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iCAAD London 2019 - Pippa Hugo - FIGHTING CHILD STARVATION - GIVING EATING DISORDERS NO WHERE TO HIDE WITHIN THE FAMILY UNIT

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Eating disorders are serious illnesses in young people, with profound consequences for physical, social and emotional development affecting the whole family.

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iCAAD London 2019 - Pippa Hugo - FIGHTING CHILD STARVATION - GIVING EATING DISORDERS NO WHERE TO HIDE WITHIN THE FAMILY UNIT

  1. 1. Pippa Hugo Fighting child starvation – giving eating disorders nowhere to hide within the family unit
  2. 2. © 2019 Schoen Clinic Page 2 Summary • What is anorexia nervosa • Overview of aetiology of anorexia nervosa • The effect of starvation • Family Treatment models • Factors associated with recovery
  3. 3. © 2019 Schoen Clinic Page 3 What is anorexia nervosa? • Serious psychiatric illness • High rates of comorbidity – up to 50% meet criteria for other disorder • Impaired quality of life • Highest mortality of any psychiatric illness • Develop during adolescence • Significant developmental, medical and psychological consequences • Low body weight • Fear of weight gain • Behaviour that interferes with weight gain • Disturbance in the way in which body image is perceived • Over evaluation of weight or shape • Lack of recognition of seriousness of illness • May be different in younger people
  4. 4. © 2019 Schoen Clinic Page 4 Description of adolescent anorexia nervosa 1705 – Papers from Royal Society The Woman by Llongollen:She livd ten Weeks and some odd days without Sustenance, she had livd so before for a fortnight, and always in a trance. It may be (for ought I know) a Disorder of Nature in her, … as we sometimes find it in Exces of Appetite: and both very Unnaccountable. For the Woman of Llongollen’s character, I find it agreed upon in Generall, that she was grave, sober, and Religious, but not without a deep tincture of melancholy, being from her Childhood Subject to disquieting thoughts, and frightfull Dreams. She was constantly at the Service off the Church .. From much attention to dark thoughts, she came at last to believe that Something spoke to her, & gave advice, & Comfort against Severe Temptation and Tryalls from her spiritual enemy. Derbyshire Woman: who is said to have lived sixteen moneths without Meat or Drink … and afterwards recovered her health. BJPsych March 2019
  5. 5. © 2019 Schoen Clinic Page 5 GENES Temperament & Personality Socio-cultural Factors Vulnerability PubertyStressors Family EATING DISORDER Biological Substrate Lask and Bryant Waugh
  6. 6. © 2019 Schoen Clinic Page 6 The Development of an eating disorder in a child predisposed to do so VULNERABLE CHILD Sense of Failure Low Self-Esteem Sense of Loss of Control Need To Gain Control Dieting Sense of Achievement Increased Dieting Eating disorder Stressors Stressors Lask , Bryant -Waugh
  7. 7. © 2019 Schoen Clinic Page 7 Genetic / biological, family, environment, relationships I am unlikeable / unnoticeable I am worthless •I must always be perfect to get others to like me. •I must always do well Parental Beliefs & Behaviours Boarding school, “whats the point of me?” I must not eat to be noticed / loved /special Early Experiences Core Beliefs (Who I am) Dysfunctional assumptions (rules for life) Critical Incident(s) Puberty Activation of beliefs Sociocultural pressures Weight & shape comments EATING DISORDER Negative automatic thoughts (ED Spec) Cognitive Conceptualisation of Development of Eating Disorder
  8. 8. Understanding anorexia – maintenance Dietary restriction INITIAL POSITIVE RESPONSES: •Increased energy •Bright eyes •Clear thinking •Positive comments EXTREME DIETING NEGATIVE RESPONSES: •Neurobiological changes •Denial, rigidity, obsession • Increased preoccupation •Mood changes •Family concern •Social changes •Avoidance of challenges Binge eating Exercise Purging Contributory factors
  9. 9. © 2019 Schoen Clinic Page 9 Minnesota study 1944 - 45
  10. 10. © 2019 Schoen Clinic Page 10 Effects of starvation Food related: • Increased preoccupation with food • Planning meals • Changes in speed of eating • Use of condiments • Increased hunger initially Mood related • Significant Depression • Apathy • Self mutilation • Anxiety • Irritability • Neglect personal hygiene • Anger
  11. 11. © 2019 Schoen Clinic Page 11 Effect of starvation Social and sexual changes • Social withdrawal • Sense of inadequacy • Loss of libido • Reduced sense of humour • Isolation • Strained relationships Physical activity • Tiredness • Weakness • Apathy
  12. 12. © 2019 Schoen Clinic Page 12 Effect of starvation Physical changes • Gastrointestinal discomfort • Reduced need for sleep • Dizziness • Headache • Hypersensitivity to noise and light • Reduced strength • Hair loss • Oedema • Low body temperature • Abnormal sensations / prickling hands and feet Cognitive changes • Impaired concentration, alertness, judgement
  13. 13. Understanding anorexia – maintenance Dietary restriction INITIAL POSITIVE RESPONSES: •Increased energy •Bright eyes •Clear thinking •Positive comments EXTREME DIETING NEGATIVE RESPONSES: •Neurobiological changes •Denial, rigidity, obsession • Increased preoccupation •Mood changes •Family concern •Social changes •Avoidance of challenges Binge eating Exercise Purging Contributory factors
  14. 14. © 2019 Schoen Clinic Page 14 What’s happening in the brain
  15. 15. © 2019 Schoen Clinic Page 16 AN Brain response to pleasure EMOTION AND EATING Kaye, 2003, 2013; Strober, 1995; Vitousek, 1994; Steinglass 2010 Most*People *Anorexia*Nervosa% Reward Circuit Anxiety, Consequence Circuit F
  16. 16. © 2019 Schoen Clinic Page 17 What’s happening to the mind experience
  17. 17. © 2019 Schoen Clinic Page 18 What’s happening in the family We watched on helplessly….We often had no idea what to say. I would range between anger “cant you see what you are doing to yourself?, pure frustration : “for goodness sake just eat”; and exhaustion : “ we’re sick to death of this – you are so selfish.” We became world experts in saying the wrong thing, …. family life was a war zone and anorexia had a profound effect on the whole family. Marg Oaten; Guardian Feb 2017 “What I failed to grasp was that she was seriously mentally ill and could not see a future for herself…..I told her she was being ridiculous. I told her to get a grip and grow up …I even remember saying “if you really want to starve yourself to death, just get on with it”. And at least once, exasperated and at a loss, I think I actually meant it.” Mark Austin Jan 2017
  18. 18. © 2019 Schoen Clinic Page 19 What’s happening in the family Accommodation to the needs of the illness Restructuring of family routines Delayed decision making Disruption of family life / rituals Imbalance in attention Distortion of family identity Narrowing of time focus on here and now Amplification of aspects of family functioning Family life cycle halted Loss of agency / helplessness Illness central to organising the family Steinglass, P et al (1987) The Alcoholic Family. New York: Basic Books. Steinglass, P (1998) Multiple family discussion groups for patients with chronic medical illness. Families, Systems and Health 16, 55–70
  19. 19. © 2019 Schoen Clinic Page 20 GENES Temperament & Personality Socio-cultural Factors Vulnerability PubertyStressors Family EATING DISORDER Biological Substrate Lask and Bryant Waugh Treatment?
  20. 20. © 2019 Schoen Clinic Page 21 Sir William Gull (1873) “The treatment required is obviously that which is fitted for persons of unsound mind. The patients should be fed at regular intervals, and surrounded by persons who would have moral control over them; relations and friends generally being the worst attendants” Charles Lasegue (1873) Described anorexia hysterique as intimately connected to the dynamics and conflicts in the patient’s family and recommended separating her from the family. Treatment of adolescent anorexia nervosa
  21. 21. © 2019 Schoen Clinic Page 22 The Psychosomatic Family First, the child is physiologically vulnerable, …. Second, the child’s family has four transactional characteristics: • enmeshment, • overprotectiveness, • rigidity • lack of conflict resolution. Third, the sick child plays an important role in the family’s pattern of conflict avoidance; and this role is an important source of reinforcement for his symptoms. Salvador Minuchin 1975 Ivan Eisler
  22. 22. © 2019 Schoen Clinic Page 23 GENES Temperament & Personality Socio-cultural Factors Vulnerability PubertyStressors Family Eating Disorder Biological Substrate CBT, IPT, supportive psychotherapy Maintaining factors – starvation, avoidance of life challenges, special care, family interactions Family interventions Dietetic advice
  23. 23. © 2019 Schoen Clinic Page 24 Family therapy principles • No assumptions made about cause of illness • Identify what needs to be done to move forward • Externalise the illness – the child does not have control over the illness, they did not choose to develop it, reduces parents criticism • Therapist takes a non-authoritative stance – seen as expert consultant • Aim to empower parents, see parents as best resource for the family. Parents are in charge of recovery • Initial focus on symptom reduction, reversing starvation and addressing maintenance factors •
  24. 24. © 2019 Schoen Clinic Page 25 Family therapy model Phase one: focus on rapid restoration of physical health, parents in charge therapist weighs the patient decisions re eating taken out of patient’s hands aim to recover in day to day environment siblings given supportive role family meal session – guidance on managing the meal Continues until steady weight gain and child less resistant Phase two: Gradually giving back responsibility for eating back to adolescent e.g. child to serve self, manage meals at school Phase three: issues re adolescent development / challenges . Help negotiate difficulties without resorting to eating disorder. (exercise) What are essential elements ?
  25. 25. © 2019 Schoen Clinic Page 26 Case – 13 year old girl Highly intelligent, difficult transition to secondary school changed twice At new school craved acceptance so went on diet Bullied both at school and online but unable to let parents know Dramatic weight loss Extreme tantrums including violence to mother Parents resourceful, read extensively and began to adopt FBT approach themselves Systemic family therapy not helpful First step describing illness – named “Ed” Diet changes, weekly weighing Creative activities to understand “Ed” Dealing with tantrums----------------- ? medication Decisions re school Reasserting parents authority
  26. 26. © 2019 Schoen Clinic Page 27 Multifamily therapy MFG Some families need different or more intensive treatment MFG developed Dresden, previous applications in substance abuse / schizophrenia / conduct disorder Same principles as FBT 4 – 6 families Introductory session – meet expert family 4 Day intensive workshop with follow up days. Whole group / separate parents / young people / sibling days Combined with FBT if needed
  27. 27. © 2019 Schoen Clinic Page 28 Multi family therapy – benefits Bringing together families with shared experiences Focusing on the impact the problem has had on family life Rediscovering family strengths and resilience to enable parents to take central role in tackling their daughter’s eating problems Creating new and multiple perspectives and helping families to take an observational stance Reduce isolation and stigma and impact chronic staff patient relationships Offering expertise in the context of a highly collaborative therapeutic relationship To address problematic family interactions and communications, that have developed around the eating problems
  28. 28. © 2019 Schoen Clinic Page 29 Typical MFG Day 1 9.00 - 10.30 Multi family introductions, hopes, fears expectations 10.30 - 11.00 Morning Snack: 11.00 - 12.30 Parents: lunch planning Young people: ‘Portraying anorexia’ (draw, model, write something that represents anorexia for you/your family) 12.30 - 2.00 Multi-family lunch: observed and supported by staff 2.00 - 3.30 Extensive feed back of all families to each other about their experiences and observations from lunch 3.30 - 4.00 Afternoon Snack: Tea, soft drinks, biscuits 4.00 - 5.00 Reflections on the ‘portrayals of anorexia’
  29. 29. © 2019 Schoen Clinic Page 30 Multifamily therapy – exercises Systemic interventions: Circular and reflexive questioning / externalising/ reflecting team / boundary making / family trees Non-verbal therapy techniques: drawing / collage Action techniques: Family sculpt / Timeline / role play / swapping roles / brain exercise / Plate exercise / developing survival toolkit Body image work Psychoeducation: Starvation / individual / family life cycle issues Group techniques: MFG meals / parent / siblings / young person
  30. 30. © 2019 Schoen Clinic Page 31 Family therapy evidence • RCT Maudsley 1987 : 80 patients 14 - 55 admitted for weight restoration and on discharge randomised to 1 year Family therapy. AN duration illness < 3 years ; less than 18 years old responded better to FT • Robin et al: 37 compared BFST (included nutritional counselling ) to ego-orientated individual therapy. BFST gained more weight and more resumed menstruation • Le Grange et al: 121 randomised comparing FBT with adolescent focussed individual therapy. FBT – significantly more achieved full remission at follow up Different models: • Eisler et al: no difference between conjoint family therapy and separated family therapy although latter may be better with high conflict in family • Lock et al – Short and long term FBT • Le Grange et al – FBT compared to parent focussed treatment where adolescent is seen by nurse at beginning of session, no difference at follow up • MFG Outcomes - some indication that more people in MFG group had better outcomes at end of treatment and 6 month follow up mean % BMI higher but no difference in other variables. User satisfaction
  31. 31. © 2019 Schoen Clinic Page 32 Carer burden Interventions for the carers of patients with eating disorders. Janet Treasure and Bruno Nazar. Current Psychiatry rep 2016; 16:18
  32. 32. © 2019 Schoen Clinic Page 33 New Maudsley Collaborative Care approach Developed particularly to help families with prolonged illness Teaches positive communication using motivational interviewing, meal support, managing difficult behaviours Lay and professional trained to deliver including experts by experience Group, self help and book format
  33. 33. © 2019 Schoen Clinic Page 34 And what else….
  34. 34. © 2019 Schoen Clinic Page 35 GENES Temperament & Personality Socio-cultural Factors Vulnerability PubertyStressors Family Eating Disorder Biological Substrate CBT-E, IPT, MANTRA, supportive psychotherapy, CFT. ACT, CRT Maintaining factors – starvation, avoidance of life challenges, special care, family interactions Family interventions Dietetic advice
  35. 35. © 2019 Schoen Clinic Page 36 Factors associated with recovery Supportive relationships Parents working together Re-engaging with life – school, friendships, developmentally appropriate peer activities Development of an identity separate from eating disorder Good therapeutic alliance Seeing recovery as a work in progress Developing ability to cope with difficult feelings / self acceptance /conflict resolution High motivation for change
  36. 36. © 2019 Schoen Clinic Page 37 Conclusion Addressing nutritional deficits imperative to recovery and to prevent entrenched eating disorder Urgency in adolescence because crucial developmental stage Families are most important resource in recovery Specific family therapy interventions have proved most effective in treating adolescents Do not forget significant burden to carer
  37. 37. © 2019 Schoen Clinic Page 38 References Steinglass, P et al (1987) The Alcoholic Family. New York: Basic Books. Steinglass, P (1998) Multiple family discussion groups for patients with chronic medical illness. Families, Systems and Health 16, 55–70 Whitney J. & Eisler I. (2005) Theoretical and empirical models around caring for someone with an eating disorder: The reorganization of family life and inter-personal maintenance factors. Journal of Mental Health,14, 575 – 585 Eisler, I. (2005) The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy, 27, 104 – 131. Rienecke R (2017) Family-based treatment of eating disorders in adolescents: current insights. Adolescent health, medicine and therapeutics, 8: 69-79 Treasure J (2016) : Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method F.E.A.S.T – Families Empowered and Supporting Treatment of Eating Disorders https://www.feast-ed.org/
  38. 38. © 2019 Schoen Clinic Page 39 Thank you

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