Anorexia nervosa, parental 'expressed emotion' and dropping out of treatment

Expressed emotion and early treatment response in family-based treatment for adolescent anorexia nervosa

This study examined the effect of pre-treatment levels of parental expressed emotion (EE) on early treatment response for adolescent anorexia nervosa (AN). Data were collected from 121 adolescents, ages 12-18, who met DSM-IV criteria for AN excluding the amenorrhea criterion, and their parents. Participants were randomized to family-based treatment (FBT) or adolescent-focused therapy (AFT). To examine the effects of different thresholds of EE, we used two different levels of EE in analyses. Results demonstrated that adolescents who had at least one parent with elevated EE indicated by a lower threshold (i.e. even mild levels) at baseline were less likely to achieve an early treatment response, suggesting that EE might interfere with treatment success from the start of treatment. When high EE was defined by a higher threshold, these effects were no longer significant, regardless of treatment type (FBT or AFT). These findings suggest that adolescents with AN may be more sensitive to EE than other mental illnesses, such that lower thresholds of EE impact the speed with which they are able to reduce symptoms and gain weight in treatment. It may be necessary to target parental EE prior to or early in treatment or pivot to parent-focused treatment to change the trajectory of treatment response. Future research is needed to explore ways parental EE can be reduced.

Emotion coaching skills as an augmentation to family-based therapy for adolescents with anorexia nervosa: A pilot effectiveness study with families with high expressed emotion

OBJECTIVE

To examine the feasibility and acceptability of augmenting family-based treatment (FBT) for adolescents with anorexia nervosa (AN) or atypical anorexia nervosa (AAN) with a parent emotion coaching intervention (EC) focused on reducing parent expressed emotion.

METHOD

In this pilot effectiveness trial, families of adolescents with AN/AAN exhibiting high expressed emotion received standard FBT with either (1) EC group or (2) support group (an attention control condition focused on psychoeducation).

RESULTS

Forty-one adolescents with AN or AAN were recruited (88% female, Mage  = 14.9 ± 1.6 years, 95% White: Non-Hispanic, 1% White: Hispanic, 1% Bi-racial: Asian). Most study adolescents were diagnosed with AN (59%) while 41% were diagnosed with AAN. Participating parents were predominantly mothers (95%). Recruitment and retention rates were moderately high (76% and 71%, respectively). High acceptability and feasibility ratings were obtained from parents and interventionists with 100% reporting the EC intervention was "beneficial"-"very beneficial." The FBT + EC group demonstrated higher parental warmth scores at post-treatment compared to the control group (standardized effect size difference, d = 1.58), which was maintained at 3-month follow-up. Finally, at post-treatment, the FBT + EC group demonstrated higher rates of full remission from AN/AAN (40%) compared to FBT + support (27%), and were nine times more likely to be weight restored by 3-month follow-up.

DISCUSSION

Augmenting FBT with emotion coaching for parents with high expressed emotion is acceptable, feasible, and demonstrates preliminary effectiveness.

PUBLIC SIGNIFICANCE

Family based treatment for AN/AAN is the recommended treatment for youth but families with high criticism/low warmth are less likely to respond to this treatment. Adding a parent emotion coaching group (EC) where parents learn to talk to their adolescents about tough emotions is feasible and well-liked by families.

Attachment-Based Family Therapy to Improve Family Functioning in Adolescent Binge-Spectrum Eating Disorders: An Initial Evaluation Via Case Series Design

Binge-spectrum eating disorders (EDs; bulimia nervosa, binge eating disorder) often develop during adolescence and are associated with serious psychological and physical consequences. Current treatments for adolescents are highly behavioral in nature and while efficacious, many patients do not reach remission indicating that current treatments fail to target a key maintenance factor for EDs. One potential maintenance factor is poor family functioning (FF). In particular, high family conflict (e.g., arguing, critical comments) and low family cohesion (e.g., warmth, support) are known to maintain ED behaviors. Poor FF can (1) cause or exacerbate an adolescent's use of ED behaviors to cope with life stress and/or (2) inhibit parents from being a resource to adolescents during ED treatment. Attachment-Based Family Therapy (ABFT) is specifically designed to improve FF, and thus may be a promising adjunct to behavioral ED intervention strategies. ABFT, however, has not been tested in adolescents with binge-spectrum EDs. Thus, the current study is the first to evaluate a 16-week adapted ABFT treatment for adolescents with EDs (N = 8, Mage = 16.00, 71.43% female, 71.43% White) fusing together behavioral treatment for EDs with ABFT for highest possible impact. Eight families were treated in an open pilot trial to examine treatment feasibility, acceptability, and preliminary efficacy on FF and eating pathology. Overall, findings were promising. ABFT + B treatment was feasible and acceptable and showed preliminary evidence that it could improve FF and ED behaviors. Future research will test this intervention in a larger sample and further examine the role of FF in maintaining ED symptoms.

Expressed emotion and treatment outcome in higher levels of care for eating disorders

OBJECTIVE

Expressed emotion (EE) among caregivers toward the affected offspring is a negative prognostic indicator for adolescent patients with eating disorders (EDs) in outpatient treatment. Less research has examined its impact on adolescents in higher levels of care (HLOC). The current study examined differences in caregiver EE according to the subtype of anorexia nervosa (AN) (restricting [AN-R] versus binge/purge [AN-BP]), and level of care (LOC). We also examined the main effects of baseline caregiver EE (emotional overinvolvement [EOI] or criticism), AN subtype, and their interaction on eating pathology and depression at discharge.

METHOD

Adolescent patients (N = 203) receiving treatment at HLOCs completed measures of ED pathology (Eating Disorder Examination-Questionnaire) and depression (Patient Health Questionnaire-9) at baseline and discharge, and one caregiver of each patient completed a measure of EE (Family Questionnaire) at baseline.

RESULTS

No differences in caregiver EE were found between patients with AN-R versus AN-BP, or relative to LOC. Caregiver EE did not predict outcome for ED symptoms or depression at discharge.

DISCUSSION

The impact of high caregiver EE may be less substantial at HLOCs than outpatient care given that caregivers are less involved in treatment at HLOCs. Future research is needed to determine if high caregiver EOI leads to poor treatment outcome for adolescents as it does for adults, or whether it is an appropriate expression of care for patients who are ill enough to require HLOC treatment.

PUBLIC SIGNIFICANCE STATEMENT

High caregiver EE was not found to predict treatment outcome for adolescents with eating disorders in higher levels of care (HLOCs), possibly due to the limited involvement of caregivers in HLOCs. However, patients step down to outpatient treatment, where high caregiver EE can have a significant negative impact on outcome. HLOCs should incorporate efforts to reduce high caregiver EE in anticipation of step-down to outpatient treatment.

Treatment-engagement fears in family-oriented interventions: validation of the caregiver traps scale for eating disorders

As more caregivers of children (of any age) struggling with an eating disorder are recruited as partners in care, it is important to identify potential barriers to such involvement. The Caregiver Traps Scale for Eating Disorders (CTS-ED) was developed as a measure of caregiver fears with respect to treatment-engagement. The purpose of this study was to evaluate its psychometric properties. One hundred and twenty four parents of children with ED participated in the validation of this instrument. Data were analyzed through exploratory factor analysis. The exploratory factor analysis revealed one factor, accounting for 39% of the variance, with a mean of 3.99 (scale from 1 to 7), indicating that caregivers endorsed clinically significant fears relating to their involvement in their child's treatment. The scale yielded high internal consistency (α = .89). As expected, the CTS-ED was significantly positively correlated with a measure of accommodating and enabling of ED symptoms, and negatively correlated with a measure of parental self-efficacy. This scale shows promise as a measure for clinicians and researchers to identify parental fears that could potentially fuel accommodating, enabling or treatment-interfering behaviors. Suggestions for its utility as a clinical and supervision tool are also provided.Clinical SignificanceDevelopment of an assessment tool to identify caregiver fears with respect to therapy engagement in the context of family-oriented interventions for eating disordersTool has the potential to increase the positive involvement of caregivers to support their child (of any age) with an eating disorderTool can be used clinically and to support self-reflective practices to improve compassionate clinician engagement of caregivers struggling to support their child.

Maintaining Factors of Anorexia Nervosa Addressed from a Psychotherapeutic Group for Parents: Supplementary Report of a Patient's Therapeutic Success

(1) Background: Anorexia nervosa is an eating disorder (ED) where up to 30% of individuals remain unresponsive to treatments, whether they partially respond, or do respond and later relapse. It has been broadly reported how presenting maladaptive family functioning and communication style contributes to treatment drop-out, poor treatment compliance, and poor long-term outcomes. We studied the mother and father of a patient with AN, binge-purge subtype (according to DSM-IV TR) who achieved remission after her parents but not her attended an intervention through a psychotherapy group for parents (PGP). (2) Methods: We previously reported this patient's case report, and now, through an Interpretative Phenomenological Analysis (IPA) approach, we aimed to explore the understanding and meanings ascribed by the mother and father to their experience at the PGP and to their daughter's clinical and functional improvement. (3) Results: We identified two main stages along the process: one related to the presence of maintaining factors of their daughter's disorder, and the other related to the emergence of a reflective function and to the implementation of behavioral, emotional and cognitive changes. (4) Conclusions: The interview revealed both parents' experience at the PGP promoted a change process, where they were able to modify their previous style of communication and functioning, and to identify them as a contributors to maintain their daughter's disorder. Reflective function (RF) emerged in the mother and father throughout the psychotherapeutic process. Both parents also revealed some elements that were intergenerationally transmitted, that affected three generations and contributed to maintaining the ED. We observed the multilevel open-group structure of the PGP, enhancing the mother's and father's change process.

Expressed Emotion and Health Care Use in Borderline Personality Disorder Patients and Relatives

Introduction: Expressed emotion (EE) is a global index of attitudes, emotions, and behaviors of relatives who have family members with a mental or psychiatric disorder. The objective of this cross-sectional study was to study EE in relatives and patients’ perceived EE in a borderline personality disorder (BPD) outpatient sample. Methods: The sample was composed of 134 relatives and 111 BPD outpatients who were receiving psychological treatment. Relevant clinical outcomes, number of medical visits, EE in relatives and perceived EE in BPD patients were measured. Subsequently, descriptive statistical analyses, dependent-samples t tests, and correlation analyses were performed. Results: Relatives' EE was not significantly different than patients' perceived EE. Expressed emotion factors were weakly associated to emergency department visits and hospital admissions. Discussion: Contrary to EE studies in other diagnoses, results show that the BPD patients' emotional climate in their proximate relationships might not influence health care use.

Exploring carer burden amongst those caring for a child or adolescent with an eating disorder during COVID-19

BACKGROUND

Carer burden amongst carers of youth with an eating disorder is substantial and if not addressed can lead to negative outcomes for the patient, carer and family. The Coronavirus Disease 2019 (COVID-19) pandemic has made caring for youth with an ED even more onerous and preliminary research is beginning to emerge demonstrating the profound negative impact the pandemic is having upon individuals with EDs and their carers. MAIN: In this review, we briefly summarize what is known about carer burden in families where a young person has an ED, consider the additional impact consequent to COVID-19 and highlight the need for interventions aimed at alleviating this. Pre-COVID-19 research identifies high levels of psychological and physical strain amongst those caring for a child with an ED. Themes are beginning to emerge as to why COVID-19 may further exacerbate carer burden: (1) reduced access to ED services; (2) increased physical vulnerability and exacerbation of psychiatric co-morbidity amongst youth with EDs; (3) increased practical demands placed on carers; and (4) social isolation and decreased social support.

CONCLUSION

The COVID-19 pandemic poses a specific threat to the mental health of youth with EDs and their carers. Given the salient role families play in caring for youth with an ED, attending to carer burden is imperative. Supporting carers through all phases of their child's ED journey by offering adaptive and flexible supportive services which accommodate time constraints, geographic barriers and possible COVID-19 spread is essential.

Expressed Emotion in the Family: A Meta-Analytic Review of Expressed Emotion as a Mechanism of the Transgenerational Transmission of Mental Disorders

BACKGROUND

High Expressed Emotion (HEE) has been identified as a risk factor for the exacerbation and course of mental illness. EE has been investigated as a caregiver's response to an offspring's problem behavior and pathology. The present meta-analysis regards EE from a transgenerational perspective and as one mechanism that might explain the transgenerational transmission of mental disorders.

METHOD

We identified a total of 13 studies relying on 16 independent samples of parent-child dyads of parents with a mental illness and healthy controls; these were included in our analysis. Results were synthesized into one effect size per sample; meta-regression on additional effects of parental diagnostic category, child mental illness, and child age were also applied.

RESULTS

Parents with a mental illness are classified as HEE significantly more often. Effects were established for high criticism, albeit of small size (OR = 1.45), although they become stronger whenever offspring exhibit mental illness themselves (OR = 2.82).

CONCLUSION

The current study highlights the dearth of studies on EE in families in which a parent has a mental illness and its effects on their children. Our findings highlight EE as a potential mechanism for attributing the transgenerational transmission of mental disorders, especially for the EE-variable criticism, indicating dysfunctional parent-child interactions.

SYSTEMATIC REVIEW REGISTRATION

http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019117609, identifier: CRD42019117609.

Caregiving experience and expressed emotion among parents of adolescents suffering from anorexia nervosa following illness onset

The aim of this study was to better understand the relationship between parents' experience of caregiving and expressed emotion during the early stage of their child's eating disorder. Fifty mothers and 38 fathers of adolescents suffering from anorexia nervosa and hospitalized for the first time participated in this study. They completed the Experience of Caregiving Inventory, a measure of the negative and positive aspects of the caregiving experience, and the Family Questionnaire, which measured the different dimensions of expressed emotion, namely emotional over-involvement and critical comments. Results showed that caregiving experience is significantly and positively correlated to expressed emotion. Among the negative aspects of caregiving, sense of loss contributed most to emotional over-involvement, while difficult behaviours contributed most to critical comments. The results suggest that parents' perceptions of their child and child's future are strongly related to their tendency to be over-involved. The perception of disruptive behaviours in their child could be one of the principal triggers or exacerbating factors of parents' critical attitudes.

Family-based treatment: Where are we and where should we be going to improve recovery in child and adolescent eating disorders

OBJECTIVE

Family therapy has long been advocated as an effective intervention for eating disorders. A specific form of family therapy, one that utilizes family resources, has proven especially effective for adolescents with anorexia or bulimia nervosa (AN and BN). First developed in London, a behaviorally focused adaptation, called family-based treatment (FBT), has been manualized and systematically studied in six randomized clinical trials for adolescent AN and two for adolescent BN.

METHOD

This Commentary focuses on manualized FBT; what we know, what we do not know (yet), and what we hope for.

RESULTS

We do know that efficacy data for FBT, especially adolescent AN, are quite robust, even though remission rates remain elusive for more than half of all cases. While preliminary, moderators of FBT for adolescent AN have been identified and could aid us in determining the most (or least) responsive patient groups. And weight gain (∼2.5kg) by week four has been confirmed as an early predictor of remission at end-of-treatment. What we do not know, yet, is whether specific adaptations to manualized FBT will confer improved remission rates.

DISCUSSION

Finally, and in terms of what is hoped for, we highlight the promise of improved access, dissemination, and implementation of FBT.

Treatment dropout in a family-based partial hospitalization program for eating disorders

Treatment dropout is a significant challenge in the treatment of eating disorders. In day hospital/partial hospitalization program settings, little is known about factors associated with treatment dropout. The purpose of the present study was to assess factors associated with treatment dropout in a partial hospitalization program for adolescents and young adults with anorexia nervosa. Patients and parents completed self-report and interview-based measures at baseline and at end of treatment in the partial hospitalization program. Few factors were found that differentiated the two groups. Those who dropped out had lower body weight at end of treatment, were less likely to have purged in the previous month, and had fathers who scored higher on the criticism subscale of expressed emotion. Patients who are purging may be seen as having more severe symptoms, thus possibly reducing the chances of parents prematurely discontinuing treatment. Parental criticism is a potentially modifiable factor in treatment. Further research is needed to identify effective ways to reduce parental criticism, and to identify additional modifiable factors associated with treatment dropout to reduce dropout rates in this population.Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Heterogeneous weight restoration trajectories during partial hospitalization treatment for anorexia nervosa

Early response to treatment has been shown to predict good outcome in family-based treatment, but little is known about who responds quickly.

OBJECTIVE

The purpose of the current study was to examine the short-term weight gain trajectories among youth receiving partial hospitalization program services for anorexia nervosa (AN), and to identify predictors of these trajectories.

METHOD

Adolescent and young adults (n = 102) with AN or subthreshold AN completed semi-structured interviews and self-report measures on admission to a family-based partial hospitalization program. Patients participated in programming 5 days a week.

RESULTS

Three weight gain trajectories were found to indicate slow, moderate, and rapid weight gain trajectories. All rapid responders gained at least four lbs. in the first 4 weeks of treatment, compared to 86.1% of moderate responders and 51.2% of slow responders. Patients were less likely to have a moderate or rapid response trajectory if they had a mood disorder diagnosis and higher parental expressed emotion. Additionally, the presence of compensatory behavior increased the likelihood of having a rapid response.

DISCUSSION

Despite the sometimes chronic nature of AN, most patients fell into one of the two favorable response trajectories. The identification of these trajectories underscores the importance of considering the core disordered eating behaviors (i.e., restricting, binge eating, and purging), comorbid psychopathology, and parental expressed emotion.

Parental Expressed Emotion During Two Forms of Family-Based Treatment for Adolescent Anorexia Nervosa

High parental expressed emotion (EE), reflected by criticism or emotional over-involvement, has been related to poorer outcome in family-based treatment (FBT) for adolescent anorexia nervosa. This study assessed EE in 89 mothers and 64 fathers at baseline and end of treatment in a randomised trial comparing conjoint FBT to parent-focused FBT (PFT). Compared with conjoint FBT, PFT was associated with a decrease in maternal criticism, regardless of adolescent remission. Furthermore, an increase in maternal criticism was more likely to be observed in conjoint FBT (80%) than PFT (20%, p = 0.001). Adolescents of mothers who demonstrated an increase in EE, or remained high in EE, were less likely to remit compared with adolescents for whom EE decreased or remained low (33% and 0% vs. 43% and 50%, p = 0.03). There were no significant effects for paternal EE. The results highlight the importance of considering EE when implementing FBT for adolescents with anorexia nervosa. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Psychopathology and expressed emotion in parents of patients with eating disorders: Relation to patient symptom severity

The purpose of the current study was to examine the relation between parental psychopathology, parental expressed emotion, and patient symptom severity. One hundred twenty-six parents of 79 patients receiving treatment for an eating disorder completed measures of expressed emotion and general psychopathology, and patients completed a measure of eating disorder psychopathology. Mothers reported higher expressed emotion scores than fathers. Both mothers and fathers scored higher on general psychopathology compared to nonpatient population means. Maternal psychopathology was found to be associated with symptom severity. Parental psychopathology and expressed emotion were found to be related, and MANCOVAs revealed that maternal criticism and maternal psychopathology were associated with patient symptom severity, but fathers' scores on the same measures were not. It is recommended that parental expressed emotion and parental psychopathology are assessed at the beginning of treatment so that appropriate clinical interventions can be utilized.

Family-based treatment of eating disorders in adolescents: current insights

Eating disorders are serious illnesses associated with significant morbidity and mortality. Family-based treatment (FBT) has emerged as an effective intervention for adolescents with anorexia nervosa, and preliminary evidence suggests that it may be efficacious in the treatment of adolescents with bulimia nervosa. Multifamily therapy for anorexia nervosa provides a more intensive experience for families needing additional support. This review outlines the three phases of treatment, key tenets of family-based treatment, and empirical support for FBT. In addition, FBT in higher levels of care is described, as well as challenges in the implementation of FBT and recent adaptations to FBT, including offering additional support to eating-disorder caregivers. Future research is needed to identify families for whom FBT does not work, determine adaptations to FBT that may increase its efficacy, develop ways to improve treatment adherence among clinicians, and find ways to support caregivers better during treatment.

Exploring the effects of a family admissions program for adolescents with anorexia nervosa

BACKGROUND

This study investigated patient experience in a Family Admissions Program (FAP) - a pilot treatment program for adolescents with Anorexia Nervosa at the Children's Hospital, Westmead. Based on Maudsley Family Based Treatment (FBT), the FAP involves an adolescent and his/her family undergoing a two-week family-based hospital admission at the outset of treatment. The program aims to increase intensity and support to a level needed by some families struggling to engage with or access FBT.

METHOD

Narrative Inquiry and Interpretative Phenomenological Analysis were used as a dual methodological approach to explore the prospective expectations and retrospective experiences of participants partaking in the program.

RESULTS

Results indicated that in cases where the family unit has been particularly fractured as a result of the eating disorder, the FAP offers an opportunity for relational strengthening and reunification. Combined with the program's intensive support and proximity to hospital services, this serves to provide struggling families with enhanced skills and a stronger foundation for outpatient FBT.

CONCLUSIONS

For families deemed at risk of unsuccessful outcomes with FBT, the FAP can be considered as an appropriate treatment adjunct to place alongside or before the commencement of FBT.

Patterns of expressed emotion in adolescent eating disorders

BACKGROUND

This goal of this study was to understand the patterns of expressed emotions (EEs) in adolescent eating disorders. As such, this study compared EE among families of adolescents with anorexia nervosa (AN), bulimia nervosa (BN), and a psychiatric control group, major depressive disorder (MDD). This study also examined the influence of family status (intact vs. nonintact) and the presence of siblings on EE.

METHODS

Two-hundred and fifteen adolescents (ages 12-19) and their families were recruited for this study including 121 adolescents with AN, 54 adolescents with BN, and 40 adolescents with MDD. Adolescents with at least one parent completed the Standardized Clinical Family Interview. Adolescents completed structured diagnostic interviews to assess eligibility for the study, as well as a standardized questionnaire to assess depression.

RESULTS

Analyses revealed that fathers showed higher levels of critical comments to adolescents with BN or MDD than those with AN, whereas mothers made more critical comments toward patients with BN. Mothers made the least number of positive remarks toward patients with MDD. In terms of the influence of family status, fathers from intact families showed more expressions of warmth and were less critical than fathers from nonintact families, whereas mothers from intact families were less critical but also made fewer positive remarks than mothers from nonintact families. The presence of siblings appeared to reduce mothers' expression of warmth and emotional overinvolvement.

CONCLUSIONS

Unique patterns of EE were found to characterize AN, BN, and MDD. Family status and the presence of siblings exert an influence on EE that should be taken into consideration in future research.

Influence of Parental Expressed Emotions on Children's Emotional Eating via Children's Negative Urgency

We investigated whether parental expressed emotion (criticism and emotional overinvolvement) is related to children's emotional eating and whether this relationship is mediated by children's negative urgency. One hundred children, aged 8 to 13 years, either healthy or have binge-eating disorder and/or attention-deficit/hyperactivity disorder, completed the questionnaires, along with their parents. Parental criticism and, to a lesser extent, parental emotional overinvolvement were both positively related to children's emotional eating, and this relationship was mediated by children's negative urgency. Further exploratory analyses revealed that the mediating role of children's negative urgency in the relationship between parental criticism and children's emotional eating was pronounced in the clinical group of children with binge-eating disorder and attention-deficit/hyperactivity disorder but almost absent in the healthy control group. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Clinicians' views on parental involvement in the treatment of adolescent anorexia nervosa

A questionnaire and in-depth interviews with 20 allied health clinicians generated data on key aspects of family-based treatment for adolescent anorexia nervosa that enhance recovery, processes that engage parents in treatment, and how and why clinicians modify or adapt the manualized Maudsley Family Based Treatment model. Findings indicate that clinicians support key principles in the Maudsley model, but that the approach is not implemented in the full, manualized form. Rather, aspects are integrated with clinicians' own clinical judgements based on assessment of the needs and capacities of families, cultural appropriateness, impact on family dynamics, and gains during early treatment.

Family Therapy for Child and Adolescent Eating Disorders: A Critical Review

Eating disorder-focused family therapy has emerged as the strongest evidence-based treatment for adolescent anorexia nervosa, supported by evidence from nine RCTs, and there is increasing evidence of its efficacy in treating adolescent bulimia nervosa (three RCTs). There is also emerging evidence for the efficacy of multifamily therapy formats of this treatment, with a recent RCT demonstrating the benefits of this approach in the treatment of adolescent anorexia nervosa. In this article, we critically review the evidence for eating disorder-focused family therapy through the lens of a moderate common factors paradigm. From this perspective, this treatment is likely to be effective as it provides a supportive and nonblaming context that: one, creates a safe, predictable environment that helps to contain anxiety generated by the eating disorder; two, promotes specific change early on in treatment in eating disorder-related behaviors; and three, provides a vehicle for the mobilization of common factors such as hope and expectancy reinforced by the eating disorder expertise of the multidisciplinary team. In order to improve outcomes for young people, there is a need to develop an improved understanding of the moderators and mediators involved in this treatment approach. Such an understanding could lead to the refining of the therapy, and inform adaptations for those families who do not currently benefit from treatment.

Therapeutic alliance, expressed emotion, and treatment outcome for anorexia nervosa in a family-based partial hospitalization program

Adolescent therapeutic alliance has been found to be associated with improvements in eating disorder cognitions and with early weight gain. The current study assessed patient and parent therapeutic alliance, correlates of parent alliance, and relationship between alliance and treatment outcome. Fifty-six patients with anorexia nervosa completed measures of therapeutic alliance and eating disorder symptoms. Patients' parents completed measures of therapeutic alliance, expressed emotion, and psychopathology. Patients' alliance predicted cognitive and behavioral symptomatology at end of treatment (β=-0.39, p=0.001), though it was not related to changes in weight (β=0.12, p=0.377). Maternal hostility was associated with lower maternal alliance (r=-0.34, p=0.05). Findings suggest that maternal hostility should be addressed in treatment, and that patient alliance may be important in achieving psychological recovery from disordered eating.

Expressed emotion in panic disorder: Relationship with demographic and clinical variables and quality of life

OBJECTIVE

Expressed emotion (EE) predicts the outcome of treatment in patients with anxiety disorders. We aimed to investigate the relationship between EE and demographic and clinical characteristics of patients with panic disorder (PD), to determine whether there is a difference between PD, major depressive disorder (MDD) patients and healthy controls (HC) in terms of EE and to investigate the effect of EE on quality of life (QOL) in patients with PD.

METHODS

Our study involved a total of 150 participants (50 patients in each group). All participants were given the Level of Expressed Emotion (LEE) scale and the short-form health survey (SF)-36 . Furthermore, the EE scale was completed by the participant's key relatives.

RESULTS

EE was associated with some sociodemographic and clinical variables in patients with PD. There was no significant difference between PD and MDD and between PD and HC in terms of the LEE and the EE and their subscale scores. It was also demonstrated that EE had no effect on the QOL in patients with PD.

CONCLUSION

EE was not different in PD compared to MDD and HC. Additionally, EE was not related to QOL in PD.

Validity of the Brief Dyadic Scale of Expressed Emotion in Adolescents

PURPOSE

Perceived expressed emotion is a valuable predictor of clinical outcome in psychiatric and community samples, but its assessment is limited to few instruments. A recent development to briefly assess expressed emotion from the patient's perspective is the 14-item Brief Dyadic Scale of Expressed Emotion (BDSEE). Although psychometric properties of the BDSEE have been provided for adult eating disorders, validity for adolescents is still lacking. In this study, BDSEE's factorial, convergent, and divergent validity was tested in an adolescent sample with binge-eating disorder and a matched community sample.

METHODS

For validation, well-established self- and mother-report questionnaires and adolescent's Five Minute Speech Sample were used.

RESULTS

Confirmatory factor analysis on the German BDSEE replicated the proposed three-factor structure in adolescents. BDSEE's convergent validity with the Five Minute Speech Sample and construct-related questionnaires was shown. Divergent validity was documented with BDSEE subscales being unrelated to socio-demographic and clinical characteristics. Further, BDSEE subscales were unrelated to measures of maternal distress.

CONCLUSIONS

While the results underline that the BDSEE is a valid self-report measure for assessing perceived expressed emotion in adolescents with and without binge-eating disorder, the evaluation of its predictive validity is still in need.

The Experience of Caring For or Living with an Individual with an Eating Disorder: A Meta-Synthesis of Qualitative Studies

Eating disorders (ED) has the highest mortality rate of psychiatric disorders and a high incidence of comorbidity. Because of the average age of onset, care typically befalls family members. However, despite the severity of the disorder and the burden placed on the family, research into the caregiving experience is still developing. Studies have shown caregivers of individuals with ED to experience high levels of distress, burden and expressed emotion. Recent theoretical models have underscored the importance of caregivers' responses as a maintenance factor for the ED, and family therapy has proved efficacious. However, the literature pertaining to the experience of family members living with or caring for an individual with an ED has not been systematically reviewed. This review aimed to synthesize qualitative studies relating to the caring experience and its impact, thereby gaining an understanding from the perspective of the individuals themselves. Relevant search terms were utilized to systematically search key databases. Twenty studies, with a total sample of 239 participants, met the inclusion criteria. Nine core themes emerged from the synthesis, forming the basis of an explanatory theory. The ED was found to have a pervasive impact upon family members, mediated by a number of factors. Cognitive appraisals affected the caregiving experience and responses to the individual. The experience of caregiving was continually reappraised leading to a process of adaptation. The majority of studies identified unmet carer needs. The implications of the findings are discussed with reference to existing theoretical models and in terms of clinical practice. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGES

Carers experience a significant amount of guilt and distress once they have found out about their loved one's eating disorder. Across the studies, there were many themes of unmet need for carers. Siblings have often been overlooked by both clinicians and researchers. Interventions for people with eating disorders should also acknowledge carers and close family members.

Expressed Emotion, Family Functioning, and Treatment Outcome for Adolescents with Anorexia Nervosa

The current study examined the relation between parental expressed emotion (EE) and treatment outcome among adolescents participating in a treatment study for adolescent anorexia nervosa, as well as its impact on family functioning. One hundred and twenty-one families were assigned to family-based treatment or adolescent-focused therapy. Paternal criticism predicted lesser improvement in eating disorder psychopathology at end of treatment. There was also a significant interaction between maternal hostility and treatment, indicating that adolescents whose mothers displayed hostility had greater increases in percent of expected body weight in adolescent-focused therapy than family-based treatment. In addition, maternal hostility predicted less improvement in general family functioning and family communication at the end of treatment. Findings suggest that maternal and paternal EE may differentially impact treatment outcome and should be directly attended to in clinical settings. Future research is needed to further explore ways in which parental EE can be effectively modified in treatment.

Family Profiles of Expressed Emotion in Adolescent Patients With Anorexia Nervosa and Their Parents

The current study examined expressed emotion (EE) among families of adolescents with anorexia nervosa (AN) participating in a treatment study. EE ratings were made from 110 adolescents toward their parents and from parents toward their children using videotaped family interviews. Participants were 92% female and 75% Caucasian with a mean age of 14.41 years. Four family profiles were created (low patient EE/low parent EE, high patient EE/high parent EE, low patient EE/high parent EE, high patient EE/low parent EE). Family EE profile was not related to full remission at end of treatment. Groups were then combined according to EE level of parent. The low parent group (defined as low on criticism, hostility, and emotional overinvolvement) had significantly lower scores on a measure of eating disorder psychopathology than the high parent group at the end of treatment. Patients with AN in low EE families do better in treatment than those patients belonging to high EE families. These findings are true regardless of the EE status of the patient.

A bidirectional examination of expressed emotion among families of adolescents with bulimia nervosa

OBJECTIVE

The purpose of this paper was to examine expressed emotion (EE) measured from adolescents with bulimia nervosa (BN) toward their parents, in addition to measuring EE from parents toward patients.

METHOD

Fifty-four adolescents and their parents who were receiving treatment for BN participated in a videotaped family interview, from which ratings of EE were made.

RESULTS

Parent and patient scores were highly correlated. Four family profiles were created (Low Patient EE/Low Parent EE; High Patient EE/High Parent EE; Low Patient EE/High Parent EE; High Patient EE/Low Parent EE) to determine whether the match between parent and patient EE was related to treatment outcome. The Low Patient EE/Low Parent EE group demonstrated the greatest reduction in purging from baseline to end-of-treatment; the High Patient EE/Low Parent EE group showed the smallest reduction in purging.

DISCUSSION

EE has historically been rated from relatives toward patients, but patients' own EE may also be related to treatment outcome.

Family functioning in two treatments for adolescent anorexia nervosa

OBJECTIVE

Family functioning impairment is widely reported in the eating disorders literature, yet few studies have examined the role of family functioning in treatment for adolescent anorexia nervosa (AN). This study examined family functioning in two treatments for adolescent AN from multiple family members' perspectives.

METHOD

Participants were 121 adolescents with AN ages 12-18 from a randomized-controlled trial comparing family-based treatment (FBT) to individual adolescent-focused therapy (AFT). Multiple clinical characteristics were assessed at baseline. Family functioning from the perspective of the adolescent and both parents was assessed at baseline and after 1 year of treatment. Full remission from AN was defined as achieving both weight restoration and normalized eating disorder psychopathology.

RESULTS

In general, families dealing with AN reported some baseline impairment in family functioning, but average ratings were only slightly elevated compared to published impaired functioning cutoffs. Adolescents' perspectives on family functioning were the most impaired and were generally associated with poorer psychosocial functioning and greater clinical severity. Regardless of initial level of family functioning, improvements in several family functioning domains were uniquely related to full remission at the end of treatment in both FBT and AFT. However, FBT had a more positive impact on several specific aspects of family functioning compared to AFT.

DISCUSSION

Families seeking treatment for adolescent AN report some difficulties in family functioning, with adolescents reporting the greatest impairment. Although FBT may be effective in improving some specific aspects of family dynamics, remission from AN was associated with improved family dynamics, regardless of treatment type.

Long Term Outcome of Anorexia Nervosa

The long-term outcome (mean follow-up period 5.7 years) for 20 patients with anorexia nervosa was assessed on a comprehensive battery of self-report inventories and a structured clinical interview. Two thirds of the cohort were improved to a clinically significant degree at follow-up, but the majority still showed higher than normal scores on inventories of anorexic symptomatology, social maladjustment, anxiety, and hostility. The remaining one third were unimproved and demonstrated a broad range of impairment including distorted attitudes toward eating, overconcern about body shape, poor social functioning, high levels of anxiety, hostility, depression, and external locus of control. Moderate to strong correlations were found across outcome measures. Longer duration of eating difficulties before presentation was a strong predictor of poor long-term outcome, suggesting a chronic relapsing form of the disorder occurred in a subgroup of patients.

Relatives' emotional involvement moderates the effects of family therapy for bipolar disorder

OBJECTIVE

The "critical comments" dimension of the expressed emotion (EE) construct has been found to predict the illness course of patients with bipolar disorder, but less is known about the "emotional overinvolvement" component. The goal of this study was to evaluate whether relatives' observed appropriate and inappropriate emotional involvement (intrusiveness, self-sacrifice, and distress about patients' well-being) moderated the effectiveness of a family-based intervention for bipolar disorder.

METHOD

108 patients with bipolar disorder (mean age = 35.61 years, SD = 10.07; 57% female) and their relatives (62% spouses) from 2 clinical trials completed 10-min problem-solving interactions prior to being treated with pharmacotherapy plus family-based therapy (FBT) or brief psychoeducation (crisis management [CM]). Patients were interviewed every 3-6 months over 2 years to assess mood symptoms.

RESULTS

When relatives showed low levels of inappropriate self-sacrifice, CM and FBT were both associated with improvements in patients' manic symptoms over 2 years. When relatives showed high levels, patients in CM became more manic over time, whereas patients in FBT became less manic. Group differences in mania trajectories were also observed at high levels of inappropriate emotional response but not at low. When relatives showed high levels of appropriate self-sacrifice, patients in both groups became less depressed. At low levels of appropriate self-sacrifice, patients in CM did not improve, whereas patients in FBT became less depressed.

CONCLUSIONS

Future studies of bipolar disorder should consider the prognostic value of the amount and appropriateness of relatives' emotional involvement with patients in addition to their critical behaviors.

The roles of adolescent attentional bias and parental invalidation of sadness in significant illness: a comparison between eating disorders and chronic pain

Biopsychosocial conceptualizations of eating disorders (EDs) suggest the combination of an individual's emotional vulnerability and invalidating environment increases the likelihood of developing pervasive emotion dysregulation, and subsequent use of ED behaviors to regulate emotion (Haynos & Fruzetti, 2011; Safer, Telch, & Chen, 2009). The current study aimed to provide initial support for this model in adolescent EDs, through examining the interaction between an adolescent's emotional vulnerability, indexed by attentional biases for emotions, and an invalidating family environment. Specifically, we examined the ability of this interaction to discriminate youth with EDs from a comparison group of youth with chronic pain diagnoses, who were used to control for the presence of non-specific effects of having any illness. Fifty adolescent girls (25 with EDs and 25 with chronic pain) completed an emotional dot-probe task assessing attentional biases for emotional faces, and parents completed the Emotions as a Child Scale (Magai, 1996; Klimes-Dougan et al., 2007) to assess response to teen emotion. Results showed that teen angry attentional bias moderated the relationship between parental response to sadness and teen ED status: for teens with high attention bias towards angry faces, maladaptive parental response to sadness predicted increased odds of ED status versus chronic pain status.

Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa

AIM

The literature on clinical characteristics associated with premature termination of treatment (PTT) is beset with conflicting and non-replicated findings. This study explores clinical characteristics potentially associated with PTT in a randomised controlled outpatient psychotherapy trial for anorexia nervosa (AN).

METHODS

Participants were 56 women aged 17-40 years with spectrum AN. The completer group (n = 35) included those completing at least 15/20 planned sessions with the remainder of the sample comprising the PTT group (n = 21). Variables examined included demographic factors, psychosocial functioning, psychiatric history, lifetime comorbidity, temperament and eating disorder characteristics. Logistic regression was used to examine significant variables. A Kaplan-Meier survival curve was used to illustrate time taken to PTT.

RESULTS

The mean number of sessions in the PTT group was 8.1. Lower self-transcendence scores on the Temperament and Character Inventory were associated with PTT.

CONCLUSIONS

Recognising and addressing personality factors have the potential to enhance retention in treatment.

Expressed emotion in anorexia nervosa: what is inside the "black box"?

OBJECTIVE

Expressed Emotion has been called a "black box", since little is known about contributing factors. The aim of this study was to examine which parental and which patient/illness-related characteristics contribute to maternal and paternal Expressed Emotion levels.

METHOD

Sixty adolescent girls with Anorexia Nervosa (AN) and their parents completed instruments that evaluate characteristics of the adolescent's illness and patient/parental psychological characteristics (depression; anxiety; obsession-compulsion; social anxiety and alexithymia). The following illness-related characteristics were recorded: age at AN onset, duration of illness, AN subtype (restrictive AN-R vs. purging type AN-B), current Body Mass Index (BMI) (in kg/m(2)), minimum lifetime BMI and number of previous hospitalizations, the Global Outcome Assessment Scale total score. Levels of Expressed Emotion were assessed for the two parents using the Five-Minute Speech Sample.

RESULTS

Less than 30% of the parents in our sample expressed high levels of Critical EE and Emotional Over-Involvement. Our main findings indicate that maternal Criticism (Critical EE levels, Critical Comments, Dissatisfaction) and the sub-dimensions of maternal Emotional Over-Involvement (EOI EE) (Statement of loving Attitudes and Excessive Details about the past) were related both to the severity of the daughters' clinical state and to maternal psychological functioning. Only paternal levels of anxiety explained paternal Dissatisfaction, EOI EE and Statement of loving Attitudes.

DISCUSSION

Parental psychological functioning and the severity of the daughters' clinical state have an impact on the family relationships. These elements should be targeted by individual treatment for parents where necessary, and by psycho-educational sessions about Anorexia Nervosa for parents generally.

Post-stroke depression and expressed emotion

PRIMARY OBJECTIVES

This study examined the role of expressed emotion (EE) in post-stroke depression (PSD) and the extent to which partner/spouse EE interacted with lesion laterality in PSD. The relationship between (i) lesion location and levels of PSD and (ii) levels of EE and levels of PSD were investigated. The role of perceived EE in PSD was also explored.

DESIGN

Cross-sectional, between-subjects design.

METHODS

Measures applied to stroke survivors included Extended Activities of Daily Living Scale (EADL), Post-Stroke Depression Rating Scale (PSDRS) and Level of Expressed Emotion Scale (LEE); spouses/partners completed the LEE.

RESULTS

The interaction between lesion laterality and levels of partner/spouse EE on PSD was not statistically significant (p = 0.63, F = 0.24, df = 1,56). However, a clear relationship was found between lesion laterality and PSD (p = 0.028). As levels of spouse/partner LEE scores increased, levels of PSD also increased (p = 0.039). Perceived EE scores illustrated a significant interaction between lesion laterality and levels of EE on PSD (p = 0.005, F = 8.591, df = 1,56).

CONCLUSION

Whilst spouse/partner EE scores showed no interaction with lesion laterality to determine levels of PSD, a significant interaction was found when compared with stroke survivor perceived EE scores. Furthermore, left hemisphere (LHS) stroke survivors reported higher levels of depression than right hemisphere (RHS) stroke survivors. As levels of EE increased, PSD also increased, with LHS being greater than RHS.

Collaborative Care Skills Training workshops: helping carers cope with eating disorders from the UK to Australia

PURPOSE

The Collaborative Care Skills Training workshops, developed by Treasure and associates aim to improve the well-being, coping strategies and problem-solving skills of carers of someone with an eating disorder. Evidence has demonstrated the effectiveness of the workshops in the UK where it was developed. The aim of this pilot study was to examine whether conducting the workshops in different contexts by facilitators trained in its delivery could lead to similar impact.

METHODS

The workshops were conducted with 15 carers in VIC, Australia and delivered by experienced health professionals trained in its content and delivery. A non-experimental research design with repeated measures was implemented. Quantitative data were collected at pre-and post-intervention and 8 weeks after completion of the workshops.

RESULTS

Participation led to significant reductions in carers' reported expressed emotion, dysfunctional coping, distress, burden and accommodation and enabling of the eating disorder behaviour, which were maintained at the 8-week follow-up.

CONCLUSION

Results suggest the workshops are effective in reducing carer distress and burden as well as modifying unhelpful emotional interactional styles when caring for family members with an eating disorder. The content of the workshops and its delivery, once experienced facilitators have received training, are transferable to other contexts.

The Spanish Validation of Level of Expressed Emotion Scale for Relatives of People with Eating Disorders

Expressed emotion (EE) is considered a general predictor of poor outcome across a range of conditions, including eating disorders, and is valuable in measuring the effect of family interventions. There are no self-report questionnaires validated in Spanish to measure EE among relatives of patients with a psychiatric condition. The aim of this study was to examine the psychometric properties of the Spanish version of the Level of Expressed Emotion scale (LEE) among relatives of eating disorder patients. A cross-sectional study of 270 relatives of patients with an eating disorder was conducted to examine the factor structure, reliability and validity of the LEE scale. Results indicated that the LEE-S (Spanish version) did not correspond to the a priori subscales described in the original version. The refined 45-item LEE-S scale consisted of four factors which explained 25.5% of variance in EE for relatives. Reliability was acceptable (α ranged from .73 to .86). The discriminant validity of the subscales was moderately supported by correlations with psychological distress (GHQ-12; rho = .34) and specific caregiving experience (EDSIS; rho = .39). The LEE-S instrument has adequate psychometric properties and may be of value to assess families at risk of a negative emotional climate at home.

Bonding and expressed emotion: two interlinked concepts?

BACKGROUND

Bonding and expressed emotion (EE) are two concepts modeling family relationships. Two studies, with contradictory results, have explored whether these concepts and their corresponding instruments [the Parental Bonding Instrument (PBI) and the Camberwell Family Interview] do indeed measure the same aspects of family relationships. Our first objective was to compare the adolescents' perceptions of family relationships using the PBI, and the parental viewpoint using the Five-Minute Speech Sample (FMSS-EE). Secondly, we compared the PBI scores and EE levels of the parents.

SAMPLING AND METHODS

Sixty adolescent girls with anorexia nervosa completed the PBI. The FMSS and a modified version of the PBI were administered to parents separately.

RESULTS

No significant link was identified between adolescent PBI scores and parental EE levels. However, a link between maternal 'modified' PBI scores and maternal EE was observed: when mothers registered a high Final EE, they were more likely to deny their daughter's psychological autonomy compared to mothers with lower EE.

CONCLUSIONS

Our empirical results do not support the hypothesis of an overlap between the two concepts. Indeed bonding and EE measure the same object, i.e. the quality of family relationships, but time scales differ and so do the perspectives (patient vs. parental viewpoint).

Predictors of dropout from in-patient treatment of eating disorders: an Italian experience

INTRODUCTION

The aim of the study was to examine possible risk factors for dropout from in-patient treatment for eating disorders (ED).

MATERIALS AND METHODS

The present study consisted of a retrospective analysis of clinical and non-clinical available information about 186 patients suffering from ED consecutively admitted into the Villa Maria Luigia Private Hospital (Parma, Italy) in a three-year period (01/01/2006 - 31/12/2009). Sociodemographics, clinical history and current features, and results to the following psychometric instruments were analysed: Eating Disorder Questionnaire (EDQ), Predisposing, On-set and Maintaining risk factors list for Eating Disorders, Eating Disorders Inventory-II, Body Uneasiness Test and SCL-90.

RESULTS

Of the 186 patients, 46 (24.7%) voluntarily left the treatment program prematurely. Predictive factors included poor educational and professional achievements, parents' divorcing, parents' history of substance abuse and difficulties in interpersonal relationships.

DISCUSSION

Dropout is a multifactorial phenomenon with deep clinical consequences: the recognition of possible risk factors may support the choice of specific therapeutic strategies to improve the treatment of ED and its outcomes.

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Parental expressed emotion of adolescents with anorexia nervosa: outcome in family-based treatment

OBJECTIVE

The purpose of this study was to determine the relationship between expressed emotion (EE) and outcome in family-based treatment (FBT) for anorexia nervosa (AN).

METHOD

Eighty-six adolescents with AN participated in an RCT comparing two doses of FBT. Seventy-nine of these patients and their parents participated in a structured interview, from which EE ratings were made at baseline. Parents were compared on five subscales of EE as well as overall level of EE (high vs. low).

RESULTS

Overall EE levels were low with 32.9% of families presenting as High EE at baseline. Ratings of baseline warmth for both mothers (p = .014) and fathers (p = .037) were related to good outcome at end-of-treatment.

DISCUSSION

EE in parents of adolescents with AN is remarkably low. Notwithstanding, parental warmth may be a predictor of good outcome.

Moderators and mediators of remission in family-based treatment and adolescent focused therapy for anorexia nervosa

Few of the limited randomized controlled trails (RCTs) for adolescent anorexia nervosa (AN) have explored the effects of moderators and mediators on outcome. This study aimed to identify treatment moderators and mediators of remission at end of treatment (EOT) and 6- and 12-month follow-up (FU) for adolescents with AN (N = 121) who participated in a multi-center RCT of family-based treatment (FBT) and individual adolescent focused therapy (AFT). Mixed effects modeling were utilized and included all available outcome data at all time points. Remission was defined as ≥ 95% IBW plus within 1 SD of the Eating Disorder Examination (EDE) norms. Eating related obsessionality (Yale-Brown-Cornell Eating Disorder Total Scale) and eating disorder specific psychopathology (EDE-Global) emerged as moderators at EOT. Subjects with higher baseline scores on these measures benefited more from FBT than AFT. AN type emerged as a moderator at FU with binge-eating/purging type responding less well than restricting type. No mediators of treatment outcome were identified. Prior hospitalization, older age and duration of illness were identified as non-specific predictors of outcome. Taken together, these results indicate that patients with more severe eating related psychopathology have better outcomes in a behaviorally targeted family treatment (FBT) than an individually focused approach (AFT).