Reclamation of power and self: a meta-synthesis exploring the process of recovery from anorexia nervosa

The focus on weight in the inpatient care of anorexia nervosa: A qualitative investigation of consumer perspectives

Anorexia nervosa has a high mortality rate and is often treated in the inpatient setting, where close monitoring and medical support are available. Consistent with objective biomedical benchmarks, conventional inpatient treatment is often focussed on weight gain. Consumers report that clinicians provide care focussed on weight and physical restoration without adequate consideration of their full spectrum of needs. The aim of this study was to explore consumers' perspectives of the biomedical focus on weight gain in the inpatient care of anorexia nervosa. This study employed a qualitative approach, involving semistructured interviews, and participants were recruited from relevant social media communities. This study was ethically approved by a university ethics committee and the COREQ checklist ensured ethical reporting. Ten women participated in interviews. Participants reported that the biomedical imperative of weight gain is focussed on at the exclusion of other relevant determinants of well-being, and the narrow focus on weight gain does not suitably prepare consumers for discharge. The conflict between clinicians' biomedical focus and consumers' broader unmet needs leads to harmful interpersonal dynamics and feelings of invalidation. The inpatient care of anorexia nervosa needs to develop beyond biomedically driven objectives and incorporate the merits of an approach that substantively integrates person-centred care, therapeutic relationships and trauma-informed principles.

Plant-based recovery from restrictive eating disorder: A qualitative enquiry

OBJECTIVES

Plant-based/vegan diets are growing in popularity. There are growing numbers of individuals adopting plant-based diets and there are legitimate concerns from professionals that this can enable food restriction or mask disordered eating. The aim of this study was to examine the role a plant-based diet can play for those in recovery from restrictive eating disorders (anorexia and bulimia nervosa).

METHODS

Interviews conducted with fourteen individuals who identified as having a restrictive eating disorder for which a plant-based diet played/plays an important part in their recovery. Semi-structured interviews explored the individual's lived experiences and motivations of adopting a plant-based diet, and perceptions of the role it played in recovery. Data was transcribed verbatim and analyzed using thematic analysis (Braun & Clarke, 2006).

RESULTS

Three key themes with six contributory subthemes were identified. Key themes were plant-based as a gateway to recovery, the changing value of food, and the function of control. Theme content highlighted an evolving role of identity and community, with a shift in meaning and value of food described, and for some, the development of a new relationship with their body. This facilitated a de-coupling of anxieties about food and promoted positive experiences of eating, esteem and empowerment.

CONCLUSIONS

These findings present a unique insight into the role that plant-based eating may play in recovery for some restrictive eating disorders. The data demonstrated that motivations to control food intake may contribute to the decision to eat plant-based. However, for these individuals it provided a "gateway" to a new more meaningful relationship with food. These findings highlight some of the risks and benefits of eating plant-based in recovery and an important role for health professionals in understanding/supporting individuals during recovery. w/c 280.

Anorexia nervosa through the lens of a severe and enduring experience: 'lost in a big world'

BACKGROUND

Severe and enduring anorexia nervosa (SE-AN), is a serious and persistent illness, despite 'state of the art' treatment. Criteria have been theoretically proposed, but not tested, and may not adequately capture illness complexity, which potentially inhibits treatment refinements. The clinical reality of death as an outcome for some people who experience SE-AN (1 in 20) and broadening access to voluntary assisted dying, further complicates the field, which is undeveloped regarding more fundamental concepts such as nosology, treatment, recovery definitions and alternative conceptualisations of SE-AN. The present paper is in response to this and aims to build upon qualitative literature to enhance phenomenological understandings of fatal SE-AN.

METHOD

A published book, being the legacy of a 32-year-old professional artist offers a rich account of a life lived with AN, for 18 years with continuous treatment. A polysemous narrative via the interrelationship between the languages of the artist's words and visual art is translated via interpretative phenomenological analysis (IPA), offering rich insight into the SE-AN experience.

FINDINGS

The process of analysis induced three superordinate themes (1) Disappearing Self (2) Dialectical Dilemma (3) Death and Dying: Finding Meaning. Two cross cutting themes traversed these themes: (a) Colour and (b) Shifting Hope, where the former produced a visual representation via the 'SE-AN Kaleidoscope'. Collectively the themes produce a concept of SE-AN, grounded in the data and depicted visually through the artist's paintings.

CONCLUSIONS

The picture of SE-AN revealed in the analysis extends upon conceptualisations of SE-AN, highlighting key processes which are thus far under explored. These factors are implicated in illness persistence eliciting opportunities for further research testing including diagnostic considerations and treatment directions. In SE-AN, distorted body image extends to a global distortion in the perception of self. Additional criteria for the severe and enduring stages of illness related to (1) self and identity processes (2) measures of 'global impoverishment' across life domains are proposed for consideration in the future testing of putative defining features of SE-AN.

Conceptualisation of severe and enduring anorexia nervosa: a qualitative meta-synthesis

BACKGROUND

Severe and enduring anorexia nervosa (SE-AN) is amongst the most impairing of all mental illnesses. Collective uncertainties about SE-AN nosology impacts treatment refinement. Qualitative research, particularly lived experience literature, can contribute to a process of revision and enrichment of understanding the SE-AN experience and further develop treatment interventions. Poor outcomes to date, as evidenced in clinical trials and mortality for people with SE-AN (1 in 20) demonstrate the need for research that informs conceptualisations and novel treatment directions. This interpretative, meta-ethnographic meta-synthesis aimed to bridge this gap.

METHODS

A systematic search for qualitative studies that explored the AN experiences of people with a duration of greater than 3 years was undertaken. These studies included those that encompassed phenomenology, treatment experiences and recovery.

RESULTS

36 papers, comprising 382 voices of SE-AN experiences informed the meta-ethnographic findings. Four higher order constructs were generated through a synthesis of themes and participant extracts cited in the extracted papers: (1) Vulnerable sense of self (2) Intra-psychic processes (3) Global impoverishment (4) Inter-psychic temporal processes. Running across these meta-themes were three cross cutting themes (i) Treatment: help versus harm, (ii) Shifts in control (iii) Hope versus hopelessness. These meta-themes were integrated into conceptualisations of SE-AN that was experienced as a recursive process of existential self-in-relation to other and the anorexia nervosa trap.

CONCLUSIONS

The alternative conceptualisation of SE-AN proposed in this paper poses a challenge to current conceptualisations of AN and calls for treatments to engage with the complex intra and inter-psychic processes of the SE-AN, more fully. In doing so, clinicians and researchers are asked to continue to be bold in testing novel ideas that may challenge our own rigidity and attachment to dominant paradigms to best serve the individual person with SE-AN. The 'global impoverishment of self', found in this synthesis of AN experiences, should inform proposed diagnostic criteria for SE-AN.

A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope

The ethical approach to treatment non-response and treatment refusal in severe-enduring anorexia nervosa (SE-AN) is the source of significant ethical debate, particularly given the risk of death by suicide or medical complications. A recent article proposed criteria to define when anorexia nervosa (AN) can be diagnosed as 'terminal' in order to facilitate euthanasia or physician-assisted suicide (EAS), otherwise known as medical assistance in dying, for individuals who wish to be relieved of suffering and accept treatment as 'futile'. This author utilises their personal lived experience to reflect on the issues raised, including: treatment refusal, iatrogenic harm, suicidality and desire to end suffering, impact of diagnosis/prognosis, schemas, alexithymia, countertransference, ambivalence, and holding on to hope. Within debates as critical as the bioethics of involuntary treatment, end-of-life and EAS in eating disorders, it is crucial that the literature includes multiple cases and perspectives of individuals with SE-AN that represent a wide range of experiences and explores the complexity of enduring AN illness, complex beliefs, communication patterns and relational dynamics that occur in SE-AN.

The Treatment Experience of Anorexia Nervosa in Adolescents from Healthcare Professionals' Perspective: A Qualitative Study

Anorexia nervosa (AN) is a serious psychiatric illness with a high mortality rate and a poor outcome. AN in adolescents can be difficult to treat. The prognosis of patients with AN depends highly on how early specialized AN treatment starts. Therefore, the purpose of this study was to explore the experiences of healthcare professionals in treating adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, 16 healthcare professionals, including 10 nurses, 3 dieticians and 3 physicians from the paediatric ward at a university-affiliated medical centre in central Taiwan, shared their experiences. Recorded interviews were transcribed and analyzed by content analysis. Five themes and ten subthemes were identified: 1. Building a trusting relationship first: (a) spending time to build trust with the client and (b) establishing a relationship with the client's parents; 2. The key to treatment success: (a) Clients' awareness of the illness and (b) parents' support for clients; 3. Consistency of team treatment goals: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. In conclusion, the findings will provide important information for healthcare professionals to apply in monitoring the psychological and emotional states of adolescents with AN. The findings indicate that healthcare professionals should invite parents to participate in the treatment, support and guide them in their adolescent care, develop scales of family stress and support for AN in adolescents, develop interventions, and establish an early therapeutic alliance.

'In an otherwise limitless world, I was sure of my limit.'† Experiencing Anorexia Nervosa: A phenomenological metasynthesis

Anorexia Nervosa (AN) has the highest mortality rate of the mental disorders, with still less than 50% of affected individuals achieving recovery. Recent calls to bring innovative, empirical research strategies to the understanding of illness and its core psychopathological features highlight the need to address significant paucity of efficacious treatment. The current study brings a phenomenological approach to this challenge, synthesizing lived experience phenomena as described by qualitative literature. Fifty-three studies published between the years 1998 and 2021 comprising a total of 1557 participants aged 12-66 suffering from AN or sub-threshold AN are included. Reciprocal and refutational analysis generated six key third-order constructs: "emotion experienced as overwhelming," "identity," "AN as a tool," "internal conflict relating to Anorexia," "interpersonal communication difficulties" and "corporeality." Twenty-six sub-themes were identified, the most common being fear, avoidance, AN as guardian/protector, and AN as intertwined with identity. Some themes associated with current treatment models such as low self-esteem, need for social approval and feelings of fatness were less common. We highlight the significant role of intense and confusing emotion in AN, which is both rooted in and engenders amplified fear and anxiety. Restrictive eating functions to numb these feelings and withdraw an individual from a chaotic and threatening world whilst providing a sense of self around which to build an illness identity. Results have implications for therapeutic practice and overly protective weight and shape focused medical treatment models, which may serve to reinforce the disease.

Seeing Through the Façade of Anorexia: A Grounded Theory of Emotional Change Processes Associated With Recovery From Anorexia Nervosa

OBJECTIVES

Difficulties in managing emotions have been implicated in the development and maintenance of anorexia nervosa (AN), and psychological treatment models seek to address this in putative targets of change. Yet the field of psychotherapy remains unclear and insufficiently evidenced about the process of change and how this is actually achieved, including in what steps and in what order within clinical treatment. This qualitative study sought to develop theory about the process of emotional change during recovery from anorexia.

METHODS

Semi-structured interviews were carried out with nine women currently engaged in psychological treatment for anorexia. Interviews included questions pertaining to participants' experience of anorexia, emotions, and emotion management. A constructivist version of grounded theory was employed.

RESULTS

The analysis produced 10 major categories, comprising over 60 focused codes. Categories were clustered together into three super categories, reflecting 3 distinct but interrelated phases of participants' journeys toward recovery. The phases were: (1) Coping in a world of uncertainty, (2) Seeing through the façade of anorexia, and (3) Recovery and growth. Whilst movement toward later positions often appeared to be contingent on earlier ones, the analysis suggests that this was not an entirely linear process and that participants moved between positions as they grappled with the process of change. Participants came to view behaviors associated with anorexia as emotion-management strategies that were not working and as a façade. As they moved toward recovery and growth, they became less confined by their need for safety, and to see emotions as meaningful and valuable. Becoming more connected to emotional experience and expression, coincided with positive shifts in their intra and interpersonal relationships.

CONCLUSION

These findings support the recent shift toward emotion-focused models of anorexia. They also highlight an important focus in supporting individuals with AN to connect with, and be guided by, emotional experiences in their relationships with themselves and the world around them. This new grounded theory offers a putative process of change that could be utilized to guide intervention development.

Experiences of eating disorders from the perspectives of patients, family members and health care professionals: a meta-review of qualitative evidence syntheses

BACKGROUND

Eating disorders are serious conditions that cause major suffering for patients and their families. Better knowledge about perceptions of eating disorders and their treatment, and which factors that facilitate or hinder recovery, is desired in order to develop the clinical work. We aimed to explore and synthesise experiences of eating disorders from the perspectives of those suffering from an eating disorder, their family members and health care professionals through an overarching meta-review of systematic reviews in the field.

METHODS

A systematic literature search was conducted in the databases PubMed, PsycInfo, Scopus, and CINAHL. Inclusion criteria were systematic reviews of qualitative research on experiences, perceptions, needs, or desires related to eating disorders from the perspective of patients, family members or health care professionals. Systematic reviews that fulfilled the inclusion criteria were assessed for relevance and methodological limitations by at least two researchers independently. The key findings were analysed and synthesised into themes.

RESULTS

We identified 17 systematic reviews that met our inclusion criteria. Of these, 13 reviews reported on the patients' perspective, five on the family members' perspective, and three on the health care professionals' perspective. The study population in the reviews was predominantly girls and young women with anorexia nervosa, whilst systematic reviews focusing on other eating disorders were scarce. The findings regarding each of the three perspectives resulted in themes that could be synthesised into three overarching themes: 1) being in control or being controlled, 2) balancing physical recovery and psychological needs, and 3) trusting relationships.

CONCLUSIONS

There were several similarities between the views of patients, family members and health care professionals, especially regarding the significance of building trustful therapeutic alliances that also included family members. However, the informants sometimes differed in their views, particularly on the use of the biomedical model, which was seen as helpful by health care professionals, while patients and family members felt that it failed to address their psychological distress. Acknowledging these differences is important for the understanding of anorexia nervosa and other eating disorders, and may help clinicians to broaden treatment approaches to meet the expectations of patients and family members.

Service user and eating disorder therapist views on anorexia nervosa recovery criteria

OBJECTIVES

Recovery from anorexia nervosa (AN) is difficult to define, and efforts to establish recovery criteria have led to several versions being proposed. Using the perspectives of people with histories of AN and therapists working in the field, we sought to explore the face validity of Khalsa et al (2017) as one of the most recent examples of proposed systematic recovery criteria.

DESIGN

We interviewed 11 health service users (SUs) with histories of AN who had previously received treatment alongside 8 eating disorder therapists (EDTs), exploring their views on the proposed AN recovery criteria.

METHODS

Data from verbal and written interviews were analysed thematically. Separate thematic analyses of SU and EDT interviews highlighted where concerns converged and diverged across participants.

RESULTS

Both groups saw some merits of having universally recognized recovery criteria, and the multidimensional approach was welcomed, but EDTs were uncomfortable with considering their use in therapy and SUs felt key components were missing around emotional coping and life quality. SUs disliked the prominence of body mass index (BMI) in the criteria, and all struggled with the proposed duration for recovery. Conceptually, the notion of recovery as an endpoint rather than a journey was contested.

CONCLUSIONS

Our findings indicate disparities between academically derived recovery criteria and lived experiences and indicate perceived challenges in using such criteria in therapeutic settings. Including SUs and EDTs in the development of criteria may improve the likelihood of consolidating AN recovery criteria, but conceptual challenges remain.

PRACTITIONER POINTS

AN recovery is complex, and the use of research-based AN recovery criteria in therapeutic settings could have a detrimental effect on SUs' outcomes. EDTs should be aware of efforts to define AN recovery criteria. EDTs should engage with debates on defining AN recovery and seek to promote participation in such debates to SUs.

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

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

Discrepancies Between Explicit Feelings of Power and Implicit Power Motives Are Related to Anxiety in Women With Anorexia Nervosa

Background

Several studies identified low subjective feelings of power in women with anorexia nervosa (AN). However, little is known about implicit power motives and the discrepancy between explicit feelings of power and implicit power motives in AN.

Aim

The study investigated the discrepancy between explicit feelings of power and implicit power motives and its relationship to anxiety in patients with AN.

Method

Fifty-three outpatients and inpatients with AN and 48 participants without AN were compared regarding subjective feelings of power and anxiety. Explicit power [investigated with the Personal Sense of Power Scale (trait focus) and a visual analog scale (state focus)], implicit power motives [investigated with the Multi-Motive Grid (MMG)] and trait anxiety [measured with the State-Trait Anxiety Inventory (STAI)], were assessed.

Results

Explicit feelings of power (state and trait level) were lower in patients with AN compared to non-AN participants. No differences in implicit power motives were found when comparing the groups against each other. However, looking at the groups separately, women with AN had similar levels of implicit fear of losing power and hope for power, whereas woman without AN had significantly lower fear of losing power than hope for power. Focusing on discrepancies between powerful feelings and power motives, results were mixed, depending on the subscale of the MMG. Lastly, discrepancies between implicit power motives and explicit feelings of power were positively correlated with trait anxiety in AN patients.

Conclusion

These findings underline that individuals with AN display significantly lower explicit feelings of power, however, they show similar implicit power motives compared to individuals without AN. The discrepancy between explicit feelings of power and implicit power motives is related to anxiety in AN and may represent a vulnerability factor to illness maintenance.

Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences

The pharmacological treatment of patients with an eating disorder (ED) often includes medications to treat their ED, comorbid mental health problems, malnutrition and the physical health problems resulting from it. The currently approved pharmacological treatment options for EDs are limited to fluoxetine for bulimia nervosa (BN) and - in some countries - lisdexamfetamine for binge eating disorder (BED). Thus, there are no approved pharmacological options for anorexia nervosa (AN), even though study results for olanzapine and dronabinol are promising. Topiramate might be an additional future option for the treatment of BN and BED. Selective serotonin reuptake inhibitors (SSRI), mirtazapine and bupropion could be considered for the treatment of comorbid unipolar depression. However, AN and BN are contraindications for bupropion. For ED patients with a manic episode, we recommend olanzapine in AN and risperidone in BN and BED; whereas for bipolar depression, olanzapine (plus fluoxetine) seems appropriate in AN and lamotrigine in BN and BED. Acute anxiety or suicidality may warrant benzodiazepine treatment with lorazepam. Proton-pump inhibitors, gastroprokinetic drugs, laxatives and hormones can alleviate certain physical health problems caused by EDs. Therapeutic drug monitoring, pharmacogenomic testing, a more restrictive use of "pro re nata" (PRN) medication, an interdisciplinary treatment approach, shared decision making (SDM) and the formulation of common treatment goals by the patients, their family or carers and clinicians could improve treatment success and safety. Novel genetic, immunological, microbiome and brain imaging research as well as new pharmacological developments like the use of psychedelics, stimulants, novel monoaminergic drugs, hormone analogues and drugs which enhance the effects of psychotherapy may extend our therapeutic options in the near future.

The development and assessment of a scale to measure the experience of an anorexic voice in anorexia nervosa

The anorexic voice (AV) is defined as a critical internal dialogue, which has been implicated in the development and maintenance of anorexia nervosa (AN). Systematic research to explore this further requires a valid and reliable measurement tool. This study aimed to develop and assess the validity of the Experience of an Anorexic VoicE Questionnaire (EAVE-Q). EAVE-Q items were developed and checked for face and content validity through cognitive interviews with seven individuals diagnosed with AN. Participants with a diagnosis of AN (N = 148) completed the EAVE-Q, sociodemographic questions and measures of mood and quality of life to assess internal consistency and construct validity. Forty-nine participants completed the EAVE-Q twice more to assess test-retest reliability. The EAVE-Q had good face and content validity and good acceptability. Principal axis factoring resulted in an 18-item scale organized into five domains with high internal consistency (α = 0.70 to α = 0.85). Domains correlated significantly with eating disorder symptoms, psychological distress, and quality of life. The EAVE-Q did not discriminate between participants on the basis of body mass index. Test-retest reliability was moderate. Although the factor structure of the EAVE-Q requires replication in other AN samples, the EAVE-Q is the first measure of a critical internal dialogue in AN. It is hoped that it will aid future research to increase understanding of AN and the continued development of person-centred treatments.

Why I recovered: A qualitative investigation of factors promoting motivation for eating disorder recovery

OBJECTIVE

It is difficult for individuals with eating disorders (EDs) to build and maintain motivation to recover. This challenge contributes to high rates of treatment dropout and relapse. To date, motivational interventions have been largely ineffective, and there is little research on factors that affect recovery motivation. To better understand recovery motivation and identify potential intervention targets, this study examines factors that affect recovery motivation in individuals with EDs.

METHOD

N = 13 participants completed qualitative interviews. All had been recovered from their diagnosed and treated ED for at least 1 year. We applied thematic analysis to interview transcripts in order to identify factors that had influenced recovery motivation and to classify their effects as helpful, harmful, or mixed.

RESULTS

Six main themes were identified, with subthemes detailed under each: (a) important people and groups (e.g., social circle, mentor), (b) actions and attitudes of others (e.g., judgmental responses, failure to intervene), (c) treatment-related factors (e.g., therapeutic skills, therapeutic alliance), (d) influential circumstances (e.g., removing triggers, pregnancy/children), (e) personal feelings and beliefs (e.g., obligation to others, hope for the future), and (f) the role of epiphanies (i.e., sudden insights or moments of change).

DISCUSSION

In this study, we identified potentially malleable factors that may affect ED recovery motivation (e.g., removing triggers, focusing on obligation to others, getting involved in meaningful causes, securing non-judgmental support, building hope for the future). These factors may be investigated as potential targets or strategies in motivational interventions for EDs.

A framework to conceptualize personal recovery from eating disorders: A systematic review and qualitative meta-synthesis of perspectives from individuals with lived experience

BACKGROUND

An extensive literature exists describing treatment interventions and recovery from eating disorders (EDs); however, this body of knowledge is largely symptom-based and from a clinical perspective and thus limited in capturing perspectives and values of individuals with lived experience of an ED. In this study, we performed a systematic review to coproduce a conceptual framework for personal recovery from an ED based on primary qualitative data available in published literature.

METHODS

A systematic review and qualitative meta-synthesis approach was used. Twenty studies focusing on ED recovery from the perspective of individuals with lived experience were included. The studies were searched for themes describing the components of personal recovery. All themes were analyzed and compared to the established connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (CHIME) and Substance Abuse and Mental Health Services Administration (SAMHSA) frameworks of recovery, which are applicable to all mental disorders. Themes were labeled and organized into a framework outlining key components of the ED personal recovery process.

RESULTS

Supportive relationships, hope, identity, meaning and purpose, empowerment, and self-compassion emerged as the central components of the recovery process. Symptom recovery and its relationship to the personal recovery process are also significant.

DISCUSSION

Individuals with lived experience of EDs noted six essential elements in the personal ED recovery process. This framework is aligned with several of the key components of the CHIME and SAMHSA frameworks of recovery, incorporating person-centered elements of the recovery process. Future research should validate these constructs and develop instruments (or tools) that integrate the lived experiences into a measurement of recovery from an ED.

Recovery as a process: Exploring definitions of recovery in the context of eating-disorder-related social media forums

OBJECTIVE

Online forums related to eating disorders (EDs) represent sources of support for recovery, and comments on these platforms might therefore highlight aspects of recovery that have been previously neglected in research. Reddit, an online discussion platform, hosts several ED-related forums. Due to the unique benefits of examining ED-related social media comments, we aimed to use a qualitative approach to conduct an exploratory study to examine users' conceptualizations of recovery from an ED.

METHOD

We extracted public comments mentioning recovery that were posted on three ED-related online forums on Reddit between March 2017 and August 2017. We thematically analyzed the data corpus using an inductive approach to examine how recovery is defined in the context of ED-related online communities.

RESULTS

Two superordinate themes ("Recovery as a Process," "Psychosocial Factors") and three subordinate themes emerged (within the "Psychosocial Factors" theme: cognitive/affective, behavioral/physical, social).

DISCUSSION

The data support a definition of recovery that includes positive aspects of well-being and quality of life. Furthermore, the data highlight that recovery is experienced as an ongoing process that is unique to each individual.

Personal recovery of young adults with severe anorexia nervosa during adolescence: a case series

PURPOSE

Despite the emergence of a growing qualitative literature about the personal recovery process in mental disorders, this topic remains little understood in anorexia nervosa (AN), especially severe AN during adolescence. This cases series is a first step that aims to understand recovery after severe AN among adolescents in France, from a first-person perspective.

METHODS

This cases series applied the interpretative phenomenological analysis (IPA) method to data collected in semi-structured face-to-face interviews about the recovery process of five young women who had been hospitalized with severe AN 10 years earlier during adolescence.

RESULTS

A model of recovery in four stages (corseted, vulnerable, plastic, and playful) crossing seven dimensions (struggle and path of initiation; work on oneself; self-determination and help; body; family; connectedness; and timeline) emerged from the analysis. New features of the AN personal recovery process were characterized: bodily well-being and pleasure of body; stigmatization; the role of the group; relation to time; and importance of narratives. We suggest a new shape to model the AN recovery process, one that suggests several tipping points. Recruitment must now be widened to different AN contexts.

CONCLUSIONS

The personal recovery paradigm may provide a new approach to care, complementary to medical paradigm.

REGISTRATION OF CLINICAL TRIAL

No. NCT03712384. Our study was purely observational, without assignment of medical intervention. As a consequence, this clinical trial was registered retrospectively.

LEVEL OF EVIDENCE

Level V, descriptive study.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

External support and personal agency - young persons' reports on recovery after family-based inpatient treatment for anorexia nervosa: a qualitative descriptive study

BACKGROUND

Recommended treatment for adolescent anorexia nervosa (AN) is usually family-based and an overarching treatment aim is to empower the parents to manage the difficult meals and aid their child toward recovery. While family-based treatment prioritize collaborating with the parents, understanding the young persons' views on recovery is also important. Understanding the young person's views and ideas is relevant as this may facilitate the therapeutic alliance and thus aid the therapeutic process. The purpose of the present study was to investigate the reflections of young persons with a lived experience of anorexia nervosa, and what factors they consider important for the recovery process. All participants had been provided with a family-based inpatient treatment program, a program inspired by the core features of outpatient family-based treatment.

METHODS

Participants (n = 37) presented with an extensive treatment history, including outpatient and inpatient treatment for AN. Interview transcripts were analyzed by applying a predominantly inductive thematic approach to generate themes across participants.

RESULTS

The qualitative analysis generated a thematic structure entailing three levels. The superordinate theme, "Recovery is a long and winding journey: recognizing the need for support and highlighting the need for action", captured three main themes, "Realizing you have a problem", "Being involved in important relationships", and "Giving treatment a real chance".

CONCLUSIONS

Our results demonstrated that although young persons with a lived experience of anorexia nervosa recognized the importance of support from others, they placed a distinctive emphasis on self-responsibility and determination. We recommend clinicians working within the recommended family-based treatment frameworks be curious about young patient's subjective perspectives of the recovery process, as connecting with their views can potentially strengthen therapeutic relationships and facilitate change.

PLAIN ENGLISH SUMMARY

Recommended treatment for adolescent anorexia nervosa is usually family-based. These recommendations are supported by decades of research. In family-based treatment the overarching aim is to empower the young person's parents to manage and take charge of the difficult situation caused by the eating disorder. As recommended family-based treatments usually prioritize collaborating with the parents, it is important to be curious on the adolescents own views of what is regarded as important for the recovery process. The present study offers insights into factors considered important to the recovery process by young persons with lived experience of AN. Although voicing the importance of enlisting support from families, friends, and loved ones, the young participants distinctly emphasized their own responsibility, motivation and self-determination as critical factors for recovery. Inspired by our findings, we recommend that clinicians address the young patient's own preferred ideas for recovery during treatment.

Eating Disorder Recovery: A Metaethnography

BACKGROUND: Eating disorders seriously affect both physical health and psychosocial functioning. Breaking the confines of an eating disorder requires engagement in a multifaceted recovery process. OBJECTIVE: This article provides a synthesis of 12 qualitative research studies with various eating disordered populations (anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified, and other specified feeding and eating disorders) to elucidate the recovery process from the perspective of those who have overcome the disease. METHOD: A metasynthesis of qualitative studies was conducted using Noblit and Hare's metaethnographic methodology. RESULTS: Five overarching themes emerged from the data: (1) the eating disorder as a life jacket, (2) drowning: recognizing consequences, (3) treading the surface: contemplating recovery, (4) swimming: the path toward recovery, and (5) reaching recovery: a sense of freedom. CONCLUSIONS: Eating disorder treatment often entails a cycle of transitions before recovery occurs. Synthesizing the experiences from the perspective of individuals who have overcome an eating disorder presents a unique understanding of the treatment and recovery process.

Perceptions of the "anorexic voice": A qualitative study of health care professionals

People with anorexia nervosa (AN) often report experiencing a highly critical inner voice (AV) focused on their eating, shape, and weight. There are promising preliminary findings for its role in the treatment of AN, and the support of staff is vital for the AV to be embedded in treatment, but their views remain unknown. The aims of this study were to undertake a qualitative exploration of the perceptions of the AV among health care professionals (HCPs) in specialist eating disorder services. A thematic analysis was applied to interviews with 15 HCPs, including nurses, therapists, psychiatrists, health care assistants, psychologists, and dietitians. Two overarching themes were identified: "The AV is a vehicle for increasing compassion" and "It's not a one-size-fits-all." The AV was seen as a means of developing and sustaining compassion, but participants noted that it does not resonate for all clients. All HCPs in this study believed that there was potential benefit in utilizing the AV in their work with people with AN, and it is likely that doing so would help to reduce burnout and frustration within clinical teams.

Women's recovery from anorexia nervosa: a systematic review and meta-synthesis of qualitative research

Anorexia nervosa (AN) is a complex and challenging condition and recovery can be a slow and difficult process. Predicting factors remain largely unknown. This paper aims to systematically review qualitative studies which have investigated female service users' experiences of recovering from AN and carry out a meta-synthesis of the themes they identified. Meta-ethnography was used to select and synthesize the studies. Articles published between 2002 and 2017 were searched in PsycInfo, EMBASE, CINAHL and Medline. Studies were included if they explored recovery from AN using a qualitative methodology. The methodological quality of the studies was systematically and critically appraised. Fourteen studies were selected for inclusion. Common themes reported by participants describe the process of recovery from AN as dealing with a fragmented sense of self, a turning point where insight and commitment to recovery is developed, and, in recovery, a reclamation of self through meaningful relationships, rebuilding identity and self-acceptance. Recovery from AN is experienced as a complex psychological process with many contributing factors. Findings highlight the need to reconsider clinical practice and treatment provision to incorporate the psychological components of self-identity into recovery programs.

A systematic review of the 'eating disorder voice' experience

The 'eating disorder voice' experience has been reported by both clinicians and by patients with eating disorders (ED) as an important feature of eating psychopathology, however this has only become an area of research in the last decade. The main aim of this paper was to systematically review and synthesize the available literature on this topic. Systematic searches of seven electronic databases were performed up to June 2018. Thirteen peer-reviewed articles were identified. Findings suggested that the existence of an 'ED voice' is often recognized by patients with eating disorders and that this voice has a powerful, negative and omnipotent nature. Feelings of entrapment and defeat are commonly experienced in response to it and patients appear ambivalent towards it. The negative characteristics and responses to the voice are associated with eating disorder symptoms. Addressing the eating disorder voice using relational and interpersonal approaches has the potential to improve clinical and treatment outcomes for patients with eating disorders.

Can Recovery From an Eating Disorder Be Measured? Toward a Standardized Questionnaire

Background: There is a clear need for a standardized definition of recovery from eating disorders (EDs) and for self-report instruments to assess where individuals with an ED are situated at a given point of time along their process of illness and recovery. It has been acknowledged that psychological and cognitive symptoms are important to recovery in addition to physical and behavioral indices. This study proposes a 28-item multidimensional questionnaire encompassing the main features of recovery from ED, derived from the endorsement of different criteria by people with a lifetime ED diagnosis, family members and ED clinicians. Methods: Participants were 213 volunteers over the age of 18 (118 people with a lifetime ED diagnosis, 58 healthy family members of people with EDs and 37 ED clinicians), who completed the ED-15 and indicated online how important they thought each of 56 criteria were for recovery from an ED. Results: Four factors were identified in an exploratory factor analysis: Lack of Symptomatic Behavior (LSB), Acceptance of Self and Body (ASB), Social and Emotional Connection (SEC), and Physical Health (PH). Confirmatory factor analysis using the seven highest loading items from each subscale confirmed the structure validity of a shortened version of this questionnaire, the Eating Disorders Recovery Endorsement Questionnaire (EDREQ), which had excellent goodness-of-fit indices. Despite a few between-group differences, there was general agreement that LSB was most salient to recovery, followed by ASB, SEC, and PH in that order. Conclusion: Despite the absence of a standardized definition of recovery from ED, there is a general consensus about its components. The EDREQ is a psychometrically sound questionnaire containing items that people with an ED history, their family members and therapists all define as important components of recovery. The inclusion of emotional and psychosocial aspects of recovery in addition to symptomatic and medical aspects is important to expand treatment goals and the concept of recovery from EDs beyond symptom relief and the absence of disease markers. As a clinical tool, the EDREQ stands to assist in setting and refining therapeutic goals throughout therapy, and in establishing standardized, comparable norms for recovery levels in research.

Childhood trauma, dissociation, and the internal eating disorder 'voice'

Many individuals diagnosed with eating disorders describe their disorder as being represented by an internal 'voice'. In line with cognitive models of voice-hearing, previous research has identified associations between voice appraisals and eating psychopathology in anorexia nervosa. Whether these findings generalise to other eating disorder subtypes remains unknown. The aetiology of the internal eating disorder voice also remains unclear. Traumatic-dissociative models of voice-hearing, which link such experiences to decontexualised material arising from early traumatic events, might also be relevant to eating disorder groups. To determine whether cognitive models of trauma and voice-hearing apply across eating disorder subtypes, 85 individuals fulfilling ICD-10 criteria for an eating disorder completed self-report measures regarding eating disorder cognitions, voice-related appraisals, childhood trauma, and dissociation. The relative power of the eating disorder voice was found to be positively associated with experiences of childhood emotional abuse, and this relationship was partly mediated by dissociation. In addition, eating disorder voices appraised as powerful and benevolent predicted more negative attitudes towards eating across diagnostic groups, but were unrelated to disordered eating behaviours or weight. These findings suggest that the eating disorder voice plays a meaningful role in eating pathology across diagnoses and that this experience might be related, in part, to experiences of childhood maltreatment. Therapeutic implications are discussed.

Insidious: The relationship patients have with their eating disorders and its impact on symptoms, duration of illness, and self-image

OBJECTIVES

In published clinical and autobiographical accounts of eating disorders, patients often describe their disorder in personified ways, that is, relating to the disorder as if it were an entity, and treatment often involves techniques of externalization. By encouraging patients to think about their eating disorder as a relationship, this study aimed to examine how young female patients experience their eating disorder as acting towards them, how they react in response, and whether these interactions are associated with symptoms, illness duration, and self-image.

DESIGN

Structural Analysis of Social Behavior (SASB) was used to operationalize how patients experience the actions of their eating disorder and their own reactions to the disorder.

METHOD

The relationship between patients (N = 150) and their eating disorders was examined with respect to symptoms, duration of illness, and self-image. Patients were also compared on their tendency to react with affiliation in relation to their disorder.

RESULTS

Patients' responses on the SASB indicated that they tended to conceptualize their eating disorders as blaming and controlling, and they themselves as sulking and submitting in response. Greater experience of the eating disorder as being controlling was associated with higher levels of symptomatology. Patients reacting with more negative affiliation towards their disorder were less symptomatic.

CONCLUSIONS

When encouraging patients to think about their eating disorder as a relationship, comprehensible relationship patterns between patients and their eating disorders emerged. The idea that this alleged relationship may resemble a real-life relationship could have theoretical implications, and its exploration may be of interest in treatment.

PRACTITIONER POINTS

Patients were able to conceptualize their eating disorder as a significant other to whom they relate when encouraged to do so. Patients tended to experience their disorder as controlling and domineering. Exploring the hypothetical patient-eating disorder relationship may prove helpful in understanding dysfunctional relational patterns. Helping patients to rebel against their eating disorder could potentially aid in symptom reduction.

Identifying fundamental criteria for eating disorder recovery: a systematic review and qualitative meta-analysis

BACKGROUND

Outcome studies for eating disorders regularly measure pathology change or remission as the only outcome. Researchers, patients and recovered individuals highlight the importance of using additional criteria for measuring eating disorder recovery. There is no clear consensus on which additional criteria are most fundamental. Studies focusing on the perspectives of recovered patients show criteria which are closely related to dimensions of positive functioning as conceptualized in the complete mental health model. The aim of this study was to identify fundamental criteria for eating disorder recovery according to recovered individuals.

METHODS

A systematic review and a qualitative meta-analytic approach were used. Eighteen studies with recovered individuals and meeting various quality criteria were included. The result sections of the included papers were searched for themes that were stated as criteria for recovery or 'being recovered'. All themes were analyzed using a meta-summary technique. Themes were labeled into criteria for recovery and the frequency of the found criteria was examined.

RESULTS

In addition to the remission of eating disorder pathology, dimensions of psychological well-being and self-adaptability/resilience were found to be fundamental criteria for eating disorder recovery. The most frequently mentioned criteria were: self-acceptance, positive relationships, personal growth, decrease in eating disorder behavior/cognitions, self-adaptability/resilience and autonomy.

CONCLUSIONS

People who have recovered rate psychological well-being as a central criterion for ED recovery in addition to the remission of eating disorder symptoms. Supplementary criteria, besides symptom remission, are needed to measure recovery. We recommend including measurements of psychological well-being and self-adaptability/resilience in future research, such as outcome studies and in routine outcome measurement.

Quality of life as a vulnerability and recovery factor in eating disorders: a community-based study

BACKGROUND

Emerging evidence suggests that changes in quality of life (QoL) predicts later changes in eating disorder (ED) symptoms. The objective of this study was to explore individual sufferers' perspectives on the influence of QoL on the onset, maintenance, and/or remission of ED symptoms.

METHOD

19 women from the community with a history of eating disorders (n = 13 currently symptomatic; n = 6 recovered) were interviewed about their observations on the relationship between QoL and ED symptoms over time in their own lives. Interviews were audio-taped and transcribed, and then thematically analysed.

RESULTS

Thematic analysis uncovered two major themes: 1. QoL as a Vulnerability Factor, and 2. QoL as a Recovery Factor. In relation to the first theme, onset of ED symptoms was discussed by women in this study as having been triggered by impairment in QoL, including a general sense of lacking control in life, stress, abusive intimate relationships, poor role modelling from family, physical impairment related to obesity, peer pressure, and weight-related teasing. On the other hand, and in relation to the second theme, subsequent improvement in QoL was nominated as central to symptom improvement and recovery. QoL improvement was described by participants differently, but included increased general satisfaction in life, emotional maturation, prioritising and improving physical health, the development of a supportive intimate relationship and social relationships, and having children.

CONCLUSIONS

Impairment in QoL may act as a trigger for the onset and maintenance of ED symptoms, whereas improvement in QoL may be central to eating disorder improvement and eventual recovery. Treatment should involve consideration of a core focus on QoL improvement as a potential 'backdoor' approach to improving ED symptoms.