Moria Golan

An integrative quantitative model of factors influencing the course of anorexia nervosa over time

OBJECTIVE To identify factors influencing the course of anorexia nervosa (AN) over time. METHOD Former female patients with AN (36 remitted and 24 nonremitted) and 31 healthy females responded to standardized interviews and self-rating questionnaires. Remitted patients maintained normal eating, normal weight, and regular menses for the past 12 months. Patients not fulfilling these criteria were considered nonremitted. RESULTS Using logistic regression, we identified that number of hospitalizations, duration of ambulatory treatment, past vegetarianism, past anxiety, and childhood sexual abuse differentiated remitted from nonremitted patients, predicting nonremission. A similar analysis identified that elevated follow-up vegetarianism and eating-related concerns and lower body mass index (BMI) differentiated remitted from nonremitted patients, contributing to nonremission. Univariate analyses identified that remitted patients had elevated anxiety and eating-related obsessionality compared with the controls, suggesting these variables to potentially predispose to AN. DISCUSSION Elevated anxiety and eating-related obsessionality may increase the risk for the development of AN and for nonremission.

Anorexia nervosa, perfectionism, and dopamine D4 receptor (DRD4).

The dopamine D4 receptor (DRD4), a well‐characterized, polymorphic gene, is an attractive candidate for contributing risk to disordered eating and anorexia nervosa (AN). We tested association using UNPHASED for 5 DRD4 polymorphic loci, 3 promoter region SNPs (C‐521T, C‐616G, A‐809G), the 120 bp promoter region tandem duplication and the exon III repeat, in 202 AN trios and 418 control families. Since perfectionism characterizes AN, we tested these five loci for association with the Child and Adolescent Perfectionism Scale (CAPS) in the AN and control groups. Single locus analysis showed significant association between the ‘C’ C‐521T allele and AN. Haplotype analysis also showed significant association, particularly a 4‐locus haplotype (exon III&120 bp repeat&C‐521T&A‐809G). Association was also observed between DRD4 and CAPS scores both for AN and control subjects. The insulin‐like growth factor 2 (IGF2) and the arginine vasopressin 1a receptor (AVPR1a), previously shown to be associated with disordered eating, were also associated with CAPS scores. Three genes associated with AN were also associated with perfectionism. Personality traits are potential endophenotypes for understanding the etiology of eating disorders and one of the several pathways to eating pathology may be mediated by the impact of DNA sequences on perfectionism.

Managing Childhood Overweight: Behavior, Family, Pharmacology, and Bariatric Surgery Interventions

IntroductIon A dramatic rise in overweight has been recently shown to occur among male and female adolescents in many countries, reaching epidemic proportions in Western industrialized countries (1). This increase in childhood obesity places a significant burden on physical, psychological, and social health and calls for an urgent implementation of diverse treatment strategies. It is currently accepted, and probably even required, for professionals to relate to childhood overweight, which signifies a physiological construct, rather than to childhood obesity, which bears considerable derogatory connotation (1). Accordingly, the US Centers for Disease Control and Prevention defines overweight among individuals 2–19 years old as the 95th percentile or greater of BMI-for-age (BMI = weight/height2), and risk for overweight as the 85th to 95th percentile of BMI-for-age (2). In this review we will use the term overweight, unless the use of obesity is required. Treating overweight children is of extreme importance, not only because it affects their physical and psychological well-being and development, but because a considerable proportion of overweight children are at risk to become obese adults (3). Thus, although the indications for medical interventions in overweight children are still not well defined, it is suggested, in accordance with this risk-related definition, that treatment is required in almost all overweight children, and in at risk for overweight children with related medical complications (1). All the authors of the present review article took part in an international multiprofessional consensus meeting dedicated to the issue of pediatric obesity held at the Dead Sea in Israel, in March 2004. The result of this meeting was a comprehensive consensus document where the evidence was summarized, and recommendations developed (1). The present review incorporates the findings of this consensus meeting with respect to currently available treatment options in pediatric obesity with an updated comprehensive systematic literature search of the Cochrane, PUBMED, PSYCHLIT, PSYCHINFO, and ERIC databases. Originally, we aimed to carry out a literature search for the decade before the consensus meeting (1994–2003), but subsequently added comprehensive updated information, including data published between 2004 and 2007. This time period has envisioned the most dramatic increase in the rates of pediatric obesity ever to occur (1). This suggests the presence of a very different treatment environment than before (3), calling for a critical appraisal of currently adequate treatments, promotion of new strategies, and enhancing the conditions for improving treatment outcome. The review is based on a total of 80 articles published between the years 1994 and 2007. The following interventions will be discussed: dieting and nondieting weight reduction programs (15 articles), change in lifestyle (18 articles), behavioral treatment (12 articles), family interventions (18 articles), pharmacotherapy (18 articles), surgical interventions (9 articles), and multidisciplinary in-patient interventions (7 articles) (quite a few articles relate to more than one treatment strategy). The study relates mostly to the findings of randomized control trials (RCTs), or controlled trials, unless otherwise specified.

Parenting styles and weight-related symptoms and behaviors with recommendations for practice.

With the incidence of eating disorders increasing in recent years, the role of parents in the pathology of these illnesses is of great interest, particularly the impact of their parenting style. Few studies have investigated the connection between parenting styles and adolescent eating disorders. Reviewed here are key studies on parenting style categorized into the following four broad areas related to eating disorder pathology: food-related symptoms, feeding style, research on ethnic populations, and populations with eating disorders. The results reflect previous findings on the benefits of the authoritative parenting style. Suggestions for parenting programs and further research are included.

Protective self-presentation style: association with disordered eating and anorexia nervosa mediated by sociocultural attitudes towards appearance.

OBJECTIVE: We tested the hypothesis that a protective self-presentation style (Lennox and Wolfe, 1984) is associated with eating pathology and anorexia nervosa (AN) and that this association is mediated by sociocultural attitudes towards appearance emphasizing the thin ideal. METHOD: We compared the protective-presentation style of women with AN (N=17), partially recovered women (N=110), fully recovered women (N=73), and female controls (N=374). RESULTS: Ill women had a more protective self-presentation style than partially or fully recovered women, who in turn had a more protective self-presentation style than controls. Sociocultural attitudes towards appearance fully mediated the association between protective self-presentation and disordered eating. CONCLUSIONS: Protective self-presentation may therefore be a risk factor for AN and/or a prognostic factor. Implications for therapy and prevention are discussed.

Self-Regulation and the Management of Childhood Obesity

Failure in self-regulation has been proposed as a moderator in the development of overweight and obesity, primarily through its effects on deregulated eating behavior. As a result, it might cause regulatory problems in the energy balance, as well as rapid weight gain from early childhood through adolescence. Self-control is the exertion of control over the self by the self. Self-control occurs when a person (or other organism) attempts to change the way he or she would otherwise think, feel, or behave. Thus, self-control may be view as part of self-regulation. Parents and health care providers face the challenge of helping children practice regulation and develop coping skills alongside the ability to take care of their own well-being. This paper attempts to bridge the gap between self-control theories and interventions for the management of childhood obesity. The dietary restriction approach will be compared with the trust paradigm, which emphasizes children’s internal hunger, satiety cues and a division of responsibilities between parents and children.

Fifteen years of the Family Eating and Activity Habits Questionnaire (FEAHQ): an update and review.

The FEAHQ was originally developed in Israel and designed for use in family‐based weight‐management interventions that emphasized changes in the environment and in parents’ knowledge, behaviors, and modeling. A key distinction of the FEAHQ from other tools is the ability to evaluate the overall obesogenic environment and, at the same time, each of the family members’ eating and activity patterns, reflecting the importance of parenting behaviors and modeling in child weight status. The FEAHQ is a useful clinical tool for identifying target behaviors for treatment and monitoring treatment progress.

The journey from opposition to recovery from eating disorders: multidisciplinary model integrating narrative counseling and motivational interviewing in traditional approaches.

BackgroundIn the world of today’s of ever-briefer therapies and interventions, people often seem more interested in outcome than process. This paper focuses on the processes used by a multidisciplinary team in the journey from opposition to change to recovery from eating disorders. The approach outlined is most relevant to those with severe and enduring illness.MethodsThis paper describes a five-phase journey from eating-disorder disability and back to health as it occurs for patients in a community-based facility. This integrative model uses narrative and motivational interviewing counseling weaved into traditional approaches. It approaches illness from a transdiagnostic orientation, addressing the dynamics and needs demanded by the comorbidities and at the same time responding effectively in a way that reduces the influence of the eating disorder.The treatment described involves a five-phase journey: Preliminary phase (choosing a shelter of understanding); Phase 1: from partial recognition to full acknowledgment; Phase 2: from acknowledgment to clear cognitive stance against the eating disorder; Phase 3: towards clear stance against the “patient” status; Phase 4: towards re-authoring life and regaining self-agency; Phase 5: towards recovery and maintenance.ResultsIn a longitudinal study of patients with a severe and debilitating eating disorder treated with this approach. The drop-out rate was less than 10%. This was during the first two months of treatment for those diagnosed with bulimia nervosa, and this was higher than in those diagnosed with anorexia nervosa. At the end of treatment (15 months to 4 years later) 65% of those treated with anorexia nervosa and 81% of those treated with bulimia nervosa were either in a fully recovered state or in much improved. At the four-year follow-up, 68% of those diagnosed with anorexia nervosa and 83% of those diagnosed with bulimia nervosa were categorized as either fully recovered or much improved. All patients who completed the program were gainfully employed.ConclusionsThe collaborative work, which is the heart of the described model increases the patient’s and family’s ownership of treatment and outcome and strengthen the therapeutic bond, thus enhances recovery.

Engaging Patients with Eating Disorder to Treatment via Collaborative Understanding of their Emotional Issues Across Lifespan

Most patients with eating disorder (ED) are ambivalent regarding change. The more severe the eating disorder, symptoms are perceived as being preferable to the alternative distresses and patients present negative coping mechanisms such as denial and/or opposition to treatment. This report describes clinically driven strategy for engaging patients with eating disorders to therapeutic process. It describes a structured procedure for the preliminary meeting with the patient focusing on developmental tasks, difficulties and coping mechanisms. There is an emphasis on the process of achieving collaboratively narration of the context in which the eating disorder invaded and how it relates to the patients’ emotional issues across the life span, as well as the etiological theories in which it is rooted. We review the patients’ history from childhood through adolescence or adulthood, exploring the nature of emotional and developmental difficulties in the different ages. We track how they impacted the person’s behaviors, personality and coping mechanisms, as well as the reasons he/she was tempted to the eating disorders’ ‘shelter’. A dynamic understanding, motivational interviewing, and engagement in externalizing conversation are the means used to reveal the prices and motivate the patient to take control of his/her life and choose to be treated.

Parenting and the parallel processes in parents’ counseling supervision for eating-related problems

This paper presents an integrative model for supervising counselors of parents who face eating-related problems in their families. The model is grounded in the theory of parallel processes which occur during the supervision of health-care professionals as well as the counseling of parents and patients. The aim of this model is to conceptualize components and processes in the supervision space, in order to: (a) create a nurturing environment for health-care facilitators, parents and children, (b) better understand the complex and difficult nature of parenting, the challenge counselors face, and the skills and practices used in parenting and in counseling, and (c) better own practices and oppose the judgment that often dominates in counseling and supervision. This paper reflects upon the tradition of supervision and offers a comprehensive view of this process, including its challenges, skills and practices.