Exploring Interactive Change Processes in Multifamily Therapy for Adolescents With Anorexia Nervosa.

Multi-family therapy (MFT-AN) is a promising group-based treatment for adolescent anorexia nervosa. This study aimed to explore how young people and parents perceived change to occur during MFT treatment. Young people (10-18years) diagnosed with anorexia nervosa or atypical anorexia nervosa and their parents who completed MFT-AN alongside family therapy for anorexia nervosa within the preceding 2years were eligible for this study. Semi-structured qualitative interviews were conducted. Recordings were transcribed verbatim and analysed using reflexive thematic analysis. Twenty-three participants (8 young people, 10 mothers and 5 fathers) completed interviews. Five main themes were identified; (1) Powerful connection, (2) Intensity, (3) New learning and perspective shifts, (4) Comparisons, and (5) Discharge is not recovery. There was a strong sense that being with others in a similar position in an intense environment were key factors in promoting change. Comparisons were inevitable and could promote insight and foster motivation, but could also be unhelpful at times. Participants spoke about how recovery continues beyond service use and requires ongoing attention and support. Through the mechanisms of connection, intensity, new learning and comparisons change is perceived to occur in MFT-AN. Some of these are considered unique to this treatment format.

This paper, which has been produced from the experience that we have developed since 1995 with multi-family groups, intends to highlight the multifamily therapy in the field of psychotherapy, group therapy and family therapy. Family therapists have been faced with several families who live in contexts of extreme vulnerability. These families are marked by intense suffering and helplessness engendered more by socio-cultural issues than by psychiatric “deviations”. This fact has made rethink the psychotherapy practice, based on the tradition of individualistic psi practices with the necessity of recovering the historical and social dimension of subjectivity production and psychological distress, to rescue the collective strength, both in the disease production and in the invention of health. Believing in healthy resources of families and communities, the redemption of subjectivity and citizenship of these suffering individuals as protagonists of their stories can be through the sharing of their pains and hopes. Thus, the aim is to present the creative and “subversive” alternative of multi-family groups – subversive of some ideological postures that operate in favor of the dichotomy between public and private, alleging that mental suffering, often perceived as a private matter, is actually produced in collective, therefore, social and political, rather than intrapsychic or familiar. Initially, we describe the emergence of group therapy in its historical, theoretical and epistemiological aspects, as well as the incorporation of multifamily and networks paradigm in the family therapy field. Some concepts about group therapy and multifamily group therapy, as well as some advantages and disadvantages of these approaches are presented. Key words: multifamily groups, group therapy, psychotherapy.

Multifamily therapy (MFT) for adolescent eating disorders (ED) is anchored in systemic theory and family therapy, but two conceptual and practical paths have emerged from this common framework. The first one, called ED-focused MFT, is centered on behavioral change and weight gain in the early stages of treatment, while the second, known as relationship-focused MFT, is less directly focused on symptom improvement and more on family changes. Compared to ED-focused MFT, validation of more relationship-focused MFT models has been lagging behind although they are frequently implemented and practiced in Europe. The purpose of this article is to give more visibility to existing relationship-focused MFT models by presenting an integrative, yet predominantly family-oriented MFT program developed for adolescent anorexia nervosa (AN) (12 to 18 years) on the ED unit of a large pediatric hospital in France. After presenting the history and development of this relationship-focused MFT program, including the challenges it encountered and its evaluation, we describe its rationale and objectives, then outline its course and content, giving illustrations of techniques and activities for each of the five phases of the program. Finally, we review the current status of this model, its advantages and limitations, and provide a critical appraisal of existing evidence and recommended future research directions.

This review examines family therapy as an effective intervention for Anorexia Nervosa (AN) in adolescents. An electronic and manual literature search was conducted. Studies pertaining to family therapy in the treatment of AN and specifically, the Maudsley Method/Family-Based Treatment were identified. A limited number of randomized control trials exist implicating family therapy. Of the existent studies, methodological limitations pertaining to small, homogeneous sample sizes are evident. Despite the limited number of studies, family therapy appears to illustrate probable efficacy. Additional research and funding are necessary to fully support family therapy in the treatment of AN in adolescents.

Several studies assessed adiponectin levels in anorexia nervosa (AN) patients, however, data regarding the dynamics of changes in adiponectin levels during refeeding of these patients is limited and contradicting. Our objective was to assess adiponectin levels and the distribution of its different isoforms in AN patients before and after long-term refeeding, and to relate them to alterations in body mass index, leptin, insulin sensitivity, and additional endocrine parameters. We conducted a longitudinal controlled study of 38 female adolescent malnourished AN inpatients, with 13 young, lean, healthy women serving as controls. Blood samples were obtained upon admission and thereafter at 1, 3, and 5 months (at target weight). Changes in body mass index, leptin, adiponectin, insulin sensitivity, and adiponectin multimeric forms were measured. At admission, leptin levels of AN patients were significantly lower, whereas insulin sensitivity (assessed by homeostasis model assessment-insulin resistance), adiponectin levels, and the ratio of high molecular weight (HMW) adiponectin to total adiponectin were significantly higher compared with controls. During weight recovery, leptin levels and homeostasis model assessment-insulin resistance increased significantly, whereas adiponectin and HMW adiponectin/total adiponectin ratio decreased significantly, to levels similar to controls. An initial increase in adiponectin levels was observed after 1 month of refeeding. There was no correlation between adiponectin and either T(4) or cortisol levels. Our study demonstrates hyperadiponectinemia, increased adiponectin HMW isoform, and increased insulin sensitivity in adolescent AN female patients and reversal of these findings with weight rehabilitation. We hypothesize that increased adiponectin levels may have a protective role in maintaining energy homeostasis during extreme malnourishment.

BackgroundYoung patients suffering from anorexia nervosa (AN) frequently need further treatment in Adult Mental Health Services (AMHS). The transition period from Child and Adolescent Mental Health Services (CAMHS) to AMHS is a critical time, with a high risk of disengagement from healthcare. We explored physicians’ perspectives of the transition to triangulate the multiple perspectives of physicians, parents and those with a lived AN experience to more comprehensively characterize the challenges in this process of treatment transition.MethodsUsing purposive sampling, we recruited 16 physicians confronted with transition in AN (adult psychiatrists, child and adolescent psychiatrists and pediatrician) and conducted semi-structured interviews, which were anonymized, transcribed, and analyzed following the reflexive thematic analysis framework.ResultsOur analysis produced three main themes. First, a shared agreement on the transition’s malfunction, where participants depicted transition as a dissatisfying, violent event. Second, the conception of AN as a disorder with specific needs, challenging the transition process especially regarding physicians’ engagement. Finally, the ideal transition conceived as a serene experience of separation, with unanimous agreement on the necessity to start the transition depending on patients’ needs rather than their age, in order to turn transitions into moments of care.ConclusionOur results are in line with other qualitative research studying transition in AN and in other chronic diseases, either focusing on the experience of healthcare workers, families, or patients. Our research shows transition in AN as an anxiety-inducing experience for physicians, patients and families alike. Moreover, we highlight a gap in the way physicians perceive and assist the patient’s greater autonomy, depending on their specialty. Helping physicians to manage their patient’s autonomy, which is a cornerstone of the transition readiness concept, could be a very efficient way to improve transitions in AN.Plain English summaryAnorexia Nervosa (AN) is a severe disease, which most of the time starts during adolescence. Transition from Child and Adolescent Mental Health Services to Adult Mental Health Services is at risk of disengagement from healthcare. In order to better understand this process, we interviewed expert physicians about their experiences of transition in AN using a qualitative thematic analysis which highlighted three main themes. First, a shared agreement on the transition’s malfunction. Second, the conception of AN as a disorder with specific needs challenging the transition process. Finally, the ideal transition conceived as a serene experience of separation, which needs to be started depending on patients’ needs rather than their age. We also show differences in the way physicians perceive and assist the patient’s greater autonomy acquired during the transition. Helping physicians to support their patients in acquiring autonomy, which is a cornerstone of the transition readiness concept, could be a very efficient way to improve transitions in AN.

While clinical practice recognises and research findings reveal an association between social functioning and relationships with close others and recovery for adults with Anorexia Nervosa (AN), few treatment modalities comprehensively address the social conditions that contribute to and sustain AN. This post-treatment qualitative retrospective study engaged Multifamily Therapy Group (MFTG) alumni as co-investigators in the development and evaluation of a new and innovative Relational/Motivational model of MFTG (MFTG-RM) [Tantillo, M., Sanftner, J., & Hauenstein, E. (2013). Restoring connection in the face of disconnection: An integrative approach to understanding and treating anorexia nervosa. Advances in Eating Disorders: Theory, Research and Practice, 1(1), 21–38.] for adults with AN. Ten families (N = 17) comprising 5 adult patients (ages 20–34, M = 23.4, SD = 5.98), 9 mothers, and 3 fathers participated in one of 2 two-hour study focus groups. Qualitative content analysis was used to code text data and identify themes [Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288]. Findings revealed that recovery is long, arduous, and marked by many disconnections and intense emotions and that MFTG-RM promoted communication and connections, helped with identification and expression of emotions, and indirectly helped AN symptoms. These findings add to those of other studies that note the high burden of illness for patients and families. They also suggest the potential promise of MFTG-RM in leveraging its strong therapeutic community to restore intra-and interpersonal connections and foster recovery.

IntroductionReports assessing long-term treatment outcomes for anorexia nervosa (AN) are divergent and refer to different populations. They lack long-term observations in AN patients in Poland.Aim of the studyAnalysis of the recovery, relapse rate, and predictive factors in patients treated due to AN in adolescence. Material and methods: A total of 201 subjects were given a survey. Ninety-seven women were recruited: 56 reported to the clinic and 41 filled in the survey.ResultsThe average period from hospitalization to the survey was 7.76 ±4.39 years. Remission was found in 78.4%, 21.6% still presented AN, and 84.2% required a one-off hospitalisation, 10.5% twice. The average BMI was: 20.08 ±3.24 kg/m2. The rate of attempted suicides was 6.2%. Predictive factors for poor outcome were as follows: older age of the patient when falling ill, lower SDS-BMI score at the onset of AN, transition from the restrictive type of AN into a binge-eating/purging type, and failure to maintain contact with the mother.ConclusionsMost girls suffering from the restricting type of AN in adolescence are cured permanently.The severity of symptoms in these girls does not eliminate the chance of recovery and achieving important life goals, completing education, finding a life partner, and having children.Girls with a smaller degree of cachexia at onset of AN, with no binge-eating/purging symptoms, maintaining regular contact with their mothers, have a better prognosis for recovery.Six per cent of women treated in their youth for AN face the risk of attempted suicide, which points to the need to monitor their mental state for many years.

Reduction in cerebral volume is often found in underweight patients with anorexia nervosa (AN), but few studies have investigated other morphological measures. Cortical thickness (CTh) and surface area (CSA), often used to produce the measure of cortical volume, are developmentally distinct measures that may be differentially affected in AN, particularly in the developing brain. In the present study, we investigated CTh and CSA both separately and jointly to gain further insight into structural alterations in adolescent AN patients. Thirty female AN inpatients 12-18 years of age, and 27 age-matched healthy controls (HC) underwent structural magnetic resonance imaging. Group differences in CTh and CSA were investigated separately and jointly with a permutation-based nonparametric combination method (NPC) which may be more sensitive in detecting group differences compared to traditional volumetric methods. Results showed significant reduction in in both CTh and CSA in several cortical regions in AN compared to HC and the reduction was related to BMI. Different results for the two morphological measures were found in a small number of cortical regions. The joint NPC analyses showed significant group differences across most of the cortical mantle. Results from this study give novel insight to areal reduction in adolescent AN patients and indicate that both CTh and CSA reduction is related to BMI. The study is the first to use the NPC method to reveal large structural alterations covering most of the brain in adolescent AN.

Although there is well-documented evidence for hyperactivity of hypothalamic–pituitary–adrenal (HPA) axis function in anorexia nervosa (AN), there has been little research into secretory patterns of salivary cortisol and dehydroepiandrosterone (DHEA) in this condition. The cortisol awakening response (CAR), a prominent and discrete feature of the cortisol cycle, has not been extensively explored in adolescent AN. Saliva samples were collected at awakening, 30 min and 12 h post-awakening on two consecutive weekdays from eight female adolescents with clinically diagnosed AN and 41 healthy control (HC) age-matched females. Adolescent AN patients had greater salivary cortisol and DHEA concentrations than HC girls at all points. Increased hormone secretion was unrelated to body mass index. However, despite hypersecretion of both hormones, the circadian pattern including the CAR paralleled that of the HC group. Findings from this preliminary study confirm dysregulation of HPA axis function in adolescent AN as evidenced by hypersecretion of both cortisol and DHEA, which share the common secretagogue adrenocorticotropic hormone. However, the parallel diurnal profiles for AN and HC participants, including the CAR, may indicate hypersecretion per se rather than differential regulation of the diurnal pattern of these two adrenal steroids in AN.

P-547 - Is family therapy the most effective treatment for adolescents with anorexia nervosa?

multifamily group therapy

Intoduction. Eating disorders, including anorexia nervosa, are common, severe, and often chronic mental disorders. The debate over the pathogenesis and supporting factors of anorexia nervosa continue because therapeutic interventions do not lead to satisfactory and long-lasting remission rates and persistent (resistant) forms of the disease are increasingly common. Several of English-language studies with a fundamental analysis that indicates a direct influence of psychoemotional state and/or existing psychopathological manifestations in parents on the development of eating disorders, including anorexia nervosa. Historically negative family dynamics are indicated as a key element in the development of anorexia nervosa, along with personality vulnerabilities. Emotional dysfunction within the family and interaction with individual personality traits contribute to the development and maintenance of anorexia nervosa. Concerning individual personality traits, studies have shown that anorexia nervosa in female adolescents is associated with difficulties in emotional regulation, which are associated with obsessive-compulsive / perfectionist and impulsive personality traits. However, the analysis of the array of Ukrainian-language scientific literature accumulated in recent years on this issue has not yet been made. Understanding the cause and effect of anorexia nervosa and treatment-resistant forms of the disease is a necessary prerequisite for further research and development of new effective approaches to therapy.Goal. Determining the current state of analysis of the problem of emotional regulation in patients with anorexia nervosa in Ukraine in comparison with world scientific developments. Describe a clinical case showing a violation of emotional regulation in a patient with anorexia nervosa.Materials. Qualitative and quantitative content analysis and concept analysis were conducted using meta-analyses and systematic reviews of scientific Ukrainian-language and English-language literature published for the period from January 2015 to December 2019.Results. Dysfunctional emotional processing and regulation play an important role in the development and maintenance of anorexia nervosa. Systematic reviews indicate that people with anorexia nervosa have difficulty with emotional awareness (including alexithymia and poor emotional clarity), along with high levels of disgust and shame. The limitations of modern theories of anorexia nervosa and the context of the phenomenological and interpersonal nature of the disorder led to the emergence of the theory of the organizing function of the mind I in anorexia nervosa. According to this theory, anorexia nervosa occurs against the background of vague emotional experience as a means of regulating emotions and restoring the sense of bodily I, which is determined by the judgments and appearance of others. Studies also show that patients with anorexia nervosa have particularly low rates of reflex function. Low reflexive functioning together with low consistency of opinion is a consequence of uncertainty in attachment and is manifested by increased anxiety of attachment or avoidance of attachment. The clinical significance of attachment dynamics for patients with anorexia nervosa is underscored by the association between greater attachment anxiety and the avoidance and symptoms of eating disorders.The above clinical case demonstrates a violation of emotional regulation in a patient with anorexia nervosa. The combination of psychotherapeutic methods (individual and family psychotherapy), which were aimed at correcting the I and adaptive changes in reflexive functioning, together with medical intervention, allowed to obtain positive results of treatment, as evidenced by the annual follow-up.Conclusions. At the heart of anorexia nervosa is marked dysfunctional emotional processing and regulation. Patients with anorexia nervosa have low rates of reflex function. The practical significance of the model of anorexia nervosa as a disorder, which is supported by difficulties with emotional experience, is proved by the application of their provisions in the psychotherapeutic process in real clinical practice. Developing interventions to improve emotional regulation skills in the treatment of patients with anorexia nervosa, in combination with family psychotherapy, can be an important component in improving treatment outcomes, reducing relapses, and developing resistant forms of the disease.

Our aim was to examine the relationship between resting energy expenditure (REE) and circulating leptin levels during long-term refeeding in adolescent girls with anorexia nervosa (AN). We measured REE, the plasma leptin level, the free T(3) level, body surface area (BSA), and dietary energy intake in AN adolescents before and 8 weeks after refeeding therapy. All parameters in AN subjects before the refeeding therapy were significantly lower than those in AN subjects after the therapy and in the controls. There were no significant differences in REE and BSA between posttherapy AN subjects and controls, but plasma leptin levels in the posttherapy AN subjects were still significantly lower than those in the controls. Significant correlations between REE and BSA were detected in the AN subjects both before and after the refeeding therapy, but REE did not correlate significantly with plasma leptin level in either of the AN groups. Our results suggest that the REE in AN subjects after long-term refeeding therapy is not associated with the changes in plasma leptin levels but with BSA.

Regarding executive functioning in anorexia nervosa (AN), little is known about differences between the restricting (AN-R) and binge eating/purging (AN-BP) subtypes. Especially for adolescents, there is sparse data. Hence, the current aim is to investigate differences in set-shifting, central coherence, and self-reported executive functioning across adolescent AN subtypes. Ninety AN-R, 21 AN-BP, and 63 controls completed an extensive assessment battery including neuropsychological tests for executive functioning and the self-report questionnaire Behavior Rating Inventory of Executive Functioning. Patients with AN-R and AN-BP did not differ on neuropsychological measures, and both performed similarly to controls. Behavior Rating Inventory of Executive Functioning scores fell within the normal range with AN subtypes showing mostly comparable ratings. AN-BP patients scored higher on 2 composite indices and the "shift" subscale compared with AN-R. The results suggest similar cognitive functioning in adolescent AN subtypes as well as healthy controls. However, more research is needed to draw more general conclusions.