Gillian Todd

The experience of caregiving for severe mental illness: a comparison between anorexia nervosa and psychosis

Background: The aim of this study was to examine the experience of care giving for people with anorexia nervosa and to compare it with the experiences of those people who care for a person with a psychotic illness. Method: Carers (parents, siblings and husbands) of people with eating disorders who had experienced an episode of inpatient care for anorexia nervosa (n=71) were given the General Health Questionnaire and the Experience of Caregiving Inventory. A sample of carers (N=68) of people with a psychotic illness from the community were used as a comparison group. A subgroup of the carers (n=20) of people with anorexia nervosa were asked to write about their experiences. Results: The clinical samples had a similar duration of illness, but the patients with anorexia nervosa were significantly younger and a larger proportion were living at home. The general health scores were significantly higher in the carers of anorexia nervosa and they experienced higher levels of difficulties in most areas of caregiving. A variety of variables from the Caregiving Inventory contributed to the level of psychological distress, accounting for 36 % of the variance. The themes of guilt and shame were additional dimensions that were addressed in the letters. Conclusions: Carers of people with anorexia nervosa are challenged by the difficulties their role produces.

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy.

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.

A cognitive model of bulimia nervosa.

This paper describes a new cognitive model of bulimia nervosa. It provides a detailed account of the development of the disorder and explains, in detail and encompassing cognition, behaviour, emotion, and physiology, how binge eating is maintained. Relevant maintaining factors include positive beliefs about eating, negative beliefs about weight and shape, permissive thoughts, and thoughts of no control. Relevant developmental factors include negative early experiences, negative self-beliefs, schema compensation processes, and different types of underlying assumption. Recent empirical findings on which the new model is based, and which support the model, are described. Existing observations and findings are also presented, and their consistency with the new model is confirmed. Novel features of the model are highlighted, and phenomena unexplained by existing cognitive models of bulimia nervosa, including treatment failure and relatively poor outcome following treatment with cognitive therapy, are assessed in the light of the new model. The relationship to recent findings on the role of dieting in bulimia nervosa and to developments in the understanding or normal eating is considered. Implications for basic and treatment-related research are then discussed. Finally, the clinical implications of the new model, including the use of schema-focused techniques, are briefly discussed.

QT interval in anorexia nervosa.

OBJECTIVES--To determine the incidence of a long QT interval as a marker for sudden death in patients with anorexia nervosa and to assess the effect of refeeding. To define a long QT interval by linear regression analysis and estimation of the upper limit of the confidence interval (95% CI) and to compare this with the commonly used Bazett rate correction formula. DESIGN--Prospective case control study. SETTING--Tertiary referral unit for eating disorders. SUBJECTS--41 consecutive patients with anorexia nervosa admitted over an 18 month period. 28 age and sex matched normal controls. MAIN OUTCOME MEASURES--maximum QT interval measured on 12 lead electrocardiograms. RESULTS--43.6% of the variability in the QT interval was explained by heart rate alone (p < 0.00001) and group analysis contributed a further 5.9% (p = 0.004). In 6 (15%) patients the QT interval was above the upper limit of the 95% CI for the prediction based on the control equation (NS). Two patients died suddenly; both had a QT interval at or above the upper limit of the 95% CI. In patients who reached their target weights the QT interval was significantly shorter (median 9.8 ms; p = 0.04) relative to the upper limit of the 60% CI of the control regression line, which best discriminated between patients and controls. The median Bazett rate corrected QT interval (QTc) in patients and controls was 435 v 405 ms.s-1/2 (p = 0.0004), and before and after refeeding it was 435 v 432 ms.s1/2 (NS). In 14(34%) patients and three (11%) controls the QTc was > 440 ms.s-1/2 (p = 0.053). CONCLUSIONS--The QT interval was longer in patients with anorexia nervosa than in age and sex matched controls, and there was a significant tendency to reversion to normal after refeeding. The Bazett rate correction formula overestimated the number of patients with QT prolongation and also did not show an improvement with refeeding.

The Eating Disorder Belief Questionnaire: Preliminary development

This paper describes the development of a self-report questionnaire designed to assess assumptions and beliefs associated with eating disorders. Factor analyses suggested to replicable four-factor structure consisting of the following dimensions: negative self-beliefs; weight and shape as a means to acceptance by others; weight and shape as a means to self-acceptance; and control over eating. The subscales possess good psychometric properties and significant correlations were found between the subscales and other measures of the specific and general psychopathology of eating disorders. The questionnaire also distinguished two groups of patients with eating disorders from normal controls. The usefulness of the measure and implications of the findings for cognitive theories of eating disorders are briefly discussed.

Content, Origins, and Consequences of Dysfunctional Beliefs in Anorexia Nervosa and Bulimia Nervosa

A semi-structured interview was used to investigate negative self beliefs in female patients with eating disorders and women without an eating disorder history. Information about possible developmental influences on these beliefs was also collected. Beliefs linking eating behavior with weight and shape and beliefs about the self were identified, but only by the patients. Self-beliefs were invariably negative and unconditional. Beliefs about eating, weight and shape were usually in the form of conditional assumptions. Most patients identified specific origins for their negative self-beliefs: usually trauma or abuse in childhood. All patients believed that dieting was a way of counteracting the negative implications associated with their self-beliefs. Bingeing seemed to provide an initial distraction in some cases from negative automatic thoughts, images, negative self-beliefs and negative emotional states. However, after bingeing, these intensified. Implications for cognitive theories of eating disorders and for clinical practice are discussed.

The Assessment of the Family of People with Eating Disorders

The National Institute for Clinical Excellence (NICE) guidelines for eating disorders recommend that carers should be provided with information and support and that their needs should be considered if relevant. The aim of this paper is to describe how to structure an assessment of carers needs so that the family factors that can contribute to the maintenance of eating disorder symptoms are examined. We describe in detail the pattern of interpersonal reactions that can result when a family member has an eating disorder. Shared traits such as anxiety, compulsivity and abnormal eating behaviours contribute to some of the misperceptions, misunderstandings and confusion about the meaning of the eating disorder for family members. Unhelpful attributions can fuel a variety of emotional reactions (criticism, hostility, overprotection, guilt and shame). Gradually these forces cause family members to accommodate to the illness or be drawn in to enable some of the core symptoms.

Carers' assessment, skills and information sharing: theoretical framework and trial protocol for a randomised controlled trial evaluating the efficacy of a complex intervention for carers of inpatients with anorexia nervosa

Experienced Carers Helping Others (ECHO) is a guided self-help intervention for carers of people with eating disorders to reduce distress and ameliorate interpersonal maintaining factors to improve patient outcomes. The aim of this paper is to describe the theoretical background and protocol of a randomised controlled trial that will establish whether ECHO has a significant beneficial effect for carers and the person they care for. Individuals with anorexia nervosa and carers will be recruited from eating disorder inpatient/day patient hospital services in the UK. Primary outcomes are time until relapse post-discharge (patient) and distress (carer) at 12 months post-discharge. Secondary outcomes are body mass index, eating disorder symptoms, psychosocial measures and health economic data for patients and carers. Carers will be randomised (stratified by site and illness severity) to receive ECHO (in addition to treatment as usual) or treatment as usual only. Potential difficulties in participant recruitment and delivery of the intervention are discussed.

Assessing eating disorder thoughts and behaviors: The development and preliminary evaluation of two questionnaires

This paper describes the development of two measures. The first is designed to assess eating disorder-related automatic thoughts; the second is designed to assess a wide range of eating disorder-related behaviors. Principal components analysis identified three dimensions of thoughts: positive thoughts about eating, negative thoughts about eating, and permissive thoughts. Principal components analysis also identified six dimensions of behavior related to: shape and weight, bingeing, dieting, food, eating, and overeating. Both measures possess promising psychometric properties, including good construct and criterion-related validity. Both successfully discriminated eating disorder patients from dieting and non-dieting groups. The two measures may be useful additions to those currently available to researchers (and clinicians) interested in eating disorders.

Clinical effectiveness of a skills training intervention for caregivers in improving patient and caregiver health following in-patient treatment for severe anorexia nervosa: pragmatic randomised controlled trial

Background Families express a need for information to support people with severe anorexia nervosa. Aims To examine the impact of the addition of a skills training intervention for caregivers (Experienced Caregivers Helping Others, ECHO) to standard care. Method Patients over the age of 12 (mean age 26 years, duration 72 months illness) with a primary diagnosis of anorexia nervosa and their caregivers were recruited from 15 in-patient services in the UK. Families were randomised to ECHO (a book, DVDs and five coaching sessions per caregiver) or treatment as usual. Patient (n=178) and caregiver (n=268) outcomes were measured at discharge and 6 and 12 months after discharge. Results Patients with caregivers in the ECHO group had reduced eating disorder psychopathology (EDE-Q) and improved quality of life (WHO-Quol; both effects small) and reduced in-patient bed days (7–12 months post-discharge). Caregivers in the ECHO group had reduced burden (Eating Disorder Symptom Impact Scale, EDSIS), expressed emotion (Family Questionnaire, FQ) and time spent caregiving at 6 months but these effects were diminished at 12 months. Conclusions Small but sustained improvements in symptoms and bed use are seen in the intervention group. Moreover, caregivers were less burdened and spent less time providing care. Caregivers had most benefit at 6 months suggesting that booster sessions, perhaps jointly with the patients, may be needed to maintain the effect. Sharing skills and information with caregivers may be an effective way to improve outcomes. This randomised controlled trial (RCT) was registered with Current Controlled Trials ISRCTN06149665. Declaration of interest J.T. is a co-author of the book used in the ECHO intervention and receives royalties. Copyright and usage