WELCOME TO THE FIRST SEDIG/EEATS BASIC TRAINING IN EATING DISORDERS

SEDIG/EEATS basic SEDIG/EEATS basic training day June 2009training day June 2009

FAMILIESFAMILIES& EATING & EATING

DISORDERSDISORDERS

Jane Morris

This Be The VerseThey fuck you up, your mum and dad. They may not mean to, but they do. They fill you with the faults they had And add some extra, just for you. But they were fucked up in their turn By fools in old-style hats and coats, Who half the time were soppy-stern And half at one another's throats.

Man hands on misery to man. It deepens like a coastal shelf. Get out as early as you can, And don't have any kids yourself. Philip Larkin

Charles Darwin (1809–82)

Sigmund Freud (1856 – 1939)

What did early clinicians think about families & eating disorders?

Louis-Victor Marce

William Gull

Charles Lasegue

Early 20th century clinicians

Louis-Victor Marce

‘This hypochondriacal delirium, then, cannot be advantageously countered so long as the subjects remain in the midst of their own family...it is therefore indispensable to change the habitation and surrounding circumstances, and to entrust the patients to the care of strangers’

(1860)

William Withey Gull (1816-90)

‘In… 1868, I referred to a peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation.... The want of appetite is, I believe, due to a morbid mental state.... We might call the state hysterical.’ (Gull, 1874)

‘these wilful patients.... should be fed at regular intervals, and surrounded by persons who should have moral control over them, relatives and friends being generally the worst attendents’

Ernest-Charles Lasegue (1816-83)

L’anorexie hysterique(1873)

‘A young girl..suffers from some emotion which she avows or conceals..at first she feels uneasiness after food..at the end of some weeks there is …a refusal of food that may be indefinitely prolonged’

‘The family has but two methods at its service, which it always exhausts – entreaties and menaces’

Lasegue writes of himself as

‘always placing in parallel the morbid condition of the hysterical subject and the preoccupations of those who surround her. These two circumstances are intimately connected, and we should acquire an erroneous idea of the disease by confining ourselves to an examination of the patient….the moral medium amidst which the patient lives exercises an influence which it would be equally regrettable to overlook or misunderstand’

‘It is curious that Lasegue did not have recourse to a treatment which suggested itself from his very description of the illness. He had established that the milieu in which the patient lived is the proper ground for the development of the anorexia and it did not occur to him to separate the patient from her family’

Mathieu and Roux, 1904

Early 20th century views

Use of ‘isolation’ – or rather, spearation of the patient from her family

Increased interest in physiology and theories of pituitary malfunction

Two world wars and pressures of food rationing set aside interest in disorders of self-starvation for some time

1970sHilde Bruch

The ‘desperate struggle for a self-respecting identity’ - Anorexia as a young girl’s fight to free herself from a stifling family context in which mother uses the child to serve her own needs rather than the other way round.

1970s family theorySalvador Minuchin –

‘anorexogenic’ families’ Enmeshment, rigidity, overprotective mothers, aloof or

absent fathers, involvement of the child in the parental conflict

Structural family therapy to restore parent powerSelvini-Palazzoli – positive connotations of anorexia and its

symptoms, paradoxical encouragement framed as part of strategic family ‘game’ – helping sufferer extricate herself

Minuchin’s uncontrolled trial of structural family therapy for AN

53 patientsall but three were adolescentsFairly short duration of illness86% recovery rate

Minuchin et al, 1975, 1978

More recent family theory

Genetic studies

Neuropsychology

Brain scanning

Genetics:

• First degree relatives of patients with anorexia nervosa are at increased risk. 

• Associations with family history of obsessional personality (perfectionism), OCD, autistic spectrum disorders and with anxiety disorders

• Twin studies MZ:DZ = 65%:32%

Walter H. Kaye, University of Pittsburgh, Janet Treasure Institute of Psychiatry, et al

Supported by National Institute of Mental Health (NIMH),

12-site international collaboration seeking to identify genetic variants that affect risk for anorexia nervosa (AN).

400 families with 2 or more individuals affected with AN. The assessment battery produces a rich set of phenotypes comprising eating disorder diagnoses and psychological and personality features known to be associated with vulnerability to eating disorders.

Linkage analyses for DNA, genotypes, and phenotypes to form a national eating disorder repository maintained by NIMH and available to qualified investigators.

Neuropsychology

Reduced central coherence (local and global processing) in women with anorexia nervosa tested for visuospatial and verbal aspects of central coherence.Tchanturia, International Journal of Eating Disorders, 2007 Ravello Profile has investigated this in younger patients

Brain scans showed unilateral temporal lobe hypoperfusion in 13/15 children and adolescents with anorexia

(Gordon et al, 1997)

Month of birth (Eagles, Millar et al, 2001) increased births in Spring in AN

Environmental agent or increased conception in warm weather?

The families of anorexia nervosa and cystic fibrosis patients. Blair, C., Freeman, C., & Cull, A. Psychological Medicine, 1995

87 families participated.Self-report questionnaires, interview rated for Expressed Emotion (EE), direct observation of a family problem solving task rated for evidence of Minuchin's 'psychosomatic family' dimensions.

Most self-report measures of family functioning did not distinguish between groups. There were no differences in levels of EE criticism.

AN & CF families showed more EE emotional over-involvement than well families.

Over-involvement correlated with illness severity. More households in the AN group were poor at problem

solving than in the CF and well groups. Minuchin's conceptualization of the anorexia nervosa

family was partly supported.

Parental high concern & adolescent onset anorexia nervosa

Shoebridge & Gowers,

BJPsych, 2000 40 index and 40 control families Index mothers reported higher rates of: near-exclusive child

care, infant sleep difficulties, severe distress at first regular separation, high maternal trait anxiety levels and later age for first sleeping away from home.

More index families had experienced a severe obstetric loss prior to their daughter's birth.

‘In total, 10 of the group with anorexia nervosa had experienced a prior severe obstetric loss (25%) compared with three (7.5%) of their matched controls (P=0.0661).

In all but one of these cases the subjects with anorexia nervosa were the next-born female child….

A larger number of mothers with anorexia nervosa recollected worrying significantly about miscarrying during their pregnancy (10/40 v. 2/40; P=0.028)….

‘We obtained a wide range of both direct and indirect evidence

suggestive of high-concern maternal attitudes and behaviour….

Our finding of increased rates of exclusive maternal caring among index mothers in the first five years and the differential rates of spending their first weekend away from parents before the age of 11 years would seem to fit with a pattern of overprotective parenting …(Levy, 1943).

This parental behaviour might tend to encourage the development of enmeshed, overly dependent relationships

characterised by excessively compliant behaviours in the child, a frequent observation in patients with anorexia nervosa.’

Is there a more complex interpretation?

Bear in mind that:

Both anxiety and anorexia nervosa run in families Low weight at conception associated with threat to

pregnancy ‘High constitutional levels of anxiety’ also affect

ability to mourn healthily after a tragedy Anxiety during pregnancy now known to affect

brain development of the unborn child

Is there a more complex interpretation?So that perhaps There was already a tendency to lose weight in these parents,

as well as a tendency to experience high levels of anxiety This was reflected in inadequate nutrition at conception or

during pregnancy leading to increased levels of perinatal loss...

...followed by even greater anxiety during the following pregnancy

..which affects the brain of the unborn child ...who has perhaps already inherited a somewhat anxious

personality and a tendency to lose weight in response to stress

Is there a more complex interpretation?

This child then

Demonstrates insecurity and anxiety Especially around separation As well as a tendency to lose weight in response to stress To which the highly attuned and sensitive parents respond

‘overprotectively’ - is there a healthier way to respond to such highly

sensitive children?- particularly AFTER anorexia nervosa has developed?

Maudsley family studies

Russell et al, 1987 – FT vs Individual Le Grange et 1993 – conjoint vs separated

FT Robin et al 1995 – FT vs Individual Eisler et al, 2000 – conjoint vs separated FT Lock et al, 2005 – different dose-levels of FT

Russell et al, 1987 – FT vs Individual

One year’s FT better than individual therapy for recently discharged adolescent patients

Benefits maintained at 5 years Poor prognosis for 19+ age group and

neither therapy clearly better

Le Grange et 1993 – conjoint vs separated FT

Both forms of FT effective ‘Separated’ model better for families with

older patients and where high EE

High EE in family may delay recovery (Butzlaff & Hooley, 1998)

Robin et al 1995 – FT vs EOIT (Ego-Oriented Individual Therapy) At one year follow up 82% FT patients and 50%

EOIT patients had reached menstruating weight FT very like Maudsley model – ie family told NOT

to stand back, but to engage assertively in refeeding the child

Both groups showed less family-daughter conflict Interesting that in EOIT family conflict reduced

without family involvement

Families deserving of care in their own right

Santonastoso et al (1997),Treasure et al (2001) found that the burden of care for families of people with anorexia nervosa is at least as great as for families of people with psychosis.

Padua study found 70% relatives depressed, 68% ‘unable to cope’, 65% needed respite

Binge –purge subtype AN associated with worst burden FT outcomes on family psychopathology not yet fully

explored

Towards possible solutions…the ‘expanded family’?

Dare & Eisler (2000) in London, and Scholz & Asen (2001) in Dresden, have pioneered Multi-family day-hospital therapy with up to 6 families together – 4 full days as block + further monthly day attendence

What about ‘separated’ multifamily groups? Maudsley, EDGE, NEEDS etc

‘... Learning from each other and neutralising chronic staff-patient relationships....’

Staff as part of family The ‘magnetic forces’ generated by anorexia in a

patient seem to determine a predictable configuration of interpersonal dynamics around the affected individual. (Freudians will not be surprised by this)

We may recognise in ourselves either the ‘overinvolved mother’ or ‘aloof, distant father’. Younger staff and fellow patients are often understandably angry and jealous of the attention paid to the anorexic patient.

Staff too need ‘family therapy’

All families are complex, comorbid, creative human enterprises

Humans instinctively recreate family dynamics in the groups around them

The propensity to develop anorexia nervosa seems to be partly a matter of inherited brain function, so members of a family sharing this sensitivity may start out showing helpful empathy which can unwittingly become unhelpful collusion

The inherited tendency to focus on fine detail at the expense of the bigger picture can impede problem solving

However, we should not ‘isolate’ patients,

because families who engage wholeheartedly in therapy can support a young patient through a period of blinkered obsession and facilitate recovery, better than any other treatment so far developed

...provided that they are not crushed by the overwhelming burden of caring

....and provided they can collaborate with a non-blaming, healthy staff team who are themselves well-supervised and supported

We are all ‘family’We are all ‘family’