Investigating service users' perspectives of eating disorder services: A meta-synthesis.

OBJECTIVE: Despite a number of qualitative studies published from the perspective of eating disorder (ED) service users, there has been no attempt to exclusively synthesize their views to gain a fuller understanding of their ED service experiences. It is important to understand this perspective, since previous research highlights the difficulties ED healthcare professionals report when working with this client group. METHOD: A systematic search of the literature was conducted to identify qualitative studies focusing on experiences of ED services from the perspective of service users. Twenty-two studies met the inclusion criteria and underwent a quality appraisal check using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. These were then synthesized using a meta-synthesis approach. RESULTS: Four overarching themes were generated: "Treatment: Focus on physical vs. psychological symptoms"; "Service Environment: The role of control within services"; "Staff: Experiences with staff and the value of rapport"; and "Peer Influence: Camaraderie vs. comparison." Service users expressed a desire for more psychological input to tackle underlying difficulties relating to their ED. A complex relationship with feelings of control was described, with some feeling over-controlled by service providers, while others retrospectively recognized the need for control to be taken away. Staff values, knowledge and trust played a significant role in treatment and recovery. Peers with an ED were described to be a valuable source of understanding and empathy, but some found peer influence to perpetuate comparison and competitiveness. DISCUSSION: The results portray some of the conflicts and complexities that service users encounter in ED services. A running thread throughout is the perceived importance of adopting an individualized approach within these services.

Attentional bias in eating disorders: A meta-review.

OBJECTIVE: This meta-review summarizes and synthesizes the most reliable findings regarding attentional bias in eating disorders across paradigms and stimulus types and considers implications for theory and future research. METHOD: Four databases were systematically searched, along with reference lists of included reviews, yielding 15 systematic reviews (four of which were also meta-analyses). The quality of each review was appraised using the AMSTAR-2. RESULTS: Key findings from systematic reviews are summarized, organized by paradigm and stimulus type. DISCUSSION: The authors synthesize evidence from the highest-quality studies. There is evidence for attentional avoidance and vigilance in eating disorders depending on stimulus properties (low vs. high-calorie food; high-body mass vs. low-body mass index photos of others) and attentional avoidance of food stimuli in those with anorexia nervosa. Sad mood induction may generate attentional bias for food in those with binge-eating disorder. There may also be attentional bias to general threat in eating disorder samples. This meta-review concludes that most systematic reviews in this field are low in quality and summarizes the main areas that could be improved upon in future reviews. Implications of this study's findings for theory and intervention research are also discussed.

OBJETIVO: Esta meta-revisión resume y sintetiza los hallazgos más confiables con respecto al sesgo de atención en los trastornos de la conducta alimentaria a través de paradigmas y tipos de estímulos y considera las implicaciones para la teoría y la investigación futura. MÉTODO: Se realizaron búsquedas sistemáticas en cuatro bases de datos, junto con listas de referencias de las revisiones incluidas, lo que arrojó 15 revisiones sistemáticas (cuatro de las cuales también fueron metanálisis). La calidad de cada revisión se evaluó mediante el AMSTAR-2. RESULTADOS: Se resumen los hallazgos clave de las revisiones sistemáticas, organizados por paradigma y tipo de estímulo. DISCUSIÓN: Los autores sintetizan evidencia de estudios de la más alta calidad. Existe evidencia de evitación atencional y vigilancia en los trastornos alimentarios dependiendo de las propiedades de los estímulos (alimentos bajos en caloróas frente a alimentos ricos en calorías; fotos de otros con índice de masa corporal alto o bajo) y la evitación atencional de los estímulos alimentarios en personas con anorexia nerviosa. La inducción del estado de ánimo triste puede generar un sesgo de atención hacia la comida en personas con trastorno por atracón. También puede haber un sesgo de atención a la amenaza general en las muestras de trastornos alimentarios. Esta meta-revisión concluye que la mayoría de las revisiones sistemáticas en este campo son de baja calidad y resume las áreas principales que podrían mejorarse en revisiones futuras. También se discuten las implicaciones de los hallazgos de este estudio para la investigación de la teoría y la intervención.

The lived experience of working with people with eating disorders: A meta-ethnography.

OBJECTIVE: Working with people with eating disorders (EDs) is known to elicit strong emotional reactions, and the therapeutic alliance has been shown to affect outcomes with this clinical population. As a consequence, it is important to understand healthcare professionals' (HCPs') experiences of working with this client group. METHOD: A meta-synthesis was conducted of qualitative research on HCPs' lived experiences of working with people with EDs. The results from the identified studies were analyzed using Noblit and Hare's meta-ethnographic method. Data were synthesized using reciprocal translation, and a line of argument was developed. RESULTS: Thirty-seven studies met the inclusion criteria. Reciprocal translation resulted in a key concept: "Coping with caring without curing." This was underpinned by the following third-order concepts: (a) "The dissonance and discomfort of being a helper struggling to help," (b) "Defending against the dissonance," and (c) "Accepting the dissonance to provide safe and compassionate care." These concepts were used to develop a line-of-argument synthesis, which was expressed as a new model for understanding HCPs' experiences of working with people who have an ED. DISCUSSION: Although the conflict associated with being a helper struggling to help led some HCPs to avoid and blame people with EDs, others adopted a compassionate stance characterized by humanity, humility, balance, and awareness.

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

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

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

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

Emotional development in eating disorders: A qualitative metasynthesis.

Emotions are considered to be an important feature in eating disorders. The present study aimed to conduct a systematic review and metasynthesis of qualitative studies, which considered the role of emotions in eating disorders in order to gain further insight on how these individuals experience various emotions and the strategies they use to manage them. Databases including Web of Science, PsychInfo, EMBASE, Medline, and the Cochrane library were searched for qualitative studies. The search identified 16 relevant studies. Meta-ethnography was used to synthesize the data, which involved identifying the key findings and concepts of the studies and creating metaphors. The synthesis involved reciprocal translations and lines of argument approaches being applied to the present data. Results of the synthesis identified four second-order themes and one third-order theme relating to the emotional experiences of such individuals. The second-order themes were (a) negative emotional environments, (b) interpersonal vulnerability, (c) the experience of negative emotions in social contexts, and (d) the management of emotions. The third-order theme was the emotional self within a social environment. This is the first metasynthesis on emotions and eating disorders, and our synthesis highlights the important role that emotions play in the development and maintenance of eating disorders. Our model demonstrates how poor emotional development whilst growing up results in development of poor socioemotional bonds and the inability to handle negative emotions. The most significant finding of the review is that individuals use their eating disorder to manage negative emotions.

Accommodation of Symptoms in Anorexia Nervosa: A Qualitative Study.

Anorexia nervosa (AN) continues to remain poorly understood within eating disorders. Recent research and theory have moved away from understanding its aetiological causes, addressing instead potential maintaining factors. This study is focused on interpersonal maintenance factors: the response of close others. Relatives of those with AN typically carry the main burden of care, and research has found high levels of carer distress and unmet needs. Recent theories have proposed this emotional impact to contribute to expressed emotion and other unhelpful caregiver interactions which inadvertently maintain AN. One such understudied response is accommodation, described as a 'process' whereby caregivers 'assist or participate' in symptomatic behaviours of the cared for individual. There is a dearth of research relating to accommodation within eating disorders, particularly qualitative accounts. This study utilized a grounded theory methodology to explore caregivers' responses to managing AN, focusing particularly on carers' experience of accommodation. Eight participants with experience of caring for an individual diagnosed with AN were interviewed. Participants were recruited from a national eating disorder charity and regional eating disorder service. A number of themes emerged, including the importance of caregivers' emotional resources in mediating accommodation responses. Low-perceived efficacy over AN contributed to caregiver burnout. Decreased emotional resources influenced a shift in caregiving aims conducive with accommodation. Nevertheless, carers perceived accommodation as counterproductive to recovery and consequently experienced internal conflict (cognitive dissonance). Dissonance was reduced using a number of cognitive and behavioural strategies. The implications of these findings are discussed with reference to existing literature. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Anorexia nervosa (AN) can be difficult to manage. Over time, carers can feel powerless, and their emotional resources diminish. Diminished resources led to a shift in caregiving aims and responses. Subsequently, carers accommodated AN-related behaviours. Carers recognized accommodation as counterproductive and experienced internal conflict (dissonance). This was reduced using a number of strategies. Skill-based interventions designed to empower carers to manage difficult AN behaviours are recommended. Motivational interviewing to develop discrepancies between caregiving aims and responses may promote a shift in the caregiving approach.

Development and Validation of the Pride in Eating Pathology Scale (PEP-S).

There is a growing body of theoretical and clinical literature highlighting the role of pride in maintaining eating disordered behaviours. Despite its clinical importance, there are no measures to assess feelings of pride associated with eating psychopathology. This study describes the development and validation of the Pride in Eating Pathology Scale (PEP-S), a self-report questionnaire that examines feelings of pride towards eating disordered symptoms (e.g., pride in food restriction, thinness and weight loss). Participants were 390 females, recruited from university and community populations, whose mean age was 26.99 years. Respondents rated pride in eating pathology on a 7-point Likert-scale. Principal Component Analysis indicated that the 60-item scale comprised a four component structure: (1) pride in weight loss, food control and thinness, (2) pride in healthy weight and healthy eating, (3) pride in outperforming others and social recognition and (4) pride in capturing other people's attention due to extreme thinness. These four components explained a total of 65.31% of the variance. The PEP-S demonstrated very good internal reliability (α ranging from 0.88 to 0.98) and very good test-retest reliability over a 3-week time-span (r ranging from 0.81 to 0.93). The PEP-S also showed excellent convergent and discriminant validity. Furthermore, the scale discriminated between women with high and low levels of eating psychopathology. The PEP-S is a psychometrically robust measure of pride in eating pathology. It has the potential to advance theoretical understanding and may also be clinically useful. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The PEP-S is a valid, reliable, quick and easy to administer self-report questionnaire that measures pride related to eating pathology. The PEP-S assesses four clinically relevant dimensions: (1) pride in weight loss, food control and thinness, (2) pride in healthy weight and healthy eating, (3) pride in outperforming others and social recognition and (4) pride in capturing other people's attention due to extreme thinness. The PEP-S has very good internal and test-retest reliability, and very good convergent and discriminant validity. The PEP-S distinguishes between women with higher and lower levels of eating psychopathology. The PEP-S makes an important contribution to understanding pride in eating psychopathology, which is essential from both clinical and theoretical perspectives.

Investigating the 'jumping to conclusions' bias in people with anorexia nervosa.

'Jumping to conclusions' (JTC) is an established reasoning bias in people with psychosis and delusion proneness. Research investigating the JTC bias in other clinical populations remains in its infancy. This study investigated whether individuals with anorexia (AN) displayed the JTC bias compared with healthy controls and, if so, whether the bias was greater in relation to emotionally salient information. The study also investigated whether delusionality was correlated with the JTC bias. JTC was measured using the 'beads task'. Three versions were employed: the standard version and two emotionally salient tasks. Results indicated that a majority (55.6%) of people with AN (n=26) displayed poor insight into their eating disorder beliefs but did not display an elevated JTC compared with healthy controls (n=33) on any task. The level of delusionality in the AN group was not correlated with JTC bias. Findings suggest that although a majority of people with AN demonstrated limited insight, they did not display the JTC bias. This may suggest that poor insight in eating disorders has different characteristics to that found in psychotic disorders, which may suggest that differences are needed in relation to how they are treated using psychological means. However, this was a small study, and study replication is required.

Supervisee self-disclosure: a clinical psychology perspective.

UNLABELLED: Clinical supervision is a multi-functional intervention within numerous psychotherapeutic professions, including clinical psychology. It often relies on supervisees' verbal disclosures of pertinent information. There is limited research on supervisee self-disclosure in the UK, and none using clinical psychology populations. This study aimed to address the limitations in the evidence base. It used a constructivist grounded theory methodology to investigate qualified UK clinical psychologists' use of self-disclosure in supervision in order to develop a theoretical understanding of their self-disclosure processes. Ten clinical psychologists from various time points across the career span were recruited to the study. Four core conceptual categories were identified in the analysis as being integral to participants' decision-making processes: 'Setting the Scene', 'Supervisory Relationship', 'Using Self-disclosure' and 'Reviewing Outcome of Self-disclosure'. These four categories are comprised of a number of subcategories. The study's findings are compared with the current literature base, and it is argued that there are tensions with the scientist-practitioner model as it could be interpreted to encourage an expert stance, which may limit the self-disclosure of qualified supervisees. The implications of this perspective are discussed. KEY PRACTITIONER MESSAGE: Supervision is a key process in supporting qualified clinical psychologists and the use of disclosure appears to be important in facilitating useful supervision. It appears that clinical psychologists go through a number of complex processes in deciding whether to self disclose.

Effects of kangaroo mother care on maternal mood and interaction patterns between parents and their preterm, low birth weight infants: a systematic review.

The birth of a premature infant can have adverse effects on the mood of mothers and on the interaction patterns between parents and their preterm babies. The aim of the present systematic review was to examine whether the Kangaroo Mother Care (KMC) intervention can attenuate these adverse psychological effects of a premature birth by ameliorating negative maternal mood and/or promoting more positive interactions between preterm infants and their parents. The results showed that although findings of studies were inconclusive, there is some evidence to suggest that KMC can make a positive difference on these areas. Specifically, it was found that KMC can improve negative maternal mood (e.g., anxiety or depression) and promote more positive parent-child interactions. Limitations and directions for future research are discussed.

Hyperglycaemia aversion in type 1 diabetes: A grounded theory study.

OBJECTIVE: Very little is known about the circumstances under which hyperglycaemia aversion develops and is maintained. The present study aimed to identify psychological factors involved in the process of hyperglycaemia aversion and to understand how it affects people's self-management of type 1 diabetes. DESIGN: Qualitative, in-depth interviews were used. METHODS: A constructivist grounded theory study, using semi-structured participant interviews, was undertaken to build a theoretical model of the process of hyperglycaemia aversion. RESULTS: Eighteen participants were interviewed. Fifteen were considered hyperglycaemia averse and included in the analysis. A theoretical model was developed to describe and explain processes involved in hyperglycaemia aversion. Many participants held very high standards for themselves and often had a strong preference for control. While some participants described anxiety associated with higher blood glucose, the most proximal driver of their approach was self-criticism and frustration associated with not meeting their own high standards for blood glucose. A number of attentional processes and beliefs, mostly related to hypoglycaemia, maintained and reinforced their blood glucose preference. Diabetes technology served as an enabler, raiser of standards, and additional critical judge of participants' hyperglycaemia aversion. CONCLUSIONS: The trans-diagnostic concept of emotional over-control is used to understand the proposed model of processes of hyperglycaemia aversion. The present study offers new insight which will aid clinicians in identifying and supporting those who may be at risk of psychological distress and harm associated with a preference for avoidance of higher blood glucose levels.

A meta-ethnography of autistic people's experiences of social camouflaging and its relationship with mental health.

LAY ABSTRACT: Some autistic people describe trying to hide autistic behaviour and seem more neurotypical. Researchers called this 'social camouflaging' and have linked it with mental health difficulties. We used a step-by-step approach to identify research where autistic people talk about social camouflaging to explore the relationship between camouflaging and poor mental health. Thirteen studies were combined. The results describe how society negatively impacts autistic people's mental health, and camouflaging is a way to try and cope with this. Many autistic people find their camouflaging strategies have accidental negative consequences which also affect their mental health. Strategies which seemed 'successful' involved a lot of self-monitoring, were very mentally demanding or were very habitual and seemed to have more of an effect on mental health. This might be important for clinicians who support autistic people with mental health difficulties.

The experience and management of emotions on an inpatient setting for people with anorexia nervosa: a qualitative study.

OBJECTIVES: Research has identified how people with anorexia nervosa (AN) have problematic relationships with their own emotions, which can impact recovery. The aim of this study was to understand factors that were important in the care and emotional management of people with eating disorders on an inpatient unit. DESIGN: Semi-structured interviews were conducted with eight participants with AN. METHOD: Interview transcripts were analysed using a qualitative approach that was based upon interpretative phenomenological analysis, but also incorporated a theoretical component. RESULTS: From the qualitative analysis, two overarching and related themes were developed: 'difficulty with emotion' and 'predictability and care'. These were underpinned by a number of theoretical important constructs, such as 'staff factors', 'understanding of emotion', 'validity of emotion' and 'looking for ideal care'. CONCLUSION: Results suggested that the management strategies employed by some staff could serve to maintain eating disorders symptoms, whilst patient factors were also important as they had negative effect on staff's impact to care for this patient group.

Emotion coupling and regulation in anorexia nervosa.

OBJECTIVE: The present study sought to investigate emotion regulation strategies in people with anorexia nervosa (AN) and whether the theoretical concept of 'emotion coupling' between anger and disgust could help to explain some of the specific eating disorder symptomatology in people with AN. METHOD: This 'emotion coupling' hypothesis was tested using a mood induction procedure within laboratory conditions, where individuals with AN (n = 22) were matched with control participants (n = 19). Participants completed a bank of different measures prior to the study, and these included measures of eating pathology, core beliefs about the self and others, and emotion regulation strategies. Within the experimental part of this study, anger, disgust and body size estimation were measured prior to and after an anger induction procedure (i.e., a repeated measures design). RESULTS: People with AN demonstrated a significantly more internal-dysfunctional way to regulate their emotional states, when compared with matched controls. Within the 'emotional coupling' part of the study, participants showed a significant increase in levels of disgust and body size estimation following an anger induction when compared with matched controls. DISCUSSION: The significance of these results was considered in the light of the new Schematic, Propositional, Analogical and Associative Representation Systems in eating disorders model.

The relationship between shame, perfectionism and Anorexia Nervosa: A grounded theory study.

OBJECTIVES: The aim of this study was to explore the potential relationship between shame, perfectionism and Anorexia Nervosa (AN) and their impact on recovery from AN. METHOD: Semi-structured interviews were conducted with 11 people currently accessing services for AN. Interviews were transcribed and analysed using constructivist-grounded theory methodology. RESULTS: A model was developed which found a vicious cycle between shame and perfectionism. Participants tried to alleviate their feelings of shame by striving for perfectionism, however failing caused them more shame. Participants who disclosed childhood trauma believed their shame preceded their perfectionism. Participants who did not disclose trauma either believed their perfectionism preceded shame or they were unsure of which occurred first. Participants' responses suggested the following pathways from perfectionism to AN: needing goals; the need for a perfect life including a perfect body and AN being something they could be perfect at. The pathways identified between shame and AN entailed mechanisms via which AN could be used to escape shame, either by seeking pride through AN, seeking to numb shame through AN, seeking to escape body shame and punishing the self. AN was found to feed back into shame in two ways: when people had AN they felt ashamed when they broke their dietary rules, and also simultaneously people felt ashamed of their AN as they were not able to recover. Shame and perfectionism influenced one another in a cyclical pattern, in which shame drove perfectionism and not attaining high standards led to shame. Shame and perfectionism also impacted on recovery in several ways. AN functioned to numb participants' emotions, becoming part of their identity over time. AN also brought respite from a constant striving towards perfectionism. The need for a perfect recovery also influenced their motivation to engage in treatment, and fear of a return of strong emotions was another deterrent to recovery. CONCLUSION: The findings of this paper show perfectionism and shame to both be important in the aetiology and maintenance of AN and to have an impact on recovery from AN.

"Work WITH us": a Delphi study about improving eating disorder treatment for autistic women with anorexia nervosa.

BACKGROUND: There is an increased prevalence of anorexia nervosa (AN) in autistic women and this group has poorer treatment outcomes compared to non-autistic women with AN. However, there is little research into improving eating disorder treatment for autistic women. This study investigated how best to support autistic women with AN within eating disorder services. METHOD: A three-stage Delphi study was conducted with 49 participants with relevant expertise as a researcher, clinician, or expert by experience. RESULTS: A total of 70 statements were generated, with 56 reaching consensus after the final round. Statements reaching consensus made recommendations for adaptations to treatment, staff training, and service organisation. CONCLUSIONS: The results highlight the need to distinguish between autism- and AN-related difficulties, accommodate autistic traits such as sensory sensitivities and communication differences, and ensure the autistic voice is present in both the development and delivery of care. Future research should investigate the impact of these adaptations on outcomes. The applicability of these recommendations to autistic people with other eating disorders and of other genders needs to be investigated further.

Autistic women are more likely to have anorexia nervosa (AN) than non-autistic women. Autistic women can find eating disorder treatment unhelpful and need adaptations to treatment. This study asked a group of 49 researchers, staff, and people with personal experience of autism and eating disorders what they thought would help autistic women with AN. The study used a Delphi study method, which allows the calculation of how much participants agree without them needing to meet and make a decision. The study created 56 suggestions that the participants agreed on. The results give suggestions for changing treatment, training staff, and changing how services work to be better for autistic women. The suggestions highlight the importance of being able to tell the difference between autism- and AN- related behaviour, adjusting care to accommodate autistic traits, and involving autistic people in the development of care. Many of the suggestions recommend that changes are flexible to the individual autistic person. In the future, research should check if these changes are helpful for autistic women with AN, and if they would be helpful for autistic people who are not female or have other eating disorders.

Altered social hedonic processing in eating disorders.

OBJECTIVE: Exploring social anhedonia in eating disorders (ED) was the main objective of this study. Social anhedonia relates to a reduced feeling of pleasure from social stimulation. Researching the exact nature of problems in interpersonal relationships is an important topic for clinicians and researchers in the field. METHOD: The revised social anhedonia scale was completed by 148 participants: anorexia nervosa (AN) n = 72; bulimia nervosa (BN) n = 19; recovered AN n = 14; healthy controls (HC) n = 43. Participants also completed mood related measures and the Toronto Alexythimia scale. RESULTS: People with AN and BN had higher self-reported social anhedonia than people without ED. Recovered AN had an intermediate profile in between AN and HC. Clinical severity and alexithymia were strongly associated with social anhedonia scores. DISCUSSION: Difficulty identifying and expressing feelings could be related to this diminished drive for social pleasure. Tackling these interpersonal maintaining factors in treatment is likely to be a worthwhile endeavor.

Staff construal of inpatients with anorexia nervosa.

The present study uses personal construct theory and the repertory grid technique to examine staff views of individual clients with a diagnosis of anorexia nervosa, in particular those clients who purge and restrict. Fourteen members of nursing staff, both qualified and non-qualified, participated in the research. The results suggest that the 14 members of staff interviewed did construe clients who purge and clients who restrict in markedly different ways. The theoretical implications of this finding are discussed.

Negative childhood events and the development of the anorexic voice: A grounded theory.

BACKGROUND: Many individuals diagnosed with anorexia nervosa (AN) describe their disorder as being represented by an internal 'anorexic voice' (AV). Previous studies have identified associations between eating psychopathology and multifarious forms of adverse life experiences. AIMS: This study explores the relationship between adverse experiences in childhood and the development of the AV. MATERIALS AND METHODS: Twelve women who had the experience of the AV in the context of a diagnosis of AN took part in semi-structured interviews. The interview data were analysed using a constructivist grounded theory methodology. RESULTS: Participants recalled feeling unsafe in a variety of relationships and a theory was constructed in which the AV provides a sense of conditional safety, becoming increasingly hostile and belittling when it is disobeyed, revealing similar characteristics to abusers and bullies in childhood. DISCUSSION: Findings are related to the broader literature on the link between trauma and eating disorders, and to existing theories of internal voices. CONCLUSIONS: The findings have implications for a trauma-focused approach when working with the AV.