More Related Content Similar to iCAAD London 2019 - Pippa Hugo - FIGHTING CHILD STARVATION - GIVING EATING DISORDERS NO WHERE TO HIDE WITHIN THE FAMILY UNIT (20) More from iCAADEvents (20) iCAAD London 2019 - Pippa Hugo - FIGHTING CHILD STARVATION - GIVING EATING DISORDERS NO WHERE TO HIDE WITHIN THE FAMILY UNIT2. © 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
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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
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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
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GENES
Temperament &
Personality
Socio-cultural
Factors
Vulnerability
PubertyStressors
Family
EATING DISORDER
Biological
Substrate
Lask and Bryant Waugh
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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
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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. 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
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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
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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
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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. 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
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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
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What’s happening to the mind experience
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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
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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
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GENES
Temperament &
Personality
Socio-cultural
Factors
Vulnerability
PubertyStressors
Family
EATING DISORDER
Biological
Substrate
Lask and Bryant Waugh
Treatment?
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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
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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
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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
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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
•
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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 ?
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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
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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
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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
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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’
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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
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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
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Carer burden
Interventions for the carers of patients with eating disorders. Janet Treasure and Bruno
Nazar. Current Psychiatry rep 2016; 16:18
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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
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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
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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
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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
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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/