The value of including families in the treatment of anorexia nervosa

Treatment escalation for people with anorexia nervosa: setting, therapies and nutritional interventions

PURPOSE OF REVIEW

Adult patients with severe anorexia nervosa often receive the same unsuccessful treatment without changes regarding the setting, the therapies, or nutritional interventions.

RECENT FINDINGS

Settings where people with anorexia nervosa are treated include their general practitioner, an independent psychiatric practice, a community mental health team (CMHT), a specialized eating disorder outpatient service, eating disorder early intervention services, a highly intensive eating disorder outpatient or home treatment programme, eating disorder daycare, an inpatient eating disorder service, a general hospital or a general psychiatric hospital, or residential treatment. At a specialized eating disorder service, patients should be offered evidence-based psychotherapy for anorexia nervosa, dietary advice and physical health monitoring as a first step. Additionally, they may be allocated to a specific treatment pathway, family interventions and creative therapies. As a second step, clinicians may consider integrating interventions targeting psychiatric or physical comorbidities, medication for anorexia nervosa or noninvasive neurostimulation. After several years of futile treatment, deep brain stimulation (DBS) should be considered to prevent a chronic course of anorexia nervosa. Nutritional interventions can be escalated from nutritional counselling to nasogastric tube feeding. Patients who rely on nasogastric tube feeding might benefit from percutaneous endoscopic gastrostomy (PEG). Patients with an who vomit despite a nasogastric tube, might need nasojejunal tube feeding.

SUMMARY

Treatment for people with anorexia nervosa should be regularly reviewed and, if necessary, escalated to avoid a chronic and longstanding disease course.

Striving to support the supporters: A mixed methods evaluation of the strive support groups for caregivers of individuals with an eating disorder

This mixed-methods study evaluated a peer-led support group for ED caregivers; the Eating Disorders Families Australia strive support groups. Quantitatively, 110 past or current strive attendees completed an online survey assessing their own and their care recipients' demographic profiles, strive's impact on caregiving experiences, and caregivers' psychological distress, burden, caregiving skills and self-efficacy. Qualitative assessment comprised open-ended survey questions about caregivers' strive experiences, reinforced by in-depth focus group assessment of nine participants. Quantitative analyses revealed that participants felt more confident and supported, and less isolated in their caregiving since attending strive. Caregivers displayed mid-range psychological distress and caregiver burden, and moderate caregiver skills and self-efficacy. Qualitatively, the most helpful aspects of strive were the shared experience among participants, education, and support. The most difficult elements were emotional distress and overly dominant members. Reflections discussed the necessity of caregiver support and factors impacting strive attendance. Participants recommended resuming face-to-face contact and differentiating groups based on participant characteristics (e.g. care recipients' age/stage of illness). The current findings provide support for the importance and overall positive contribution of support groups led by caregivers, such as strive.

Attitudes and gaps in knowledge of the diagnosis, treatment, and psychopathology of eating disorders among different health professionals

BACKGROUND

Health professionals from different specialties in medical and psychological areas play an important role in diagnosis and treatment of eating disorders (EDs). This study aimed to identify gaps in knowledge about the diagnosis, etiology, and management of EDs and to assess health professionals' attitudes towards these illnesses.

METHODS

A new questionnaire was developed and validated. Residents and consultants working in disciplines involved in the management of EDs (namely, internal medicine, general practitioners, psychiatric area, psychological area, and surgical area) completed the questionnaire. Knowledge and attitudes were compared among the study groups through one-way ANCOVA and chi-square tests.

RESULTS

The final version of the questionnaire consisted of 54 items assessing the following areas: stigma, treatment, physical complications, diagnosis, and aetiopathogenesis of EDs. For all health professionals the area of most deficiency was the aetiopathogenesis, while the best one was the management of physical complications. All medical professionals showed less knowledge than psychiatrists in terms of etiology, diagnosis, and treatment of EDs. A lack of knowledge about evidence-based psychotherapies, general psychopathology, and family members' role in the management of EDs emerged among all health professionals. Stigma was found among non-mental health professionals who considered these patients to be different from others and responsible for their abnormal eating behaviors.

CONCLUSIONS

Clarifying the health professionals' specific gaps occurring in the knowledge of EDs and in the attitudes towards these individuals may inform educational programs to improve early detection and management of EDs.

Characteristics, correlates of burden and support service use of a help-seeking carers of loved ones with an eating disorder

OBJECTIVE

Carers, vital in the care of individuals with an eating disorder (ED), experience substantial caregiving burden and unmet needs. This study aims to identify factors which contribute to the burden experienced by carers of a loved one with an ED and their support service usage.

METHOD

Carers (N = 245) completed an online questionnaire assessing demographic, carer-specific, individual and ED factors. Multivariate relationships with caregiving burden were examined using forwards elimination to produce a parsimonious model of carer burden.

RESULTS

The final model, consisting of caregiving factors (e.g., relationship type, skills), carer mental health) and loved one wellbeing (i.e., purging symptoms, depression/self-harm/suicidality) explained a large proportion (62%) of the variance in carers' burden. Carer mental health, caregiving skills and relationship type (e.g., parent, spouse, sibling) were key predictors of carers' burden. Nearly a third of carers had not used any carer support services, yet most carers expressed an interest in such services.

CONCLUSION

Caregiving burden is determined by experiences and skills of the carer as well as the person they are caring for. Carer support services should continue to address the general wellbeing of carers and caregiver skills. Research into the barriers to carer support uptake is needed.

Anorexia nervosa: diagnostic, therapeutic, and risk biomarkers in clinical practice

In anorexia nervosa (AN), measurable biological parameters can inform the process of treating patients. Such biomarkers include established laboratory parameters as well as a range of potential future biomarkers, including genetic, metabolomic, microbiomic, endocrine, immunological, hematological, electrophysiological, and neuroimaging parameters. In this opinion article we discuss how these biomarkers can support diagnosic and therapeutic processes at specific steps during the AN treatment cycle, that is, the diagnosis, diagnostic specification, risk management, choice of therapy, therapy monitoring, and treatment review. History-taking, physical and neuropsychological examination, clinical observation, and judgment about treatment success by the patient, their carers, and members of the multidisciplinary team are essential to interpret laboratory and imaging data appropriately and to assess the full clinical picture.

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

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

Comparing randomized controlled trials of outpatient family-based or inpatient multimodal treatment followed by outpatient care in youth with anorexia nervosa: Differences in populations, metrics, and outcomes

OBJECTIVE

Various approaches exist to treat youth with anorexia nervosa (AN). Family-based treatment (FBT) has never been compared to long inpatient, multimodal treatment (IMT) in a randomized controlled trial (RCT). The aim of this study was to compare data on body weight trajectories, change in eating disorder psychopathology, hospital days and treatment costs in RCTs delivering FBT or IMT.

METHOD

Review of RCTs published between 2010 and 2020 in youth with AN, delivering FBT or IMT.

RESULTS

Four RCTs delivering FBT (United States, n = 2; Australia, n = 2), one RCT delivering Family Therapy for AN (United Kingdom) and two RCTs delivering IMT (France, n = 1; Germany, n = 1) were identified from previous meta-analyses. The comparison of studies was limited by (1) significant differences in patient baseline characteristics including pretreated versus non-pretreated patients, (2) use of different psychometric and weight measures and (3) different initial velocity of weight recovery. Minimal baseline and outcome reporting standards for body weight metrics and nature/dose of interventions allowing international comparison are needed and suggestions to developing these standards are presented.

DISCUSSION

An RCT should investigate, whether FBT is a viable alternative to IMT, leading to comparable weight and psychopathology improvement with less inpatient time and costs.

[Therapy of Food Refusal and Anorexia Nervosa in German-Language Psychiatry Textbooks of the Past 200 Years]

The aim of this study was to describe how the therapy of anorexia nervosa (AN) and food refusal have been discussed in leading textbooks used in German-speaking academic psychiatry over the past 200 years. For this purpose, 18 textbooks of important school psychiatrists were selected. These were analyzed in a structured way to determine the content of the subject taught at universities in German-speaking countries at a given period. We found that AN was not taught as a distinct disorder until the end of the 20th century, although great attention had been paid to food refusal as a symptom and manifold therapeutic concepts had been developed much earlier. Whereas at the beginning of the 19th century forced feeding using feeding tubes was established, in the following years pharmacotherapies and special diets were developed. It is noteworthy that since the beginnings of academic psychiatry, some early forms of psychotherapy have been developed; for instance, special kinds of behavior were recommended when dealing with the patient, as the therapist was supposed to serve as a role model to encourage patients to eat. Treatment of food refusal by means of structured psychotherapeutic approaches were not established before AN was generally accepted as a distinct disease entity. The understanding of etiological factors that might lead to AN as well as potential psychotherapeutic interventions have changed fundamentally over the past decades.

Silent witnesses: the experience of having a sibling with anorexia nervosa

BACKGROUND

This study explored the experience of having a sibling with anorexia nervosa and the sibling perspectives on service provision.

METHOD

Four focus groups were conducted with 14 siblings (8 female, 6 male, age 11-19 years) of adolescents with anorexia nervosa or related restrictive eating disorders. Group discussions were transcribed and analysed using thematic analysis.

RESULTS

Four themes and eight sub-themes were generated. These illustrated siblings feel greatly affected by the way the family needs to change to support someone with anorexia nervosa. Feelings of ambivalence and acceptance were also evident. They described silencing their own emotions and needs so as not to trouble others, and distancing themselves from their families in order to cope. Some female (but no male) siblings identified an impact on their own perceptions of eating and body image. Siblings generally felt that services had not attended to their needs, and that they had not been appropriately included in treatment.

CONCLUSIONS

Data from this study suggest the sibling experience needs to be more carefully considered and included in treatment. This may include a more explicit invitation to sessions and a more active discussion about their own needs and useful involvement in treatment sessions. Findings point to ways siblings may be better supported, such as peer support groups.

A description of virtual skills workshops for supporters of loved ones with eating disorders: Indicators of benefit and acceptability, clinical reflections and consideration of neurodiversity

Objective

Providing information and support to those supporting a loved one with an eating disorder is a key part of evidence‐based service provision. We report on how we took our workshops for supporters online during the Covid‐19 Pandemic when country‐side physical distancing restrictions meant we were unable to work face to face.

Methods

We outline the structure of an eight‐session 2‐h workshop series delivered fortnightly facilitated by a multidisciplinary team of clinicians, researchers and experts by experience. We use a repeated‐measures design to understand the possible benefits of the workshops on supporter skills (n = 76).

Results

Measured using the Caregiver Skills Scale, we observed small‐sized improvements in the overall skills (D = 0.43) of n = 17 supporters who provided data at the end of the intervention. Supporters gave largely positive feedback on the virtual format. They particularly liked the opportunity to interact with other supporters. As facilitators, we overcome our initial anxiety around workshop delivery using a new platform and reflected that having more time to cover key information and for skills practice over a period of 16 weeks offered opportunities to develop and reflect on new skill together as a group. We were also able to work with larger groups of supporters, as several barriers to access were removed.

Conclusions

As the workshops reached a larger number of supporters than through face to face delivery and were of benefit to those who reported on their skills, we plan to continue offering workshops to supporters online in future.

The National Institute for Health and Care Excellence (NICE) Guidelines for eating disorders recommend that those supporting loved ones with eating disorders have access to information and support.

Online workshops for supporters might remove barriers to access and increase uptake, and we wanted to learn more about this mode of delivery and its benefits on supporter skills.

We were also interested in thinking about neurodiversity within the workshops, in particular whether supporters have traits of autism spectrum disorder. This information is important in helping us plan for more inclusive workshops.

Around 1/3 of supporters scored over the cut‐off on the Autism Quotient (AQ10) suggesting it is important to think carefully about how online workshops might benefit (or present challenges for) a more diverse group of attendees.

Supporters reported benefits in terms of improvements in their skills and positive feedback at the end of one of five workshop series.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Analyzing Psychotherapy on Twitter: An 11-Year Analysis of Tweets From Major U.S. Media Outlets

BACKGROUND

The Internet has become the main source of information on health issues, and information now determines the therapeutic preferences of patients. For this reason, it is relevant to analyze online information discussing psychotherapy.

OBJECTIVE

To investigate tweets posted by 25 major US media outlets between 2009 and 2019 concerning psychotherapy.

METHODS

We investigated tweets posted by 25 major US media outlets about psychotherapy between January 2009 and December 2019 as well as the likes generated. In addition, we measured the sentiment analysis of these tweets.

RESULTS

Most of the tweets analyzed focused on Mindfulness (5,498), while a low number were related to Psychoanalysis (376) and even less to Cognitive-Behavioral Therapy (61). Surprisingly, Computer-supported therapy, Psychodynamic therapy, Systemic therapy, Acceptance and commitment therapy, and Dialectical behavior therapy did not generate any tweet. In terms of content, efficacy was the main focus of the posted tweets, receiving Cognitive-Behavioral Therapy and Mindfulness a positive appraisal.

CONCLUSIONS

US media outlets focused their interest on Mindfulness which may have contributed to the growing popularity in the past years of this therapeutic modality.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

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

Introduction: One of the major problems with inpatient treatment of adolescent girls with an eating disorder (ED) is that the strategies learned during their hospital stay are not easily applied or maintained in their daily lives, and this has been related to high rates of relapse and readmission. The ECHOMANTRA programme was developed to optimize outcomes during and following inpatient or day-patient treatment. ECHOMANTRA is based on interventions for carers (Experienced Carers Helping Others, ECHO) and patients (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) and is developed from the cognitive interpersonal model of anorexia (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013). This study aims to describe the study protocol of a randomized controlled trial (RCT) for evaluating the efficacy of an adaptation of a novel intervention for patients and carers (ECHOMANTRA) to be implemented as an add-on to treatment-as-usual (TAU). Method: In a multi-center pilot RCT, 80 female adolescent patients with a DSM-5 diagnosis of an ED and their carers will be invited to participate in the study. They will then be randomized to receive either the ECHOMANTRA intervention as an add-on to TAU or TAU alone. A repeated measures design will be conducted across four time points. Primary outcomes will be patient psychological well-being and eating disorder symptoms, and secondary outcomes will include body mass index, obsessive-compulsive symptoms, perfectionism, motivation to change and psychosocial adjustment. For carers, outcome variables will include psychological well-being, expressed emotion, accommodation and enabling behaviors, burden, and care skills. Discussion: The results from this trial will establish the effectiveness of ECHOMANTRA and may reveal whether and to what extent this novel intervention can optimize outcomes during and following inpatient treatment. This study will also provide the adaptation of the ECHOMANTRA in the Spanish context for inpatient/day-care treatment.

Coping With Adolescents Affected by Anorexia Nervosa: The Role of Parental Personality Traits

Introduction

Anorexia nervosa (AN) promotes psychological distress in caregivers who adopt different coping strategies. Dysfunctional caregiving styles exacerbate further distress in the patient promoting the maintenance of the illness. We aimed to assess the possible contribution of personality traits of caregivers to the adoption of different coping strategies to deal with the affected relative.

Methods

About 87 adolescents with AN were recruited. Their parents completed the Family Coping Questionnaire for Eating Disorders (FCQ-EDs) and the Temperament and Character Inventory-Revised (TCI-R). Differences between mothers and fathers were assessed through the independent sample t-test. Multivariate regression analyses were run to assess if personality traits, the occurrence of psychiatry conditions in the parents, the marital status, and the duration of the illness predicted parental coping strategies.

Results

The group of mothers showed higher levels of avoidance and seeking for information coping strategies than the sample of fathers. Lower illness duration predicted higher collusion with the illness in both parents. Harm avoidance, cooperativeness, and self-directedness positively predicted parental coercion, collusion, and seeking for information strategies with some differences between mothers and fathers.

Discussion

Illness duration and personality traits of parents affect the type of parental coping strategies developed to face AN in adolescents. These variables should be considered in the assessment of families of adolescents with AN and may be addressed to promote more fine-tuned clinical interventions for caregivers.

Optimising care pathways for adult anorexia nervosa. What is the evidence to guide the provision of high-quality, cost-effective services?

The aim of this paper is to consider how changes in service planning and delivery might improve the care pathways for adult anorexia nervosa. Although anorexia nervosa has a long history in Europe, its framing as a mental disorder is quite recent. The changing forms and increasing epidemiology of eating disorders has led to the expansion of specialised services. Although some services provide care over the entire clinical course, more often services are divided into those that care for children and adolescents or adults. The transition needs to be carefully managed as currently these services may have a different ethos and expectations. Services for adults have a broad range of diversity (diagnostic subtype, medical severity, comorbidity, stage of illness and psychosocial functioning) all of which impacts on prognosis. A tailored, approach to treatment planning could optimise the pathway. Facilitating early help seeking and rapid diagnosis in primary care and reducing specialised services waiting lists for assessment and treatment could be a form of secondary prevention. The use of precision models and /or continuous outcome monitoring might reduce the third of patients who require more intensive care by applying augmentation strategies. Finally, gains from intensive care might be sustained by relapse prevention interventions and community support to bridge the transition home. Together these measures might reduce the proportion of patients (currently a third) with ill health for over 20 years. For this group rehabilitation strategies may improve functioning until new treatment emerge.