The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of ...the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.
This study compared the quantity and quality of social group memberships in patients with anorexia nervosa (n = 30), carers of patients with anorexia nervosa, unrelated to those patients (n = 30), ...and two cohorts of healthy controls (n = 60) age‐matched to these focal groups. A secondary aim was to examine the associations between the quality of group relationships and severity of eating disorder and depression symptoms in patients; and depression symptoms in carers. Participants completed the online Social Identity Mapping Tool, which was used to measure the quantity and quality of social group memberships (e.g., number of social groups, number of groups rated ‘highly positive’). Participants also completed self‐report measures of clinical symptoms. Compared to controls, patients reported fewer social groups when eating disorder‐related groups were included, and significantly fewer social groups, and community groups in particular, when eating disorder‐related groups were excluded. Number of positive groups was negatively associated with severity of eating disorder and depression symptoms in patients when eating disorder‐related groups were excluded. Carers reported fewer groups overall, fewer family groups, and fewer positive and supportive groups compared to healthy controls. There was a weak association between the number of positive groups and the severity of depression symptoms in carers. Positive group memberships might play a protective role towards developing more severe eating disorder and depression symptoms.
Highlights
Patients with anorexia nervosa reported fewer social groups than healthy peers
Positive group membership was associated with lower eating disorder and depression symptoms in patients
Carers reported fewer social groups than healthy peers
Positive group membership was weakly associated with depression symptoms in carers
Objective
This qualitative study explores the ways in which the coronavirus disease 2019 (COVID‐19) pandemic and associated lockdown measures have affected the lives of adult patients with anorexia ...nervosa (AN) and their carers.
Method
Semi‐structured interviews were conducted with patients with AN (n = 21) and carers (n = 28) from the start of UK Government imposed lockdown. Data related directly to the impact of lockdown and COVID‐19 were analysed using thematic analysis.
Results
Four broad themes were identified for patients and carers separately. Patients experienced: 1. reduced access to eating disorder (ED) services; 2. disruption to routine and activities in the community; 3. heightened psychological distress and ED symptoms; 4. increased attempts at self‐management in recovery. Carer themes included: 1. concern over provision of professional support for patients; 2. increased practical demands placed on carers in lockdown; 3. managing new challenges around patient wellbeing; 4. new opportunities.
Conclusions
Reduced access to ED services, loss of routine and heightened anxieties and ED symptoms resulting from COVID‐19 and lockdown measures presented challenges for patients and carers. Increased remote support by ED services enabled the continuation of treatment and self‐management resources and strategies promoted self‐efficacy in both groups.
Objective
Providing information and support to those supporting a loved one with an eating disorder is a key part of evidence‐based service provision. We report on how we took our workshops for ...supporters online during the Covid‐19 Pandemic when country‐side physical distancing restrictions meant we were unable to work face to face.
Methods
We outline the structure of an eight‐session 2‐h workshop series delivered fortnightly facilitated by a multidisciplinary team of clinicians, researchers and experts by experience. We use a repeated‐measures design to understand the possible benefits of the workshops on supporter skills (n = 76).
Results
Measured using the Caregiver Skills Scale, we observed small‐sized improvements in the overall skills (D = 0.43) of n = 17 supporters who provided data at the end of the intervention. Supporters gave largely positive feedback on the virtual format. They particularly liked the opportunity to interact with other supporters. As facilitators, we overcome our initial anxiety around workshop delivery using a new platform and reflected that having more time to cover key information and for skills practice over a period of 16 weeks offered opportunities to develop and reflect on new skill together as a group. We were also able to work with larger groups of supporters, as several barriers to access were removed.
Conclusions
As the workshops reached a larger number of supporters than through face to face delivery and were of benefit to those who reported on their skills, we plan to continue offering workshops to supporters online in future.
Key points
The National Institute for Health and Care Excellence (NICE) Guidelines for eating disorders recommend that those supporting loved ones with eating disorders have access to information and support.
Online workshops for supporters might remove barriers to access and increase uptake, and we wanted to learn more about this mode of delivery and its benefits on supporter skills.
We were also interested in thinking about neurodiversity within the workshops, in particular whether supporters have traits of autism spectrum disorder. This information is important in helping us plan for more inclusive workshops.
Around 1/3 of supporters scored over the cut‐off on the Autism Quotient (AQ10) suggesting it is important to think carefully about how online workshops might benefit (or present challenges for) a more diverse group of attendees.
Supporters reported benefits in terms of improvements in their skills and positive feedback at the end of one of five workshop series.
Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides ...psychoeducation and support to augment usual care.
To explore patient and carer experiences of receiving the ECHOMANTRA intervention.
This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts.
Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability.
Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.
Background: Empirical data suggests a high comorbid occurrence of eating disorders (EDs) and substance use disorders (SUDs), as well as neurological and psychological shared characteristics. However, ...no prior study has identified the neuropsychological features of this subgroup. This study examines the prevalence of alcohol and/or drug abuse (A/DA) symptoms in ED patients. It also compares the clinical features and neuropsychological performance of ED patients with and without A/DA symptoms. Methods: 145 participants (74.5% females) with various forms of diagnosed EDs underwent a comprehensive clinical (TCI-R, SCL-90-R and EDI-2) and neuropsychological assessment (Stroop, WCST and IGT). Results: Approximately 19% of ED patients (across ED subtypes) had A/DA symptoms. Those with A/DA symptoms showed more impulsive behaviours and higher levels of interoceptive awareness (EDI-2), somatisation (SCL-90-R) and novelty seeking (TCI-R). This group also had a lower score in the Stroop-words measure, made more perseverative errors in the WCST and showed a weaker learning trajectory in the IGT. Conclusions: ED patients with A/DA symptoms display a specific phenotype characterised by greater impulsive personality, emotional dysregulation and problems with executive control. Patients with these temperamental traits may be at high risk of developing a SUD.
Aim
In the short term, intensive treatment focusing on restoring weight for anorexia nervosa can remediate many symptoms. However, there is a high level of relapse after discharge. This paper ...examines interventions developed to bridge the transition from intensive to less intensive forms of treatment for adult anorexia nervosa.
Method
We undertook a systematic review of the literature on interventions aimed at providing transition support. The Template for Intervention Description and Replication was used to describe components of the transition interventions. Patient's drop‐out rates, weight, eating disorder psychopathology and mood data were extracted at end of treatment and follow‐up to describe preliminary efficacy.
Results
Fourteen studies were selected: nine used psychological interventions delivered through face‐to‐face talking therapy or guided self‐help, three examined the use of fluoxetine and two assessed stepped‐care approaches. Transition support was delivered to patients in 11 studies, to patients and carers in two studies, and carers alone in another study.
Conclusions
There was a great heterogeneity in the content and structure of the transition interventions evaluated. Overall, drop‐out rates were lower for psychological support than pharmacological interventions or stepped‐care approaches. Changes in eating disorder outcomes and mood were small to moderate throughout for studies that included a comparison group.
Highlights
Psychological interventions to support the transition from inpatient care have good adherence
The digital formats that have been piloted appear to be a feasible means to bridge the gap between specialist inpatient care and community care
Medication (fluoxetine) and stepped‐care approaches are characterised by higher drop‐out rates
Background
Relapse rates for individuals with anorexia nervosa after intensive hospital treatment (in-patient or full-time day care) are high. Better knowledge about the difficulties and ...opportunities that arise during this transition is needed to identify factors that support or hinder continued recovery upon discharge.
Aims
The aim of this study was to explore the experiences of adult patients and their chosen carers on the process of transitioning from intensive eating disorder treatment settings to the community.
Method
Semi-structured interviews were conducted with patients with anorexia nervosa (
n
= 11) discharged from day or in-patient care from specialised eating disorder units across the UK, and their chosen carers (
n
= 20). Data were analysed with inductive thematic analysis.
Results
Four interrelated themes were identified for both groups. For patients, themes were continuity of care, ambivalence about continued recovery, the value of social support and a call for enhanced transition support. For carers, themes were the impact of the eating disorder on themselves and the family, perceptions of recovery and support post-discharge, the impact of previous treatment and care experiences, and desire to create a supportive transition process.
Conclusions
The study provides an insight into the unique challenges that individuals with anorexia nervosa face upon leaving intensive treatment. A lack of post-discharge planning, support system and identity formation outside of anorexia nervosa were perceived as barriers to continued recovery. Patients and carers advocated for transition support that incorporates a phased, inclusive approach with accessible professional and social support in the community.
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