Differences in treatment trajectory following brief paediatric inpatient admissions for children and young people with eating disorders.

OBJECTIVE: Little is known about factors associated with treatment trajectory following brief paediatric admissions for children and young people (CYP) admitted for medical complications of their eating disorder (ED). This project aimed to identify possible factors and ways to improve the usefulness of paediatric admissions. METHOD: Retrospective NHS data was analysed to explore differences between paediatric admissions followed by community-based care or inpatient psychiatric care. Twelve parents were interviewed to seek feedback about paediatric admissions. RESULTS: Patients who received subsequent inpatient psychiatric care were unwell for longer, had longer paediatric admissions and more crisis team input, were more likely to have had previous admissions, and had higher parent-reported anxiety and depression. However, the groups did not significantly differ in ED severity. The interviews identified recommendations for improving paediatric admissions, which included improving understanding of EDs, enhancing communication channels, and providing psychological support to parents. CONCLUSIONS: Factors linked with illness severity (but not illness severity itself) appear to be associated with the difference between CYP either returning to community-based care or requiring more intensive psychiatric input. These factors may help clinicians understand who requires subsequent inpatient care, allowing clinicians to target more intensive support earlier and facilitate smoother transitions between services.

Moderators and mediators of outcome in treatments for anorexia nervosa and bulimia nervosa in adolescents: A systematic review of randomized controlled trials.

OBJECTIVE: To critically appraise papers reporting on moderators and mediators of recommended psychological treatments for anorexia nervosa (AN) and bulimia nervosa (BN) in adolescents. METHOD: A systematic search of databases was conducted including PsycINFO, Embase, MEDLINE, AMED, CINAHL, and the Cochrane Library. Studies were included where a randomized controlled trial (RCT) compared therapies for AN or BN and reported on moderators or mediators of treatment effect. Twenty-one eligible papers were included, all based on data from eight RCTs. RESULTS: Family therapies were dominant in the literature. Individual or separated treatment appeared superior for families with more difficult relationships, whereas conjoint family treatment appeared to be superior where good family relationships were reported. Where there was greater eating disorder psychopathology in AN, including eating disorder-related obsessions and compulsions, the response was better to a family approach than to individual therapies. There was some evidence that a family treatment was superior for those engaging in purging behaviors in BN. Measures of family relationships, parental self-efficacy, and early change emerged as possible mediators; however, the quality of evidence was mixed and the findings, in some cases, arguably circular. Moderator and mediator analyses were underpowered in all studies, with multiple, and post-hoc, analyses being run, and a broad range of outcome measures used. DISCUSSION: This review recommends that emerging findings are explored further in adequately powered trials of the different recommended therapies, with a move toward focusing on effect sizes. A consensus on acceptable definitions of outcome, including remission and recovery, would benefit future research.

OBJETIVO: Evaluar críticamente los artículos que informan sobre moderadores y mediadores de los tratamientos psicológicos recomendados para la anorexia nervosa (AN) y la bulimia nervosa (BN) en adolescentes. MÉTODO: Una búsqueda sistemática fue realizada en bases de datos incluyendo PsycINFO, Embase, MEDLINE, AMED, CINAHL y la Bibliotrca Cochrane. Los estudios fueron incluidos cuando un ensayo controlado aleatorio (RCT) comparaba terapias para AN o BN y reportaba en efectos del tratamiento de moderadores o mediadores. Se incluyeron veintiún artículos elegibles, todos basados en datos de ocho RCTs. RESULTADOS: Las terapias familiares fueron dominantes en la literatura. El tratamiento individual o separado parecía superior para familias con relaciones más difíciles, mientras que el tratamiento familiar en conjunto parecía ser superior cuando fueron reportadas buenas relaciones familiares. Cuando hubo una mayor psicopatología de trastorno de la conducta alimentaria en AN, incluyendo obsesiones y compulsiones relacionadas al trastorno de la conducta alimentaria, la respuesta a un abordaje familiar fue mejor que a terapias individuales. Hubo alguna evidencia de que un tratamiento familiar fue superior para aquellos involucrados en conductas purgativas en BN. Las medidas de las relaciones familiares, autoeficacia de los padres y cambio temprano emergieron como posibles mediadores, sin embargo, la calidad de la evidencia fue mixta y los hallazgos, en algunos casos, posiblemente circulares. Los análisis de moderadores y mediadores tenían poca potencia en todos los estudios, con multiples análisis llevados a cabo, y post-hoc, y un amplio rango de medidas de resultados utilizadas. DISCUSIÓN: Esta revisión recomienda que los hallazgos emergentes sean explorados más a fondo en ensayos adecuadamente potenciados de las diferentes terapias recomendadas, con un movimiento hacia enfocarse en el tamaño del efecto. Un consenso sobre definiciones aceptables del resultado, incluyendo remisión y recuperación, beneficiaría la investigación futura.

Mothers' experiences of home treatment for adolescents with anorexia nervosa: an interpretative phenomenological analysis.

Home treatment (HT) is emerging as an alternative to admission for adolescents with anorexia nervosa. It relies heavily on parental (often maternal) input to be effective. Given the high levels of carer stress reported by mothers, the current study aimed to explore mothers' experience of HT. A qualitative study using purposeful sampling was conducted. Nine interviews were analyzed using interpretative phenomenological analysis. Two contextual themes described the mother-daughter relationship and maternal stress and distress prior to HT. The third theme, "experience of help," included sub-themes of when help is needed, the need for containment, gaining strength and skills, and how HT met families' philosophy and values. The results support previous research on the stress that mothers particularly are under when their adolescent daughters have anorexia nervosa, and provides rich data on their experiences. HT is perceived as having both helpful and unhelpful aspects. Further research on its effectiveness is needed.

Adolescents with anorexia nervosa have their say: a review of qualitative studies on treatment and recovery from anorexia nervosa.

Anorexia nervosa often begins in adolescence, and there is a growing body of quantitative literature looking at the efficacy of treatment for adolescents. However, qualitative research has a valuable contribution to make to the understanding of treatment and recovery. This paper aims to review qualitative studies on the experience of treatment and recovery for adolescents with anorexia nervosa. Key themes from the 11 studies identified the role of family, peers and professionals, family therapy, the inpatient setting, emphasis on physical versus psychological and conceptualisation of recovery. Future studies would benefit from relating their findings to adolescent theory and considering reflexivity. Implications for clinical practice are also discussed.

Creating a care pathway for patients with longstanding, complex eating disorders.

BACKGROUND: Recovery rates for people with eating disorders are low; fewer than half recover and approximately 20% develop a longstanding eating disorder. Patients with longstanding eating disorders are often referred to as "SEED" (severe and enduing eating disorders) although this remains controversial and is not acknowledged in the British treatment guidance. This project aimed to generate recommendations for a longstanding eating disorder care pathway by identifying what proportion of patients have longstanding eating disorders and how to best identify and support them. METHODS: Initially, a literature review was completed, followed by interviews with service-users who consider themselves to have longstanding eating disorders, and focus groups with staff members. The results were combined to create a definition of a longstanding eating disorder which was used to establish how many service-users could benefit from the pathway. The qualitative data was used to produce recommendations for a tailored pathway for those with longstanding eating disorders. RESULTS: The results highlighted that, although "SEED" is often used, participants preferred to be referred to as "longstanding" or having no label. Qualitative analysis identified four themes in relation to supporting this population group which described how to structure the service and individualise care, as well as patients' relationship to the service, and how to build a life after eating disorder services. CONCLUSIONS: Recommendations included promoting a hopeful message, focusing on quality of life and introducing peer support. Crucially, accessing the pathway should not result in being labelled "SEED", nor should it prevent access to recovery focused interventions including weight restoration. The full list of recommendations are included as well as the implications of the project and limitations.

It is known that as many as 20% of people with eating disorders do not recover, and go on to live with their eating disorder for a number of years. However, there is relatively little research or guidance for professionals about how to support this group of people. Therefore, this project aimed to design a pathway for patients with longstanding eating disorders by combining the research evidence, staff's expert opinion and patient's views. The results highlighted that the majority of participants in this sample expressed a dislike for the term 'SEED' (severe and enduring eating disorder) and preferred 'longstanding eating disorder' or having no label. The results were used to generate a set of recommendations about how services can best support this group of patients which covered how to structure the service, individualise care, manage patient's relationship to the service, and build a life after eating disorder services. Key ideas included the importance of remaining hopeful about future recovery, introducing peer support, and supporting patients to improve their quality of life.

An examination of the concept of central coherence in women with anorexia nervosa.

OBJECTIVE: To examine central coherence (local and global processing) in women with anorexia nervosa (AN). METHOD: 42 women with AN and 42 healthy women (HC) completed neuropsychological testing measuring visuospatial and verbal aspects of central coherence: Rey-Osterrieth Complex Figure (RCFT), Embedded Figures Test (EFT), Homograph Reading Test (HRT), and Sentence Completion Task (SCT). RESULTS: People with AN displayed superior performance on the EFT and poorer performance in RCFT with the exception of accuracy in the copy trial. Long hesitations in the SCT were observed. Verbal coherence tasks were not sensitive enough to detect coherence anomalies in AN. CONCLUSION: Women with AN have strengths in tasks requiring local processing (EFT) and weaknesses on tasks benefited by global processing (RCFT and SCT). These results are consistent with the weak central coherence account. This trait might play a role in the maintenance of AN and can be addressed in specific clinical interventions.

Personality pathology among individuals with a lifetime history of anorexia nervosa.

Anorexia nervosa (AN) appears to be associated with certain personality features. The degree to which personality pathology persists after the acute phase of illness is unclear. This study aimed to investigate personality pathology in a large sample (n = 153) of women with histories of AN using the Dimensional Assessment of Personality Pathology (DAPP) and to evaluate the persistence of pathological personality features by comparing women with acute (n = 83) and remitted AN (n = 55). Women with AN demonstrated high levels of emotional dysregulation, social inhibition and compulsivity relative to age-matched healthy women (n = 124). Identity problems, intimacy problems and schizotypal features were highlighted as important. The same 14 pathological personality dimensions were significantly elevated in both ill and remitted participants, though remitted individuals' scores were reduced on 4 of the subscales. These results indicate that pathological personality features in AN are persistent traits, although some features may become exaggerated in the acute phase.

Is impaired set-shifting an endophenotype of anorexia nervosa?

OBJECTIVE: Set-shifting difficulties have been reported in subjects with anorexia nervosa and appear to persist after recovery; therefore, they may be endophenotypic traits. The goals of this study were to investigate whether set-shifting difficulties are familial by examining discordant sister-pairs in comparison with healthy unrelated women and to replicate, with a broader battery, the lack of influence of an acute illness state on neuropsychological performance. METHOD: Forty-seven pairs of sisters discordant for anorexia nervosa and 47 healthy unrelated women who were comparable in age and IQ completed neuropsychological tasks selected to assess set-shifting ability. Analyses of variance with standard errors that are robust against correlations within family clusters were used to compare the groups. Results were adjusted for obsessive-compulsive, anxiety, and depression symptoms. Subjects with acute (N=24) and fully remitted (N=23) anorexia nervosa were compared to assess state versus trait effects. RESULTS: Sisters with and without anorexia nervosa took significantly longer than unrelated healthy women to shift their cognitive set (CatBat task) and demonstrated greater perceptual rigidity (Haptic Illusion task) but did not differ significantly from each other. Women with anorexia nervosa were slower than other groups on Trail Making tasks. Women who had fully recovered from anorexia nervosa made significantly fewer errors than those with acute anorexia nervosa on the Trail Making alphabet task, but these subgroups did not differ on other measures. CONCLUSIONS: Both affected and unaffected sisters had more set-shifting difficulties than unrelated healthy women. This finding, together with the replicated finding that set-shifting difficulties persist after recovery, suggests that set-shifting difficulties are trait characteristics and may inform the search for the endophenotype in anorexia nervosa.

Do illness characteristics and familial risk differ between women with anorexia nervosa grouped on the basis of personality pathology?

BACKGROUND: In view of the potential utility of personality-based groupings in eating disorders (EDs), and the lack of studies using this approach in large samples of individuals with anorexia nervosa (AN), this study set out to examine (i) the nature of personality-based clusters of women with lifetime AN and (ii) if these clusters are associated with either clinical symptoms or aetiological variables. METHOD: The self-report Dimensional Assessment of Personality Pathology (DAPP) was completed by 153 women with a lifetime diagnosis of DSM-IV AN. A cluster analysis was used to identify personality-based subgroups. Clusters were then compared on clinical and aetiological variables. RESULTS: Three personality-based clusters were identified, defined by broad, avoidant and compulsive types of personality pathology. Dimensions of low dissocial behaviour, high inhibition and high compulsivity were common to all clusters, while dimensions related to emotional dysregulation appeared more heterogeneous. Clinical symptoms were not related to personality profile with the exception of a trend towards more fasting behaviour in the broad group. The compulsive cluster with the narrowest range of extreme personality traits reported the highest familial risk of eating pathology. CONCLUSIONS: The three clusters identified in our AN sample were similar to those previously identified in broader eating disordered samples. Personality-based clusters did not correspond overall to clinical symptoms but aetiological differences supported their validity. Broader personality pathology indicative of emotional dysregulation, problems with identity and relationships, in addition to core traits, may increase vulnerability to AN in those with less familial risk.

The pros and cons of change in individuals with eating disorders: a broader perspective.

OBJECTIVE: The goals of the current study were to develop a questionnaire measuring the pros and cons of eating disorder symptoms and to explore the themes endorsed by different eating disorder groups. METHOD: Participants recruited from an eating disorder volunteer register and an outpatient clinic completed the Pros and Cons of Eating Disorders scale (P-CED). Principal components analyses (PCA) were performed to validate the factorial structure of the original items and to explore the factorial structure of the new items. Planned comparisons were used to compare P-CED scores between diagnostic groups. RESULTS: PCA indicated a 10-factor solution for the original Pros and Cons of Anorexia Nervosa scale (P-CAN) items and a 4-factor solution for the new items. Participants with anorexia nervosa (AN) scored significantly higher than participants with bulimia nervosa (BN) on five of the P-CED subscales but there were no significant differences between the two AN subtypes. CONCLUSION: The P-CED is a useful tool for identifying the positive and negative aspects of eating disorders that can be targeted in treatment or used as an outcome measure in research.

Perceptions of illness in individuals with anorexia nervosa: a comparison with lay men and women.

OBJECTIVE: The current study examined and compared perceptions of illness in individuals with anorexia nervosa (AN) and lay men and women. METHOD: Participants with AN (n = 95) completed the Revised Illness Perception Questionnaire (IPQ-R). Lay participants (n = 80) completed a modified IPQ-R to elicit perceptions of AN. RESULTS: Participants with AN viewed their illness as chronic and highly distressing, with strong negative consequences. They had fairly negative perceptions of illness controllability and curability, which contrasted with the more optimistic beliefs held by lay participants. Both groups implicated emotional and psychological causes. DISCUSSION: The profile of illness perceptions expressed by the AN sample is associated with poor mental health and functioning and may inform the treatment approach. Lay perceptions of AN differed in the conceptualization of AN as a "slimming disease" amenable to change. This discrepancy may contribute to the stigmatization of AN.