Frances Connan

A neurodevelopmental model for anorexia nervosa

This paper integrates genetic and biological data on aetiological risk for anorexia nervosa (AN) with cognitive and psychosocial explanatory models. We have reviewed clinical and basic science data from each of these domains and then used a developmental perspective to formulate a multifactorial threshold model. By positioning interpersonal stress as a central component of this model, psychological, social and biological conceptualisations of AN can be used to generate a data driven, neurodevelopmental hypothesis for the aetiology of this complex disorder.

The Effects of Stress on Body Weight: Biological and Psychological Predictors of Change in BMI

Objective: To investigate individual differences in the effects of stress on BMI.

A multi-centre cohort study of short term outcomes of hospital treatment for anorexia nervosa in the UK

BackgroundIndividual, family and service level characteristics and outcomes are described for adult and adolescent patients receiving specialist inpatient or day patient treatment for anorexia nervosa (AN). Potential predictors of treatment outcome are explored.MethodAdmission and discharge data were collected from patients admitted at 14 UK hospital treatment units for AN over a period of three years (adult units N = 12; adolescent N = 2) (patients N = 177).ResultsOne hundred and seventy-seven patients with a severe and enduring illness with wide functional impairment took part in the study. Following inpatient care, physical improvement was moderate/good with a large increase in BMI, although most patients continued to have a clinical level of eating disorder symptoms at discharge. The potentially modifiable predictors of outcome included confidence to change, social functioning and carer expressed emotion and control.ConclusionsOverall, the response to inpatient treatment was modest particularly in the group with a severe enduring form of illness. Adolescents had a better response. Although inpatient treatment produces an improvement in physical health there was less improvement in other eating disorder and mood symptoms. As predicted by the carer interpersonal maintenance model, carer behaviour may influence the response to inpatient care, as may improved social functioning and confidence to change.

Caregiving and coping in carers of people with anorexia nervosa admitted for intensive hospital care

OBJECTIVE The aim of the study was to examine how carers cope practically and emotionally with caring for individuals with anorexia nervosa who require intensive hospital care. METHOD This study explores objective burden (time spent with caregiving and number of tasks), subjective burden (psychological distress), and social support in a sample of parents (n = 224) and partners (n = 28) from a consecutive series of patients (n = 178) admitted to inpatient units within the United Kingdom. RESULTS Most time was spent providing emotional support and less with practical tasks. Time spent with caregiving was associated with carer distress and was fully mediated by carer burden. This was ameliorated by social support. Partners received minimal support from others, and we found similar levels of burden and distress for mothers and partners. DISCUSSION The data indicate that professional and social support alleviates carer distress and may be of particular value for partners who are more isolated than parents. The data also suggest that time spent with practical support may be of more value than emotional support.

Personality Disorder Cognitions in the Eating Disorders

The eating disorders are frequently found to be comorbid with Axis II cluster B and C personality disorders. It is important to identify the personality-level cognitions that typify these disorders. This study of a clinical group examines the personality disorder cognitions in the eating disorders. The cognitions that were most relevant to the eating disorder pathology were those relating to avoidant and obsessive-compulsive personality disorder. Other personality disorder cognitions were associated with comorbid psychopathology in largely clinically meaningful ways. These findings extend our understanding of the comorbidity of eating disorders and personality pathology, suggesting that some cases need to be assessed and formulated with such cognitions in mind. Treatment strategies are required that address both the eating and the personality pathology, while considering the impact of these cognitions on the therapeutic relationship.

Schedule for personality assessment from notes and documents (SPAN-DOC): Preliminary validation, links to the ICD-11 classification of personality disorder, and use in eating disorders.

BACKGROUND The underlying core of personality is insufficiently assessed by any single instrument. This has led to the development of instruments adapted for written records in the assessment of personality disorder. AIMS To test the construct validity and inter-rater reliability of a new personality assessment method. METHOD This study (four parts) assessed the construct validity of the Schedule for Personality Assessment from Notes and Documents (SPAN-DOC), a dimensional assessment from clinical records. We examined inter-rater reliability using case vignettes (Part 1) and convergent validity in three ways: by comparison with NEO Five-Factor Inventory in 130 Korean patients (Part 2), with agreed ICD-11 personality severity levels in two populations (Part 3) and determining its use in assessing the personality status in 90 British patients with eating disorders (Part 4). RESULTS Internal consistency (alpha = .90) and inter-rater reliability (intraclass correlation coefficient ≥ .88) were satisfactory. Each factor in the five-factor model of personality was correlated with conceptually valid SPAN-DOC variables. The SPAN-DOC domain traits in those with eating disorders were categorized into 3 clusters: self-aggrandisement, emotionally unstable, and anxious/dependent. CONCLUSIONS This study provides preliminary support for the usefulness of SPAN-DOC in the assessment of personality disorder. Copyright

Confirmatory factor analysis for two questionnaires of caregiving in eating disorders.

Objective: Caring for someone diagnosed with an eating disorder (ED) is associated with a high level of burden and psychological distress which can inadvertently contribute to the maintenance of the illness. The Eating Disorders Symptom Impact Scale (EDSIS) and Accommodation and Enabling Scale for Eating Disorders (AESED) are self-report scales to assess elements of caregiving theorised to contribute to the maintenance of an ED. Further validation and confirmation of the factor structures for these scales are necessary for rigorous evaluation of complex interventions which target these modifiable elements of caregiving. Method: EDSIS and AESED data from 268 carers of people with anorexia nervosa (AN), recruited from consecutive admissions to 15 UK inpatient or day patient hospital units, were subjected to confirmatory factor analysis to test model fit by applying the existing factor structures: (a) four-factor structure for the EDSIS and (b) five-factor structure for the AESED. Results: Confirmatory factor analytic results support the existing four-factor and five-factor structures for the EDSIS and the AESED, respectively. Discussion: The present findings provide further validation of the EDSIS and the AESED as tools to assess modifiable elements of caregiving for someone with an ED.

Both focused and enhanced cognitive behavioural therapy improve eating disorder symptom severity.

ED FROM Fairburn CG, Cooper Z, Doll HA, et al. Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Am J Psychiatry 2009;166:311–19. Correspondence to: Professor Fairburn, Department of Psychiatry, Warneford Hospital, Oxford University, Oxford OX3 7JX, UK; credo@medsci.ox.ac.uk Source of funding: Wellcome Trust. c Additional notes are published online only at http://ebmh.bmj.com/content/vol12/ issue4 C O M M EN TA R Y E ating disorders (EDs) affect a substantial proportion of the population, particularly female adolescents and young adults. The majority of cases are atypical, and although they suffer in similar ways to those with full syndrome anorexia and bulimia nervosa, there has been little or no research into treatment outcomes. This study examines the effects of two modified versions of cognitive behavioural therapy (CBT) with ED patients, with a body mass index above the anorexic range (.17.5). Strengths include appropriate statistical power and use of intent to treat analysis. While this research does not improve the outcome for bulimia nervosa substantially (comparability with other studies is limited by a change in the means of determining a positive outcome), there are two key findings here. Firstly, such CBT is applicable to atypical cases. Secondly, while the two forms of CBT had equivalent overall effects, the broader form is more effective for cases with more complex pathology while the focused form is more effective for less complex cases. In terms of clinical practice, this finding enhances the position of CBT as the default option for people with nonanorexic EDs (the majority of cases), including atypical cases. However, while clinicians clearly need CBT in their toolbox, no service should be expected to offer a single approach as no therapy is anywhere near all embracing. We also need to be aware of the value of addressing wider issues (eg, relationships, affect) in more complex cases. This approach could be implemented in a wide range of clinical settings. However, there are some limitations to the generalisability of these clinical conclusions. The attrition rate, while low for this population, means that there is room for further work on enhancing attendance. In addition, 40% of eligible cases did not take part and there were exclusion criteria that would not apply in routine practice (eg, previous receipt of a comparable treatment, presence of an ‘‘interfering’’ axis I disorder). Finally, it remains to be established how these findings will generalise to other settings (less well established services, inpatient and day patient settings, services for younger people). The other significant issue is the need to establish whether this approach is effective for patients with weight in the anorexic range, but that is another story... Frances Connan, PhD, MRCPsych and Glenn Waller, DPhil Vincent Square Eating Disorders Service, Central and North West London NHS Foundation Trust, London, UK Competing interests: GW is the lead author of a treatment manual on CBT for patients with eating disorders which takes a broadly comparable approach to treatment to the one employed here. Therapeutics EBMH November 2009 Vol 12 No 4 119