purge symptoms than among those with the restricting subtype of anorexia nervosa. Differences in perceptions of family functioning among family members were found, with patients generally reporting worse functioning than their parents. Worse family functioning was generally found to be related to worse ED symptoms. The variety of treatment approaches and different assessments of outcome made it somewhat unclear whether family functioning consistently improves with ED treatment. More research is needed on family functioning and EDs, particularly in understudied groups such as males, and those with ED diagnoses other than anorexia nervosa or bulimia nervosa.
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Affiliation(s)
- Renee D Rienecke
- Eating Recovery Center/Pathlight Mood & Anxiety Center, USA; Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA.
| | - Xanthe Trotter
- School of Psychology and Clinical Language Sciences, University of Reading, Reading RG6 6ES, United Kingdom
| | - Paul E Jenkins
- School of Psychology and Clinical Language Sciences, University of Reading, Reading RG6 6ES, United Kingdom
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Cripps S, Serpell L, Pugh M. Processes of change in family therapies for anorexia nervosa: a systematic review and meta-synthesis of qualitative data. J Eat Disord 2024; 12:104. [PMID: 39054560 PMCID: PMC11270895 DOI: 10.1186/s40337-024-01037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/31/2024] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVE To synthesise young person and family member perspectives on processes of change in family therapy for anorexia nervosa (AN), including systemic family therapy and manualised family-based treatments, to obtain an understanding of what helps and hinders positive change. METHOD A systematic search of the literature was conducted to identify qualitative studies focussing on experiences of therapeutic change within family therapies for AN from the perspectives of young people and their families. Fifteen studies met inclusion criteria and underwent quality appraisal following which they were synthesised using a meta-synthesis approach. RESULTS Six overarching themes were generated: "A holistic focus on the young person's overall development"; "The therapeutic relationship as a vehicle for change"; "The therapist's confinement to a script and its impact on emotional attunement"; "A disempowering therapeutic context"; "Externalisation of the eating disorder (ED)"; and "The importance of family involvement". Positive change was helped by understanding and support given to the young person's overall development including their psychological, emotional, social and physical wellbeing, positive therapeutic relationships, relational containment within the family system and externalising conversations in which young people felt seen and heard. Positive change was hindered by inflexibility in the treatment approach, counter-effects of externalisation, negative experiences of the therapist, a narrow focus on food-intake and weight, as well as the neglect of family difficulties, emotional experiences, and psychological factors. CONCLUSIONS Positive change regarding the young person's eating-related difficulties ensued in the context of positive relational changes between the young person, their family members, the therapist and treatment team, highlighting the significance of secure and trusting relationships. The findings of this review can be utilised by ED services to consider how they may adapt to the needs of young people and their families in order to improve treatment satisfaction, treatment outcomes, and in turn reduce risk for chronicity in AN.
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Affiliation(s)
- Sophie Cripps
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Lucy Serpell
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK.
| | - Matthew Pugh
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
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Ali SH, Meltzer G, DiClemente RJ, Islam NS, Yi SS, Yang LH, Misra S. How Shared Dietary Behaviors Within Asian American Families Are Influenced by Emotional Interaction Qualities: A Nationwide Cross-sectional Analysis. Int J Behav Med 2024:10.1007/s12529-024-10303-4. [PMID: 38867005 DOI: 10.1007/s12529-024-10303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Asian American (AA) young adults face a looming diet-related non-communicable disease crisis. Interactions with family members are pivotal in the lives of AA young adults and form the basis of family-based interventions; however, little is known on the role of these interactions in shared family food behaviors. Through an analysis of 2021 nationwide survey data of 18-35-year-old AAs, this study examines how the quality of family member interactions associates with changes in shared food purchasing, preparation, and consumption. METHOD Interaction quality was assessed through 41 emotions experienced while interacting with family, and was categorized as positive (e.g., "I look forward to it"), negative (e.g., "I feel annoyed"), and appreciation-related (e.g., "I feel respected") interactions. Participants were also asked how frequently they ate meals, ate out, grocery shopped, and cooked with their family. RESULTS Among the 535 AAs surveyed (47.6% East Asian, 21.4% South Asian, 22.6% Southeast Asian), 842 unique family interactions were analyzed; 43.5% of interactions were with mothers, followed by siblings (27.1%), and fathers (18.5%). Participants most frequently ate meals with their family (at least daily for 33.5% of participants), followed by cooking (at least daily for 11.3%). In adjusted analyses, an increase in shared food behaviors was particularly associated with positive interactions, although most strongly with cooking together and least strongly with eating meals together; significant differences between ethnic subgroups were not observed. CONCLUSION Findings revealed the importance of family interaction quality when leveraging family relationships to develop more tailored, impactful AA young adult dietary interventions.
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Affiliation(s)
- Shahmir H Ali
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, USA.
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore.
| | - Gabriella Meltzer
- Department of Environmental Health, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Ralph J DiClemente
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, USA
| | - Nadia S Islam
- Department of Population Health, Grossman School of Medicine, New York University, New York, NY, USA
| | - Stella S Yi
- Department of Population Health, Grossman School of Medicine, New York University, New York, NY, USA
| | - Lawrence H Yang
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, USA
| | - Supriya Misra
- Department of Public Health, San Francisco State University, San Francisco, CA, USA
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Katsuki F, Watanabe N, Kondo M, Sawada H, Yamada A. Remote family education and support program for parents of patients with adolescent and early adulthood eating disorders based on interpersonal psychotherapy: study protocol for a pilot randomized controlled trial. J Eat Disord 2024; 12:61. [PMID: 38760800 PMCID: PMC11102252 DOI: 10.1186/s40337-024-01013-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/25/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND In cases of adolescent and early adulthood eating disorders, despite the importance of the patients' relationship with their parents, conflict and confusion frequently occur among them. Interpersonal psychotherapy (IPT) is a present-focused psychotherapy that emphasizes the interpersonal context of symptoms. We developed a remote family education and support program exclusively for parents of patients with eating disorders, based on the principle of IPT. The use of IPT is expected to reduce conflicts in the patient-parent relationship. Consequently, parents will be better able to listen to patients, and patients will be better able to express their thoughts and desires. In this study, we describe the protocol for a randomized controlled trial designed to examine the effectiveness of this program in promoting effective communication in their home based on active listening skills of parents of patients with adolescent and early adulthood eating disorders. METHODS Participants will be parents of patients aged 12-29 years with adolescent and early adulthood eating disorders. Individually randomized, parallel-group trial design will be employed. Seventy participants will be allocated to one of two treatment conditions: (1) remote family education and support program (four, 150 min weekly group sessions) for parents plus treatment-as-usual for patients (consultation by physicians or no treatment), or (2) waiting for the control condition (parents will wait to start the program for 8 weeks) plus treatment-as-usual for patients. The primary outcome measure will be parents' active listening ability as measured by the Active Listening Attitude Scale at 8 weeks after randomization. Additionally, perception of social support (Social Provision Scale-10 item), loneliness (UCLA Loneliness Scale), mental health status (K6), family function (Family Assessment Device), and parent-evaluated eating disorder symptoms (Anorectic Behavior Observation Scale) will be assessed. Data from the intention-to-treat sample will be analyzed 8 weeks after randomization. DISCUSSION This is the first study to evaluate the effectiveness of a family education and support program for parents of patients with adolescent and early adulthood eating disorders based on IPT. If this type of intervention is effective, although indirect, it could be a new support method for this patient population. TRIAL REGISTRATION Clinical Trials. gov ID NCT05840614.
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Affiliation(s)
- Fujika Katsuki
- Department of Psychiatric and Mental Health Nursing, Nagoya City University Graduate School of Nursing, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan.
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, 101 Shimotoba, Hiroosa-machi, Fushimiku, Kyoto, Japan
| | - Masaki Kondo
- National Center for Cognitive Behavior Therapy and Research, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo, Japan
| | - Hanayo Sawada
- Department of Psychiatric and Mental Health Nursing, Nagoya City University Graduate School of Nursing, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Atsurou Yamada
- Department of Neurodevelopmental Disorders, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan
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Esmaeili A, Esmaeeli ST. A life lost to anorexia nervosa: A case report of rapid progressive disease and its psychological aspects. Clin Case Rep 2024; 12:e8709. [PMID: 38566976 PMCID: PMC10985021 DOI: 10.1002/ccr3.8709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
The prevalence of anorexia nervosa has been on the rise. Exploring key factors in treating this condition as well as psychological factors influencing the onset and maintenance of the disorder can increase the chance of treatment success.
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Affiliation(s)
- Amirreza Esmaeili
- Department of Clinical Health Psychology, School of Behavioral Science and Mental HealthIran University of Medical SciencesTehranIran
| | - Soode Tajik Esmaeeli
- Fellowship of Psychosomatic Medicine, Mental Health Research Center, Psychosocial Health Research Institute, Department of Psychiatry, School of MedicineIran University of Medical SciencesTehranIran
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Bohon C, Flanagan K, Welch H, Rienecke RD, Le Grange D, Lock J. Expressed emotion and early treatment response in family-based treatment for adolescent anorexia nervosa. Eat Disord 2024; 32:153-168. [PMID: 37942724 DOI: 10.1080/10640266.2023.2277054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12-18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced.
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Affiliation(s)
- Cara Bohon
- Eating Disorders Research Program, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
- Clinical, Equip Health, Inc, Carlsbad, California, USA
| | - Katie Flanagan
- Eating Disorders Research Program, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - Hannah Welch
- Eating Disorders Research Program, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | - Renee D Rienecke
- Research, Eating Recovery Center/Pathlight Mood & Anxiety Centers, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA (Emeritus)
| | - James Lock
- Eating Disorders Research Program, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
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Aarnio-Peterson CM, Grange DL, Mara CA, Modi AC, North EO, Zegarac M, Stevens K, Matthews A, Mitan L, Shaffer A. Emotion coaching skills as an augmentation to family-based therapy for adolescents with anorexia nervosa: A pilot effectiveness study with families with high expressed emotion. Int J Eat Disord 2024; 57:682-694. [PMID: 38318997 PMCID: PMC10947854 DOI: 10.1002/eat.24149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/12/2024] [Accepted: 01/12/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE To examine the feasibility and acceptability of augmenting family-based treatment (FBT) for adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) with a parent emotion coaching intervention (EC) focused on reducing parent expressed emotion. METHOD In this pilot effectiveness trial, families of adolescents with AN/AAN exhibiting high expressed emotion received standard FBT with either (1) EC group or (2) support group (an attention control condition focused on psychoeducation). RESULTS Forty-one adolescents with AN or AAN were recruited (88% female, Mage = 14.9 ± 1.6 years, 95% White: Non-Hispanic, 1% White: Hispanic, 1% Bi-racial: Asian). Most study adolescents were diagnosed with AN (59%) while 41% were diagnosed with AAN. Participating parents were predominantly mothers (95%). Recruitment and retention rates were moderately high (76% and 71%, respectively). High acceptability and feasibility ratings were obtained from parents and interventionists with 100% reporting the EC intervention was "beneficial"-"very beneficial." The FBT + EC group demonstrated higher parental warmth scores at post-treatment compared to the control group (standardized effect size difference, d = 1.58), which was maintained at 3-month follow-up. Finally, at post-treatment, the FBT + EC group demonstrated higher rates of full remission from AN/AAN (40%) compared to FBT + support (27%), and were nine times more likely to be weight restored by 3-month follow-up. DISCUSSION Augmenting FBT with emotion coaching for parents with high expressed emotion is acceptable, feasible, and demonstrates preliminary effectiveness. PUBLIC SIGNIFICANCE Family based treatment for AN/AAN is the recommended treatment for youth but families with high criticism/low warmth are less likely to respond to this treatment. Adding a parent emotion coaching group (EC) where parents learn to talk to their adolescents about tough emotions is feasible and well-liked by families.
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Affiliation(s)
- Claire M. Aarnio-Peterson
- Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
- Department of Psychiatry and Neurosciences, The University of Chicago, Chicago, IL, USA (Emeritus)
| | - Constance A. Mara
- Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
| | - Avani C. Modi
- Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
| | - Emily Offenbacker North
- Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Ohio, USA
| | - Miriam Zegarac
- Department of Psychology, University of Georgia, Athens, GA, USA
| | - Kimberly Stevens
- Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
| | - Abigail Matthews
- Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
| | - Laurie Mitan
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, OH, USA
- Cincinnati Children’s Hospital Medical Center, Division of Adolescent Medicine, Cincinnati, OH USA
| | - Anne Shaffer
- Department of Psychology, University of Georgia, Athens, GA, USA
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Manasse SM, Russon J, Lampe EW, King A, Abber SR, Trainor C, Gillikin LM, Levy S, Diamond G. Attachment-Based Family Therapy to Improve Family Functioning in Adolescent Binge-Spectrum Eating Disorders: An Initial Evaluation Via Case Series Design. Clin Child Psychol Psychiatry 2024; 29:45-62. [PMID: 37384823 DOI: 10.1177/13591045231187433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Binge-spectrum eating disorders (EDs; bulimia nervosa, binge eating disorder) often develop during adolescence and are associated with serious psychological and physical consequences. Current treatments for adolescents are highly behavioral in nature and while efficacious, many patients do not reach remission indicating that current treatments fail to target a key maintenance factor for EDs. One potential maintenance factor is poor family functioning (FF). In particular, high family conflict (e.g., arguing, critical comments) and low family cohesion (e.g., warmth, support) are known to maintain ED behaviors. Poor FF can (1) cause or exacerbate an adolescent's use of ED behaviors to cope with life stress and/or (2) inhibit parents from being a resource to adolescents during ED treatment. Attachment-Based Family Therapy (ABFT) is specifically designed to improve FF, and thus may be a promising adjunct to behavioral ED intervention strategies. ABFT, however, has not been tested in adolescents with binge-spectrum EDs. Thus, the current study is the first to evaluate a 16-week adapted ABFT treatment for adolescents with EDs (N = 8, Mage = 16.00, 71.43% female, 71.43% White) fusing together behavioral treatment for EDs with ABFT for highest possible impact. Eight families were treated in an open pilot trial to examine treatment feasibility, acceptability, and preliminary efficacy on FF and eating pathology. Overall, findings were promising. ABFT + B treatment was feasible and acceptable and showed preliminary evidence that it could improve FF and ED behaviors. Future research will test this intervention in a larger sample and further examine the role of FF in maintaining ED symptoms.
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Affiliation(s)
- Stephanie M Manasse
- Center for Weight, Eating, and Lifestyle Science, Drexel University, Philadelphia, PA, USA
| | - Jody Russon
- Department of Human Development & Family Science, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Elizabeth W Lampe
- Center for Weight, Eating, and Lifestyle Science, Drexel University, Philadelphia, PA, USA
- Department of Psychology, Drexel University, Philadelphia, PA, USA
| | - Allie King
- Center for Family Intervention Science, Drexel University, Philadelphia, PA, USA
| | - Sophie R Abber
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Claire Trainor
- Center for Weight, Eating, and Lifestyle Science, Drexel University, Philadelphia, PA, USA
- Department of Psychology, Drexel University, Philadelphia, PA, USA
| | | | - Suzanne Levy
- Center for Family Intervention Science, Drexel University, Philadelphia, PA, USA
| | - Guy Diamond
- Center for Family Intervention Science, Drexel University, Philadelphia, PA, USA
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Marazzi F, Orlandi M, De Giorgis V, Borgatti R, Mensi MM. The impact of family alexithymia on the severity of restrictive eating disorders in adolescent patients. Child Adolesc Psychiatry Ment Health 2023; 17:139. [PMID: 38115116 PMCID: PMC10731864 DOI: 10.1186/s13034-023-00692-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/11/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Alexithymia is the inability to identify and describe one's own emotions. Adolescents who suffer from Restrictive Eating Disorders (REDs) show a higher prevalence of alexithymia than the general population. METHODS The study explored the correlation between levels of alexithymia in mothers, fathers, and adolescents affected by REDs and patients' ability to recognize their emotions. The study also aimed to evaluate if patients' emotional distress can significantly impact the severity of their disorder and functioning measured by the Clinical Global Impression Scale - Severity (CGI-S) and the Children's Global Assessment Scale (CGAS). We enrolled 67 families of adolescents affected by REDs. Parents and patients' levels of alexithymia were assessed through the Toronto Alexithymia Scale (TAS-20). Spearman's correlation shows a statistically significant correlation between mothers and patients' levels of alexithymia. RESULTS Our findings also suggest that fathers and mothers' TAS scores correlate with each other. However, there is no statistically significant relationship between the influence of the TAS scores of fathers and sons/daughters. CONCLUSIONS In conclusion, mothers' level of alexithymia could influence both fathers and patients' difficulty in identifying and describing their own emotions. This relationship can be investigated further when considering externally oriented thinking. However, the severity of the disease and overall functioning do not appear to be affected by patients' levels of alexithymia.
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Affiliation(s)
- Francesca Marazzi
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Marika Orlandi
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy.
| | - Valentina De Giorgis
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Renato Borgatti
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
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Lim J, White J, Withington T, Catania S, Wilson D, Knight P, Rees B, Middeldorp C, Krishnamoorthy G. Family-based treatment takes longer for adolescents with mental health comorbidities: findings from a community mental health service. Eat Disord 2023; 31:588-609. [PMID: 37066723 DOI: 10.1080/10640266.2023.2201995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Children and adolescents diagnosed with an eating disorder often meet the diagnosis of another mental health disorder. In addition to eating disorders, individuals with comorbid disorders have higher suicide rates and more severe and chronic eating disorder symptoms. The present research aimed to investigate the influence of comorbid conditions on the treatment outcomes of children and adolescents that attended a public community mental health service. It was hypothesised that the patients with comorbidities would have a more extended treatment duration, slower rates of weight restoration, more hospital admissions for medical compromise, and poorer functioning than those without comorbidities. Data from 78 past patients at the Eating Disorder Program in Queensland, Australia, were analysed. Patients with comorbidities demonstrated similar recovery rates to those without comorbidities. However, those with comorbid conditions had longer episodes of treatment. The study's results support using Family Based Treatment for patients with and without comorbidities. The implications of the findings for public mental health services and directions for future research are discussed.
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Affiliation(s)
- Jacqueline Lim
- School of Psychology and Wellbeing, University of Southern Queensland, Ipswich, Australia
| | - Jacinda White
- Child and Youth Mental Health Service, Children's Health Queensland, Ipswich, Australia
| | - Tania Withington
- Child and Youth Mental Health Service, Children's Health Queensland, Ipswich, Australia
- Child Health Research Center, University of Queensland, South Brisbane, Australia
| | - Salvatore Catania
- Child and Youth Mental Health Service, Children's Health Queensland, Ipswich, Australia
| | - Daniel Wilson
- Child and Youth Mental Health Service, Children's Health Queensland, Ipswich, Australia
- Child Health Research Center, University of Queensland, South Brisbane, Australia
| | - Penny Knight
- Child and Youth Mental Health Service, Children's Health Queensland, Ipswich, Australia
| | | | - Christel Middeldorp
- Child Health Research Center, University of Queensland, South Brisbane, Australia
| | - Govind Krishnamoorthy
- School of Psychology and Wellbeing, University of Southern Queensland, Ipswich, Australia
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Aarnio-Peterson CM, Mara CA, Modi AC, Matthews A, Le Grange D, Shaffer A. Augmenting family based treatment with emotion coaching for adolescents with anorexia nervosa and atypical anorexia nervosa: Trial design and methodological report. Contemp Clin Trials Commun 2023; 33:101118. [PMID: 37008797 PMCID: PMC10064114 DOI: 10.1016/j.conctc.2023.101118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
This article characterizes the design, recruitment, methodology, participant characteristics, and preliminary feasibility and acceptability of the Families Ending Eating Disorders (FEED) open pilot study. FEED augments family-based treatment (FBT) for adolescents with anorexia nervosa (AN) and atypical anorexia nervosa (AAN) with an emotion coaching (EC) group for parents (i.e., FBT + EC). We targeted families high in critical comments and low warmth (assessed by the Five-Minute Speech Sample), known predictors of poor response in FBT. Eligible participants included adolescents initiating outpatient FBT, diagnosed with AN/AAN, ages 12-17, with a parent high in critical comments/low in warmth. The first phase of the study was an open pilot which demonstrated feasibility and acceptability of FBT + EC. Thus, we proceeded with the small randomized controlled trial (RCT). Eligible families were randomized to either 10 weeks of FBT + EC parent group treatment or the 10- week parent support group (control condition). The primary outcomes were parent critical comments and parental warmth, while our exploratory outcome was adolescent weight restoration. Novel aspects of the trial design (e.g., specifically targeting typical treatment non-responders), as well as recruitment and retention challenges in the context of the COVID-19 pandemic are discussed.
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Affiliation(s)
- Claire M Aarnio-Peterson
- Cincinnati Children's Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Constance A Mara
- Cincinnati Children's Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Avani C Modi
- Cincinnati Children's Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Abigail Matthews
- Cincinnati Children's Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, 401 Parnassus Ave., San Francisco, CA, 94143, USA
- Department of Psychiatry and Neurosciences, University of Chicago, Chicago, IL, 60637, USA
| | - Anne Shaffer
- Department of Psychology, University of Georgia, Athens, GA, USA
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12
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Rienecke RD, Gorrell S, Johnson M, Duffy A, Mehler PS, Le Grange D. Expressed emotion and treatment outcome in higher levels of care for eating disorders. Int J Eat Disord 2023; 56:628-636. [PMID: 36584076 PMCID: PMC9992295 DOI: 10.1002/eat.23890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Expressed emotion (EE) among caregivers toward the affected offspring is a negative prognostic indicator for adolescent patients with eating disorders (EDs) in outpatient treatment. Less research has examined its impact on adolescents in higher levels of care (HLOC). The current study examined differences in caregiver EE according to the subtype of anorexia nervosa (AN) (restricting [AN-R] versus binge/purge [AN-BP]), and level of care (LOC). We also examined the main effects of baseline caregiver EE (emotional overinvolvement [EOI] or criticism), AN subtype, and their interaction on eating pathology and depression at discharge. METHOD Adolescent patients (N = 203) receiving treatment at HLOCs completed measures of ED pathology (Eating Disorder Examination-Questionnaire) and depression (Patient Health Questionnaire-9) at baseline and discharge, and one caregiver of each patient completed a measure of EE (Family Questionnaire) at baseline. RESULTS No differences in caregiver EE were found between patients with AN-R versus AN-BP, or relative to LOC. Caregiver EE did not predict outcome for ED symptoms or depression at discharge. DISCUSSION The impact of high caregiver EE may be less substantial at HLOCs than outpatient care given that caregivers are less involved in treatment at HLOCs. Future research is needed to determine if high caregiver EOI leads to poor treatment outcome for adolescents as it does for adults, or whether it is an appropriate expression of care for patients who are ill enough to require HLOC treatment. PUBLIC SIGNIFICANCE STATEMENT High caregiver EE was not found to predict treatment outcome for adolescents with eating disorders in higher levels of care (HLOCs), possibly due to the limited involvement of caregivers in HLOCs. However, patients step down to outpatient treatment, where high caregiver EE can have a significant negative impact on outcome. HLOCs should incorporate efforts to reduce high caregiver EE in anticipation of step-down to outpatient treatment.
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Affiliation(s)
- Renee D. Rienecke
- Eating Recovery Center/Pathlight Mood & Anxiety Center, Denver, Colorado, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| | - Sasha Gorrell
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Madelyn Johnson
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Alan Duffy
- Eating Recovery Center/Pathlight Mood & Anxiety Center, Denver, Colorado, USA
| | - Philip S. Mehler
- Eating Recovery Center/Pathlight Mood & Anxiety Center, Denver, Colorado, USA
- ACUTE Center for Eating Disorders at Denver Health, Denver, Colorado, USA
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
- Department of Psychiatry & Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
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13
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Baker JH, Temes E, Bohon C, Derenne J, Duvall A, Steinberg D. Enhanced Family-Based Treatment for an Adolescent With Binge-Eating Disorder: A Case Report. COGNITIVE AND BEHAVIORAL PRACTICE 2023. [DOI: 10.1016/j.cbpra.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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14
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Clerc E, Mesquida L, Raynaud JP, Revet A. Therapeutic groups for parents of patients with anorexia nervosa: A systematic review of subjective experiences and state of current practices in France. ANNALES MÉDICO-PSYCHOLOGIQUES, REVUE PSYCHIATRIQUE 2022. [DOI: 10.1016/j.amp.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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García-Anaya M, Caballero-Romo A, González-Macías L. Maintaining Factors of Anorexia Nervosa Addressed from a Psychotherapeutic Group for Parents: Supplementary Report of a Patient's Therapeutic Success. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11396. [PMID: 36141668 PMCID: PMC9517022 DOI: 10.3390/ijerph191811396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/07/2022] [Accepted: 08/11/2022] [Indexed: 06/16/2023]
Abstract
(1) Background: Anorexia nervosa is an eating disorder (ED) where up to 30% of individuals remain unresponsive to treatments, whether they partially respond, or do respond and later relapse. It has been broadly reported how presenting maladaptive family functioning and communication style contributes to treatment drop-out, poor treatment compliance, and poor long-term outcomes. We studied the mother and father of a patient with AN, binge-purge subtype (according to DSM-IV TR) who achieved remission after her parents but not her attended an intervention through a psychotherapy group for parents (PGP). (2) Methods: We previously reported this patient's case report, and now, through an Interpretative Phenomenological Analysis (IPA) approach, we aimed to explore the understanding and meanings ascribed by the mother and father to their experience at the PGP and to their daughter's clinical and functional improvement. (3) Results: We identified two main stages along the process: one related to the presence of maintaining factors of their daughter's disorder, and the other related to the emergence of a reflective function and to the implementation of behavioral, emotional and cognitive changes. (4) Conclusions: The interview revealed both parents' experience at the PGP promoted a change process, where they were able to modify their previous style of communication and functioning, and to identify them as a contributors to maintain their daughter's disorder. Reflective function (RF) emerged in the mother and father throughout the psychotherapeutic process. Both parents also revealed some elements that were intergenerationally transmitted, that affected three generations and contributed to maintaining the ED. We observed the multilevel open-group structure of the PGP, enhancing the mother's and father's change process.
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Affiliation(s)
- María García-Anaya
- Clinical Research Division, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City 14370, Mexico
| | - Alejandro Caballero-Romo
- Eating Disorders Clinic, Clinical Services Division, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City 14370, Mexico
| | - Laura González-Macías
- Eating Disorders Clinic, Clinical Services Division, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City 14370, Mexico
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16
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Gorrell S, Byrne CE, Trojanowski PJ, Fischer S, Le Grange D. A scoping review of non-specific predictors, moderators, and mediators of family-based treatment for adolescent anorexia and bulimia nervosa: a summary of the current research findings. Eat Weight Disord 2022; 27:1971-1990. [PMID: 35092554 PMCID: PMC9872820 DOI: 10.1007/s40519-022-01367-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/13/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE This scoping review presents an up-to-date synthesis of the current evidence base for non-specific predictors, moderators, and mediators of family-based treatment (FBT) for adolescent anorexia and bulimia nervosa. METHODS We identify ways in which end-of-treatment outcomes have been shown to differ based upon baseline clinical features and person-specific factors and explore psychological mechanisms that may explain differences in treatment response. We draw from this evidence base to outline recommendations for clinical practice, as well as directions for future clinical eating disorder research. RESULTS Noted findings from review include that early response in weight gain and parental criticism may be particularly influential in treatment for anorexia nervosa. Further, for adolescents with either anorexia or bulimia nervosa, eating-related obsessionality may be a key intervention target to improve outcomes. CONCLUSION In addition to highlighting a need for attention to specific patient- and caregiver-level factors that impact treatment response, recommendations for research and clinical practice include testing whether certain targeted treatments (e.g., exposure-based approaches) may be suitable within the context of FBT for eating disorders. LEVEL OF EVIDENCE Level I: Evidence obtained from: at least one properly designed randomized controlled trials; experimental studies.
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Affiliation(s)
- Sasha Gorrell
- Department of Psychiatry and Behavioral Sciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | | | | | - Sarah Fischer
- Department of Psychology, George Mason University, Fairfax, VA, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, 401 Parnassus Avenue, San Francisco, CA, 94143, USA.,Department of Psychiatry and Behavioral Neurosciences, The University of Chicago, Chicago, IL, USA
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17
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Blum M, Ribner A. Parents’ expressed emotions and children’s executive functions. J Exp Child Psychol 2022; 219:105403. [DOI: 10.1016/j.jecp.2022.105403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 11/17/2022]
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18
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Rienecke RD, Le Grange D. The five tenets of family-based treatment for adolescent eating disorders. J Eat Disord 2022; 10:60. [PMID: 35505444 PMCID: PMC9066936 DOI: 10.1186/s40337-022-00585-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/17/2022] [Indexed: 11/26/2022] Open
Abstract
Family-based treatment (FBT) is the leading treatment for adolescent eating disorders and is based on five tenets, or fundamental assumptions: (1) the therapist holds an agnostic view of the cause of the illness; (2) the therapist takes a non-authoritarian stance in treatment; (3) parents are empowered to bring about the recovery of their child; (4) the eating disorder is separated from the patient and externalized; and (5) FBT utilizes a pragmatic approach to treatment. Learning these tenets is crucial to the correct practice and implementation of manualized FBT. The purpose of the current paper is to provide an in-depth overview of these five tenets and to illustrate how they are used in clinical practice. This overview will aid clinicians who are learning FBT.
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Affiliation(s)
- Renee D Rienecke
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, 333 N. Michigan Avenue, Ste. 1900, Chicago, IL, 60601, USA. .,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA.
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, IL (Emeritus), USA
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19
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Coleman M, Jones EJ, Hoiles KJ, McEvoy PM. The association between carer self-compassion, expressed emotion, quality of life, and paediatric eating disorder symptoms. Eat Behav 2022; 45:101628. [PMID: 35490441 DOI: 10.1016/j.eatbeh.2022.101628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 03/15/2022] [Accepted: 03/23/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The aim of this study was to investigate carer variables on paediatric eating disorders. We examined whether carer self-compassion, the tendency to treat oneself with kindness during distress and disappointments, was associated with lower carer expressed emotion, and, in turn, whether lower carer expressed emotion would be associated with both higher carer quality of life and lower eating disorder symptoms in young people. Further, we examined whether higher carer quality of life was associated with lower adolescent eating disorder symptoms. METHOD Data were extracted from the Helping out Paediatric Eating Disorders (HOPE) project database. Participants included children and adolescents diagnosed with a DSM5 eating disorder and their primary carer (N of dyads = 359). Primary carers completed the Self-Compassion Scale-Short Form (SCS-SF), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF), and the Family Questionnaire-Expressed Emotion (FQ-EE). Children and adolescents completed an adapted version of the Eating Disorder Examination (EDE). RESULTS As hypothesised, structural equation modelling (SEM) revealed a direct relationship between higher carer self-compassion and lower expressed emotion, and between lower expressed emotion and both higher carer quality of life and lower eating disorder symptoms. However, contrary to our hypothesis, carer quality of life was not significantly associated with paediatric eating disorder symptoms. Expressed emotion carried significant indirect effects between carer self-compassion and (a) paediatric eating disorder symptoms and (b) carer quality of life. DISCUSSION The results highlight the importance of further research to determine whether targeting carer self-compassion is helpful in the treatment of eating disorders in young people.
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Affiliation(s)
| | - Emily J Jones
- Eating Disorders Program, Child and Adolescent Mental Health Service, Perth, Australia.
| | - Kimberley J Hoiles
- Eating Disorders Program, Child and Adolescent Mental Health Service, Perth, Australia
| | - Peter M McEvoy
- School of Psychology, Curtin University, Perth, Australia; Centre for Clinical Interventions, Perth, Australia
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20
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Giles EM, Cross AS, Matthews RV, Lacey JH. Disturbed families or families disturbed: a reconsideration. Eat Weight Disord 2022; 27:11-19. [PMID: 33721219 PMCID: PMC8860793 DOI: 10.1007/s40519-021-01160-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 01/25/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The relationship between anorexia nervosa (AN) and family disturbance has been a subject of debate since its first description. What began as a clear view of the pathologically disturbed family causing AN has become ever more complex over the decades. OBJECTIVE The aim of this review is to explore the literature to examine the changes and evolution of clinical opinion around family dysfunction and AN over the last 20 years. METHODS A narrative review of heterogeneous studies in peer-reviewed publications sourced from the major databases, including PubMed and ScienceDirect, to illuminate the topic of family distress and AN by highlighting the conflicting and complementary ways it has been studied. RESULTS This review has highlighted the complexity of the relationship between anorectic sufferers and their families. It has explored the literature about parental burden, emotions and cognitive mechanisms together with parental attitudes about weight and shape. It is clear that there is no consistent psycho-social pathology in families which has been shown to be causative. However, over the last twenty years, research has highlighted the distress and family dysfunction caused by having to look after an anoretic child with poor mentalisation skills, insecure attachment and emotion dysregulation. CONCLUSION The area has become clearer over the last 20 years; research suggests a bi-directional relationship between AN and family dysfunction, with difficult dynamics becoming entrenched within the family. This is best addressed, the consensus suggests, by specialist family therapy and carer skills interventions. Longitudinal research is needed to definitively answer the question with rigorous scientific certainty. EMB RATING Level V. LEVEL OF EVIDENCE Level I: Evidence obtained from: at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies. Level II: Evidence obtained from well-designed controlled trials without randomization. Level III: Evidence obtained from well-designed cohort or case-control analytic studies. Level IV: Evidence obtained from with multiple time series analysis such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.
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Affiliation(s)
| | | | | | - J Hubert Lacey
- Schoen Clinic Newbridge, Birmingham, UK.
- St Georges, University of London, London, UK.
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21
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Homan KJ, Crowley SL, Rienecke RD. Predictors of improvement in a family-based partial hospitalization/intensive outpatient program for eating disorders. Eat Disord 2021; 29:644-660. [PMID: 32174240 DOI: 10.1080/10640266.2020.1734410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The efficacy of family-based treatment (FBT) in outpatient settings has led to efforts to incorporate FBT principles into higher levels of care. The present study examined predictors of improvement in an FBT-based partial hospitalization program/intensive outpatient program (PHP/IOP) as measured by the Eating Disorder Examination-Questionnaire. Participants were 113 patients with anorexia nervosa (AN) or eating disorder not otherwise specified (EDNOS) consecutively participating in an FBT-based PHP/IOP. Multilevel modeling was used to investigate predictors for adolescents and young adults separately. Predictors considered included illness duration, previous hospitalization, hospitalization immediately prior to treatment, previous outpatient therapy, hospitalization during treatment, diagnosis, gaining 4 pounds in 4 weeks, and family status as time-invariant variables. Time-varying variables considered included depression symptoms and mothers'/fathers' ratings of parental self-efficacy and expressed emotion. For adolescents, depression by time and diagnosis by time interactions were statistically significant. At all levels of depression, adolescent patients with AN demonstrated greater reductions in eating disorder symptoms compared to patients with EDNOS. For young adults, depression and gaining 4 pounds in 4 weeks were significant predictors. The relationships for young adults were curvilinear such that, while lower eating disorder symptoms were found during treatment, these gains were not maintained at follow up.
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Affiliation(s)
- Kendra J Homan
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Susan L Crowley
- Department of Psychology, Utah State University, Logan, Utah, USA
| | - Renee D Rienecke
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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22
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Rienecke RD, Gorrell S, Blalock DV, Smith K, Lock J, Le Grange D. Expressed emotion and long-term outcome among adolescents with anorexia nervosa. Int J Eat Disord 2021; 54:2019-2024. [PMID: 34553396 PMCID: PMC8810289 DOI: 10.1002/eat.23613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/03/2021] [Accepted: 09/13/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The purpose of the current study is to examine expressed emotion (EE) and long-term treatment outcome among adolescents participating in a randomized controlled trial (RCT) for treatment of anorexia nervosa (AN). It was hypothesized that patients with high EE parents at baseline would show more severe symptoms at end-of-treatment, 12-month follow-up, and 4-year follow-up than patients from low EE families. METHOD Secondary data analysis was conducted of original RCT data from a two-site eating disorder treatment trial conducted in the United States. Participants were 121 adolescents with AN who completed measures of EE, eating disorder psychopathology, depression, and self-esteem. RESULTS Generalized estimating equations showed that participants who were in the Low EE group achieved a more accelerated drop in depression scores in the context of treatment (first 12 months) than participants in the High EE group. No other significant Group × Time interactions were found. DISCUSSION Findings suggest that high parental EE at baseline does not indicate that adolescent patients with AN will fare poorly 4 years later.
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Affiliation(s)
- Renee D. Rienecke
- Eating Recovery Center/Pathlight Mood and Anxiety Center, Chicago, Illinois, USA,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| | - Sasha Gorrell
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kathryn Smith
- Department of Psychiatry and the Behavioral Sciences, University of Southern California, Los Angeles, California, USA
| | - James Lock
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
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23
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Nilsen JV, Hage TW, Rø Ø, Halvorsen I, Oddli HW. Family-based inpatient treatment for adolescent anorexia nervosa: a thematic analysis of former patients' post-treatment reflections. Eat Disord 2021; 29:390-407. [PMID: 31682534 DOI: 10.1080/10640266.2019.1656469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This study investigated former patients' experiences with family-based inpatient treatment. Interviews of thirty-seven patients diagnosed with anorexia nervosa during the admissions were conducted to examine their post-treatment perspectives. The accounts were analyzed by utilizing an inductive thematic analytic approach. The analysis yielded 4 main themes, constituted by in all 8 subthemes. The main themes were; 1) Enabling new ways of understanding and relating, 2) Enhancing or maintaining negative power dynamics, 3) Vulnerable transitions, and 4) Sibling relationships and different ways of involvement. With its "insider focus," this study contributes to knowledge on how family-based inpatient treatment is perceived from a user perspective. The current study has value for both advancing the development of family-based inpatient treatment, and by adding patient perspectives to the ongoing effort of providing family-based approaches at higher levels of care.
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Affiliation(s)
- Jan-Vegard Nilsen
- Department of Psychology, University of Oslo and Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Trine Wiig Hage
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Øyvind Rø
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Norway and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Inger Halvorsen
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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24
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Zeiler M, Wittek T, Kahlenberg L, Gröbner EM, Nitsch M, Wagner G, Truttmann S, Krauss H, Waldherr K, Karwautz A. Impact of COVID-19 Confinement on Adolescent Patients with Anorexia Nervosa: A Qualitative Interview Study Involving Adolescents and Parents. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4251. [PMID: 33923791 PMCID: PMC8074137 DOI: 10.3390/ijerph18084251] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 12/19/2022]
Abstract
COVID-19-related restrictions may have a serious impact on patients with eating disorders. We conducted semistructured interviews with female adolescent patients with anorexia nervosa (AN) (n = 13, 13-18 years) currently receiving inpatient or outpatient treatment and their parents (n = 10). We asked for their experiences during COVID-19 confinement regarding everyday life, AN symptoms, and treatment. We used thematic analysis to interpret the data. The main themes identified from the patients' interviews involved restrictions of personal freedom (i.e., leading to tension between patients and family members, reduced motivation to work on recovery), interruption of the treatment routine (emerging risks through self-monitored weight, challenges/opportunities of teletherapy), changes in AN symptoms (more exposure to triggering situations), COVID-19-related fears, and compulsions but also potential opportunities (less stress, better family relationships). The parents discussed changes in daily routines as negative (challenges in maintaining day structures) and positive (more family time, "slowing down"). They expressed reservations about reduced outpatient monitoring and increased teletherapy and discussed challenges in keeping contact with the child and clinicians during inpatient treatment. Moreover, the parents discussed deteriorations and improvements in the patients' psychopathology. Clinical implications from these in-depth insights include the importance of strengthening communication between changing staff cohorts, patients, and parents; motivational work; and joint weight monitoring with the therapist.
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Affiliation(s)
- Michael Zeiler
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
| | - Tanja Wittek
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
| | - Leonie Kahlenberg
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
| | - Eva-Maria Gröbner
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
| | - Martina Nitsch
- Department for Research and Development, Ferdinand Porsche FernFH-Distance Learning University of Applied Sciences, 2700 Wiener Neustadt, Austria; (M.N.); (K.W.)
| | - Gudrun Wagner
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
| | - Stefanie Truttmann
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
| | - Helene Krauss
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
| | - Karin Waldherr
- Department for Research and Development, Ferdinand Porsche FernFH-Distance Learning University of Applied Sciences, 2700 Wiener Neustadt, Austria; (M.N.); (K.W.)
| | - Andreas Karwautz
- Eating Disorder Unit, Department of Child and Adolescent Psychiatry, Medical University of Vienna, 1090 Vienna, Austria; (T.W.); (L.K.); (E.-M.G.); (G.W.); (S.T.); (H.K.); (A.K.)
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25
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Freizinger M, Jhe G, Pluhar E, Mancini L. Integrating Family-Based Treatment Principles in the Acute Inpatient Treatment of Adolescents with Restrictive Eating Disorders. Psychol Res Behav Manag 2021; 14:449-454. [PMID: 33859508 PMCID: PMC8044072 DOI: 10.2147/prbm.s304921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/22/2021] [Indexed: 11/23/2022] Open
Abstract
Eating disorders (ED) are serious psychiatric illnesses with one of the highest mortality rate of any psychiatric disorder. The health sequelae of eating disorders are one of the most common causes of medical hospitalizations at freestanding pediatric hospitals in the United States. The economic impact of EDs on health systems and families is substantial. The Society for Adolescent Medicine (SAHM) recommends family-based treatment (FBT) as the first-line approach for adolescents with restrictive eating disorders due to a large body of evidence demonstrating the treatment's efficacy and cost effectiveness. Although FBT was originally developed as an outpatient treatment, the tenets and principles of the treatment have also been used in higher levels of care. This brief report discusses how components of FBT were adapted for a medical inpatient unit at a pediatric hospital in order to integrate empirically based treatment.
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Affiliation(s)
- Melissa Freizinger
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, USA
| | - Grace Jhe
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, USA
| | - Emily Pluhar
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, USA
| | - Lisa Mancini
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, MA, 02115, USA
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Treatment dropout in a family-based partial hospitalization program for eating disorders: a response to Kawada. Eat Weight Disord 2021; 26:403. [PMID: 32144689 DOI: 10.1007/s40519-020-00882-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/23/2020] [Indexed: 10/24/2022] Open
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RE: treatment dropout in a family-based partial hospitalization program for eating disorders. Eat Weight Disord 2021; 26:401. [PMID: 32065377 DOI: 10.1007/s40519-020-00870-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/06/2020] [Indexed: 10/25/2022] Open
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Reilly EE, Orloff NC, Luo T, Berner LA, Brown TA, Claudat K, Kaye WH, Anderson LK. Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions. Eat Disord 2020; 28:122-141. [PMID: 32301680 DOI: 10.1080/10640266.2020.1743098] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Over the past several decades, Dialectical Behavior Therapy (DBT) has been adapted for a range of presenting problems related to emotion dysregulation. Considerable enthusiasm exists regarding the use of DBT for treating eating disorders; however, to date, there have been no reviews summarizing empirical efforts to adapt DBT for eating disorders in youth. Accordingly, in the present narrative review, we provide a comprehensive summary of existing work testing DBT for adolescent eating disorders. First, we briefly review existing work applying DBT to eating disorders in adults and general adolescent samples. We then review research focused specifically on the use of DBT for adolescent eating disorders, including both those studies applying DBT as the primary treatment and investigations of DBT as an adjunctive treatment. Overall, initial results for DBT-based approaches are promising. However, rigorous empirical work testing DBT for treating adolescent eating disorders remains limited; the majority of existing research is comprised of case series and small-scale studies. Therefore, we close with specific recommendations for future research testing this approach.
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Affiliation(s)
- Erin E Reilly
- Department of Psychiatry, University of California, San Diego, CA, USA.,Department of Psychology, Hofstra University, Hempstead, NY, USA
| | - Natalia C Orloff
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Tana Luo
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Laura A Berner
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Tiffany A Brown
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Kimberly Claudat
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Walter H Kaye
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Leslie K Anderson
- Department of Psychiatry, University of California, San Diego, CA, USA
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Hamadi L, Holliday J. Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials. Int J Eat Disord 2020; 53:3-19. [PMID: 31506978 DOI: 10.1002/eat.23159] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To critically appraise papers reporting on moderators and mediators of recommended psychological treatments for anorexia nervosa (AN) and bulimia nervosa (BN) in adolescents. METHOD A systematic search of databases was conducted including PsycINFO, Embase, MEDLINE, AMED, CINAHL, and the Cochrane Library. Studies were included where a randomized controlled trial (RCT) compared therapies for AN or BN and reported on moderators or mediators of treatment effect. Twenty-one eligible papers were included, all based on data from eight RCTs. RESULTS Family therapies were dominant in the literature. Individual or separated treatment appeared superior for families with more difficult relationships, whereas conjoint family treatment appeared to be superior where good family relationships were reported. Where there was greater eating disorder psychopathology in AN, including eating disorder-related obsessions and compulsions, the response was better to a family approach than to individual therapies. There was some evidence that a family treatment was superior for those engaging in purging behaviors in BN. Measures of family relationships, parental self-efficacy, and early change emerged as possible mediators; however, the quality of evidence was mixed and the findings, in some cases, arguably circular. Moderator and mediator analyses were underpowered in all studies, with multiple, and post-hoc, analyses being run, and a broad range of outcome measures used. DISCUSSION This review recommends that emerging findings are explored further in adequately powered trials of the different recommended therapies, with a move toward focusing on effect sizes. A consensus on acceptable definitions of outcome, including remission and recovery, would benefit future research.
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Affiliation(s)
- Layla Hamadi
- Oxford Institute of Clinical Psychology Training, Isis Education Centre, Warneford Hospital, Headington, Oxford.,Eating disorder CAMHS Community Services, Oxford Health NHS Foundation Trust
| | - Joanna Holliday
- Eating disorder CAMHS Community Services, Oxford Health NHS Foundation Trust
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Jaite C, Bühren K, Dahmen B, Dempfle A, Becker K, Correll CU, Egberts KM, Ehrlich S, Fleischhaker C, von Gontard A, Hahn F, Kolar D, Kaess M, Legenbauer T, Renner TJ, Schulze U, Sinzig J, Thomae E, Weber L, Wessing I, Antony G, Hebebrand J, Föcker M, Herpertz-Dahlmann B. Clinical Characteristics of Inpatients with Childhood vs. Adolescent Anorexia Nervosa. Nutrients 2019; 11:nu11112593. [PMID: 31661861 PMCID: PMC6893829 DOI: 10.3390/nu11112593] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 10/19/2019] [Accepted: 10/22/2019] [Indexed: 12/20/2022] Open
Abstract
We aimed to compare the clinical data at first presentation to inpatient treatment of children (<14 years) vs. adolescents (≥14 years) with anorexia nervosa (AN), focusing on duration of illness before hospital admission and body mass index (BMI) at admission and discharge, proven predictors of the outcomes of adolescent AN. Clinical data at first admission and at discharge in 289 inpatients with AN (children: n = 72; adolescents: n = 217) from a German multicenter, web-based registry for consecutively enrolled patients with childhood and adolescent AN were analyzed. Inclusion criteria were a maximum age of 18 years, first inpatient treatment due to AN, and a BMI <10th BMI percentile at admission. Compared to adolescents, children with AN had a shorter duration of illness before admission (median: 6.0 months vs. 8.0 months, p = 0.004) and higher BMI percentiles at admission (median: 0.7 vs. 0.2, p = 0.004) as well as at discharge (median: 19.3 vs. 15.1, p = 0.011). Thus, in our study, children with AN exhibited clinical characteristics that have been associated with better outcomes, including higher admission and discharge BMI percentile. Future studies should examine whether these factors are actually associated with positive long-term outcomes in children.
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Affiliation(s)
- Charlotte Jaite
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany.
| | - Katharina Bühren
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, 52074 Aachen, Germany.
| | - Brigitte Dahmen
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, 52074 Aachen, Germany.
| | - Astrid Dempfle
- Institute of Medical Informatics and Statistics, Kiel University, 24105 Kiel, Germany.
| | - Katja Becker
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps-University Marburg and University Hospital Marburg, 35039 Marburg, Germany.
- Center for Mind, Brain and Behavior (CMBB), Philipps-University Marburg, 35032 Marburg, Germany.
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany.
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY 11004, USA.
- Hofstra Northwell School of Medicine, Department of Psychiatry and Molecular Medicine, Hempstead, NY 11549, USA.
| | - Karin M Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Wuerzburg, 97080 Wuerzburg, Germany.
| | - Stefan Ehrlich
- Department of Child and Adolescent Psychiatry & Division of Psychological & Social Medicine and Developmental Neurosciences, Faculty of Medicine, Technische Universität Dresden, 01307 Dresden, Germany.
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Freiburg, 79104 Freiburg, Germany.
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, 66421 Homburg, Germany.
| | - Freia Hahn
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, LVR-Hospital Viersen, 41749 Viersen, Germany.
| | - David Kolar
- Department of Child and Adolescent Psychiatry, University Medicine of the Johannes Gutenberg-University, 55131 Mainz, Germany.
| | - Michael Kaess
- Clinic of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, 69115 Heidelberg, Germany.
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, 3000 Bern, Switzerland.
| | - Tanja Legenbauer
- LWL University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr University Bochum, 59071 Hamm, Germany.
| | - Tobias J Renner
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tuebingen, 72076 Tuebingen, Germany.
| | - Ulrike Schulze
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital, University of Ulm, 89075 Ulm, Germany.
| | - Judith Sinzig
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, LVR-Klinik Bonn, 53111 Bonn, Germany.
| | - Ellen Thomae
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, 01307 Dresden, Germany.
| | - Linda Weber
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps-University Marburg and University Hospital Marburg, 35039 Marburg, Germany.
| | - Ida Wessing
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Muenster, 48149 Muenster, Germany.
| | - Gisela Antony
- Central Information Office KKNMS, Philipps-University Marburg, 35112 Bellnhausen, Germany.
| | - Johannes Hebebrand
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany.
| | - Manuel Föcker
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Muenster, 48149 Muenster, Germany.
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany.
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, 52074 Aachen, Germany.
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de León-Vázquez CD, Villalobos-Hernández A, Rivera-Márquez JA, Unikel-Santoncini C. Effect of parental criticism on disordered eating behaviors in male and female university students in Mexico City. Eat Weight Disord 2019; 24:853-860. [PMID: 30155855 DOI: 10.1007/s40519-018-0564-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/29/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The aim of this study was to analyze the effect of parental criticism of their offspring's bodies in the development of disordered eating behaviors (DEBs) in university students in Mexico City. METHODS A sample of 892 freshmen (502 women and 390 men) was included. The prevalence of the internalization of the aesthetic thin ideal, body dissatisfaction, self-esteem, depressive symptoms, and body mass index was estimated by sex. For each sex, the effect of parental criticism on DEBs, together with that of the other covariates, was measured through ordinal regression models. RESULTS It was found that women received more criticism from their mothers than men. Among the participants, the likelihood of DEBs is increased in the presence of criticism from both parents (OR = 2.5), criticism from the mother alone (OR = 2.0), overweight (OR = 1.7), obesity (OR = 2.1), wanting a slimmer body (OR = 8.3), and depressive symptoms (OR = 3.3). Among men, this risk is increased in the presence of criticism from both parents (OR = 2.7), being obese (OR = 2.4), wanting a slimmer body (OR = 3.4), and depressive symptoms (OR = 2.8). CONCLUSIONS It is essential to include issues linked to parental criticism of their bodies in interventions to prevent eating disorders in college students. Level of evidence V, cross-sectional descriptive study.
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Affiliation(s)
| | | | | | - Claudia Unikel-Santoncini
- Head Office of Epidemiological and Psychosocial Research, Instituto Nacional de Psiquiatría "Ramón de la Fuente Muñiz", Calz. México-Xochimilco 101, Col. San Lorenzo Huipulco, Tlalpan, 14370, Mexico City, Mexico.
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Blondin S, Meilleur D, Taddeo D, Frappier JY. Caregiving experience and expressed emotion among parents of adolescents suffering from anorexia nervosa following illness onset. Eat Disord 2019; 27:453-470. [PMID: 30612513 DOI: 10.1080/10640266.2018.1553431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of this study was to better understand the relationship between parents' experience of caregiving and expressed emotion during the early stage of their child's eating disorder. Fifty mothers and 38 fathers of adolescents suffering from anorexia nervosa and hospitalized for the first time participated in this study. They completed the Experience of Caregiving Inventory, a measure of the negative and positive aspects of the caregiving experience, and the Family Questionnaire, which measured the different dimensions of expressed emotion, namely emotional over-involvement and critical comments. Results showed that caregiving experience is significantly and positively correlated to expressed emotion. Among the negative aspects of caregiving, sense of loss contributed most to emotional over-involvement, while difficult behaviours contributed most to critical comments. The results suggest that parents' perceptions of their child and child's future are strongly related to their tendency to be over-involved. The perception of disruptive behaviours in their child could be one of the principal triggers or exacerbating factors of parents' critical attitudes.
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Affiliation(s)
- Soline Blondin
- Department of Psychology, Adolescence and Eating Disorders Research Laboratory, Montreal University , Montreal , Quebec , Canada
| | - Dominique Meilleur
- Department of Psychology, Adolescence and Eating Disorders Research Laboratory, Montreal University , Montreal , Quebec , Canada
| | - Danielle Taddeo
- Division of Adolescent Medicine, Sainte-Justine Hospital Center , Montreal , Quebec , Canada
| | - Jean-Yves Frappier
- Division of Adolescent Medicine, Sainte-Justine Hospital Center , Montreal , Quebec , Canada
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Dimitropoulos G, Landers AL, Freeman V, Novick J, Cullen O, Le Grange D. Family-based treatment for transition age youth: the role of expressed emotion and general family functioning. Eat Disord 2019; 27:419-435. [PMID: 30358513 DOI: 10.1080/10640266.2018.1529472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The aim of this study was to investigate changes in family functioning and parental expressed emotion (EE) in parents and transition age youth (18 to 25 years old) with Anorexia Nervosa participating in Family-Based Treatment for Transition Age Youth (FBT-TAY). Further, we examined whether perceived family functioning and EE were associated with changes in eating disorder behaviour and weight in participants at end-of-treatment and three months post-treatment. Generalized estimating equations revealed that changes in family functioning significantly improved from baseline to end-of-treatment (p = .0001), and baseline to three months post-treatment (p = .0001) in parents; and from baseline to end-of-treatment (p = .011), and baseline to three months post-treatment (p = .0001) in transition age youth. The level of parental EE did not differ significantly from baseline to end-of-treatment (p = .379), or baseline to three months post-treatment (p = .185). A series of Ordinary Least Square regression models demonstrated that changes in perceived family functioning and EE were not significantly associated with changes in eating disorder behaviour and weight restoration of transition age youth at end-of-treatment and three months post-treatment. Overall, perceptions of family functioning improved during the course of FBT-TAY, but EE did not.
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Affiliation(s)
- Gina Dimitropoulos
- Toronto General Hospital Eating Disorder Program, University Health Network , Toronto , Ontario , Canada
| | - Ashley L Landers
- Department of Human Development and Family Science, Virginia Polytechnic Institute and State University , Falls Church , Virginia , USA
| | - Victoria Freeman
- Toronto General Hospital, University Health Network , Toronto Ontario , Canada
| | - Jason Novick
- Department of Sociology, Mount Royal University , Calgary Alberta , Canada
| | - Olivia Cullen
- Faculty of Social Work, University of Calgary , Calgary Alberta , Canada
| | - Daniel Le Grange
- Department of Psychiatry, University of California , San Francisco CA , USA
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Lex C, Hautzinger M, Meyer TD. Symptoms, course of Illness, and comorbidity as predictors of expressed emotion in bipolar disorder. Psychiatry Res 2019; 276:12-17. [PMID: 30981096 DOI: 10.1016/j.psychres.2019.03.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 03/29/2019] [Accepted: 03/30/2019] [Indexed: 11/28/2022]
Abstract
High levels of expressed emotions (EE) reflect the amount of criticism and/or over-involvement in families and has been linked to relapse risk in various psychiatric disorders including bipolar disorder (BD). Less clear is which factors contribute to the development and/or maintenance of EE. Therefore, we tested whether patient characteristics, specifically clinical features and personality disorder traits in BD predicted key aspects of EE as assessed by patients and their relatives. Patients with remitted BD and their relatives were asked to complete the Family Attitude Scale (FAS) and the Perceived Criticism Measure (PCM). Patient characteristics were assessed with a variety of measures including SCID I and II. The FAS and PCM shared 25% of the variance for patients and 14% for relatives, suggesting a conceptual overlap, but they may not assess identical constructs. The number of previous mood episodes, current self-rated manic symptoms, and comorbid symptoms of Cluster C personality disorder predicted patient-rated FAS. Relative-rated FAS was only predicted by comorbid symptoms of Cluster A personality disorder. In BD, specific patient characteristics seem to be linked to key aspects of EE even when in remission. However, it might depend whether the patient, his/her relative, or a neutral observer assessed EE.
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Affiliation(s)
- Claudia Lex
- Department of Psychiatry, Villach General Hospital, Nikolaigasse 43, 9500 Villach, Austria.
| | - Martin Hautzinger
- Department of Psychology, Eberhard Karls University, Schleichstrasse 4, 72076 Tuebingen, Germany
| | - Thomas D Meyer
- McGovern Medical School, Department of Psychiatry and Behavioral Sciences, University of Texas HSC at Houston, 1941 East Road (BBSB 3118), Houston, Texas 77054, USA.
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Toubøl A, Koch-Christensen H, Bruun P, Nielsen DS. Parenting skills after participation in skills-based training inspired by the New Maudsley Method: a qualitative study in an outpatient eating disorder setting. Scand J Caring Sci 2019; 33:959-968. [PMID: 31058339 DOI: 10.1111/scs.12694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/17/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Eating disorders affect the whole family and it is recommended that parents play an important role in their adolescents' recovery. Being a parent to an adolescent with an eating disorder is often linked to feelings of guilt and hopelessness and at the same time parents often feel left alone with unmet needs when it comes to handling symptoms in family life. Little is known about parents' perspectives to skills-based training in adolescent eating disorder treatment. This knowledge is urgently required, since previous research has focused mainly on adult patients showing positive effects of skills-based training as a promising adjunct in eating disorder treatment. OBJECTIVE To examine parents' perception of their new skills after having participated in skills-based training inspired by the New Maudsley Method. METHODOLOGY A qualitative study using deductive dominant content analysis. METHODS In total, 21 parents participated in focus groups. FINDINGS Three categories were identified (i) Standing outside oneself and realise that one has become entangled in the illness, (ii) Understanding the daughter's inner life with the illness offers new opportunities in the relationship, (iii) Courage to find new ways of parenting. The parents experienced themselves more calm and confident in their ability to recognise and confront the eating disorder symptoms. They expressed increased communication skills, which improved their relationship with their child and gave access to her inner life. CONCLUSION Skills-based training serves as an important intervention and it may improve parental skills, reduce high expressed emotions and reduce anxiety, guilt and stress. Skills-based training may contribute to reinforcing parents to regain parenting authority and enable parents and adolescents to 'be on the same side' in the beating the eating disorder.
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Affiliation(s)
- Annemarie Toubøl
- Health Sciences Research Center, University College Lillebaelt, Vejle, Denmark
| | - Helle Koch-Christensen
- Child and Adolescent Mental Health Services in the Region of Southern Denmark, Vejle, Denmark
| | - Poul Bruun
- Health Sciences Research Center, University College Lillebaelt, Vejle, Denmark
| | - Dorthe S Nielsen
- Health Sciences Research Center, University College Lillebaelt, Vejle, Denmark
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Abstract
BACKGROUND Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010. OBJECTIVES To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016. SELECTION CRITERIA Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa. DATA COLLECTION AND ANALYSIS Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures. MAIN RESULTS We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up. AUTHORS' CONCLUSIONS There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or other psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.
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Affiliation(s)
- Caroline A Fisher
- Royal Melbourne Hospital, Melbourne HealthAllied Health ‐ PsychologyParkvilleVictoriaAustralia3050
| | - Sonja Skocic
- HealthscopeThe Melbourne ClinicRichmondVictoriaAustralia
| | | | - Sarah E Hetrick
- University of AucklandDepartment of Psychological MedicineAucklandNew Zealand
- University of MelbourneThe Centre of Youth Mental HealthMelbourneVictoriaAustralia
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Kimber M, McTavish JR, Couturier J, Le Grange D, Lock J, MacMillan HL. Identifying and responding to child maltreatment when delivering family-based treatment-A qualitative study. Int J Eat Disord 2019; 52:292-298. [PMID: 30729594 DOI: 10.1002/eat.23036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 11/08/2022]
Abstract
INTRODUCTION This study describes practitioner strategies, perceptions, experiences with identifying and responding to child emotional abuse (CEA) and child exposure to intimate partner violence (CEIPV) when providing Family-Based Treatment (FBT) to children and adolescents with eating disorders. METHOD Using qualitative interpretive description, this study recruited a purposeful sample of practitioners (N = 30, 90% female) implementing FBT for adolescent eating disorders. Semi-structured interviews focused on eliciting their perspectives regarding identifying and responding to CEA and CEIPV in practice. Interviews were conducted over the phone, were audio recorded, transcribed verbatim, and coded using conventional content analysis. Interim member checking, the thoughtful clinician test, and coding memos were used to ensure the integrity of the analysis. RESULTS Participants were 31-57 years old and practicing FBT in five countries. Three data patterns emerged: (a) perceptions of child maltreatment prevalence and identification; (b) complicating factors; and finally (c) strategies to support family-based work. Practitioners described important considerations for CEA and CEIPV identification, as well as possible FBT adaptations that can support the safety of children and adolescents while simultaneously ensuring the treatment of the eating disorder. CONCLUSIONS Practitioners describe a need for additional training to identify and respond to CEA and CEIPV within FBT and within practice more broadly. There is a need for trials that detail the appropriateness and efficacy of FBT for patients experiencing CEA and/or CEIPV.
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Affiliation(s)
- Melissa Kimber
- Offord Center for Child Studies, Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Jill R McTavish
- Offord Center for Child Studies, Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Couturier
- Offord Center for Child Studies, Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Le Grange
- Department of Psychiatry, University of California (San Francisco), San Francisco, California.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois
| | - James Lock
- Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Harriet L MacMillan
- Offord Center for Child Studies, Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada.,Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Treatment dropout in a family-based partial hospitalization program for eating disorders. Eat Weight Disord 2019; 24:163-168. [PMID: 30027396 DOI: 10.1007/s40519-018-0543-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 07/06/2018] [Indexed: 12/20/2022] Open
Abstract
Treatment dropout is a significant challenge in the treatment of eating disorders. In day hospital/partial hospitalization program settings, little is known about factors associated with treatment dropout. The purpose of the present study was to assess factors associated with treatment dropout in a partial hospitalization program for adolescents and young adults with anorexia nervosa. Patients and parents completed self-report and interview-based measures at baseline and at end of treatment in the partial hospitalization program. Few factors were found that differentiated the two groups. Those who dropped out had lower body weight at end of treatment, were less likely to have purged in the previous month, and had fathers who scored higher on the criticism subscale of expressed emotion. Patients who are purging may be seen as having more severe symptoms, thus possibly reducing the chances of parents prematurely discontinuing treatment. Parental criticism is a potentially modifiable factor in treatment. Further research is needed to identify effective ways to reduce parental criticism, and to identify additional modifiable factors associated with treatment dropout to reduce dropout rates in this population.Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.
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Svavarsdottir EK, Gisladottir M, Tryggvadottir GB. Perception on family support and predictors' of satisfaction with the healthcare service among families of children and adolescents with serious mental illnesses who are in active psychiatric treatment. JOURNAL OF CHILD AND ADOLESCENT PSYCHIATRIC NURSING 2018; 32:6-15. [PMID: 30582258 DOI: 10.1111/jcap.12220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 11/30/2022]
Abstract
PROBLEM Little is known about the factors related to satisfaction with healthcare services among families of children with serious mental illness who were in active psychiatry treatment. METHODS A cross-sectional study was conducted to explore perceived family support, illness beliefs, and families' satisfaction with healthcare services. Sixty-eight families of children with anxiety, depression, attention-deficit/hyperactivity disorder, eating disorders, and autism/Asperger's syndrome participated. Data were collected from March 2015 to December 2016. FINDINGS Illness beliefs and perceived family support explained 23% of the variance in family satisfaction with the healthcare service. CONCLUSION Family interventions need to specifically focus on the families' satisfaction with healthcare services and on utilizing the family support network, offering emotional support, and exploring illness beliefs.
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Affiliation(s)
| | - Margret Gisladottir
- Landspitali University Hospital, Children's Psychiatry Unit, Reykjavik, Iceland
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Abstract
BACKGROUND Anorexia nervosa (AN) is characterised by a failure to maintain a normal body weight due to a paucity of nutrition, an intense fear of gaining weight or behaviour that prevents the individual from gaining weight, or both. The long-term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality. 'Family therapy approaches' indicate a range of approaches, derived from different theories, that involve the family in treatment. We have included therapies developed on the basis of dominant family systems theories, approaches that are based on or broadly similar to the family-based therapy derived from the Maudsley model, approaches that incorporate a focus on cognitive restructuring, as well as approaches that involve the family without articulation of a theoretical approach.This is an update of a Cochrane Review first published in 2010. OBJECTIVES To evaluate the efficacy of family therapy approaches compared with standard treatment and other treatments for AN. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and PsycINFO (OVID) (all years to April 2016). We ran additional searches directly on Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Ovid Embase, and PsycINFO (to 2008 and 2016 to 2018). We searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov, together with four theses databases (all years to 2018). We checked the reference lists of all included studies and relevant systematic reviews. We have included in the analyses only studies from searches conducted to April 2016. SELECTION CRITERIA Randomised controlled trials (RCTs) of family therapy approaches compared to any other intervention or other types of family therapy approaches were eligible for inclusion. We included participants of any age or gender with a primary clinical diagnosis of anorexia nervosa. DATA COLLECTION AND ANALYSIS Four review authors selected the studies, assessed quality and extracted data. We used a random-effects meta-analysis. We used the risk ratio (with a 95% confidence interval) to summarise dichotomous outcomes and both the standardised mean difference and the mean difference to summarise continuous measures. MAIN RESULTS We included 25 trials in this version of the review (13 from the original 2010 review and 12 newly-included studies). Sixteen trials were of adolescents, eight trials of adults (seven of these in young adults aged up to 26 years) and one trial included three age groups: one adolescent, one young adult and one adult. Most investigated family-based therapy or variants. Reporting of trial conduct was generally inadequate, so that in a large number of studies we rated the risk of bias as unclear for many of the domains. Selective reporting bias was particularly problematic, with 68% of studies rated at high risk of bias in this area, followed by incomplete outcome data, with 44% of studies rated at high risk of bias in this area. For the main outcome measure of remission there was some low-quality evidence (from only two studies, 81 participants) suggesting that family therapy approaches might offer some advantage over treatment as usual on rates of remission, post intervention (risk ratio (RR) 3.50, 95% confidence interval (CI) 1.49 to 8.23; I2 = 0%). However, at follow-up, low-quality evidence from only one study suggested this effect was not maintained. There was very low-quality evidence from only one trial, which means it is difficult to determine whether family therapy approaches offer any advantage over educational interventions for remission (RR 9.00, 95% CI 0.53 to 153.79; 1 study, N = 30). Similarly, there was very low-quality evidence from only five trials for remission post-intervention, again meaning that it is difficult to determine whether there is any advantage of family therapy approaches over psychological interventions (RR 1.22, 95% CI 0.89 to 1.67; participants = 252; studies = 5; I2 = 37%) and at long-term follow-up (RR 1.08, 95% CI 0.91 to 1.28; participants = 200; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 0%). There was no indication that the age group had any impact on the overall treatment effect; however, it should be noted that there were very few trials undertaken in adults, with the age range of adult studies included in this analysis from 20 to 27. There was some evidence of a small effect favouring family based therapy compared with other psychological interventions in terms of weight gain post-intervention (standardised mean difference (SMD) 0.32, 95% CI 0.01 to 0.63; participants = 210; studies = 4 with 1 of these contributing 3 pairwise comparisons for different age groups; I2 = 11%) . Overall, there was insufficient evidence to determine whether there were any differences between groups across all comparisons for most of the secondary outcomes (weight, eating disorder psychopathology, dropouts, relapse, or family functioning measures), either at post-intervention or at follow-up. AUTHORS' CONCLUSIONS There is a limited amount of low-quality evidence to suggest that family therapy approaches may be effective compared to treatment as usual in the short term. This finding is based on two trials that included only a small number of participants, and both had issues about potential bias. There is insufficient evidence to determine whether there is an advantage of family therapy approaches in people of any age compared to educational interventions (one study, very low quality) or psychological therapies (five studies, very low quality). Most studies contributing to this finding were undertaken in adolescents and youth. There are clear potential impacts on how family therapy approaches might be delivered to different age groups and further work is required to understand what the resulting effects on treatment efficacy might be. There is insufficient evidence to determine whether one type of family therapy approach is more effective than another. The field would benefit from further large, well-conducted trials.
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Affiliation(s)
- Caroline A Fisher
- Royal Melbourne Hospital, Melbourne HealthAllied Health ‐ PsychologyParkvilleAustralia3050
| | - Sonja Skocic
- HealthscopeThe Melbourne ClinicRichmondAustralia
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Berona J, Richmond R, Rienecke RD. Heterogeneous weight restoration trajectories during partial hospitalization treatment for anorexia nervosa. Int J Eat Disord 2018; 51:914-920. [PMID: 30058155 DOI: 10.1002/eat.22922] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
UNLABELLED Early response to treatment has been shown to predict good outcome in family-based treatment, but little is known about who responds quickly. OBJECTIVE The purpose of the current study was to examine the short-term weight gain trajectories among youth receiving partial hospitalization program services for anorexia nervosa (AN), and to identify predictors of these trajectories. METHOD Adolescent and young adults (n = 102) with AN or subthreshold AN completed semi-structured interviews and self-report measures on admission to a family-based partial hospitalization program. Patients participated in programming 5 days a week. RESULTS Three weight gain trajectories were found to indicate slow, moderate, and rapid weight gain trajectories. All rapid responders gained at least four lbs. in the first 4 weeks of treatment, compared to 86.1% of moderate responders and 51.2% of slow responders. Patients were less likely to have a moderate or rapid response trajectory if they had a mood disorder diagnosis and higher parental expressed emotion. Additionally, the presence of compensatory behavior increased the likelihood of having a rapid response. DISCUSSION Despite the sometimes chronic nature of AN, most patients fell into one of the two favorable response trajectories. The identification of these trajectories underscores the importance of considering the core disordered eating behaviors (i.e., restricting, binge eating, and purging), comorbid psychopathology, and parental expressed emotion.
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Affiliation(s)
- Johnny Berona
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois
| | - Rebekah Richmond
- MUSC Friedman Center for Eating Disorders, Medical University of South Carolina, Charleston, South Carolina
| | - Renee D Rienecke
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
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Duclos J, Dorard G, Cook-Darzens S, Curt F, Faucher S, Berthoz S, Falissard B, Godart N. Predictive factors for outcome in adolescents with anorexia nervosa: To what extent does parental Expressed Emotion play a role? PLoS One 2018; 13:e0196820. [PMID: 30063706 PMCID: PMC6067718 DOI: 10.1371/journal.pone.0196820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/20/2018] [Indexed: 11/18/2022] Open
Abstract
In studies on family therapy in Anorexia Nervosa, family relationships, as assessed by Expressed Emotion, have been associated with outcome. Our aim was to explore the contribution of Expressed Emotion as a predictor of 18-month outcome, above and beyond the usual predictive factors. Sixty adolescent girls suffering from Anorexia Nervosa and their parents were assessed at baseline and 18 months later. Levels of Expressed Emotion were evaluated in both parents with the Five-Minute Speech Sample. After controlling for treatment group and initial clinical status, high maternal Emotional Over-Involvement at baseline was significantly associated with better clinical state. More precisely, high maternal Emotional Over-Involvement was associated with higher nutritional status, lower eating disorder severity and fewer re-hospitalizations 18 months later. No associations were found with paternal levels of Expressed Emotion. Therefore, our study confirmed the importance of taking into account both maternal and paternal Expressed Emotion. Our results also underlined that high maternal Emotional Over-Involvement plays a positive role in the outcome of Anorexia Nervosa and needs to be explored further.
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Affiliation(s)
- Jeanne Duclos
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
- CESP, INSERM, UMR 1018, University Paris-Sud, UVSQ, Université Paris-Saclay, Paris, France
- * E-mail:
| | - Géraldine Dorard
- Laboratoire de Psychopathologie et Processus de santé (LPPS), University Paris Descartes, Boulogne, France
| | - Solange Cook-Darzens
- Service de psychopathologie de l’enfant et de l’adolescent, Hôpital Robert Debré, Paris, France
| | - Florence Curt
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
| | - Sophie Faucher
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
| | - Sylvie Berthoz
- Psychiatry Unit, Institut Mutualiste Montsouris, Paris, France
- CESP, INSERM, UMR 1018, University Paris-Sud, UVSQ, Université Paris-Saclay, Paris, France
| | - Bruno Falissard
- CESP, INSERM, UMR 1018, University Paris-Sud, UVSQ, Université Paris-Saclay, Paris, France
| | - Nathalie Godart
- CESP, INSERM, UMR 1018, University Paris-Sud, UVSQ, Université Paris-Saclay, Paris, France
- Fondation de Santé des Etudiants de France, Paris, France
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Ganci M, Pradel M, Hughes EK. Feasibility of a parent education and skills workshop for improving response to family-based treatment of adolescent anorexia nervosa. Int J Eat Disord 2018; 51:358-362. [PMID: 29417594 DOI: 10.1002/eat.22834] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 01/14/2018] [Accepted: 01/18/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Early response to family-based treatment (FBT) is a robust predictor of positive outcomes for adolescents with anorexia nervosa (AN). We introduced a parent education and skills workshop in the first 4 weeks of treatment with the aim of improving changes in parent self-efficacy in FBT and, in turn, patient weight gain. METHOD Forty-five families who had at least one parent attend the workshop were compared to a matched control of families who did FBT before the workshop was introduced. RESULTS Among adolescents who were underweight at baseline, weight gain by Week 4 of treatment was higher for adolescents whose parents attended the workshop (M = 90.84% median BMI) than those who did not (M = 88.54% mBMI, p < .05). There was no significant difference in weight at Week 12 or at end of treatment, nor was there a difference in self-efficacy as measured by the Parent Versus Anorexia Scale. Participants reported a high level of satisfaction with the workshop and significant improvements in knowledge and confidence. DISCUSSION Overall, the workshop was a feasible adjunct for improving early response to FBT.
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Affiliation(s)
- Maria Ganci
- Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, Australia
| | - Martin Pradel
- Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, Australia
| | - Elizabeth K Hughes
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Royal Children's Hospital, Centre for Adolescent Health, Melbourne, Australia
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Allan E, Le Grange D, Sawyer SM, McLean LA, Hughes EK. Parental Expressed Emotion During Two Forms of Family-Based Treatment for Adolescent Anorexia Nervosa. EUROPEAN EATING DISORDERS REVIEW 2017; 26:46-52. [PMID: 29105211 DOI: 10.1002/erv.2564] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/04/2017] [Accepted: 10/11/2017] [Indexed: 11/09/2022]
Abstract
High parental expressed emotion (EE), reflected by criticism or emotional over-involvement, has been related to poorer outcome in family-based treatment (FBT) for adolescent anorexia nervosa. This study assessed EE in 89 mothers and 64 fathers at baseline and end of treatment in a randomised trial comparing conjoint FBT to parent-focused FBT (PFT). Compared with conjoint FBT, PFT was associated with a decrease in maternal criticism, regardless of adolescent remission. Furthermore, an increase in maternal criticism was more likely to be observed in conjoint FBT (80%) than PFT (20%, p = 0.001). Adolescents of mothers who demonstrated an increase in EE, or remained high in EE, were less likely to remit compared with adolescents for whom EE decreased or remained low (33% and 0% vs. 43% and 50%, p = 0.03). There were no significant effects for paternal EE. The results highlight the importance of considering EE when implementing FBT for adolescents with anorexia nervosa. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- Erica Allan
- Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Centre for Adolescent Health, Royal Children's Hospital, Melbourne, VIC, Australia.,Faculty of Education, Monash University, VIC, Australia
| | - Daniel Le Grange
- Department of Psychiatry, University of California, San Francisco, CA, USA.,Psychiatry and Behavioral Neuroscience, The University of Chicago, IL, USA (Emeritus)
| | - Susan M Sawyer
- Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Centre for Adolescent Health, Royal Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.,Department of Adolescent Medicine, Royal Children's Hospital, Melbourne, VIC, Australia
| | | | - Elizabeth K Hughes
- Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Centre for Adolescent Health, Royal Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.,School of Psychological Sciences, Monash University, VIC, Australia
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Schwarte R, Timmesfeld N, Dempfle A, Krei M, Egberts K, Jaite C, Fleischhaker C, Wewetzer C, Herpertz-Dahlmann B, Seitz J, Bühren K. Expressed Emotions and Depressive Symptoms in Caregivers of Adolescents with First-Onset Anorexia Nervosa-A Long-Term Investigation over 2.5 Years. EUROPEAN EATING DISORDERS REVIEW 2017; 25:44-51. [PMID: 27943533 DOI: 10.1002/erv.2490] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 07/03/2016] [Accepted: 08/01/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE High levels of expressed emotions (EE) and depressive symptoms (DS) are often found in caregivers of patients with anorexia nervosa (AN). Both parameters are considered to influence AN symptoms of the patient. METHODS One hundred seventy adolescent women with AN and their caregivers were assessed at admission, discharge, at 1-year and 2.5-year follow up to evaluate AN symptoms of the patient and EE and DS of caregivers. RESULTS The EE and DS were elevated at admission and decreased during treatment, criticism (as part of EE) exhibited again at the 2.5-year follow up. Caregivers of more severely ill patients reported significantly greater levels of EE and DS. Mothers were more affected than fathers. EE and DS were interrelated. CONCLUSION Caregivers of adolescent AN patients suffer from elevated levels of EE and DS. Further studies are needed to examine whether therapeutic interventions to reduce caregivers' EE and DS might have a positive influence on treatment outcome. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- Reinhild Schwarte
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics RWTH Aachen, Aachen, Germany
| | - Nina Timmesfeld
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany
| | - Astrid Dempfle
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany.,Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Melanie Krei
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics RWTH Aachen, Aachen, Germany
| | - Karin Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Charlotte Jaite
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Charité University Berlin, Berlin, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Clinics Freiburg, Freiburg, Germany
| | - Christoph Wewetzer
- Department of Child and Adolescent Psychiatry and Psychotherapy, Köln-Holweide, Germany
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics RWTH Aachen, Aachen, Germany
| | - Jochen Seitz
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics RWTH Aachen, Aachen, Germany
| | - Katharina Bühren
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinics RWTH Aachen, Aachen, Germany
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Darrow SM, Accurso EC, Nauman ER, Goldschmidt AB, Le Grange D. Exploring Types of Family Environments in Youth with Eating Disorders. EUROPEAN EATING DISORDERS REVIEW 2017; 25:389-396. [PMID: 28675592 DOI: 10.1002/erv.2531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/08/2017] [Accepted: 05/27/2017] [Indexed: 11/10/2022]
Abstract
While many studies have explored the relationship between different eating disorder diagnoses and the familial social environment, current evidence does not support associations between distinct family interaction patterns (e.g. high enmeshment) and particular diagnoses (e.g. anorexia nervosa). The current study seeks to move beyond the current literature to explore whether empirically derived subtypes of family environment are associated with clinical features within a transdiagnostic sample of youth seeking treatment for eating disorders (n = 123). Latent class modelling of the Family Environment Scale identified three classes (i.e. different Family Environment Scale profiles): (1) Control-Oriented; (2) System Maintenance-Oriented; and (3) Conflict-Oriented. Data are presented to characterize the classes (e.g. age, gender, rates of different eating disorders, severity of eating disorder pathology and rates of comorbid disorders). These preliminary results suggest that family interaction types may help personalize treatment for eating disorders and encourage future research to guide such efforts. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
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Affiliation(s)
- Sabrina M Darrow
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Erin C Accurso
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Emily R Nauman
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Andrea B Goldschmidt
- Weight Control and Diabetes Research Center, Alpert Medical School of Brown University, The Miriam Hospital, Providence, RI, USA
| | - Daniel Le Grange
- Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, IL, USA
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Rienecke RD, Richmond RL. Psychopathology and expressed emotion in parents of patients with eating disorders: Relation to patient symptom severity. Eat Disord 2017. [PMID: 28632087 DOI: 10.1080/10640266.2017.1289795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The purpose of the current study was to examine the relation between parental psychopathology, parental expressed emotion, and patient symptom severity. One hundred twenty-six parents of 79 patients receiving treatment for an eating disorder completed measures of expressed emotion and general psychopathology, and patients completed a measure of eating disorder psychopathology. Mothers reported higher expressed emotion scores than fathers. Both mothers and fathers scored higher on general psychopathology compared to nonpatient population means. Maternal psychopathology was found to be associated with symptom severity. Parental psychopathology and expressed emotion were found to be related, and MANCOVAs revealed that maternal criticism and maternal psychopathology were associated with patient symptom severity, but fathers' scores on the same measures were not. It is recommended that parental expressed emotion and parental psychopathology are assessed at the beginning of treatment so that appropriate clinical interventions can be utilized.
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Affiliation(s)
- Renee D Rienecke
- a Departments of Pediatrics and Psychiatry , Medical University of South Carolina , Charleston , South Carolina , USA.,b Department of Psychiatry , University of Michigan , Ann Arbor , Michigan , USA
| | - Rebekah L Richmond
- c Medical University of South Carolina , Charleston , South Carolina , USA
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Rienecke RD. Family-based treatment of eating disorders in adolescents: current insights. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2017; 8:69-79. [PMID: 28615982 PMCID: PMC5459462 DOI: 10.2147/ahmt.s115775] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Eating disorders are serious illnesses associated with significant morbidity and mortality. Family-based treatment (FBT) has emerged as an effective intervention for adolescents with anorexia nervosa, and preliminary evidence suggests that it may be efficacious in the treatment of adolescents with bulimia nervosa. Multifamily therapy for anorexia nervosa provides a more intensive experience for families needing additional support. This review outlines the three phases of treatment, key tenets of family-based treatment, and empirical support for FBT. In addition, FBT in higher levels of care is described, as well as challenges in the implementation of FBT and recent adaptations to FBT, including offering additional support to eating-disorder caregivers. Future research is needed to identify families for whom FBT does not work, determine adaptations to FBT that may increase its efficacy, develop ways to improve treatment adherence among clinicians, and find ways to support caregivers better during treatment.
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Affiliation(s)
- Renee D Rienecke
- Department of Pediatrics.,Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC.,Department of Psychiatry, University of Michigan Health System, Ann Arbor, MI, USA
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Cella S, Cipriano A, Iannaccone M, Cotrufo P. Identifying Predictors Associated with the Severity of Eating Concerns in Females with Eating Disorders. ACTA ACUST UNITED AC 2017; 20:199. [PMID: 32913728 PMCID: PMC7451376 DOI: 10.4081/ripppo.2017.199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 11/08/2016] [Accepted: 12/09/2016] [Indexed: 11/30/2022]
Abstract
Considering how to improve efficacy of therapeutic strategies, the overall objective of the present study was to investigate the extent of eating concerns and to identify predictors associated with the severity of disordered eating symptomatology among people with eating pathologies. We screened 80 female eating disordered patients, ranging from 13 to 40 years, by means of self-report measures of parental behavior as perceived by the offspring, self-esteem, perfectionism, body shame and eating disorder severity. Self-reported weight and height were obtained. The diagnosis of bulimia nervosa resulted to be associated with a greater severity of the eating symptomatology. Maladaptive perfectionism, body shame and self-esteem, significantly predicted the level of eating concerns. The recognition of potential maintaining factors may support the choice of particular therapeutic strategies to improve the treatment of eating pathologies and their outcomes.
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Affiliation(s)
- Stefania Cella
- Observatory on Eating Disorders, Department of Psychology, University of Campania, Luigi Vanvitelli, Caserta, Italy
| | - Annarosa Cipriano
- Observatory on Eating Disorders, Department of Psychology, University of Campania, Luigi Vanvitelli, Caserta, Italy
| | - Mara Iannaccone
- Observatory on Eating Disorders, Department of Psychology, University of Campania, Luigi Vanvitelli, Caserta, Italy
| | - Paolo Cotrufo
- Observatory on Eating Disorders, Department of Psychology, University of Campania, Luigi Vanvitelli, Caserta, Italy
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