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.

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.

"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.

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.

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.

'The last thing you feel is the self-disgust'. The role of self-directed disgust in men who have attempted suicide: A grounded theory study.

OBJECTIVE: Globally, suicide affects more men than women. Emotional pain underpins many theoretical accounts of suicidality, yet little is known about the role of disgust in suicide. Self-directed disgust, whereby aspects of the self-serve as an object of disgust, has been hypothesised to factor in suicide. This research aimed to explore the processes which link self-disgust to attempted suicide in males. METHOD: Nine men who had attempted suicide completed semi-structured interviews. The interview data were analysed using a constructivist grounded theory methodology. RESULTS: Three concepts emerged out of the analysis: (1) self-disgust; (2) worthlessness; and (3) the endured emotional distress of 'the abyss'" - these concepts interweaved, leading the men to experience hopelessness, disconnection and an inability to cope, leading ultimately to their suicide attempt. Throughout this journey, various disgust-related processes worsened men's distress and increased their suicidal risk. Historic adversities prevailed across the data, as did the men's difficulties in understanding their emotions. CONCLUSION: Self-disgust was an important emotion in the men's experiences of suicide and shaped their views of themselves and their lives. The distancing and repellent properties of self-disgust, in addition to the fear of having their 'disgustingness' exposed, increased suicidal risk. Self-disgust appeared more pervasive in the suicidality of men with a history of multiple childhood adversities. The limitations of this research are discussed as implications for clinical practice and directions for future research.

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.

'It's not that they don't want to access the support . . . it's the impact of the autism': The experience of eating disorder services from the perspective of autistic women, parents and healthcare professionals.

LAY ABSTRACT: This study explores autistic women's experiences of eating disorder services. About 20%-30% of people with anorexia nervosa are also autistic, and current treatments seem not to work as well for them. We interviewed 15 autistic women with experience of anorexia nervosa, 12 parents of autistic women with anorexia nervosa, and 11 healthcare professionals working in eating disorder services. We asked autistic women and parents about their experiences of eating disorder services, and we asked healthcare professionals about their experiences treating autistic women with anorexia nervosa. Participants' views were represented by three overall themes: misunderstanding autism and autistic traits, one treatment does not fit all, and improving accessibility and engagement within services. We found that autistic women face many barriers when in treatment for anorexia nervosa, often because of a lack of autism understanding within eating disorder services. Future research should look at developing anorexia nervosa treatments that can specifically help autistic individuals.

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.

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.

Experiences of shame and guilt in anorexia and bulimia nervosa: A systematic review.

OBJECTIVES: Emotional states may play an important role in the development and maintenance of anorexia (AN) and bulimia nervosa (BN). This systematic review aimed to examine the evidence regarding the relationship that shame and guilt have with two eating disorders, AN and BN. METHODS: Four major databases (Pubmed, PsychINFO, Web of Science, Medline) were searched (up until April 2018) for studies measuring guilt or shame in clinically diagnosed AN and BN groups. Included papers were evaluated for risk of bias. RESULTS: Twenty-four papers met the inclusion criteria. Several methodological issues were noted within the reviewed studies, including a lack of longitudinal data and unaccounted confounding variables. Nonetheless, shame was typically more common in those with AN and BN than controls, was positively related to the severity of symptoms, and associated with the onset of eating disorder-related difficulties (e.g., binging or purging). Effect sizes were typically moderate to large. The role of guilt was less clear, with few studies and mixed results. DISCUSSION: There is preliminary evidence that shame is implicated in the aetiology of AN and BN presentations, whilst there is currently insufficient evidence of such a role for guilt. It remains unclear whether shame is a risk factor for the development of AN and BN or a consequence of these difficulties. PRACTITIONER POINTS: Elevated shame appears to be a feature of anorexia (AN) and bulimia nervosa (BN). Shame appears to fluctuate with the occurrence of eating disordered behaviours like binging, purging or restricted eating. Guilt is less consistently linked to AN and BN presentations. Interventions directed at shame may be helpful for these populations. A lack of longitudinal data means the temporal features of these relationships are still unclear.

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.

The role of pride in women with anorexia nervosa: A grounded theory study.

OBJECTIVE: Theory and clinical literature suggest that pride may play an important role in the maintenance of restrictive eating disorders. A grounded theory study explored experiences of, and reflections on, pride among women with a current or past diagnosis of anorexia nervosa. DESIGN: This is a qualitative study using grounded theory. METHOD: Semistructured interviews were conducted with 21 women recruited from an eating disorder unit in England, and from a UK self-help organization. Grounded theory from a constructivist lens was used. Analysis involved coding, constant comparison, and memo-writing. RESULTS: Pride evolves over the course of anorexia nervosa. Two overarching conceptual categories were identified: 'pride becoming intertwined with anorexia' and 'pride during the journey towards recovery'. These categories encompassed different forms of pride: 'alluring pride', 'toxic pride', 'pathological pride', 'anorexia pride', 'shameful pride', 'recovery pride', and 'resilient pride'. Initially, pride contributed to self-enhancement and buffered negative emotions. As the condition progressed, pride became a challenge to health and interfered with motivation to change. During recovery, perceptions of pride altered as a healthy approach to living ensued. CONCLUSIONS: The evolving nature of pride plays a central role in development, maintenance, and treatment of anorexia nervosa. Understanding of pride and its role in psychotherapeutic work with this client group may increase motivation to change and promote recovery. Future work should investigate whether tackling pride in eating disorders increases treatment efficacy and reduces the risk of relapsing. PRACTITIONERS POINTS: Pride associated with anorexia appeared to evolve in nature. During early stages of the eating disorder, it stopped people from seeking help. Later on, it prevented them from seeing pride in healthy domains of life (outside anorexia). Over time, pride in anorexia became an overwhelming emotion that interfered with motivation to change. It is important for practitioners to assess and discuss pride in anorexia and its evolving nature during treatment. Understanding of pride and its role in psychotherapeutic work with this client group may increase motivation to change and promote recovery.

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.

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.

Young children's experiences of living with a parent with bipolar disorder: Understanding the child's perspective.

OBJECTIVES: To explore the experiences of young children of living with a parent with bipolar disorder (BD) and how this impacts on their emotional well-being. DESIGN: Qualitative study using a computer-assisted semi-structured interview, 'In My Shoes' (IMS). METHODS: Ten children aged between 4 and 10 years with a parent with BD identified via self-help groups were interviewed about their experience of family life. Thematic analysis was used following transcription. RESULTS: Four main themes emerging from thematic analysis were as follows: perception of parents; knowledge and awareness of BD; managing family life with a 'bipolar' parent; and living in a family with BD. Four-year-old children could participate in the IMS interviews and discuss their parent's mood, behaviour, and mental health. Children had candid and insightful discussions about their parent's BD including symptoms and parenting, and could reflect on how having a parent with BD affected them emotionally and practically. Older children were better able to articulate their parent's illness and its impact. CONCLUSIONS: This exploratory study represents an important step in examining directly experiences of young children whose parents have BD. Using IMS, it was possible to gather insightful information from children to generate hypotheses and influence service development. Children of all ages had some knowledge and understanding of their parent's illness, describing both positive and negative experiences in the family. Further research to build understanding of children's perspectives and the support they feel they and their family would benefit from would enhance the development of appropriate services and interventions. PRACTITIONER POINTS: Using age-appropriate tools, it is possible to elicit the views of young children about their parent's mental health and parenting. Young children have insight into the impact of bipolar disorder in the family on themselves and family members.

The experience of involuntary detention in acute psychiatric care. A review and synthesis of qualitative studies.

OBJECTIVE: To build on a previous review and updated understanding of how patients experience involuntary detention for their mental health difficulties. DESIGN: We provide a narrative synthesis review of qualitative studies. DATA SOURCES: Using pre-defined search terms, the following databases were searched covering the period 2006 to March 2014: Psychinfo, Medline, Medline In-Process, Embase, Web of Knowledge, Scopus, Science Direct, British Nursing Index and Cinahl Plus. Three journals were electronically hand-searched. REVIEW METHODS: The search resulted in the retrieval of 6230 records which were screened by title. Relevant studies were then screened by abstract and further articles were read for full text. References of articles read for full text were screened using an inclusion and exclusion criteria. A total of fifteen studies were identified and a quality evaluation tool was applied to each study. Themes and constructs from all fifteen studies were coded and synthesised. RESULTS: Seven overarching themes emerged. 'Sanctuary', 'loss of normality and perceived independence', 'feeling terrified' and 'fluctuating emotions' illustrate the experiences of involuntary detention. The remaining themes reflect the factors that influence these experiences: 'a continuum of person-centred practice', 'disempowerment' and 'intra-psychic coping'. CONCLUSIONS: Participants varied in how they experienced involuntary detention. Some people experienced a sense of sanctuary, whereas others experienced loss, fear and trauma. People's experiences were influenced by the degree of actual or perceived person-centred and empowering care, which also had an impact on their coping style. Development of a therapeutic bond with clinicians was a key factor which influenced positive experiences of involuntary detention. The implications of the findings are discussed with reference to existing literature and recommendations are made for clinical practice. Ideas for future research are identified.

Sense of self and anorexia nervosa: A grounded theory.

OBJECTIVES: The aim of this study was to explore the nature of the relationship between the self and the eating disorder in individuals with a lifetime history of anorexia nervosa (AN). DESIGN: A qualitative design was used, given the exploratory nature of the study and the need to gain rich and in-depth data regarding the topic under investigation. METHOD: Semi-structured interviews were conducted with 11 women with a lifetime history of AN. Interview transcripts were analysed using constructivist grounded theory methodology. RESULTS: A theoretical framework of the nature of the relationship between the self and AN was developed, which included five related categories: AN taking over the self, AN protecting the self, sharing the self with AN, being no one without AN, and discovering the real me (accepting the fear). CONCLUSION: Participants described a process of the self being taken over by AN to the point where it was shared with the eating disorder. This led participants to fear being no one without AN and to be unable to let go of the disorder, appreciating AN's ability to protect the self. To recover from AN, participants had to discover the real self, by accepting the fear of the unknown and separating the self from AN. The findings have important implications for the target of therapeutic interventions to improve recovery rates. PRACTITIONER POINTS: The self is shared with the eating disorder in AN, and separating the self from AN is crucial to recover from the disorder. Therapeutic interventions for AN need to target the enmeshed relationship between the self and the eating disorder, as opposed to focusing exclusively on weight and shape concerns.