Causes of adolescent onset anorexia nervosa: patient perspectives

The role of mindfulness on the psychological aspects of anorexia nervosa

OBJECTIVE

Emotion regulation, perfectionism, and rumination are perpetuating factors in anorexia nervosa (AN). Mindfulness can be protective and therapeutic. We aimed to understand the relationship between these factors and mindfulness in AN.

METHODS

20 adolescent girls in the acute phase of the AN, 16 in remission, and 40 in the control group were evaluated.

RESULTS

Mindfulness was lowest in the acute AN group. The difference in the acute AN group regarding body dissatisfaction, emotion dysregulation, perfectionism, and mindfulness disappeared after controlling for the effects of depression and anxiety. The predictors of disordered eating in the entire study population were body dissatisfaction and depressive symptoms. Emotion regulation and perfectionism were the predictors of mindfulness in the acute AN group and the entire study population. When mindfulness decreased, concerns about body shape increased in both acute AN and remission groups, while dietary restriction and disordered eating behaviors increased only in the remission group.

DISCUSSION

Emotion regulation difficulties in acute AN could be related to depression and anxiety. Mindfulness interventions for emotion regulation could be used for depression during the acute phase while for perfectionism in remission. Early intervention for depression and body dissatisfaction seems protective, and mindfulness could be an appropriate intervention.

A Tale of Childhood Loss, Conditional Acceptance and a Fear of Abandonment: A Qualitative Study Taking a Narrative Approach to Eating Disorders

Eating disorders (EDs) are serious mental health illnesses, yet there is a need to better understand the illness experience to improve treatment outcomes. Qualitative research, and narrative approaches in particular, can elicit life stories that allow for the whole illness journey to be explored. This study aimed to explore the experiences of women with a history of an ED, identifying the life events they perceived were relevant to the onset of their ED through to recovery. Interviews were conducted with 18 women with lived experience of an ED. Through structural narrative analysis, an overarching storyline of childhood loss contributing to a belief of conditional acceptance, fear of abandonment and struggle to seek emotional support due to the fear of being a burden was identified. Negative experiences with the health sector were common. These findings have implications for the way medical professionals respond to help seeking and deliver treatment.

Covert therapeutic micro-processes in non-recovered eating disorders with childhood trauma: an interpersonal process recall study

METHOD

To uncover therapeutic micro-processes from the perspectives of eating disorder (ED) treatment non-responders with childhood trauma (CT) late effects, we explored in-session experiences of poor long-term outcome patients. Female inpatients aged 28-59 (M = 40.2, SD = 5.0) from a randomised trial comparing Compassion Focused Therapy for EDs (n = 3) with Cognitive Behavioural Therapy for EDs (n = 3) were interviewed with video-assisted recall about a self-selected session. Data were analysed through Interpretative Phenomenological Analysis (IPA) with Grounded Theory (GT) elements.

RESULTS

Covert patient strategies included self-effacement, regulating therapeutic distance to open up, and engaging with reflective rather than experiential interventions. First, self-effacement included submissive, passive or pretend responses to perceived criticising or violating therapist behaviours as well as other orientation and submission for approval. Second, some preferred a close patient-therapist alliance with therapist self-disclosure and reciprocity was a requirement for opening up; others required distance. Third, informants detached from experiential trauma work while engaging in joint reflection on post-trauma responses.

CONCLUSION

Informants were preoccupied with calibrating the emotional-relational landscape in session; we hypothesized that psychological insecurity and affective intolerance from CT limit their freedom to explore own in-session experiences.

A meta-synthesis of qualitative studies of the link between anxiety, depression and perfectionism: implications for treatment

BACKGROUND

Meta-analyses show an association between perfectionism and depression and anxiety (negative affect), and that therapy for perfectionism impacts positively on negative affect. No systematic reviews have focused on qualitative studies of perfectionism.

AIMS

Our aim was to perform a systematic, meta-synthesis of qualitative literature to (i) help inform our understanding of how perfectionism is associated with negative affect, so that we can (ii) inform future development of treatment for perfectionism in young people and to make it more effective.

METHOD

Included in the meta-synthesis were 37 qualitative studies.

RESULTS

Six themes related to perfectionism were found: (1) the association with negative affect, (2) self-worth dependent on achievement, (3) cognitive and behavioural maintaining factors, (4) the expectations of others, (5) effective elements of interventions, and (6) barriers to treatment.

CONCLUSIONS

The qualitative literature supports the notion of perfectionism as an important construct to consider in reducing negative affect. While cognitive behavioural therapy for perfectionism holds promise as a treatment to target negative affect, there was a paucity of qualitative research, particularly related to young people. A greater understanding of the views of young people are required to help tailor more effective interventions for perfectionism that can impact negative affect in this group.

Significados do Abandono do Tratamento para Pacientes com Transtornos Alimentares

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

Family Psychic Transmission and Anorexia Nervosa

Abstract Studies show that family relationships can act as mediating agents in triggering and maintaining the symptoms of anorexia nervosa (AN), especially the mother-daughter relationship configuration, which contains unconscious elements transmitted inter-generationally. This study aimed to understand the role of intergenerational psychic transmission in the articulation of anorexic symptoms in a young woman in treatment. Three generations of women of the same family were interviewed: maternal grandmother, mother and daughter, all diagnosed with AN. Some psychic contents that could not be elaborated were identified in the reports and these were, subsequently, converted into legacies transmitted to later generations. Feelings of inhibition and shame regarding sexuality and the female body, transmitted from grandmother to mother and from mother to granddaughter, seem to have blocked the emotional development in all generations. Incorporating these findings into treatment may facilitate the processing of the transmitted unconscious contents, contributing to the reorganization of the family's psychodynamic functioning.

The lived experience of anorexia nervosa in adolescence, comparison of the points of view of adolescents, parents, and professionals: A metasynthesis

BACKGROUND

Anorexia nervosa in adolescence has been increasingly documented in numerous quantitative and qualitative studies. Qualitative research, which focuses on subjective experience, is a well-established method to deepen our understanding and provide new insights about specific diseases.

OBJECTIVE

We conducted a metasynthesis of qualitative studies to explore how anorexia nervosa is experienced by adolescents, their families, and the health professionals who provide care for them and to compare their perspectives.

REVIEW METHODS

Five databases (Medline, PsycINFO, CINHAL, EMBASE, SSCI; 1990-2015) were systematically searched for qualitative studies reporting participants' views about anorexia nervosa. Article quality was assessed with the Critical Appraisal Skills Program (CASP). We used thematic synthesis to examine and summarize the topics found in the articles selected and develop their central themes.

RESULTS

We included 30 articles from seven different countries. Two domains of experience were inductively developed from the analysis: (1) constructs and beliefs about etiological theories of anorexia nervosa, and (2) the experience of the disease from the points of view of adolescents, parents, and healthcare providers.

CONCLUSIONS

We found important disparities between the three stakeholders. The adolescents underlined the psychological and emotional aspects of their experience, while the visible state of these patients' bodies impeded the work of the professionals. These difficulties shed new light on the stakes of treatment of anorexia nervosa in adolescence, which must integrate both its psychological and physical components.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

KEY PRACTITIONER MESSAGE

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

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

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

A factor analysis of the meanings of anorexia nervosa: intrapsychic, relational, and avoidant dimensions and their clinical correlates

BACKGROUND

Anorexia nervosa (AN) is a difficult to treat disorder characterized by ambivalence towards recovery and high mortality. Eating symptomatology has a sort of adaptive function for those who suffer from AN but no studies have to date investigated the relationship between the reported meanings of AN and patients' clinical characteristics. Therefore, we aimed to perform a factor analysis of a new measure testing its psychometric properties in order to clarify whether subjective meanings of AN can be related to AN severity, to ascertain if some personality traits correlate with the meanings attributed to AN by patients, and finally to verify to what extent such meanings relate to patients' duration of both illness and treatment.

METHODS

Eighty-one inpatients affected by AN were recruited for this study and clinical data were recorded. Participants were asked to complete a novel instrument, the Meanings of Anorexia Nervosa Questionnaire (MANQ) focused on the measurement of values that patients attribute to AN and other measures as follows: Eating Disorders Inventory-2, Beck Depression Inventory, Temperament and Character Inventory, and Anorexia Nervosa Stages of Change Questionnaire.

RESULTS

As measured by the MANQ, body dissatisfaction, problems of adolescence, and distress at school or work mainly triggered the onset of AN. Balance and self-control were mostly reported as meanings of AN while the most frequent negative effects were: being controlled by the illness, obsessive thoughts about body shape, and feeling alone. Differences were found between diagnostic subtypes. When a factorial analysis was performed, three factors emerged: intrapsychic (e.g., balance/safety, self-control, control/power, way to be valued), relational (e.g., communication, way to be recognized), and avoidant (e.g., the avoidance of negative feelings, emotions, and experiences). These factors correlated with patients' personality and motivation to treatments but were unrelated to duration of both illness and treatments.

CONCLUSIONS

Given the ego-syntonic nature of AN, the understanding of patients' value of their disorder could be relevant in treatment; moreover, the positive value of AN resulted to be unrelated to the duration of both illness and treatments. Future research is warranted to replicate these findings and test their clinical implications.

O Percurso e seus Percalços: Itinerário Terapêutico nos Transtornos Alimentares

RESUMO Este estudo teve por objetivo delimitar o itinerário terapêutico - busca por cuidados à saúde, diagnóstico e tratamento - percorrido por mães cujos filhos foram diagnosticados com anorexia nervosa (AN). Trata-se de estudo do tipo exploratório, descritivo e transversal, no enfoque qualitativo de pesquisa. Para a coleta de dados, foram realizadas entrevistas semiestruturadas. A análise de conteúdo temática foi utilizada como estratégia de organização dos dados. Os resultados apontaram diversas barreiras no acesso a serviços especializados para o tratamento da AN. O limitado conhecimento dos profissionais acerca dessa psicopatologia retarda o diagnóstico, o que tem consequências negativas para o prognóstico. O conhecimento produzido sobre a trajetória de busca de ajuda para o problema pode contribuir para aprimorar a oferta e qualificação dos cuidados oferecidos.

Habilidades sociais: fator de proteção contra transtornos alimentares em adolescentes

Resumo O objetivo desse estudo foi revisar a literatura a cerca da relação entre transtornos alimentares e habilidades sociais em adolescentes. Pesquisou-se as bases de dados Medline, SciELO e Lilacs, cruzando os descritores “transtornos alimentares”, “anorexia nervosa”, “bulimia nervosa” e “comportamento alimentar”, com os descritores “psicologia social” e “isolamento social”, e com as palavras chave “competência social”, “habilidade social” e “relação interpessoal”. Incluiu-se estudos com adolescentes, nos idiomas português, inglês e espanhol, e publicações realizadas entre os anos de 2007 a 2012. A busca resultou em 63 artigos, sendo incluídos 50 nesta revisão. A maioria dos estudos foi conduzido no Brasil e nos Estados Unidos. Do total, 43 eram artigos originais. Os estudos visavam compreender como o estado emocional poderia influenciar no estabelecimento dos transtornos alimentares, assim como as relações interpessoais e a relação entre os pares. Os artigos também discutiram a influência da mídia e da sociedade neste processo. A partir da análise dos estudos, observou-se que quanto maior o repertório de habilidades sociais dos adolescentes, maior será o fator de proteção contra o desenvolvimento de transtornos alimentares.

A constituição da relação mãe-filha e o desenvolvimento dos transtornos alimentares

O presente estudo buscou compreender, por meio de abordagem qualitativa, como mães de adolescentes com transtornos alimentares vivenciaram o processo de cuidar de suas filhas desde a gestação até os dois anos de idade, procurando investigar se essas vivências relacionadas à maternidade guardam relação com o aparecimento futuro do transtorno. Foram entrevistadas seis mães de pacientes com anorexia nervosa, que estavam em seguimento ambulatorial em um serviço especializado. Os relatos maternos foram examinados pela análise de conteúdo. Os resultados evidenciaram dificuldades de sustentação (holding) por parte das mães, que acarretaram intenso sofrimento e sentimento de impotência diante das necessidades básicas das filhas. As crianças foram descritas como vorazes e insatisfeitas, sugerindo que teriam vivenciado dificuldades em assimilar o cuidado oferecido por suas mães em seus primeiros anos de vida. Desse modo, os resultados corroboram a importância de investigar as experiências infantis precoces para a compreensão da etiologia dos transtornos alimentares.

Perceptions of the causes of eating disorders: a comparison of individuals with and without eating disorders

BACKGROUND

In this study, we examined perceptions regarding the causes of eating disorders, both among those with eating disorders as well as those without. By understanding the differences in perceived causes between the two groups, better educational programs for lay people and those suffering from eating disorders can be developed.

METHOD

This study used open-ended questions to assess the beliefs of 57 individuals with self-reported eating disorders and 220 without. Participants responded to the questions, "What do you think was (were) the cause(s) of your eating disorder?" and "What do you think is (are) the cause(s) of eating disorders?".

RESULTS

A list of possible codes for the causes of eating disorders was created based on a thorough review of the literature. A manually-generated set of eight codes was then created from individuals' actual responses. Frequencies and chi square analyses demonstrated differences in rates of endorsement between those with eating disorders and those without. Participants with eating disorders most frequently endorsed psychological/emotional and social problems, with genetics/biology and media/culture ideals least endorsed. Participants without eating disorders most frequently endorsed psychological/emotional problems and media/culture ideals, with traumatic life events and sports/health least endorsed. There was a difference between groups in the endorsement of the media as a cause of eating disorders, suggesting that those without eating disorders may overly attribute the media as the main cause while those with eating disorders may not be fully aware of the media's impact. Additionally, while both groups highly endorsed psychological/emotional problems, there was a noticeable stigma about eating disorders among those without eating disorders.

CONCLUSIONS

There were noteworthy differences between samples; such differences suggest that there is a need for more education on the topic of eating disorders. Furthermore, despite empirical support for the effects of genetics, sports, and family factors, these were infrequently endorsed as causes of eating disorders by both groups. Our results suggest that there is a need for more education regarding the factors associated with eating disorders, in order to reduce the stigma surrounding these disorders and to potentially aid the treatment process.

Psicodinâmica dos transtornos alimentares: indicadores do Teste das Pirâmides Coloridas de Pfister

É amplamente reconhecida a influência de fatores emocionais na gênese e manutenção dos transtornos alimentares (TAs). Este estudo teve como objetivo analisar o funcionamento lógico e afetivo de pessoas com diagnóstico de TAs. Participaram do estudo 27 pacientes (23 mulheres, média de idade de 17,5 anos, a maioria com bulimia nervosa). O instrumento utilizado foi o Teste das Pirâmides Coloridas de Pfister. Os dados foram cotados segundo recomendações da literatura. Os resultados evidenciaram que os aspectos racionais apresentam um padrão de boa capacidade de organização. Quanto aos aspectos emocionais, observou-se uma desregulação dos mecanismos de controle eficiente dos afetos e impulsos. Por não suportarem os estados de ansiedade decorrentes do descontrole dos afetos, os participantes denegam seus impulsos, gerando uma estabilidade emocional precária que dificulta a elaboração dos conflitos. Evidenciou-se o comprometimento psíquico no grupo investigado e, por conseguinte, a necessidade de oferecer acompanhamento psicológico conjugado com reabilitação nutricional.

Psychological factors predict eating disorder onset and maintenance at 10-year follow-up

The present study sought to identify psychological factors that predict onset and maintenance of eating disorders. Secondary analyses were conducted using data from an epidemiological study of health and eating behaviours in men and women (N = 1320; 72% female) to examine the prospective and independent influence of the Eating Disorder Inventory Perfectionism, Interpersonal Distrust, and Maturity Fears subscales in predicting the onset and maintenance of eating disorders at 10-year follow-up. Multivariate models indicated higher Perfectionism (p = .025), lower Interpersonal Distrust (p < .001), and higher Maturity Fears (p = .037) predicted increased risk for eating disorder onset at 10-year follow-up, but only Perfectionism (p = .004) predicted eating disorder maintenance. Differential prediction of eating disorder onset versus maintenance highlights potentially different psychological foci for prevention versus treatment efforts.

Avaliação psicológica de pacientes com anorexia e bulimia nervosas: indicadores do Método de Rorschach

Este estudo teve por objetivo avaliar o funcionamento lógico, afetivo e a adaptação social de pacientes com Anorexia Nervosa (AN) e Bulimia Nervosa (BN). A amostra foi composta por 27 participantes. Para coleta dos dados foi utilizado o Método de Rorschach. Os dados foram codificado e interpretados segundo as normas da Escola Francesa. Os resultados indicaram que os participantes apresentam capacidade produtiva e desejo de estabelecerem relacionamentos afetivos. Todavia, são facilmente invadidos por uma carga de afetos que não conseguem modular, o que os predispõe ao isolamento social, que gera acúmulo de inquietações e ansiedades introjetadas. A incapacidade de elaborar a tensão interna resultante os leva a escoar a ansiedade pela via somática. Evidenciou-se o comprometimento das funções psíquicas dos pacientes com AN e BN, o que indica a necessidade de acompanhamento psicoterapêutico integrado à assistência da equipe multiprofissional.

A pilot study of a family-based treatment for adolescent anorexia nervosa: 18- and 36-month follow-ups

The current study evaluated the outcome of family-based treatment for female adolescents with anorexia nervosa (N = 32), at the Anorexia-Bulimia Outpatient Unit in Göteborg, Sweden. Patients/parents were assessed pre-treatment, at 18- and 36-month follow-ups concerning eating disorder symptoms, general psychopathology, family climate and BMI. At the 36-month follow-up, 75% of the patients were in full remission with reduction in eating disorder symptoms and internalizing problems and they experienced a less distant and chaotic atmosphere in their families. These results show that family-based treatment appears to be effective in adolescent anorexia nervosa patients regarding areas examined in this study.

A longitudinal study of perfectionism in adolescent onset anorexia nervosa-restricting type

This longitudinal study analyses self-reported perfectionism, eating disorders and psychiatric symptoms during recovery from anorexia nervosa (AN). With a recovered design, a group of 68 previous patients with AN was studied in two follow-up studies, 8 and 16 years after 1st admission to Child and Adolescent Psychiatry (CAP). Levels of perfectionism stayed the same while eating disorder symptoms and psychiatric symptoms decreased during recovery. Levels of perfectionism were inversely related to duration of remission so that individuals that had short illness duration had lower levels of perfectionism at both follow-ups. Patients with initial high levels of perfectionism may be at risk for a long illness duration which we recommend clinicians to acknowledge.