Ivan Eisler

Evaluation of family treatments in adolescent anorexia nervosa: A pilot study

In the search for more effective methods of psychological treatment in anorexia nervosa, there are a number of controlled trials evaluating the efficacy of different forms of treatment. Previous studies have shown that family therapy is the superior treatment for patients with an early onset and short duration of illness. In order to assess the impact and the effective components of family therapy, we conducted a pilot trial in which consecutive referrals of anorexia nervosa patients were randomly assigned to one of two forms of family treatment: family therapy (conjoint family sessions) or family counselling (separate supportive sessions for the patient and counselling for the parents). Changes taking place within the patient and the family were evaluated at regular intervals, while within and between group comparisons were made. Although tentative, it was found that, in the short term, there were few differences in terms of symptomatic relief between the two treatment groups.

Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials

Abstract Objective To determine whether psychological interventions have any effect on glycaemic control in people with type 1 diabetes. Design Systematic review and meta-analysis of psychological therapies to assess their effectiveness in improving glycaemic control in type 1 diabetes. Data sources Medline, PsycINFO, Embase, and Cochrane central register of controlled trials searched to September 2004. Review methods All included studies were randomised controlled trials in children (including adolescents) or adults with type 1 diabetes that evaluated the effect of a psychological therapy (counselling, cognitive behaviour therapy, family systems therapy, and psychodynamic therapy) on control of diabetes. Data were extracted on sample size, age, duration of diabetes, type of psychological therapy, its mode of delivery, and type of intervention in control group. Main outcome measures Glycaemic control measured by percentage of glycated haemoglobin and psychological distress. Pooled standardised effect sizes were calculated. Results 29 trials were eligible for the systematic review and 21 trials for the meta-analysis. In the 10 studies of children and adolescents included in the meta-analysis, the mean percentage of glycated haemoglobin was significantly reduced in those who had received a psychological intervention compared with those in the control group (pooled standardised mean difference −0.35 (95% confidence interval −0.66 to −0.04), equivalent to a 0.48% (0.05% to 0.91%) absolute reduction in glycated haemoglobin. In the 11 studies in adults the pooled standardised mean difference was −0.17 (−0.45 to 0.10), equivalent to 0.22% (−0.13% to 0.56%) absolute reduction in glycated haemoglobin. Psychological distress was significantly lower in the intervention groups in children and adolescents (pooled standardised effect size −0.46, −0.83 to −0.10) but not in adults (−0.25, −0.51 to 0.01). Conclusion Psychological treatments can slightly improve glycaemic control in children and adolescents with diabetes but have no effect in adults.

Redefining the psychosomatic family: family process of 26 eating disorder families

This paper reports part of the data from a comparative trial of two forms of family intervention for the management of eating disorders in adolescents. Measures of family process at the beginning of treatment included Expressed Emotion (EE) and the Family Adaptability and Cohesion Evaluation Scales (FACES). EE in the families of both anorexic and bulimic patients were, on the whole, at low levels. The low levels of parental Critical Comments might be taken to represent the conflict avoiding character of the families of psychosomatic patients. However, the families showed low levels of Emotional Overinvolvement, which contradicts the clinical descriptions. The FACES scores revealed patterns that were superficially contradictory to the accepted clinical descriptions in that the patients appeared to have perceived their families as not close and as highly structured. The parents experienced their family structure as more similar to the clinical descriptions, scoring their families as more flexible and cohesive than do the patients. The FACES ideals for family organization scored by patients and parents more nearly equate with the clinical descriptions of enmeshment and lack of boundary structure. The relationship between the research findings and the clinical evaluation will be discussed.

A multi-family group day treatment programme for adolescent eating disorder

We describe a new treatment for the outpatient management of disabling eating disorder in adolescents. The pilot programme has thus far treated 14 adolescents, half with anorexia nervosa and half with bulimia. Most of the young people had been previously admitted or the current referral was for admission. None of the patients has subsequently had to be taken into an inpatient service and the preliminary results suggest that the programme may be beneficial. The programme has elicited a very positive response from the patients and their families. For the professionals involved, the experience of participating in the multi-family group treatment has been unusual and powerful and the training opportunities provided by it seem rather unique. This has led us to make this preliminary communication. We describe the context and structure of the programme and give some details of the patients so far treated. Copyright

Family Interventions in Adolescent Anorexia Nervosa

Although our understanding of the mechanisms of change in eating disorder treatment remain limited, the empiric evidence for the effectiveness of family therapy for adolescent Anorexia Nervosa is gaining strength. A history of family involvement in psychiatric care, current approaches to family intervention in eating disorders and evidence for their efficacy are reviewed.

Mothers with anorexia nervosa who underfeed their children: their recognition and management

BACKGROUND Women with anorexia nervosa have a reduced fertility but they may have borne children before the onset of their illness or after partial recovery. Little is known on how to identify the anorexic mothers who underfeed their children and how to manage them. This article aims to remedy these gaps. METHODS The clinical scientific method is the only means of identifying the children of anorexic mothers who are at risk. Eight such mothers were identified as a result of obtaining serial measurements of the childrens weights and heights over time. Tanner-Whitehouse charts were used to plot weight for age and height for age. A simple rating scale was devised to measure the acceptance of treatment involving both mother and child. RESULTS Nine children (eight boys and one girl) were found to have suffered food deprivation: with severe reduction in weight-for-age in six and in height-for-age in eight. Five siblings were not affected. Catch-up growth was correlated with the degree of engagement in treatment of both mother and child. Long-term treatment of one mother, combining family therapy with admissions to hospital, resulted in catch-up growth in her two sons. CONCLUSIONS The mechanisms underlying the privation of the children stem from the anorexic mothers abnormal concerns with body size extending to her children. The children may become unduly accepting of the underfeeding. It is essential to obtain the confidence of anorexic mothers suspected of underfeeding their children and to adopt a whole family approach to treatment.

Theoretical and empirical models around caring for someone with an eating disorder: The reorganization of family life and inter-personal maintenance factors

Background: Previous theoretical models regarding family functioning have proposed that dysfunctional family interactions may play a causal role in the development of eating disorders. Such models, while historically important, have been unhelpful in blaming families and are poorly supported by empirical evidence. Aims: The aim of this paper was to expand and develop models around familial patterns which may be more clinically valuable. Method: Recent empirical and theoretical evidence around familys experiences of caring for someone with an eating disorder were explored. Results: Recent literature supports the view that families may become “reorganized” around the illness. The following processes are discussed: (i) The central role of the symptoms in family life, (ii) The narrowing of time focus on the here-and-now, (iii) The restriction of the available patterns of family interaction processes, (iv) The amplification of aspects of family functioning, (v) The diminishing ability to meet family life-cycle needs, and (vi) The loss of a sense of agency (helplessness). Conclusions: Families may become stuck in unhelpful interactions and lose sight of their own strengths and resources. Professionals should address unhelpful processes within the family, using a collaborative approach. Declaration of interest: J. Whitney has been funded by RIED through the charitable organization, Psychiatry Research Trust.

Social class as a confounding variable in the eating attitudes test

The Eating Attitudes Test (EAT) is commonly used in studies of anorexia nervosa. This paper reports some unexpected findings concerning the relationship between the EAT and the social class of the respondent. Our analysis is based on data from a sample of over 3000 English schoolgirls from both state and private schools. Important differences were found between the results from the private and state schools suggesting a social class difference in response to this questionnaire. The mean scores on the EAT were significantly higher in the state schools than in the private schools. However the number of cases of anorexia nervosa identified on the basis of individual interviews was higher in the private schools. A detailed analysis of the responses to the individual questions indicate that this discrepancy was due to systematic differences in the way the girls responded to different sets of questions.

A randomized controlled trial of adjunctive family therapy and treatment as usual following inpatient treatment for anorexia nervosa adolescents.

Research on treatments in anorexia nervosa (AN) is scarce. Although most of the therapeutic programs used in ‘real world practice’ in AN treatment resort to multidisciplinary approaches, they have rarely been evaluated. Objective To compare two multidimensional post-hospitalization outpatients treatment programs for adolescents with severe AN: Treatment as Usual (TAU) versus this treatment plus family therapy (TAU+FT). Method Sixty female AN adolescents, aged 13 to 19 years, were included in a randomized parallel controlled trial conducted from 1999 to 2002 for the recruitment, and until 2004 for the 18 months follow-up. Allocation to one of the two treatment groups (30 in each arm) was randomised. The TAU program included sessions for the patient alone as well as sessions with a psychiatrist for the patient and her parents. The TAU+FT program was identical to the usual one but also included family therapy sessions targeting intra-familial dynamics, but not eating disorder symptoms. The main Outcome Measure was the Morgan and Russell outcome category (Good or Intermediate versus Poor outcome). Secondary outcome indicators included AN symptoms or their consequences (eating symptoms, body mass index, amenorrhea, number of hospitalizations in the course of follow-up, social adjustment). The evaluators, but not participants, were blind to randomization. Results At 18 months follow-up, we found a significant group effect for the Morgan and Russell outcome category in favor of the program with family therapy (Intention-to-treat: TAU+FT :12/30 (40%); TAU : 5/29 (17.2%) p = 0.05; Per Protocol analysis: respectively 12/26 (46.2%); 4/27 (14.8%), p = 0.01). Similar group effects were observed in terms of achievement of a healthy weight (i.e., BMI≥10th percentile) and menstrual status. Conclusions Adding family therapy sessions, focusing on intra-familial dynamics rather than eating symptomatology, to a multidimensional program improves treatment effectiveness in girls with severe AN. Trial Registration Controlled-trials.com ISRCTN71142875

Do adolescents with eating disorder not otherwise specified or full-syndrome bulimia nervosa differ in clinical severity, comorbidity, risk factors, treatment outcome or cost?

OBJECTIVE We wanted to know whether adolescents with eating disorder not otherwise specified (EDNOS) differ from those with bulimia nervosa (BN) in clinical features, comorbidity, risk factors, treatment outcome or cost. METHOD Adolescents with EDNOS (n = 24) or BN (n = 61) took part in a trial of family therapy versus guided self-care. At baseline, eating disorder symptoms, risk factors, and costs were assessed by interview. Patients were reinterviewed at 6 and 12 months. RESULTS Compared with EDNOS, BN patients binged, vomited and purged significantly more, and were more preoccupied with food. Those with EDNOS had more depression and had more current and childhood obsessive-compulsive disorder. 66.6% of EDNOS versus 27.8% of BN patients were abstinent from bingeing and vomiting at 1 year. Diagnosis did not moderate treatment outcome. Costs did not differ between groups. CONCLUSION EDNOS in adolescents is not trivial. It has milder eating disorder symptoms but more comorbidity than BN.