Patients with eating disorders and their siblings. An investigation of body image perceptions

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.

Experiences of eating difficulties in siblings of people with anorexia nervosa: a reflexive thematic analysis

BACKGROUND

Siblings of people with anorexia nervosa (AN) have been found to experience strong emotions, changing family roles and poorer wellbeing as a consequence of experiencing the effects of the illness on their sibling and family system. These factors, combined with genetic influences, may put siblings at an increased risk of developing eating disorder psychopathology in addition to other mental health issues. This research aims to explore the experiences of siblings of people with AN who have had eating difficulties themselves and investigate issues that may be important to the development and prevention of eating difficulties in this population.

METHODS

This qualitative study used a reflexive thematic analysis approach. Ten adults who had witnessed a sibling with AN and experienced eating difficulties themselves participated in semi-structured interviews.

ANALYSIS

Participants' own eating difficulties were affected by the specific experience of witnessing a sibling with AN through mealtimes becoming emotionally charged, an increased focus on body size and diet, and comparisons with their sibling. Difficult experiences, such as marital discord amongst parents were common, as was a difficulty in managing emotions. The onset of AN within the family caused participants to take on caring responsibilities for their sibling and to hide their own difficulties for fear of adding additional burden to their parents. This reduced their perceived ability to access support and for some increased a desire to restrict as a coping mechanism for the stress they were experiencing. Systemic beliefs regarding the value of thinness were prevalent and influential. Protective factors, such as not wanting to become as unwell as a sibling with AN and an understanding of the negative consequences of AN, aided recovery.

CONCLUSIONS

Eating difficulties in siblings of people with AN may be influenced by competition for slimness, increased focus on diet and body size, and a need to manage difficult emotions. The disruption to social connections and a difficulty finding emotional support that may be experienced by people when a sibling develops AN may further influence susceptibility to eating difficulties. Further research is needed into the best ways to support siblings of people with AN.

Siblings of Individuals With Eating Disorders: A Review of the Literature

Eating disorders (EDs) are serious psychopathologies characterized by a persistent disturbance in eating or eating-related behavior. Studies have shown EDs' detrimental consequences not only for patients, but also for their families. Nevertheless, a specific group that has so far been neglected, in both the research and clinical fields, are siblings of individuals with EDs. In an effort to identify this population's needs, and to facilitate effective prevention and treatment, this paper aims to review the existing literature on the subject, and examine siblings' personal experience, ways of coping, and levels of psychopathology. PubMed and PsycNet databases were searched with no publication date restrictions, yielding 26 relevant papers. Studies were categorized according to common themes they addressed, and subsequently summarized by highlighting common features, as well as information unique to each study. Several themes emerged, including emotional well-being, psychopathology, social consequences, family dynamics, and coping strategies. Results show that EDs experienced by one individual have significant effects on one's siblings, such as a decrease in quality of life, social isolation, and elevated familial strain. In several studies siblings were found to have elevated levels of psychopathology and EDs related symptoms. Nevertheless, findings' nature and magnitude were highly varied. The review indicates the need for further studies that will examine possible intra- and interpersonal moderating factors for EDs' impact on well-being among siblings, and take into consideration the substantial heterogeneity in studies conducted thus far. Additionally, this review highlights the need for novel and effective interventions, specifically targeting this at-risk group.

"Do I exist in this world, really, or is it just her?" Youths' perspectives of living with a sibling with anorexia nervosa

Little is known about how severe anorexia nervosa (AN) in youths affects siblings and siblings' experiences of family-based treatment for AN. Thirteen youths (M age = 15.5 years, SD = 3.0; 23% boys) who had been co-admitted with their sibling with AN and parents at an inpatient clinic for eating disorders 3 to 6 years earlier participated in qualitative interviews. Interviews were analyzed using systematic text condensation. Results showed AN is difficult to understand, particularly at onset, and is associated with confusion and lack of information for siblings. AN evokes difficult emotions, including fears of death, frustration about rigid behavior, and sadness about changed life situations. AN affects family dynamics and relations, including conflicts and disruptions at home, limited and divided family life, and less attention from parents and extended family. Siblings pay attention to other people eating habits, strive for a balanced view on eating, and experience family meals as conflictual. Siblings experience increased knowledge and personal development, and are ambivalent to family treatment. Ways of coping include creating distance, seeking social support, rationalizing, and keeping hope. In conclusion, siblings' experiences of severe AN are complex and ambiguous. Family-based treatment for AN in young people should address siblings' perspectives.

Living with a sibling who suffers from an eating disorder: a pilot interview study

BACKGROUND AND OBJECTIVE

Having a sibling who suffers from an eating disorder (ED) has a profound effect on healthy siblings' own health, quality of life and family relationships, yet siblings have been an excluded group within health care, and there is a lack of knowledge regarding healthy siblings' needs and wishes for information and support. Thus, the aim of this study was to examine adolescents' experiences of living with a sibling who suffers from an ED.

METHOD

In this small-scale pilot study, three boys and two girls aged 15-20 years were interviewed, and the interviews were analyzed by qualitative content analysis.

RESULTS

This study confirms prior knowledge of adolescents' experiences of living with a sibling who is suffering from an ED. The adolescents were concerned about their siblings and lacked information about their siblings' illness and treatment progress. The girls described that their everyday life had been heavily influenced by their sisters' illness, while the boys described that their everyday life with friends and activities were not affected to such a great extent. One new result that emerged as something positive was that some informants described that although the ED was a source of conflict in the family, it had led to greater awareness of the importance of gaining sufficient energy and had contributed to better meal situations in the family.

CONCLUSION

Having a sibling with an ED had a profound and negative effect on family relationships, and was often a source of conflict, especially around mealtime. However, it appeared that if parents were able to organize family meals and create an open and supportive climate, the negative effects for the family could be reduced. The health care professionals need to acknowledge the siblings' need for information and support, and support parents in their important role of caring for well siblings.

Body size estimation in anorexia nervosa: a brief review of findings from 2003 through 2013

Body size overestimation is a fundamental feature in anorexia nervosa (AN). The extent or even existence of body size overestimation in AN is controversial. The most recent review (Farrell et al., 2005) found that only half the studies reported overestimation of body size in individuals diagnosed with AN. The remaining studies found no overestimation or in some instances underestimation. The discrepancy in these findings has been attributed to the wide variety of assessment techniques that are used, including many with questionable psychometric properties. We review all 9 contemporary studies conducted in this area since the last review in 2005. For each study we describe the number of participants, methodology, reliability/validity data, amount of whole body distortion, effect sizes, and a summary of findings. In all studies that included a healthy control group, individuals with AN overestimated their whole body size more than healthy controls did. The difference was significant in all except two studies. Based on these contemporary findings, we conclude that individuals with AN overestimate their body size and that the greater consistency of findings in the studies conducted over the last decade is attributable to the use of improved methodologies and assessment tools with documented psychometric properties.

Inpatients with severe anorexia nervosa and their siblings: non-shared experiences and family functioning

OBJECTIVES

The aims of this study were the following: to identify perceptions of patients with anorexia nervosa (AN) and their siblings regarding differential experiences within and external to the family including sibling interactions, parental treatment, relationships with peers and events that are unique to each sibling; (2) to compare how patients and their siblings perceive eating disorder symptoms, parental affection/control, social support and stigma; and (3) to test associations with family functioning for patients with AN and their siblings.

METHOD

A total of 26 patients paired with their siblings were recruited from an Eating Disorder Program and administered standardized instruments measuring different experiences within and external to the family, the impact of eating disorder behaviours, stigma, social support and family functioning.

RESULTS

Patients rated high on the differential experience of jealousy in contrast to their siblings. Patients scored higher than their siblings on eating symptoms, whereas siblings scored higher on social support. The impact of AN on the family, stigma towards the individual and family, and social support accounted for 37% of the variance in family functioning from the sibling perspective after controlling for age and gender. Of these variables, impact of AN on the family made the largest contribution.

DISCUSSION

Family-based and sibling-based interventions that aim to reduce the effects of the illness on the sibling relationship and the family are recommended.

Nine-year follow-up of girls with anorexia nervosa and their siblings: retrospective perceptions of parental bonding and the influence of illness on their everyday life

BACKGROUND

Few previous anorexia nervosa (AN) studies include siblings.

OBJECTIVE

To investigate if adolescents with AN retrospectively perceived their parents as less caring and more controlling than their siblings, whether perceived parenting was related to psychological problems, and how AN had influenced their everyday lives.

METHOD

Forty-six former patients (mean age 23.1 years) and 21 siblings participated in the study by completing the Parental Bonding Inventory (PBI) and a questionnaire on the influence of AN during the acute phase.

RESULTS

Former patients and their siblings had similar PBI results. Better adaptive functioning and lower levels of internalising psychological problems were correlated with higher ratings of parental care in both patients and siblings. Both patients and siblings reported that the illness had created conflict and caused concern, but had also provided valuable experiences.

CONCLUSION

Perceived parenting was associated with psychological problems in young adulthood but not with eating disorders. Our PBI results for both former patients and siblings were quite similar to non-clinical control groups. Health personnel treating adolescent AN should be aware of siblings' perspectives and needs.

Neuropsychological psychopathology measures in women with eating disorders, their healthy sisters, and nonrelated healthy controls

OBJECTIVE

To assess the familial influence on neuropsychological dysfunction in eating disorders (ED) patients by comparing 16 patients with restricting type anorexia nervosa (AN-R), 18 patients with bingeing purging type anorexia nervosa, 20 patients with bulimia nervosa binge-purge type, 21 of the patients' nonaffected sisters, and 20 nonrelated healthy controls.

METHODS

Self-report questionnaires assessing psychopathology and 2 computerized cognitive tasks measuring hemispheric asymmetry for language and visuospatial abilities were administered to all participant groups.

RESULTS

On the self-report questionnaires, ED patients scored significantly more pathological than the healthy controls, whereas the healthy sisters were similar to the nonrelated healthy control group. For both of the computerized tasks, the behavior pattern of the sisters was similar to that of all, or most ED groups, and were significantly different from the nonrelated healthy controls. In addition, AN-R patients performed significantly worse on the visuospatial task than the other ED groups.

CONCLUSIONS

The dissociation between the performance on the cognitive tasks and psychopathology measures in healthy sisters, when compared to the ED and nonrelated healthy control groups, suggests that disturbances in neurocognitive functioning in ED patients are not necessarily the result of ED-related dysfunction. Rather, this may indicate general individual differences in cognitive processes that may run in families irrespective of the ED condition of the family member. The findings, with respect to the AN-R patients, support a neurocognitive continuum model of EDs in which AN-R represents the most severe form of the illness.

Personality development characteristics of women with anorexia nervosa, their healthy siblings and healthy controls: What prevents and what relates to psychopathology?

This exploratory study assessed attachment and personality in anorexic women, non-affected siblings, and healthy controls, examining correlations with psychopathology. Thirty-eight anorexic subjects (31 females), thirty-one siblings (22 females), and fifty controls (35 females) participated. Personality development characteristics were assessed using the Attachment Style Questionnaire (ASQ), Temperament and Character Inventory (TCI), Eating Disorders Inventory (EDI-2), Symptom Checklist-90 (SCL-90), and other inventories for clinical assessment of EDs. Both anorexic probands and their siblings described lower maternal care and higher maternal overprotection than did controls. Healthy siblings were more similar to controls, but had lower scores than either controls or affected siblings on preoccupation with relationships (P<0.005) and higher scores than controls on self-transcendence (P<0.015) and obsessive-compulsive traits (P<0.025). Logistic regression indicated that need for approval, persistence, resourcefulness, self-transcendence, state anger, pursuit of thinness, interpersonal distrust, social insecurity, and binge eating differentiated anorexic probands from siblings. The need for approval was related to several psychopathological characteristics. Low preoccupation with relationships, low need for approval, and high self-transcendence may have protected siblings from family and environmental stressors. High need for approval was independently related to psychopathological traits in anorexic siblings. Implications for prevention and treatment are discussed.

Caring for a sibling with anorexia nervosa: a qualitative study

OBJECTIVE

Few studies have explored eating disorders from the perspective of non-affected siblings. The aim of this investigation was to explore the unique experiences and challenges of siblings of women with anorexia nervosa (AN).

METHOD

Twelve semi-structured qualitative interviews were conducted with sibling participants to ascertain their perspective of caring for a sister with chronic AN.

RESULTS

Qualitative analyses gleaned six themes: (1) the sibling role as protector and mediator; (2) familial factors that influence and reinforce these sibling roles; (3) consequences and benefits of AN to non-affected sibling; (4) coping strategies; (5) current and future intentions of caregiving and (6) professional and informal support.

DISCUSSION

The findings from this qualitative study provide a window into the perceptions, feelings, and roles of siblings of women afflicted with AN. An intervention guided by the elicited themes may facilitate family functioning that is more adaptive for both siblings.