Jane Miskovic-Wheatley

A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents

Background Anorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest that longer initial hospitalizations that normalize weight produce better outcomes and fewer admissions than shorter hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of hospitalization for weight restoration (WR) to medical stabilization (MS) in adolescent AN. Method We performed a randomized controlled trial (RCT) with 82 adolescents, aged 12–18 years, with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for gender, age and height, both followed by 20 sessions of out-patient, manualized family-based treatment (FBT). Results The primary outcome was the number of hospital days, following initial admission, at the 12-month follow-up. Secondary outcomes were the total number of hospital days used up to 12 months and full remission, defined as healthy weight (>95% EBW) and a global Eating Disorder Examination (EDE) score within 1 standard deviation (s.d.) of published means. There was no significant difference between groups in hospital days following initial admission. There were significantly more total hospital days used and post-protocol FBT sessions in the WR group. There were no moderators of primary outcome but participants with higher eating psychopathology and compulsive features reported better clinical outcomes in the MS group. Conclusions Outcomes are similar with hospitalizations for MS or WR when combined with FBT. Cost savings would result from combining shorter hospitalization with FBT.

Early weight gain in family-based treatment predicts greater weight gain and remission at the end of treatment and remission at 12-month follow-up in adolescent anorexia nervosa.

OBJECTIVE To Identify whether early weight gain in family-based treatment (FBT) predicted greater weight and remission at end of FBT and 12-month follow-up. METHOD Eighty-two adolescents, with anorexia nervosa, participated in a randomized control trial comparing brief hospitalization for medical stabilization and hospitalization for weight restoration to 90% expected body weight (EBW) (1:1), followed by 20 sessions of FBT. Sixty-nine completed trial protocol. Receiver operating characteristic analyses were conducted investigating whether early weight-gain in FBT predicted outcomes at end of FBT and 12-month follow-up. Participants were analyzed according to their original randomization and as a combined set. Binary logistic regression was used to control for randomization arm effect in combined set analysis. RESULTS Weight gain greater than 1.8 kg at FBT Session 4 predicted greater %EBW (99.18 SD = 6.93 vs. 92.79 SD = 7.74, p < .05) and remission at end of FBT (46% vs. 11%, p < .05) and at 12-month follow-up (64% vs. 36%, p = .05). Binary logistic regression confirmed weight gain greater than 1.8 kg predicted remission (p < .05) while treatment arm randomization did not add significantly to the model. DISCUSSION Early weight gain has potential to distinguish likely responders in FBT from those who may need more intensive intervention to achieve remission offering the potential to improve outcomes.

A clinical profile of compulsive exercise in adolescent inpatients with anorexia nervosa

BackgroundThe aim of the current study was to contribute to the development of a clinical profile of compulsive exercise in adolescents with Anorexia Nervosa (AN), by examining associations between compulsive exercise and eating and general psychopathology.MethodA sample of 60 female adolescent inpatients with AN completed a self-report measure of compulsive exercise and a series of standardized self-report questionnaires assessing eating and general psychopathology.ResultsHigher levels of compulsive exercise were associated with increased levels of eating disorder psychopathology and anxiety. Specifically, the avoidance aspect (negatively reinforced) of compulsive exercise was associated with elevated scores on measures of eating disorder, anxiety, depression, and obsessive compulsiveness psychopathology, as well as lower self-esteem scores. The mood improvement value (positively reinforced) of compulsive exercise, however, did not reflect such trends.ConclusionsCompulsive exercise driven by avoidance of negative affect is associated with more severe psychological features in adolescent inpatients with AN. The current findings emphasize the need for research and clinical efforts in the development of treatments addressing avoidance of negative affect and compulsive exercise in adolescents with AN.

Just One More Bite: A Qualitative Analysis of the Family Meal in Family-based Treatment for Anorexia Nervosa

OBJECTIVE The family meal is an integral component of Maudsley family-based treatment for anorexia nervosa. The aim of this study was to determine whether there are different types of family meal, as suggested in the treatment manual, and whether within session processes differ according to meal type. METHOD Thirty video-recorded family meal sessions from a randomised controlled trial were transcribed and analysed using thematic analysis. RESULTS Analyses revealed two types of family meal. In the first, the patient ate one mouthful more than they were willing to eat. This meal type was characterised by processes that were consistent with the Maudsley model. In the second, the patient ate what was asked of them with little to no difficulty. Therapist and family avoidance differentiated this meal type from the first. DISCUSSION The current findings, along with the existing theory, suggest that avoidance may have reduced the therapeutic impact of the meal for many families. Strategies to challenge therapist and family avoidance are suggested. Copyright

Inside the family meal: a thematic analysis of session two in Maudsley family-based treatment for anorexia nervosa

Results Two types of family meal were identified. The first was characterised by processes that were consistent with the Maudsley model, and resulted in the patient eating one mouthful more than they were prepared to. The second was defined by processes that were mixed in terms of their consistency with the model, and resulted in the patient eating what was asked of them with little to no difficulty. Therapist and family avoidance differentiated the second meal type from the first. Discussion Avoidance seemed to diminish the therapeutic impact of the family meal for a significant number of families. Strategies to challenge avoidance during the session are suggested. This abstract was presented in the Peter Beumont Young Investigator award finalist stream of the 2014 ANZAED Conference.

Does continuing family-based treatment for adolescent anorexia nervosa improve outcomes in those not remitted after 20 sessions?

Objective: Our aim was to investigate the benefit of ongoing family-based treatment (FBT) sessions for adolescent anorexia nervosa if remission criteria were not met at session 20. Method: Participants were 69 medically unstable adolescents with Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) anorexia nervosa from a randomized controlled trial investigating length of hospital admission prior to outpatient FBT. Participants were divided post hoc into those meeting remission criteria at session 20 (n = 16), those that had not remitted but continued with FBT (n = 39) and those who ceased FBT undertaking alternative treatments (n = 14). Outcome was assessed as remission and hospital readmission days at 12 months after FBT session 20. Results: There were no differences between groups at baseline. There was a significant difference in the use of hospital admission days with those in the Alternate Treatment Group who did not continue with FBT using 71.93 days compared to those in Additional FBT Group with only 12.51 days (F(2, 66) = 13.239, p < .01). At 12 months after FBT session 20, the Additional FBT Group had a 28.2% increase in remission rate, significantly higher than those in the Alternate Treatment Group (χ2(2) = 17.68, p < .001). Discussion: Continuing FBT after session 20 if remission is not achieved can significantly reduce hospital readmission days and improve remission rates.

Exercise for the compulsive exercisers? An exploratory study in adolescent inpatients with anorexia nervosa

ABSTRACT Objective: This study aimed to explore whether exercise produced acute psychological benefits for adolescent inpatients receiving treatment for anorexia nervosa (AN). Specifically, the study examined whether a supervised inpatient exercise programme resulted in negative or positive affective changes over time, and if the participant’s reported level of compulsive exercise influenced such changes. Method: Forty-seven adolescent female inpatients with a DSM-5 diagnosis of AN completed a measure of compulsive exercise at admission to an eating-disorder inpatient programme. Participants routinely attended physiotherapy sessions (exercise condition) and school lessons (school condition) throughout their admission, and completed visual analogue scales assessing anxious, depressed, and positive affect immediately prior to and after both conditions. Results: Participants reported a significant decrease in anxious and depressed affect, and an increase in positive affect after the exercise condition compared to the school condition. Participants with higher levels of compulsive exercise features reported significantly greater decreases in anxious affect following exercise. Discussion: The current study provides promising results in terms of the acute psychological benefits supervised exercise can offer adolescent inpatients with AN. Research and clinical efforts are required to develop standardised treatment guidelines for exercise programmes and the management of compulsive exercise in this population during active treatment.

Multiple family therapy for anorexia nervosa at the Eating Disorder Service, the Children's Hospital at Westmead

The Eating Disorder Service at The Childrens Hospital at Westmead (CHW) is a tertiary service that offers a range of family focused treatment options for young people with an eating disorder. Multiple Family Therapy (MFT) is the newest treatment option provided by the service. MFT is now a key intervention offered by a number of services overseas, most notably at the Maudsley Hospital, London, where the model was developed. Despite its use for more than a decade overseas, we are the first service in Australia to systemically integrate MFT as an additional treatment option within the standard suite of interventions offered. MFT theoretically builds upon the core constructs of family based treatment for anorexia nervosa, whilst adding the unique experience of solidarity for young people and their families. The content of MFT is experiential, involving activities and specific debriefing techniques to help families develop ways to work together against anorexia, increase attunement to their childs needs and feel more agency around the process of recovery. The MFT program at CHW provides the opportunity for up to eight families to work together for a 4-day workshop. Follow-up care is provided by outpatient family therapy or integration into the Intensive Family and Adolescent Eating Disorders Day Program. MFT targets families not progressing in outpatient care or who present with some other complexity with the view that engagement in treatment may be enhanced through the group experience of MFT and the opportunity to receive treatment input from multiple sources. The presentation will describe MFT constructs, the programs implementation at CHW, show material from the therapeutic activities completed and present preliminary data and family experiences from the first five groups.

Adolescent development in family-based treatment for anorexia nervosa: Patients’ and parents’ narratives

Maudsley Family-Based Treatment (FBT) is currently the best supported treatment for adolescents with anorexia nervosa (AN); however, little is known about whether it achieves its stated aim in the final phases of promoting the patient’s return to an expected developmental trajectory. This study aimed to explore the perspectives of young people and their parents regarding the developmental impact of AN, and the role of FBT in addressing developmental challenges. Young people (N = 12) who ceased FBT a minimum 1 year prior, and their parents (N = 12), completed face-to-face semi-structured interviews, and data were analysed using a narrative inquiry method. All the participants described AN as highly disruptive to adolescent development, with phase one of FBT accentuating this experience. In phases two and three, FBT helped facilitate adolescent development in three key ways: Supporting return to adolescent pursuits, facilitating autonomy and providing freedom to develop post-FBT. This study offers preliminary insights into the variety of developmental challenges and needs experienced by families, as well as approaches clinicians can take to supporting development in phases two and three of FBT.

Using a brief family-based DBT adjunct with standard FBT in the treatment of Anorexia Nervosa

The outpatient program at The Childrens Hospital at Westmead (CHW) Eating Disorder Service uses Maudsley family-based therapy (FBT) as the main therapeutic model. For families that experience a high level of distress, avoidance of conflict or emotional expression, or if the young person is engaging in high risk behaviour like self-harm or suicide attempts, the parents ability and confidence to persist with refeeding is often severely undermined. In practice this reduces the efficacy of standard FBT, leading to poor engagement, multiple inpatient admissions, longer treatment and drop-out. The team at CHW are trialling a brief 6 session adjunct based on the core principles of Dialectical Behaviour Therapy (DBT), teaching the young person, their parents and siblings basic skills to engage in mindfulness, distress tolerance, emotion regulation and effective interpersonal relationships. These DBT skills have been adapted to a framework that maintains the core principles and structure of FBT. This oral presentation will discuss the family-based DBT adjunct and its implementation, including session outlines and a case example. Initial data on its effectiveness for patient and parent experience may also be discussed.