Understanding women's journey of recovering from anorexia nervosa

Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality

Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.

"Ordinary days would be extraordinary": The lived experiences of severe and enduring anorexia nervosa

OBJECTIVE

Approximately 25% of individuals with anorexia nervosa (AN) experience a chronic form of the disorder, referred to as severe and enduring anorexia nervosa (SE-AN). Although the classification of SE-AN remains preliminary, there have been increasing calls for a harm reduction-based, collaborative treatment model for these patients. To provide such care for patients with SE-AN, it is critical to listen to and learn from their lived experiences.

METHOD

Patients (N = 17) admitted to an inpatient eating disorders program who met initial criteria for SE-AN completed semi-structured interviews about the course of their illness and prior treatment episodes. Interviews were audio recorded and transcribed. Data were analyzed using an inductive, reflexive approach to thematic analysis that examined common themes within and across interviews.

RESULTS

Three themes were identified focused on (1) the all-encompassing nature of SE-AN, (2) treatment experiences, and (3) living with chronic illness. Within these themes, there were subthemes. Overall, individuals noted clear insight about their condition, both negative and positive experiences with previous treatment, and hope for better quality of life despite their illness.

DISCUSSION

Individuals with SE-AN describe their illness as a chronic condition and hope for a harm reduction-based treatment. Future work, including the lived experiences of individuals with SE-AN, is important to build our understanding of the classification and clinical characteristics of SE-AN and to develop treatment approaches that may best serve these individuals.

PUBLIC SIGNIFICANCE

Many people with anorexia nervosa do not achieve a full recovery despite repeated treatment episodes throughout their lifespan. Understanding the lived experiences of individuals with SE-AN may help to inform future treatment development efforts that could improve eating disorder and quality of life outcomes for these patients.

More than an outcome: a person-centered, ecological framework for eating disorder recovery

BACKGROUND

Eating disorder recovery is a complex phenomenon. While historical understandings focused on weight and behaviours, the importance of psychological factors is now widely recognized. It is also generally accepted that recovery is a non-linear process and is impacted by external factors. Recent research suggests a significant impact of systems of oppression, though these have not yet been named in models of recovery. BODY: In this paper, we propose a research-informed, person-centered, and ecological framework of recovery. We suggest that there are two foundational tenets of recovery which apply broadly across experiences: recovery is non-linear and ongoing and there is no one way to do recovery. In the context of these tenets, our framework considers individual changes in recovery as determined by and dependent on external/personal factors and broader systems of privilege. Recovery cannot be determined by looking solely at an individual's level of functioning; one must also consider the broader context of their life in which changes are being made. To conclude, we describe the applicability of the proposed framework and offer practical considerations for incorporating this framework in research, clinical, and advocacy settings.

Paper 1: a systematic synthesis of narrative therapy treatment components for the treatment of eating disorders

BACKGROUND

There are presently a number of eating disorder treatment interventions that have a research-evidence base to support their effectiveness. However, rates of attrition and treatment outcomes demonstrate that there is no one-size fits all for the treatment of eating disorders. Narrative therapy is a promising, but under-researched, intervention for the treatment of eating disorders (EDs). The aim of this study was to conduct a narrative synthesis of the literature to explore the content and use of narrative therapy in the treatment of EDs.

METHOD

Data were extracted from 33 eligible included studies following systematic search of five data bases. Data included aims and objectives, sample characteristics, treatment details and components of narrative therapy, which informed the narrative synthesis. The study is reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Narrative therapy interventions for EDs consisted of several components including the narrative worldview; unpacking the problem story; finding, thickening the meaning and performance of stories hidden by the problem story; and safety considerations. A notable proportion of the extracted articles discussed components of unpacking problem stories, and finding and re-authoring openings (or unique outcomes) that were hidden by problematic stories. Relatively fewer papers discussed the processes by identity shifts were performed or lived out, including in the eating practices of those with a lived ED experience. Furthermore, few papers addressed how therapists established client safety within the narrative framework when working with EDs.

CONCLUSION

This narrative synthesis found that narrative practitioners utilise a variety of narrative therapy techniques in working with individuals with a lived ED experience. The current literature has emphasis on specific narrative therapy techniques used in ED treatments, with some aspects of the narrative worldview and safety considerations left undiscussed. Additional research is needed to explore how identity shifts in narrative therapy are performed and lead to measurable behavioural changes, and to consider how safety considerations can be established within the narrative worldview. There are a number of psychological therapies for eating disorders that have research evidence-base. These treatments, however, do not work for everyone as indicated by drop-out rates and eating disorders running a severe and enduring course for some people. Narrative therapy is a therapeutic intervention that has been reported as a promising intervention for people with an eating disorder. The focus of narrative therapy is to engage the person in finding identities hidden by problem-saturated identities and in the performance of these hidden identities. In this review, we have explored the use of narrative therapy for eating disorders to identify what aspects of this therapy are currently being used and which components are less referenced in the literature. Findings from this study support the need for further research into narrative therapy components in the treatment of eating disorders, particularly how hidden identities are performed and safety considerations are integrated into this therapeutic intervention.

Different pathways, same goals: A large-scale qualitative study of autistic and non-autistic patient-generated definitions of recovery from an eating disorder

BACKGROUND

Definitions of recovery from an eating disorder (ED) have generally been formulated around clinical conceptualisations, rather than based on the views of patients. This paper therefore asked those with lived experience of ED for their own definitions of recovery.

METHOD

Data were collected as part of an online study looking at EDs, autism and relationships. About 173 participants identified as recovered from ED and gave free-response definitions of recovery. Responses were subject to thematic analysis.

RESULTS

Seven major themes were identified: Weight restoration, lack of ED behaviours, thoughts and behaviours, cognitions, emotional responses, getting on with life, and ongoing challenges.

CONCLUSIONS

Many definitions of recovery given by those who have lived experience of ED echoed those used by clinicians and researchers. There were also points of divergence around the ongoing challenges of recovery. Our findings highlight the need for continuing support post-weight restoration to facilitate the successful long-term recovery for those with ED.

Women, Exercise, and Eating Disorder Recovery: The Normal and the Pathological

The appropriate form, regularity, and intensity of exercise for individuals recovering from eating disorders is not agreed upon among health care professionals or researchers. When exercise is permitted, it is that which is mindful, embodied, and non-competitive that is considered normative. Using Canguilhem's concepts of "the normal and the pathological" as a theoretical frame, we examine the gendered assumptions that shape medical understandings of "healthy" and "dysfunctional" exercise in the context of recovery. The data set for this article comes from longitudinal semi-structured interviews with 19 women in the United Kingdom who engaged in weightlifting during their eating disorder recovery. We argue that women in recovery navigate multiple and conflicting value systems regarding exercise. Faced with aspects of exercise that are pathologized within the eating disorder literature (such as structure/routine, body transformations, and affect regulation), women re-inscribe positive value to these experiences, thus establishing exercise practices that serve them.

Critical incidents in anorexia nervosa: perspectives of those with a lived experience

BACKGROUND

Although social-emotional difficulties are believed play a key role in anorexia nervosa (AN), there is uncertainty regarding what these difficulties might look like. Previous research has largely focused on a "disease model" of social-emotional processing in AN with little attention paid to positive emotions and experiences. Therefore, the aim of the present study was to obtain a fuller picture of critical life events as identified by those with lived AN experience.

METHODS

Thirty-four participants aged 16-48 with current or past AN completed an online survey describing self-defined positive and difficult critical events. Thematic analysis was used to assess patterns in participants narrative responses.

RESULTS

Two major themes were identified in the descriptions of positive critical events: Moments of celebration and Unexpected positive outcomes. These major themes revealed increased external focus and some corrective experiences that challenged the participants pre-existing expectations leading to new positive outcomes. Difficult events clustered into life events that were identified as Eating disorder (ED) related and Non-ED related and included the dimensions of relational conflict and feeling unsupported.

DISCUSSION

The findings suggest that although negative emotionality was identified in the accounts of those with lived experience of AN capacity for "big-picture" thinking with and explicit focus on others was also identified. Moreover, an openness to corrective experiences that worked to challenge negative expectations was evident for some participants. Together these findings have scope as targets for further clinical research and treatment interventions.

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.

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.

Similarities and Differences in Theory of Mind Responses of Patients With Anorexia Nervosa With and Without Autistic Features

Theory of Mind (ToM) is the ability to understand and represent mental states of others, a skill that plays a key role in how we interact with people around us. Difficulties with ToM have been posited as an underlying mechanism for autism and implicated in difficulties faced by those with anorexia nervosa (AN). This study examined, both quantitatively and qualitatively, the responses of women between the ages of 14 and 25 years on the Frith-Happé Triangle Animations, a well-validated test of ToM. Participants were split into healthy controls (HCs), AN patients (AN), and AN patients with high levels of autistic features (AN+ASF). We found no significant quantitative differences between groups in performance on the task. Qualitatively, there were differences between groups such that AN patients, especially those in the AN+ASF group, were more focused on describing the videos than creating narratives, were more negative in their interpretations, and were much more anxious about their performance. These qualitative differences have clinical implications, including that not all AN patients with autistic features should be assumed to have difficulties with ToM.

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.

Psychological need satisfaction, control, and disordered eating

OBJECTIVES

Unfulfilled basic psychological needs have been associated with disordered eating behaviours, but the mechanisms underlying that associations are not well understood. This study examined a two-stage path model linking basic psychological need satisfaction to disordered eating behaviours via issues of control.

METHODS

Female university students (N = 323; M_age  = 19.61), community participants (N = 371; M_age  = 29.75), and women who self-reported having been diagnosed with an eating disorder (ED; N = 41; M_age  = 23.88) completed measures of psychological need satisfaction (i.e., autonomy and competence), issues of control (i.e., feelings of ineffectiveness and fear of losing self-control [FLC]), and ED pathology.

RESULTS

Path analysis revealed that unsatisfied needs of autonomy and competence were indirectly related to disordered eating behaviours through feelings of ineffectiveness and FLC.

CONCLUSIONS

The results indicate that issues of control might be one of the mechanisms through which lack of psychological need satisfaction is associated with disordered eating. Although the model was constructed using cross-sectional data, these findings suggest potential targets for prevention and treatment efforts aimed at reducing disordered eating in young females.

PRACTITIONER POINTS

Our results indicate that young women with chronically unfulfilled basic psychological needs might be vulnerable to developing disordered eating behaviours. The observed patterns suggest that persistent experience of need frustration may engender an internal sense of ineffectiveness and lack of control, which then compels individuals to engage in disordered eating behaviours in an attempt to regain autonomy and competence. Interventions for eating disorders may be most effective when emphasizing the promotion of people's needs for autonomy and competence. Limitations The model was constructed using cross-sectional data. Future experimental and longitudinal studies are needed to confirm the temporal sequence from basic psychological needs to issues of control. The sample only consisted of young women. Further research should explore how thwarting of psychological need satisfaction functions in men. Our clinical sample was small and diagnosis was not confirmed through clinical interview; therefore, those data should be interpreted with caution.

‘Learning to live your life again’: An interpretative phenomenological analysis of weblogs documenting the inside experience of recovering from anorexia nervosa

This study aimed to explore the construct of recovery from anorexia nervosa through the medium of weblogs, focusing on the benefits and barriers to the recovery process. Data were extracted from female ( n = 7) and male ( n = 1) participants’ textual pro-recovery weblogs, all of which were posted between 2013 and 2015 in the public domain. Data were analysed using interpretative phenomenological analysis. Three superordinate themes were identified: (1) barriers to recovery, (2) factors increasing the likelihood of recovery and (3) support. Results suggest supportive relationships, regaining control and recognising the consequences of the eating disorder benefit recovery, whereas public perceptions, the anorexia nervosa voice and time act as barriers to recovery. Out of eight participants, four described seeking professional help as part of their recovery, of which three believed their professional therapy experience helped aid recovery. Implications for anorexia nervosa treatment are discussed in detail.

Sense of self and anorexia nervosa: A grounded theory

OBJECTIVES

The aim of this study was to explore the nature of the relationship between the self and the eating disorder in individuals with a lifetime history of anorexia nervosa (AN).

DESIGN

A qualitative design was used, given the exploratory nature of the study and the need to gain rich and in-depth data regarding the topic under investigation.

METHOD

Semi-structured interviews were conducted with 11 women with a lifetime history of AN. Interview transcripts were analysed using constructivist grounded theory methodology.

RESULTS

A theoretical framework of the nature of the relationship between the self and AN was developed, which included five related categories: AN taking over the self, AN protecting the self, sharing the self with AN, being no one without AN, and discovering the real me (accepting the fear).

CONCLUSION

Participants described a process of the self being taken over by AN to the point where it was shared with the eating disorder. This led participants to fear being no one without AN and to be unable to let go of the disorder, appreciating AN's ability to protect the self. To recover from AN, participants had to discover the real self, by accepting the fear of the unknown and separating the self from AN. The findings have important implications for the target of therapeutic interventions to improve recovery rates.

PRACTITIONER POINTS

The self is shared with the eating disorder in AN, and separating the self from AN is crucial to recover from the disorder. Therapeutic interventions for AN need to target the enmeshed relationship between the self and the eating disorder, as opposed to focusing exclusively on weight and shape concerns.

'Feelings stronger than reason': conflicting experiences of exercise in women with anorexia nervosa

BACKGROUND

Individuals with anorexia nervosa frequently feel ambivalent about treatment and weight restoration, and drop out and relapse rates in treatment are high. Increased insight into the function of the eating disorder is considered essential for achieving long-lasting, meaningful change. However, research investigating the functions of anorexia nervosa tends to focus on the role of the disease per se. Distinctions are rarely made across features. In particular, the subjective experience, understanding and sense making of the engagement in compulsive exercise in individuals with anorexia nervosa has received little attention. By using a qualitative methodological approach, this paper aims to expand on prior findings by examining how patients with anorexia nervosa understand and make sense of the experience of exercise in the context of their lives and treatment programme.

METHODS

Semi-structured interviews were conducted with six females, four of whom were former athletes. Transcripts were subjected to interpretative phenomenological analysis (IPA).

RESULTS

Two overarching themes emerged in the analysis of the larger study of which this paper is a part; 'paradoxical functions of exercise' and 'diverging experiences of exercise'. Diverging experiences of exercise is the focus of this paper. Firstly, in spite of being severely underweight and suffering from exhaustion, as well as having a clear awareness of the associated negative health effects, participants were engaged in a continuous cycle of rigorous and excessive exercise, which consumed extensive amounts of time and energy. Secondly, the results demonstrate how exercise routines negatively control and interfere with the participants' involvement in the social world. Thirdly, the manner in which participants speak about their exercise reveals their wording to be characterized by efforts to downplay the extent of their actual immersion in exercise. Issues of control and ambivalence about treatment and recovery can be considered potential triggers for the participants' engagement with exercise. Implicit meanings are elaborated upon and discussed in relation to existing literature.

CONCLUSIONS

The material provides increased insight into the multi-layered meanings of exercise for individuals with anorexia nervosa. It also suggests alternatives to current ways of understanding and approaching exercise that may enable this issue to be addressed in a more meaningful way in therapy. Qualitative approaches can make a valuable contribution to furthering such understanding.

The limits to pride: A test of the pro-anorexia hypothesis

Many social psychological models propose that positive self-conceptions promote self-esteem. An extreme version of this hypothesis is advanced in "pro-anorexia" communities: identifying with anorexia, in conjunction with disordered eating, can lead to higher self-esteem. The current study empirically tested this hypothesis. Results challenge the pro-anorexia hypothesis. Although those with higher levels of pro-anorexia identification trended towards higher self-esteem with increased disordered eating, this did not overcome the strong negative main effect of pro-anorexia identification. These data suggest a more effective strategy for promoting self-esteem is to encourage rejection of disordered eating and an anorexic identity.

Close relationships and disordered eating: Partner perspectives

The role and potential significance of romantic partners have been acknowledged in the eating disorder literature; yet, few studies have addressed partner perspectives, and none of these have involved dating relationships or considered the implications of the initiation of recovery for partner perceptions. In this study, common themes in the analysis of 12 partner interviews included changing understandings of disordered eating, development of strategies to support their partners, and lack of resources. In addition, participants whose partners did not initiate recovery reported confusion and helplessness, while those whose partners initiated recovery expressed responsibility for and gratification in the positive changes.

Experiences of Detention under the Mental Health Act for Adults with Anorexia Nervosa

People with Anorexia Nervosa are often resistant to treatment and can be detained under the Mental Health Act. Detention can be distressing for some client groups; however, there is little research to explore how people with Anorexia Nervosa experience detention and how these experiences impact on recovery. This study utilized a qualitative methodology to develop a model for understanding how people perceive, experience and process detention under the Mental Health Act. Data from 12 participants was analysed using constructivist grounded theory. Four overarching categories conceptualize their experience over time: 'the battle', 'the bubble', 'stepping out of the bubble' and 'the anorexic self'. Within each overarching category are further subordinate categories that represent the nuances of the data. The resultant model is discussed in relation to the literature, whilst recommendations have been made to embed person-centred, recovery practice into inpatient services. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

People detained under the mental health act with anorexia nervosa often respond by engaging in a battle with clinicians. This follows by the person withdrawing into a 'bubble' where the individual starts to feel some relief that they are no longer in control of their eating, but this competes with the lack of self and the emerging anorexic self. Clinicians need to be aware that individuals detained may have mixed feelings about their hospital admission.

Being me and being us - adolescents' experiences of treatment for eating disorders

BACKGROUND

This qualitative study addresses adolescents' perception of treatment for eating disorders. The importance of involving parents in treatment of young people with eating disorders, especially young people with Anorexia Nervosa, is emphasized in a number of studies. Even so, this form of treatment does not work for everybody, not even within a limited diagnostic group. Previous research has revealed that many young people are not entirely satisfied with their treatment. However, there is a lack of knowledge concerning the perspectives of adolescents in outpatient treatment, whose treatment often involves family. The aim of the present study was to investigate how young people with experience from adolescent outpatient treatment for eating disorders, involving family-based and individual based interventions, perceive their time in treatment.

METHODS

This study was conducted using a hermeneutic phenomenological approach. Fifteen participants were recruited in collaboration with four specialized eating disorder units and interviewed with the purpose to gather narratives.

RESULTS

The analysis revealed that the adolescents sometimes felt more or less forced into treatment, and strong ambivalent feelings about if and how to participate in treatment permeated the adolescents' narratives. The common factors which emerged in the narratives were assembled under the two major themes: Having to involve family in treatment - in one way or another and Making progress in treatment - a matter of trust.

CONCLUSIONS

It is of great importance to involve family in treatment in order to understand the problems of the adolescents in their context and be able to take advantage of the resource that parents constitute. However, in certain situations, it is necessary to prioritise individual treatment interventions so that instead of sorting out difficult family situations the therapist focuses on enhancing the young people's resilience, thus enabling them to tackle problematic situations in life.

Interpreting genetics in the context of eating disorders: evidence of disease, not diversity

How is genetic involvement interpreted for disorders whose medicalisation is contested? Framing psychiatric and behavioural disorders in terms of genetics is expected to make them seem more medical. Yet a genetic aetiology can also be used to frame behaviour as acceptable human variation, rather than a medical problem (for example, sexual orientation). I analyse responses to the idea that there is a genetic component in anorexia and bulimia nervosa (AN or BN) via semi-structured interviews with a sample of 50 women diagnosed with an eating disorder (25 had recovered). All but three volunteered that genetics would medicalise AN or BN by (i) making eating disorders seem more like 'real diseases'; implying that these disorders need (ii) professional treatment or (iii) a biologically based treatment. The results also indicate there are several counter-logics by which genetic framing could support non-medical definitions of AN or BN. I argue that genetic framing reduces perceived individual responsibility, which can support definitions of behaviour as either a reflection of disease (which entails intervention) or a reflection of normal human diversity (which does not). In the context of public scepticism as to the 'reality' of AN or BN, genetic involvement was taken as evidence of disease in ongoing negotiations about the medical and moral status of people with eating disorders.

"Doing the impossible": the process of recovery from chronic anorexia nervosa

In this study, we aimed to explore the process of recovery over time from the perspective of those who had fully recovered from chronic anorexia nervosa (AN), using stringent recovery criteria. Eight women, assessed as fully recovered from chronic AN, told their story of the process of recovery. Data were analyzed using the qualitative method, narrative inquiry. Recovery was identified as a long and complex process that spanned four phases: from being unable or unready to change, to experiencing a tipping point where motivation increased and changed in quality, allowing the women to take action against the AN and finally allowing them to reflect and rehabilitate. Results provide a framework for understanding this complex process. Findings suggest that full recovery from chronic AN is possible and emphasize the importance of hope, motivation, self-efficacy, and support from others in the recovery process.

Figured World of Eating Disorders: Occupations of Illness

Background. The biomedical diagnosis of eating disorders signifies a mental illness with complex physical symptomology. The socio-cultural determinants and impact of eating disorders on daily occupations are not adequately addressed in this classification.

Purpose. This paper introduces the concept of a figured world as a framework for how eating disorders exist in daily activity and social discourse. How occupations become ascribed with meaning generated by an eating disorder will be proposed through the voice of a composite character in the figured world.

Key Issues. Central elements to contextualizing figured worlds include positional identity, self-authoring, and semiotic mediation. The generation of meaning in illness arises from the integration of these elements into this specific figured world.

Implications. The competing agendas of the biomedical model and figured world permit a new understanding of the challenges associated with recovery. For occupational therapists, these challenges require the reattribution of meaning of daily occupations.

Self-change in eating disorders: is "spontaneous recovery" possible?

A limited series of community studies including non-treatment-seekers has shown that a considerable number of eating disorder patients do not enter the health care system but can be considered "clinically recovered" (remission of major symptoms) if followed up long enough. The possibility of "spontaneous recovery" (overcoming an eating disorder without professional treatment or formal help) often faces scepticism on the part of professionals. Clearly, self-change is an underestimated pathway to recovery from an eating disorder, but open-minded clinicians can learn a lot from it. Active coping and making use of one's "recovery capital" are key features of self-change even if maintenance of change is associated with social support and positive life changes.

Bone loss in anorexia nervosa: leptin, serotonin, and the sympathetic nervous system

Anorexia nervosa (AN), a disorder characterized by the refusal to sustain a healthy weight, has the highest mortality of any psychiatric disorder. This review presents a model of AN that ties together advances in our understanding of how leptin, serotonin, and hypogonadism are brought about in AN and how they influence bone mass. Serotonin (5-hydroxytryptamine) is a key regulator of satiety and mood. The primary disturbance in AN results from alterations in serotonin signaling. AN patients suffer from serotonergic hyperactivity of Htr1a-dependent pathways that causes dysphoric mood and promotes restrictive behavior. By limiting carbohydrate ingestion, anorexics decrease their serotonin levels. Reduced serotonergic signaling in turn suppresses appetite through Htr1a/2b, decreases dysphoric mood through Htr1a/2a, and activates the sympathetic nervous system (SNS) through Htr2c receptors in the ventromedial hypothalamus. Activation of the SNS decreases bone mass through β2-adrenergic signaling in osteoblasts. Additional topics reviewed here include osteoblastic feedback of metabolism in anorexia, mechanisms whereby dietary changes exacerbate bone loss, the role of caloric restriction and Sirt1 in bone metabolism, hypothalamic hypogonadism's effects on bone mass, and potential treatments.

Effectiveness of self-esteem and social skills group therapy in adolescent eating disorder patients attending a day hospital treatment programme

OBJECTIVE

To evaluate self-esteem and social skills in adolescent eating disorder patients before and after specific group therapy as part of a Day Hospital Programme.

METHOD

One hundred and sixty adolescent eating disorder patients, classified as anorexia nervosa and related disorders (AN-rd) (N = 116) or bulimia nervosa and related disorders (BN-rd) (N = 44) received structured group therapy for developing self-esteem and social skills.

RESULTS

BN-rd patients had poorer perceptions of some self-esteem and social skills variables. After group therapy, both groups presented significant improvements in their perceptions of physical appearance, their self-concept related to weight and shape and to others, happiness and satisfaction, social withdrawal and leadership. BN-rd patients presented more changes on many of the variables.

DISCUSSION

Specific self-esteem and social skills group therapy in patients with eating disorders can be useful in improving certain core features.

Fathers, daughters, and anorexia nervosa

PURPOSE

The study described the nature and meaning of the father-daughter relationship throughout the daughter's (N = 11) life from the perspective of the daughter, who has been in a 2-year recovery from anorexia nervosa (AN). Particular consideration was given to the changes over time.

DESIGN AND METHODS

A narrative analysis method was used to examine the daughter's stories.

FINDINGS

Several patterns emerged. This study is an exploration of the paths and processes that lead to, through, and into recovery from AN with regard to the father-daughter relationship.

PRACTICE IMPLICATIONS

The results have implications for nursing practice, research, and health policy.

Family perception of anorexia and bulimia: a systematic review

A systematic literature review published between 1990 and 2006 using a qualitative approach was conducted to explore family members' perception of anorexia and bulimia nervosa patients. Articles were critically reviewed and a meta-synthesis analysis was carried out based on a meta-ethnographic method to analyze and summarize data. Of a total of 3,415 studies, nine met the study inclusion and exclusion criteria. Reciprocal translation was used for data interpretation allowing to identifying two concepts: disease awareness and disease impacts. Feelings of impotence were often described in family reorganization. The study results point to distortions in the concept of disease associated with family involvement, resulting in changes in communication, attitudes, and behaviors in a context of impotence.

A consideration of developmental egocentrism in anorexia nervosa

Recent research has suggested that normal adolescent processes are important in understanding psychosis, and that young adult individuals with psychosis are often struggling to develop an individual and autonomous self (the "fundamental task" of adolescence). The current paper explores the utility of considering normative adolescent developmental processes in understanding anorexia nervosa. Data were collected from 31 female young-adults with symptoms of anorexia nervosa, 26 female comparison young-adults and 71 female adolescents on measures of adolescent egocentrism. A one-way ANOVA indicated that individuals with symptoms of anorexia nervosa scored more highly than both their peers and the adolescents on several dimensions of egocentric developmental beliefs. Correlations also showed that egocentrism was positively associated with eating concern in participants with symptoms of anorexia. The results suggest that young-adult women with symptoms of anorexia nervosa tended to feel physically invulnerable while also feeling both psychologically vulnerable to others and special or different. Together with the finding of excessive self-consciousness, this supports a notion that they may be experiencing exaggerated versions of normal self-developmental phenomena. Clinically, offering alternative ways of feeling unique other than dieting may be important in therapeutic approaches to anorexia nervosa. Similarly, strategies aimed at normalisation, such as facilitating healthy attachment to peers, may be useful for individuals with anorexia nervosa.

Eating disorders, parent-child conflicts, and family therapy in Shenzhen, China

In this article, I report the results of a qualitative study conducted in Shenzhen, China, in which I aimed to (a) identify the characteristics of parent-child conflicts between Shenzhen youths suffering from eating disorders and their parents and (b) contextualize these intergenerational conflicts to understand their meanings within the immediate sociocultural context. I have employed multiple-case studies as the research design. Data have been collected through reviews of the family treatment sessions for ten families, each with an adolescent daughter suffering from eating disorders, and with the session being videotaped with written consent from the youths and the families. Emerging from the data were three types of parent-child conflicts: (a) intergenerational control and power struggle, (b) growing up versus remaining childlike, and (c) pursuit of personal goals or living up to parental expectations. Implications for clinical practice are also discussed.

Theoretical sampling and category development in grounded theory

Theoretical sampling is a hallmark of grounded theory methodology, and yet there is little guidance available for researchers on how to implement this process. A review of recently published grounded theory studies in Qualitative Health Research revealed that researchers often indicate that they use theoretical sampling to choose new participants, to modify interview guides, or to add data sources as a study progresses, but few describe how theoretical sampling is implemented in response to emergent findings. In this article, two issues that arose relative to theoretical sampling in an ongoing grounded theory study are discussed. A theoretical sampling guide that was developed by the authors' research team to facilitate systematic decision making and to enhance the audit trail relative to theoretical sampling is described, and an example of how the guide was used to develop a category is presented.

Causes of adolescent onset anorexia nervosa: patient perspectives

This qualitative study describes the perspectives of former anorexia nervosa (AN) patients with respect to why they believed they developed AN. Previous patients with initial treatment in child and adolescent psychiatric clinics in northern Sweden were interviewed 8 and 16 years after initial assessment. The question, "What do you think today about the reasons why you got AN?" was asked at both interviews. Content analyze was used to categorize the answers. Causes were attributed to self, family, and socio-cultural stressors outside of the family. Most common were high own demands and perfectionism. At the second follow-up there were more answers in the family categories. The results agreed with results from risk-factor research.

Which elements in the treatment of eating disorders are necessary ‘ingredients’ in the recovery process?—A comparison between the patient's and therapist's view

BACKGROUND

Little is known about which therapeutic 'ingredients' in the treatment of eating disorders (anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED)) are needed for recovery. Remarkably, most studies on this topic have neglected the patient's view.

METHOD

In this study, a large sample of eating disorder patients (n = 132) was invited to evaluate which elements in the treatment they consider to be helpful and effective in their recovery process. These results were compared to the view of 49 eating disorder experts.

RESULTS

Following the patient's view, 'improving self-esteem', 'improving body experience' and 'learning problem solving skills', were considered as core elements in their treatment. No major differences were found between the different patient samples when comparing the patient's and therapist's view.

DISCUSSION

The findings suggest that therapists and patients share more or less the same view about the basic and effective elements in the treatment.

Perceptions of gender ideals predict outcome of eating disorders in adolescent girls

Clinical features have low predictive value for the outcome of eating disorders. This study focuses on the possible predictive value of gender ideals. Data was from adolescent girls thoroughly assessed both at presentation and at a three-year follow up. Few variables differed between the outcome groups. However, perceptions of gender ideals, as measured by the Three Questions of Ideals, were found to contribute to the prediction of outcome. A discriminant analysis showed that gender ideals, maturity fears, sexual debut, and vomiting were significant discriminators in a set of factors, which correctly classified the outcome for 75.3% of the sample.

Patient perspectives of recovery in adolescent onset anorexia nervosa

The aim of this qualitative study was to describe the patients' perspective of the recovery process from anorexia nervosa. On average 16 years after initial assessment at child and adolescent psychiatric clinics, 68 women were interviewed about what they attributed as important factors in the recovery process of their adolescent onset anorexia nervosa. The answers were coded using content analysis. Those having recovered (n = 58) were able to describe clear turning points in their history and mentioned as most important aspects in their recovery: friends, own decisions, activities, treatment, family of origin, and own family.