Caregivers in anorexia nervosa: is grief underlying parental burden?

ABSTARCT: PURPOSE: Anorexia Nervosa (AN) is a severe chronic disorder and parents' experience of caregiving is usually marked by emotional distress and burden. Severe chronic psychiatric disorders are known to be linked with the concept of grief. Grief has not been investigated in AN. The aim of this study was to explore parents' and adolescents' characteristics that may be related to parental burden and grief in AN, and the link between these two dimensions. METHODS: Eighty mothers, 55 fathers and their adolescents (N = 84) hospitalized for AN participated in this study. Evaluations of clinical characteristics of the adolescent's illness were completed, as well as self-evaluations of adolescent and parental emotional distress (anxiety, depression, alexithymia). Levels of parental burden were evaluated with the Experience of Caregiving Inventory and levels of parental grief with the Mental Illness Version of the Texas Revised Inventory of Grief. RESULTS: Main findings indicated that the burden was higher in parents of adolescents with a more severe AN; fathers' burden was also significantly and positively related to their own level of anxiety. Parental grief was higher when adolescents' clinical state was more severe. Paternal grief was related to higher anxiety and depression, while maternal grief was correlated to higher alexithymia and depression. Paternal burden was explained by the father's anxiety and grief, maternal burden by the mother's grief and her child's clinical state. CONCLUSION: Parents of adolescents suffering from AN showed high levels of burden, emotional distress and grief. These inter-related experiences should be specific targets for intervention aimed at supporting parents. Our results support the extensive literature on the need to assist fathers and mothers in their caregiving role. This in turn may improve both their mental health and their abilities as caregivers of their suffering child. LEVEL OF EVIDENCE: Level III: Evidence obtained from cohort or case-control analytic studies.

Development and implementation of a relationship-focused outpatient multifamily program for adolescent anorexia nervosa.

Multifamily therapy (MFT) for adolescent eating disorders (ED) is anchored in systemic theory and family therapy, but two conceptual and practical paths have emerged from this common framework. The first one, called ED-focused MFT, is centered on behavioral change and weight gain in the early stages of treatment, while the second, known as relationship-focused MFT, is less directly focused on symptom improvement and more on family changes. Compared to ED-focused MFT, validation of more relationship-focused MFT models has been lagging behind although they are frequently implemented and practiced in Europe. The purpose of this article is to give more visibility to existing relationship-focused MFT models by presenting an integrative, yet predominantly family-oriented MFT program developed for adolescent anorexia nervosa (AN) (12 to 18 years) on the ED unit of a large pediatric hospital in France. After presenting the history and development of this relationship-focused MFT program, including the challenges it encountered and its evaluation, we describe its rationale and objectives, then outline its course and content, giving illustrations of techniques and activities for each of the five phases of the program. Finally, we review the current status of this model, its advantages and limitations, and provide a critical appraisal of existing evidence and recommended future research directions.

Long-term follow-up of a randomized controlled trial comparing systemic family therapy (FT-S) added to treatment as usual (TAU) with TAU alone in adolescents with anorexia nervosa.

BACKGROUND: Randomized controlled trials showed the efficacy of family therapy for anorexia nervosa during adolescence, but studies examining its long-term beneficial effect are still needed. This article presents the results of a 54-month post-randomization follow-up of a previously reported randomized controlled trial that compared two post-hospitalization outpatient treatment programs: Treatment As Usual alone versus Systemic Family Therapy added to Treatment As Usual. METHODS: A consecutive series of 60 female adolescents with anorexia nervosa (DSM-IV) were randomized (30 per group). During the first 18 months, in the Treatment As Usual group, subjects received a multidisciplinary treatment. In the other group, Systemic Family Therapy sessions targeting intra-familial dynamics were added to Treatment As Usual. At 54 months, the primary outcome was defined using the Morgan and Russell global Outcome Categories (Good or Intermediate versus Poor). Secondary outcomes were the Global Outcome Assessment Schedule score, body mass index, amenorrhea, number of hospitalizations, eating disorder symptoms, psychopathological features, and family functioning. Analyses were carried out using an Intention-To-Treat with the Last Observation Carried Forward procedure. Data of 59/60 subjects were available. RESULTS: At 54 months, significant effects in favor of adding Systemic Family Therapy to Treatment As Usual were shown for the Global Outcome Categories (60% of Good/Intermediate versus 31% in the control group, p = .026), mean body mass index (p = .048), resumption of menses (70.0% vs. 40% p = .020), and mental state score (p = .010). Family cohesion scores were lower in the Systemic Family Therapy group (p = .040). CONCLUSIONS: Adding Systemic Family Therapy focusing on intra-familial dynamics to a multidimensional outpatient treatment program appeared to lead to a better long-term outcome in young women who suffered from severe anorexia nervosa during adolescence.

Is the Severity of the Clinical Expression of Anorexia Nervosa Influenced by an Anxiety, Depressive, or Obsessive-Compulsive Comorbidity Over a Lifetime?

Purpose: The relationship between anxiety or depressive comorbidities, their chronology of onset, and the severity of anorexia nervosa (AN) is not well-studied. We hypothesize that the existence of a comorbidity, particularly before the onset of AN, is associated with greater severity of AN. Methods: One hundred seventy-seven subjects were assessed. The prevalence of major depressive disorder (MDD), obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and social phobia (SP) as well as their chronology of onset were studied. The assessment criteria of AN severity were the overall clinical condition, body mass index (BMI) on admission, lowest BMI, intensity of the eating symptoms, age at the onset of AN, illness duration, number of hospitalizations, and quality of life. Results: Patients with AN had the greatest clinical severity when they had a comorbid disorder over their lifetime, such as MDD, GAD, or SP. These comorbidities along with OCD were associated with a higher level of eating symptoms and a more altered quality of life. A profile of maximum severity was associated with a higher prevalence of MDD and GAD. Concerning the chronology of onset, the age at the start of AN was later in cases of MDD or GAD prior to AN. Conclusion: There seems to be an association between severity of AN and both MDD and GAD. The chronology of onset of the comorbidity did not seem to be associated with the severity.

Health in adulthood after severe anorexia nervosa in adolescence: a study of exposed and unexposed women.

OBJECTIVE: To compare the global health status, frequency of somatic and psychological problems, and alcohol use in adulthood among women hospitalized in adolescence for severe anorexia nervosa (AN), with a matched control sample from the general population. METHOD: Women (n = 86) who had been hospitalized for AN 9.31 ± 1.82 years previously were compared with 258 controls matched for gender, age, and socio-professional category. Data were retrieved from a French survey on health and social insurance coverage, and was mainly collected by self-report, except for the assessment of current eating disorders for those previously hospitalized for AN (assessed with the MINI). RESULTS: The women who had been hospitalized for AN reported significantly poorer current health status compared to controls (OR 2.9, 95% CI 1.5-5.79). According to the MINI, 13 women previously hospitalized with severe AN still presented an eating disorder (ED). Women with past AN reported more frequent acute throat infections (OR 4.9, 95% CI 1.81-13.51), gastralgia (OR 3.6, 95% CI 1.9-6.83), gastro-oesophageal reflux (OR 5.279, 95%CI 2.11-13.22), excess blood cholesterol or triglyceride levels (OR 2.55, 95% CI 1.03-6.33), anxiety (OR 8.7, 95% CI 3.48-21.8) and depression (OR 5.02 (2.8-9.01). These differences remained significant and of the same order of magnitude in sensitivity analyses among subjects with previous AN but without current ED, except for perceived health status and excess cholesterol and triglyceride levels. DISCUSSION: Women who had been hospitalized for severe AN reported more symptoms 10 years after treatment, implies psychological and somatic follow-up in the long term. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Correction to: Multicenter randomized controlled trial on the comparison of multi-family therapy (MFT) and systemic single-family therapy (SFT) in young patients with anorexia nervosa: study protocol of the THERAFAMBEST study.

After publication of our article [1] the authors have notified us of missing to include one name to the authorship list.

Physical Activity in Eating Disorders: A Systematic Review.

Abnormally high levels of physical activity have been documented throughout the literature in patients with eating disorders (ED), especially those diagnosed with anorexia nervosa (AN). Yet no clear definition, conceptualization, or treatment of the problematic use of physical activity (PPA) in ED patients exists. The aim of this review is to propose a new classification of PPA, report the prevalence, triggers, predictors, maintainers and other related factors of PPA in ED patients, in addition to proposing a comprehensive model of the development of PPA in AN. A total of 47 articles, retrieved from Medline and Web of Science, met the inclusion criteria and were included in the analysis. As a result, the new approach of PPA was divided into two groups (group 1 and group 2) according to the dimension (quantitative vs qualitative approach) of physical activity that was evaluated. The prevalence of PPA in ED was reported in 20 out of 47 studies, the comparison of PPA between ED versus controls in 21 articles, and the links between PPA and psychological factors in ED in 26 articles, including depression (16/26), anxiety (13/26), obsessive-compulsiveness (9/26), self-esteem (4/26), addictiveness (1/26), regulation and verbal expression of emotions (1/26) and anhedonia (1/26). The links between PPA and ED symptomatology, PPA and weight, body mass index (BMI) and body composition in ED, PPA and age, onset, illness duration and lifetime activity status in ED, PPA and ED treatment outcome were reported in 18, 15, 7, 5 articles, respectively. All of the factors have been systematically clustered into group 1 and group 2. Results focused more on AN rather than BN due to the limited studies on the latter. Additionally, a model for the development of PPA in AN patients was proposed, encompassing five periods evolving into three clinical stages. Thus, two very opposite components of PPA in AN were suggested: voluntarily PPA increased in AN was viewed as a conscious strategy to maximize weight loss, while involuntarily PPA increased proportionally with weight-loss, indicating that exercise might be under the control of a subconscious biological drive and involuntary cognition.

Schadenfreude, malicious and benign envy are associated with low body mass index in restrictive-type anorexia nervosa.

PURPOSE: According to the Cognitive-Interpersonal Maintenance Model of anorexia nervosa, social factors are involved in the maintenance and development of this disorder. Therefore, this study aimed to test whether patients with restrictive-type anorexia nervosa (AN-R) experience malicious envy (negative emotions associated with the wish that others lack their superior quality), benign envy (negative emotions associated with the desire to reach and obtain the others' superior quality) and Schadenfreude (pleasure at the misfortunes of others) with a higher intensity than healthy controls (HC). METHODS: 26 AN-R patients and 32 HC completed scenarios that aimed to induce envy and Schadenfreude and completed questionnaires measuring envy, self-esteem and social comparison. RESULTS: AN-R patients reported more benign envy than HC. Interestingly, higher body mass index (BMI) was associated with less Schadenfreude, malicious and benign envy in AN-R only. CONCLUSIONS: This study shows that AN-R patients present higher motivation to evolve when facing others' superior quality (i.e., benign envy). It also underlines the importance of considering social factors in the maintenance of AN-R and the role of BMI when examining emotions related to others' fortune. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Multicenter randomized controlled trial on the comparison of multi-family therapy (MFT) and systemic single-family therapy (SFT) in young patients with anorexia nervosa: study protocol of the THERAFAMBEST study.

BACKGROUND: Anorexia nervosa (AN) is a serious psychiatric illness that begins most of the time during adolescence. An early and efficacious intervention is crucial to minimize the risk of the illness becoming chronic and to limit the occurrence of comorbidities. There is a global consensus on optimal treatment for adolescents suffering from AN: international guidelines recommend single-family therapy that involves the patient and his/her family. Several family therapy approaches have been developed to date. However, these approaches, which imply a direct questioning of intrafamilial dynamics, are not suitable for all patients and families, and the rates of dropout or poor response to treatment remain quite high. A modality of family therapy has been adapted to AN, known as multi-family therapy (MFT), which consists in bringing together several families whose children suffers from the same illness. Objectives of the present randomized clinical trial are to evaluate whether the implementation of MFT in a multi-disciplinary treatment program for adolescents with AN is at least as efficacious as the use of systemic single-family therapy (SFT), with respect to the evolution of body mass index and other clinical outcomes 12 and 18 months after the start of treatment. A cost-efficiency analysis will also be conducted. METHODS: One hundred fifty patients meeting the inclusion criteria will be randomly assigned to one of the two treatment groups. Patients and their families will receive 10 sessions of therapy spread over 12 months. Body weight, eating disorder and other psychopathology-related symptoms, quality of family relationships, and family satisfaction with treatment will be evaluated during the treatment and at an 18 months follow-up. A cost-efficiency analysis will also be carried out. DISCUSSION: We hypothesize that MFT is at least as efficacious as SFT, but at a lesser cost. The identification of possible preferential indications for each technique could help the improvement of therapeutic indications for adolescents suffering from AN and contribute to the earliness of intervention, which is associated with a better outcome. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03350594 . Registered on 22 November 2017. IDRCB number 2016-A00818-43.

Predictive factors for outcome in adolescents with anorexia nervosa: To what extent does parental Expressed Emotion play a role?

In studies on family therapy in Anorexia Nervosa, family relationships, as assessed by Expressed Emotion, have been associated with outcome. Our aim was to explore the contribution of Expressed Emotion as a predictor of 18-month outcome, above and beyond the usual predictive factors. Sixty adolescent girls suffering from Anorexia Nervosa and their parents were assessed at baseline and 18 months later. Levels of Expressed Emotion were evaluated in both parents with the Five-Minute Speech Sample. After controlling for treatment group and initial clinical status, high maternal Emotional Over-Involvement at baseline was significantly associated with better clinical state. More precisely, high maternal Emotional Over-Involvement was associated with higher nutritional status, lower eating disorder severity and fewer re-hospitalizations 18 months later. No associations were found with paternal levels of Expressed Emotion. Therefore, our study confirmed the importance of taking into account both maternal and paternal Expressed Emotion. Our results also underlined that high maternal Emotional Over-Involvement plays a positive role in the outcome of Anorexia Nervosa and needs to be explored further.

New Insights in Anorexia Nervosa.

Anorexia nervosa (AN) is classically defined as a condition in which an abnormally low body weight is associated with an intense fear of gaining weight and distorted cognitions regarding weight, shape, and drive for thinness. This article reviews recent evidences from physiology, genetics, epigenetics, and brain imaging which allow to consider AN as an abnormality of reward pathways or an attempt to preserve mental homeostasis. Special emphasis is put on ghrelino-resistance and the importance of orexigenic peptides of the lateral hypothalamus, the gut microbiota and a dysimmune disorder of neuropeptide signaling. Physiological processes, secondary to underlying, and premorbid vulnerability factors-the "pondero-nutritional-feeding basements"- are also discussed.

Psychometric properties of the French version of a scale measuring perceived emotional intelligence : the Trait Meta-Mood Scale (TMMS).

OBJECTIVE: The Trait Meta-Mood Scale (TMMS), a 30-item self-assessment questionnaire, has been developed to measure perceived emotional intelligence (EI) level in 3 dimensions: Attention, Clarity and Repair. This study aimed to explore the psychometric properties of the French version of this instrument. METHOD: The instrument factor structure, normality, internal consistency, stability and concurrent validity were assessed in a sample of 824 young adults (456 female). Besides TMMS, participants completed self-assessment questionnaires for affectivity (Shortened Beck Depression Inventory, State and Trait Anxiety Inventory, Positive and Negative emotion scale), alexithymia (Bermond-Vorst Alexithymia Questionnaire-B) and interpersonal functioning (Empathy Quotient). Discriminant validity was tested in 64 female patients with anorexia nervosa, identified in literature as having difficulties with introspection, expression and emotional regulation. RESULTS: Confirmatory factor analysis results replicate the 3-factor structure. Internal consistency and reliability indices are adequate. Direction and degree of correlation coefficients between TMMS dimensions and other questionnaires support the instrument concurrent validity. TMMS allows to highlight differences in perceived EI levels between men and women (Attention: p < 0.001 ; Clarity: p < 0.05) as well as between patients with anorexia nervosa and control subjects (p < 0.001 for all 3 dimensions). CONCLUSION: This first validation study shows satisfying psychometric properties for TMMS French version.

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.

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).

Relationship between malnutrition and depression or anxiety in Anorexia Nervosa: a critical review of the literature.

BACKGROUND: Depression, anxiety and obsessive-compulsive disorder (OCD) frequently co-occur with Anorexia Nervosa (AN). Clinical consensus admits that depressive symptoms and anxiety are the sequelae of malnutrition in AN. This review presents a critical assessment of the literature that looked into the link between depression/anxiety symptoms in relation to malnutrition and their improvement throughout the treatment. METHODS: We performed a systematic search of literature in Medline and PsychInfo for all the studies done to investigate psychological factors in relation to malnutrition in AN using the keywords "Anorexia Nervosa", "depression", "anxiety", "obsessive-compulsive disorder" and "malnutrition". Only articles published between 1980 and 2010 in English or French were reviewed. From the articles on AN and depression, anxiety, and/or OCD, only the ones which investigated on the relation with malnutrition were kept. This search was complemented by a manual search. We also checked the reference lists of the articles we found. RESULTS: Seven papers were analyzed and critically reviewed for their methods and results. Results are contradictory and inconsistent at all levels of assessment. CONCLUSIONS: Evidence based data is very rare. From the 7 reviewed studies, none of them draw the same conclusion. This is mainly due to the large differences in the samples' populations and the studies' protocols. Future studies are needed to focus on the relationship between depression/anxiety symptoms and malnutrition. A more critical nutritional assessment should be undertaken with multiple psychological assessment scales.