A bidirectional examination of expressed emotion among families of adolescents with bulimia nervosa.

OBJECTIVE: The purpose of this paper was to examine expressed emotion (EE) measured from adolescents with bulimia nervosa (BN) toward their parents, in addition to measuring EE from parents toward patients. METHOD: Fifty-four adolescents and their parents who were receiving treatment for BN participated in a videotaped family interview, from which ratings of EE were made. RESULTS: Parent and patient scores were highly correlated. Four family profiles were created (Low Patient EE/Low Parent EE; High Patient EE/High Parent EE; Low Patient EE/High Parent EE; High Patient EE/Low Parent EE) to determine whether the match between parent and patient EE was related to treatment outcome. The Low Patient EE/Low Parent EE group demonstrated the greatest reduction in purging from baseline to end-of-treatment; the High Patient EE/Low Parent EE group showed the smallest reduction in purging. DISCUSSION: EE has historically been rated from relatives toward patients, but patients' own EE may also be related to treatment outcome.

Health-related quality of life among adolescents with eating disorders.

OBJECTIVE: Health-related quality of life (HRQoL) is an emerging area of research in eating disorders (EDs) that has not been examined in adolescents in detail. The aim of the current study is to investigate HRQoL in an adolescent ED sample, examining the impact of ED symptoms on HRQoL. METHODS: Sixty-seven treatment-seeking adolescents (57 females) with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (EDNOS) completed self-report measures of HRQoL and ED symptoms. RESULTS: Participants reported poorer HRQoL in mental health domains than in physical health domains. Disordered attitudes, binge eating, and compensatory behaviors were associated with poorer mental health HRQoL, and body dissatisfaction was associated with poorer physical health HRQoL. CONCLUSION: The current study assessed HRQoL among adolescents with EDs, finding several consistencies with the literature on adults with EDs. Future research should compare adolescents and adults with EDs on HRQoL.

Adolescent bulimia nervosa.

Onset of bulimia nervosa (BN) typically occurs in adolescence and is frequently accompanied by medical and psychiatric sequelae that may have detrimental effects on adolescent development. Potentially serious medical consequences and high comorbid rates of mood disorders and suicidality underscore the need for early recognition and effective treatments. Research among adolescents with BN has lagged behind that of adults, although evidence is accumulating to support the efficacy of family-based interventions and cognitive behavioral treatments that are adapted for use with adolescent populations. The aim of the current article is to provide an overview of recent research on epidemiology, risk factors, diagnostic issues, and treatment interventions focusing on adolescent BN, and to highlight areas for future research.

Observed connection and individuation: relation to symptoms in families of adolescents with bulimia nervosa.

OBJECTIVE: To examine the relation between observed familial connection and individuation and adolescent bulimia nervosa (BN) symptoms. METHOD: As part of a treatment study for adolescent BN, adolescents (n = 54) and their parents participated in a videotaped semi-structured interview. Participants were rated on observed connection and individuation from these interviews using the Scale of Intergenerational Relationship Quality and two measures of connection. RESULTS: There was a significant negative relation between individuation from parents and adolescent BN symptoms. Connection both to and from mothers and adolescents was negatively associated with BN symptoms. Increased eating concern was significantly associated with a greater likelihood of expressing a desire for more connection with the family. DISCUSSION: Investigating and understanding family factors present at the time of adolescent BN may assist in providing treatment specific to the needs of the family to best aid the adolescent's recovery process.

A review of family-based treatment for adolescents with eating disorders.

This review focuses on the use of family-based treatment (FBT) for adolescents with eating disorders, including anorexia nervosa (AN) and bulimia nervosa (BN). AN and BN are serious disorders with significant psychiatric and medical morbidity. Data support the use of family treatments for adolescents with eating disorders. Developed at the Maudsley Hospital, FBT is a theoretically agnostic approach that externalizes the illness from the patient and empowers families to actively work to bring about recovery in their relative with an eating disorder. FBT appears to be an effective treatment for adolescents with AN and support is developing for the treatment of adolescents with BN. Manual development is currently underway for the implementation of FBT for young adults with eating disorders, overweight adolescents, and those with subsyndromal AN. Further research is needed to determine the effectiveness of FBT with other populations. In this review, we will provide a critical overview of the literature by focusing upon empirical findings regarding FBT, with particular emphasis on studies conducted with adolescents.

Cultural variability in Expressed Emotion among families of adolescents with anorexia nervosa.

OBJECTIVE: To examine the cultural variability in Expressed Emotion (EE) among families of white and ethnic minority adolescents with anorexia nervosa (AN). METHOD: One-hundred and eighty-nine AN patients and their parents completed the Eating Disorder Examination and the Structured Clinical Family Interview, from which EE ratings were made. RESULTS: No differences were found in the number of white and minority families classified as high EE. White families were higher on warmth (W) and tended to be higher on positive remarks (PR) than minority families. High EE was associated with a longer duration of illness, but was not related to eating disorder pathology. DISCUSSION: Few differences were found between white and ethnic minority families on the EE dimensions of CC, hostility (H), or EOI. Differences between families on W and PR, however, may have important treatment implications.

Parental expressed emotion of adolescents with anorexia nervosa: outcome in family-based treatment.

OBJECTIVE: The purpose of this study was to determine the relationship between expressed emotion (EE) and outcome in family-based treatment (FBT) for anorexia nervosa (AN). METHOD: Eighty-six adolescents with AN participated in an RCT comparing two doses of FBT. Seventy-nine of these patients and their parents participated in a structured interview, from which EE ratings were made at baseline. Parents were compared on five subscales of EE as well as overall level of EE (high vs. low). RESULTS: Overall EE levels were low with 32.9% of families presenting as High EE at baseline. Ratings of baseline warmth for both mothers (p = .014) and fathers (p = .037) were related to good outcome at end-of-treatment. DISCUSSION: EE in parents of adolescents with AN is remarkably low. Notwithstanding, parental warmth may be a predictor of good outcome.

Eating disorders and quality of life: a review of the literature.

Following recent scientific interest in the quality of life (QoL) of individuals with eating disorders (EDs), this paper aims to provide a summary of the relevant evidence. A literature review on QoL in EDs (EDQoL) was carried out and relevant articles are described in six main sections. Following an introduction to the area and a summary of the methods used in the review, assessment of QoL in EDs is discussed. The third section represents the body of the review and appraises EDQoL in more detail, discussing what idiosyncratic features of EDs might be important in affecting QoL. The review concludes with suggestions for further research in this evolving area and summarizes the main findings. An evidence base is constructed supporting the idea that those with EDs have impaired QoL compared to other psychiatric and physical health conditions. However, what determines impairments in QoL is yet to be delineated although ideas for such variables, such as the presence of bingeing and purging, are suggested. Development of ED-specific measures has aided greatly in the pursuit of clarity, although equivocal conclusions in this complex area necessitate further research.

Diagnostic classification of eating disorders in children and adolescents: how does DSM-IV-TR compare to empirically-derived categories?

OBJECTIVE: The purpose of this study was to empirically derive eating disorder phenotypes in a clinical sample of children and adolescents using latent profile analysis (LPA), and to compare these latent profile (LP) groups to the DSM-IV-TR eating disorder categories. METHOD: Eating disorder symptom data collected from 401 youth (aged 7 through 19 years; mean 15.14 +/- 2.35 years) seeking eating disorder treatment were included in LPA; general linear models were used to compare LP groups to DSM-IV-TR eating disorder categories on pretreatment and outcome indices. RESULTS: Three LP groups were identified: LP1 (n = 144), characterized by binge eating and purging ("Binge/purge"); LP2 (n = 126), characterized by excessive exercise and extreme eating disorder cognitions ("Exercise-extreme cognitions"); and LP3 (n = 131), characterized by minimal eating disorder behaviors and cognitions ("Minimal behaviors/cognitions"). Identified LPs imperfectly resembled DSM-IV-TR eating disorders. LP1 resembled bulimia nervosa; LP2 and LP3 broadly resembled anorexia nervosa with a relaxed weight criterion, differentiated by excessive exercise and severity of eating disorder cognitions. The LP groups were more differentiated than the DSM-IV-TR categories across pretreatment eating disorder and general psychopathology indices, as well as weight change at follow-up. Neither LP nor DSM-IV-TR categories predicted change in binge/purge behaviors. Validation analyses suggest these empirically derived groups improve upon the current DSM-IV-TR categories. CONCLUSIONS: In children and adolescents, revisions for DSM-V should consider recognition of patients with minimal cognitive eating disorder symptoms.

Are single-parent families different from two-parent families in the treatment of adolescent bulimia nervosa using family-based treatment?

OBJECTIVE: To examine whether family-based treatment (FBT) for adolescent bulimia nervosa (BN), which emphasizes family involvement in helping to reduce binge eating and purging behaviors, is differentially efficacious in single-parent families versus two-parent families. METHOD: Forty-one adolescents (97.6% female; 16.0 +/- 1.7 years old) with either BN (n = 18) or subthreshold BN (n = 23) were randomized to FBT as part of a larger randomized controlled trial studying treatments for adolescent BN. RESULTS: Two-parent (n = 27; 65.9%) and single-parent (n = 14; 34.2%) families were compared on demographic variables, presence of comorbid psychiatric illnesses, and symptoms of BN at baseline, post, and 6-month follow-up. ANOVA and chi-square analyses revealed no statistically significant differences between two-parent and single-parent families on any variables with the exception of ethnicity, for which a greater proportion of Caucasians and Hispanic families had two- parent families compared with African-American families (chi(2) = 8.68, p = .01). DISCUSSION: These findings suggest that FBT may be an appropriate and efficacious treatment for single-parent families as well as two-parent families, despite the reliance on parental intervention to reduce bulimic symptoms and normalize eating patterns.

Expressed emotion among white and ethnic minority families of adolescents with bulimia nervosa.

Expressed emotion (EE), a measure of a relative's attitudes and behaviours towards an ill family member, has been found to be related to treatment outcome for both anorexia nervosa (AN) and bulimia nervosa (BN). Although cultural and ethnic background can influence the way in which family members interact, very little is known about cultural differences in EE among families of an eating disordered adolescent. As part of a treatment study for adolescent BN, 55 patients and 84 parents participated in a structured interview, from which EE ratings were made. White and ethnic minority families were compared on five subscales of EE as well as overall level of EE (high vs. low). No significant differences were found between white and minority families. These findings are consistent with previous studies suggesting that white and minority families of eating disorder patients may share several similarities.

How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment?

OBJECTIVE: To describe therapeutic alliance and treatment acceptability ratings of adolescents with bulimia nervosa (BN) participating in family-based treatment (FBT-BN) and to explore how participant characteristics relate to these constructs. METHOD: Adolescents with BN (n = 80) in a randomized controlled trial comparing FBT-BN and individual supportive psychotherapy (SPT), completed the Eating Disorder Examination, Rosenberg Self-esteem Scale, and Beck Depression Inventory prior to treatment. The Helping Relationship Questionnaire, patient expectancy for treatment, treatment suitability, and self-reported estimates of improvement ratings were obtained at multiple points throughout treatment. RESULTS: Therapeutic alliance and treatment acceptability ratings were positive in both treatments and generally did not differ. Within FBT-BN, more severe eating disorder symptomatology pretreatment was related to lower alliance ratings mid-treatment (p < .05). However, reductions in binge and purge behaviors over the course of treatment were not related to alliance or acceptability for participants in FBT-BN (all p's > .10). CONCLUSION: Contrary to expectations of FBT-BN, adolescents receiving both treatments develop a strong alliance with the therapist.

Family interaction among white and ethnic minority adolescents with bulimia nervosa and their parents.

OBJECTIVE: To examine family adaptability, cohesion and satisfaction among white and ethnic minority families of adolescents seeking treatment for BN. METHOD: Families completed the Family Adaptability and Cohesion Evaluation Scales (FACES III) as part of their baseline assessment. RESULTS: No differences were found between white and ethnic minority patients' perceived and ideal levels of family cohesion and adaptability or level of satisfaction with family functioning, nor were differences found between white and ethnic minority parents on these measures. Both white and ethnic minority patients perceived their families to be less cohesive than did their fathers and their mothers, and their ideal levels of cohesion were lower than that of their fathers and their mothers. CONCLUSION: These findings are consistent with a growing literature on eating disorders among ethnic minorities, which suggests that there may be fewer differences and more similarities among ethnic groups than previously thought.

What can dropouts teach us about retention in eating disorder treatment studies?

OBJECTIVE: To describe strategies used to retain adolescents with bulimia nervosa (BN) in a randomized clinical trial, and to compare treatment completers and dropouts on baseline demographic and symptom severity information. METHOD: Adolescents with BN (N = 80) completed a demographic questionnaire, the Eating Disorder Examination, Rosenberg Self-esteem Scale, Family Adaptability and Cohesion Evaluation Scales, and Beck Depression Inventory prior to beginning treatment. RESULTS: Several strategies were used to promote treatment retention (e.g., encouraging parental involvement in treatment, prompt rescheduling of cancelled appointments). Six participants (7.50%) voluntarily dropped out of treatment and three additional participants (3.75%) were asked to terminate treatment for medical/psychiatric reasons. Compared with treatment completers, noncompleters reported significantly longer duration of illness (p < .01). Sixty-two percent of treatment completers and only 22% of dropouts were from intact families. CONCLUSION: Examining factors related to retention in adolescent treatment trials is important, and could be utilized to improve retention in adult studies where drop out rates are higher.

Recruitment for an adolescent bulimia nervosa treatment study.

OBJECTIVE: This objective of this study was to investigate the recruitment rate for a clinical treatment trial for adolescents with bulimia nervosa. METHOD: Recruitment rates for a 5-year randomized controlled trial for adolescent bulimia nervosa were analyzed. RESULTS: Although the rate of randomization fluctuated over the course of the study, the overall rate of participants recruited was fairly consistent. The number of participants who were assessed for the study but who did not qualify, and the number of participants who qualified for the study but who chose not to join, were also consistent. CONCLUSION: These findings suggest that it is feasible to recruit adolescents for a bulimia nervosa treatment trial. A better understanding of the reasons behind a participant's decision to stay in a treatment study versus discontinue a treatment study, as well as differences between adult and adolescent patients, could aid in the design of future treatment studies.