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Research Articles
Published: 2020-10-11

Modern approaches to the examination of patients with anorexia nervosa

Bohomolets National Medical University
Anorexia Nervosa Eating Disorders Family Functioning Attachment

Abstract

Objective. Eating disorders (EDs) are mental disorders characterized by specific brain dysfunctions that affect bodily perception, the relationship of emotions and appetite, cognitive impairment. Modern treatments for EDs are still imperfect, particularly for anorexia nervosa (AN). AN has low remission rates and high recurrence rates. Psychopathological models of AN, which are the basis of global protocols for the treatment of AN, are still far from explaining the causal relationships that underlie resistance to treatment.

Modern models of AN, as a rule, focus on the cognitive and behavioral characteristics of patients, without explaining the important etiological factors underlying emotional dysregulation, impaired interpersonal functioning, the concept of "I" and mentality, which play an important role in developing and maintaining AN. AN occurs among different age groups, but the average age of onset is most common in adolescence.

Recent studies have demonstrated a significant association between AN and parental psychopathological risks in addition to the importance of family functioning and attachment. Most of these studies have focused on the relationship between the presence of psychopathological disorders in the mother and psychopathological risks and/or the development of AN, not taking into account the likely influence of other family members involved in the upbringing of the child/adolescent.

Thus, AN is a severe psychosocial disorder involving the patient and his family; that is why the problem of a comprehensive examination of the patient AN and members of his family (parents/guardians) is relevant worldwide.

Aim. The aim of the study was scientific substantiation and improvement of medical and psychological support of patients with AN in the context of family relations based on the study of clinical and psychopathological, pathopsychological characteristics of people with AN and their parents/guardians, indicators of family functioning, and quality of social support.

Methods and materials. To conduct a study of patients with AN and their parents/guardians in the context of family relationships who first sought medical care, with further improvement of medical and psychological support of these contingents, based on qualitative and quantitative content analysis and conceptual analysis using meta- analyzes and systematic reviews of the scientific literature on the study of the problem of AN, the optimal battery of psychodiagnostic scales with their approbation within the pilot study was determined and selected.

Results. To verify the adequacy of the tests, a pilot study was conducted on 12 patients (11 girls, 1 boy) aged 14-18 years and 20 parents/guardians (12 persons - mothers, 4 persons - fathers, 2 persons - stepfathers, 2 persons - grandmothers). The study consisted of the following methods: Mini-mental State Examination (MMSE), Minnesota Multiphasic Personality Inventory (MMPI), Family Adaptation and Cohesion Scale (FACES-III), Emotional Difficulty Scale (Gratz & Roemer 2004), Toronto Alexithymia Scale, Adult Attachment Interview (AAI), Hospital Anxiety and Depression Scale (HADS). Quality of Life Assessment Scale (CQLS).

The pilot study found that most psychodiagnostic techniques provide a detailed description of family functioning and psychoemotional status of patients with NA and their parents/guardians, which allows assessing the effectiveness of the developed program of psychocorrection and prognostic value of psychoemotional changes.

Conclusions. The results of our study allow us to determine with sufficient probability the relationship between the occurrence of AN and the peculiarity of family functioning and the psycho-emotional status of parents or guardians. The selected set of research methods has confirmed its effectiveness, which makes it possible to extend it to the entire planned contingent of dissertation research participants.

Background

Eating disorders (ED) are mental disorders characterized by specific brain dysfunctions that affect the perception of the body, the relationship of emotions and appetite, cognitive impairment [1]. Modern treatments for ED are still imperfect, particularly for anorexia nervosa (AN). According to statistics, only ¼ of patients with AN achieve complete recovery [2]. Resistance to treatment, which is present in all mental disorders, is highest in ED. AN has low remission rates and high recurrence rates [3]. The time spent caring for a person with a severe course of illness is almost twice that of a patient with a physical health disorder (such as cancer) or other mental health disorder [4]. Psychopathological models of AN, which are the basis of global protocols for the treatment of AN, are still far from explaining the causal relationships that underlie resistance to treatment [5]. Thus, resistance to AN treatment is a global challenge in modern clinical practice.

AN occurs among different age groups, but the average age of onset is the most common in adolescence [6]. During the second half of the twentieth century, the prevalence of AN has increased sharply and remains relatively stable over the past 20 years [7]. According to numerous studies, adolescents are the most at-risk group due to a number of environmental, social, psychological, and biological factors [8].

Modern models of AN, as a rule, focus on the cognitive and behavioral characteristics of patients, without explaining the important etiological factors underlying emotional dysregulation, impaired interpersonal functioning, the "Self-concept" and mentality, which play an important role in developing and maintaining AN [9]. On the contrary, these aspects are elaborated in the theory of attachment, introduced in the works of John Bowlby (1969) and further improved by other authors [10]. This theory offers a comprehensive framework for understanding the individual and family characteristics that contribute to the development of AN in adolescence.

Attachment has an important impact on the perception and overcoming of difficult transformations in adolescence, and secure family relationships provide emotional support and comfort, especially during stressful situations and important life changes. It is known that a secure attachment is crucial when adapting to physical changes, creating one's own identity, or setting goals for the future, and thus is an important buffer for psychological risks [11].

Recent studies have demonstrated a significant association between AN and parental psychopathological risks [12] in addition to the importance of family functioning and attachment. Most of these studies have focused on the relationship between the presence of psychopathological disorders in the mother and psychopathological risks and/or the development of AN, not taking into account the likely influence of other family members involved in raising the child/adolescent [13].

Thus, AN is a severe psychosocial disorder involving the patients and their families; that is why the problem of a comprehensive examination of the patient with AN and their family members (parents/guardians) is relevant worldwide.

Aim

Scientific rationale and improvement of medical and psychological support of patients with AN in the context of family relations based on the study of clinical and psychopathological characteristics of people with AN and their parents or guardians, indicators of family functioning, and quality of social support.

Methods and materials

To conduct a study of patients with AN and their parents/guardians in the context of family relationships who first sought medical care, with further improvement of medical and psychological support of these contingents, based on qualitative and quantitative content analysis and conceptual analysis using meta- analyzes and systematic reviews of the scientific literature on the study of the problem of AN [14], the optimal battery of psychodiagnostic scales was determined and selected. With their approbation in a pilot study of 12 patients with AN (11 girls, 1 boy) aged 14-18 years and 20 parents/guardians (12 persons - mothers, 4 persons - fathers, 2 persons - stepfathers, 2 persons - grandmothers), in compliance with the principles of bioethics and medical deontology, on the principles of anonymity and voluntariness, subject to informed consent.

The inclusion criteria were: children and adolescents of both genders aged 10 to 18 who had parents/guardians and gave informed consent to participate in the study; the patient was diagnosed with AN with a Kettle body mass index ≤ of 17.5 and artificially induced weight loss by avoiding food and increasing physical activity.

Exclusion criteria were: lack of informed consent of the child/adolescent and/or parents/guardians to participate in the study; the presence of secondary AN (caused by chronic somatic disease); the child/adolescent has another clinically significant somatic or mental disorder, including schizophrenia, intellectual disability, Asperger's syndrome, autism spectrum disorders, etc.; use of psychoactive substances by a child/adolescent; psychotherapy of a child/adolescent for more than 3 months.

At the first stage of the study, all persons were examined according to certain methods in accordance with the objectives of the study. In the second stage, the surveyed persons were randomized into two groups: main and comparative. The main group consisted of patients with AN receiving standard treatment and their parents or guardians, with subsequent involvement in the developed program of medical and psychological support and psychocorrection in the context of family relationships. The comparison group consisted of patients with AN, who also received standard treatment, but without the involvement of parents or guardians in the developed program of medical and psychological support and psychocorrection in the context of family relationships.

Results

In the pilot study, 12 patients with AN and 20 parents/guardians were examined according to the following methods: Mini-mental State Examination (MMSE), Minnesota Multiphasic Personality Inventory (MMPI), Family Adaptation and Cohesion Scale (FACES-III), Difficulties in Emotional Regulation (DERS) (Gratz & Roemer 2004), Toronto Alexithymia Scale, Adult Attachment Interview (AAI), Hospital Anxiety and Depression Scale (HADS), Chaban Quality of Life Scale (CQLS). Data from the pilot study were mostly collected online, as quarantine measures had been taken for COVID-19 at the time.

The pilot study found that most psychodiagnostic techniques provide a detailed description of family functioning and psychoemotional status of patients with AN and their parents/guardians, which allows assessing the effectiveness of the developed program of psychocorrection and prognostic value of psychoemotional changes. The MINI and MMPI methodologies proposed at the initial stage of the study planning were excluded from the list of methodologies because they do not provide enough data that can be used to achieve the objectives of the study and are quite time-consuming.

To determine the quantitative individual-personal and pathopsychological characteristics of the examined persons we selected the following psychodiagnostic complex: Family Adaptation and Cohesion Scale (FACES-III), Difficulties in Emotional Regulation (DERS), Toronto scale of alexithymia, Adult Attachment Interview (AAI), Hospital Anxiety and Depression Scale (HADS), Chaban Quality of Life Scale (CQLS).

The Family Adaptation and Cohesion Scale (FACES-III) was established by D. H. Olson, J. Portner, and Y. Lavee in 1985 and adapted by E. G. Eidemiller and co-authors in 2003. The basis of the method was the "circular model" of D. H. Olson, which contained the three most important parameters of family behavior: cohesion, adaptation, and communication. The FACES-III scale consists of 20 statements. The task of the surveyed (child/adolescent, parents/guardians) is to double-assess the statements on the severity of manifestations using a five-point scale of Likert: almost never - 1 point, rarely - 2 points, from time to time - 3 points, often - 4 points, almost always - 5 points. The first task assesses the real family functioning, the second - the ideal (i.e., the kind that the child/adolescent and parents/guardians would like to see). Determining the type of family structure is calculated by the number of points obtained by summing the even and odd statements.

The FACES-III scale has sufficient internal consistency, is a reliable and valid methodology. Interpretation and discussion of the obtained results with family members allow increasing their motivation for family psychotherapy, psychoeducation, and individual work. A "visual" demonstration, confirming the existence of violations in the family system, allows distributing the responsibility for the effectiveness of corrective measures among all family members.

The results of the pilot study showed in 84% of the subjects, both children/adolescents and parents/guardians, a low level of family cohesion and rigidity of the family system.

The DERS Difficulties in Emotional Regulation Scale (Gratz & Roemer 2004) is a self-report used to assess emotional regulation issues in adolescents and adults. DERS has six subscales, which consist of 5-8 questions (36 in total). The conceptual definition of emotional regulation, on which DERS is based, emphasizes the functionality of emotions and focuses on adaptive ways of regulating them during or after the distress, including (a) awareness, understanding, and acceptance of emotions; (b) the ability to control behavior while experiencing negative emotions; (c) flexible use of situation-appropriate strategies to modulate the intensity and/or duration of emotional reactions, rather than to completely eliminate emotions; and (d) a willingness to experience negative emotions as part of important and necessary life processes.

Scores are assessed separately by sub-scales and the total score: (1) rejection of emotional reactions (2) difficulties in goal-oriented behavior (3) difficulties in impulse management (4) lack of emotional awareness (5) limited access to emotion regulation strategies (6) lack of emotional clarity. The scale has good internal consistency. It is a reliable technique, and allows to identify the association between emotional dysregulation and symptoms of mental disorders, other emotionally related constructs, as well as allows to track the dynamics during therapy. However, for all the usefulness and informativeness of this scale, it has a significant inconvenience - time-consuming (on average, the study lasted 25 minutes).

The results of the study showed that 75% of children/adolescents had elevated rates on subscales: difficulty managing impulse, limited access to emotional regulation strategies, lack of emotional clarity. 70% of parents/guardians showed high scores on subscales: a rejection of emotional reactions, difficulty in managing impulse, limited access to emotion management strategies. We noted that the difficulties of impulse control were a common problem for the emotional regulation of all generations of subjects.

The Toronto Alexithymia Scale (TAS-26, G.J. Taylor, et al., 1985) was customized in Bekhterev Institute (2005) and is used to determine the level of alexithymia in adults. In the adapted version, the result of 62 points and below is considered normal, patients who scored 63 - 73 points are at risk, the result of 74 points and above - indicates the presence of alexithymia. The TAS-26 scale is internally consistent, reliable, valid, and sensitive to treatment. Translation and adaptation of the scale are available in Ukrainian.

The scale was applied to parents/guardians and showed the presence of alexithymia in 80% of the subjects, and 20% of the subjects were at risk according to the level of alexithymia. According to the Diagnostic Criteria for Psychosomatic Research (DCPR) [15] for alexithymia, the parents/guardians of children/adolescents with AN had the following characteristics of varying severity: inability/difficulty to use appropriate words to describe emotions; tendency to describe details instead of feelings (for example, the circumstances of an event, not feelings); unimaginativeness of everyday life; the predominant focus of thoughts on external events, rather than on emotions or fantasies; ignorance/lack of awareness of general somatic reactions associated with various feelings; outbreaks of affective behavior [16]. Thus, the difficulties of emotional regulation in parents/guardians determined by the DERS scale were confirmed by the results of the TAS-26 scale survey.

The Adult Attachment Interview (AAI, George, Kaplan & Main, 1984; DMM-AAI Crittenden & Landini, 2011), which we have also selected for the study, is a semi-structured 20-question interview designed to study perceptions of the child/adolescent about the commitment of adults to themselves (both the actual children/adolescents in relation to the actual family and retrospectively parents/guardians in relation to their parental families). The subjects had to describe their parents/guardians and their relationship with them; describe how parents usually reacted to stressful situations; describe possible cases of child abuse. The evaluation of the interview was formed on the basis of the nature of the story and the content of four independent subscales, namely:

  • Strong commitment: relationships with parents are valuable and influential. The story is consistent and not protective in nature.
  • Avoidance: memory gaps are observed during the interview, negative aspects are minimized. Discourse is defensive.
  • Anxiety: The story is incoherent, with angry or ambivalent perceptions of the past.
  • Unreliable attachment: describe traumatic events due to loss or abuse.

According to the results of the study, almost ½ (47%) of the subjects had an idea of ​​the unreliable attachment of adults (both in current families and retrospectively). More than 1/3 of the respondents (34%) demonstrated the significance of concerns about relationships in current or retrospectively in parental families. Protective discourse on commitment (a significant avoidance subscale) was found in 13% of respondents. Only 6% of those surveyed reported a strong attachment, mostly retrospectively in parental families. The obtained data require further verification on a larger contingent of different age categories.

The text of the questionnaire was used for the first time in the Ukrainian version. The pilot study revealed difficulties in understanding the separate items of the questionnaire and some inaccuracies in the translation. Further research is planned with the use of the final adapted Ukrainian version of the methodology with its additional verification in the Ukrainian population.

The Hospital Anxiety and Depression Scale (HADS) which is used in our study, and developed by A.S. Zigmond and R.P. Snaith, is a tool for diagnosing emotional states such as anxiety and depression, in adults. The scale contains 14 statements and two subscales: subscale A (anxiety), which includes odd statements 1, 3, 5, 7, 9, 11, 13; and subscale D (depression), which includes even statements 2, 4, 6, 8, 10, 12, 14. For each subscale, the assessment is conducted separately, the answer to each question is evaluated from 0 to 3. The minimum total score for each subscale is 0 (norm), maximum 21 b. (severe). Translation and adaptation of the scale are available in Ukrainian.

The scale was applied to parents/guardians and revealed a clinically significant level of anxiety (11 points or more) in 60% of subjects. Clinically significant indicators of depression (11 points or more) were found in 20% of adults. Thus, the presence of AN in a child/adolescent is associated primarily with the presence of anxiety in adult family members.

The Chaban Quality of Life Scale (CQLS), which was also used in the study, is a self-questionnaire developed by O.S. Chaban and co-authors (2016) for adults. It contains 10 questions about satisfaction with various aspects of life, each of which should be rated on an 11-point scale from 0 (not at all satisfied) to 10 (extremely satisfied). The number of points for each statement is summed and the total score is calculated. The minimum possible score is 0 points, the maximum possible is 100 points. The scale has 5 degrees of satisfaction with the quality of life: extremely low (0-56 points), low (57-66 points), medium (67-75 points), high (76-82 points), very high (83-100 points). It has good internal consistency (α = .905), reliability (r = .923), convergent and discriminant validity.

The scale was applied to parents/guardians: 75% of respondents reported a low quality of life, 20% - an average quality of life, 5% - high quality of life. Thus, the presence of a child/adolescent AN in 2/3 of cases is associated with a low quality of life of adult family members.

Further statistical processing of the obtained data of the dissertation research is carried out using the method of descriptive statistics (determination of mean and standard deviation at normal distribution of signs, median and interquartile range at the distribution of signs different from normal, minimum, and maximum values ​​of quantitative indicators). When evaluating qualitative features, the frequency % is calculated. The Shapiro-Wilk test was used to check the normality of the trait distribution. Spearman's rank correlation coefficient was used to study the relationship between the phenomena. Analysis of variance was used to study the variability of dependent variables under the influence of psychocorrection. In all cases of comparisons, the significance level (p-level) was determined, as p ≤ 0.05 is statistically significant. IBM SPSS Statistics Base v.22 was used in the analysis. In the pilot study, only the frequency of certain symptoms in % was calculated; other statistical data processing was not performed as the number of participants was limited.

Conclusions

The results of our research allow us to determine with sufficient probability the relationship between the occurrence of AN and the peculiarity of family functioning and the psycho-emotional status of parents or guardians. The selected set of research methods has confirmed its effectiveness, which makes it possible to extend it to the entire planned contingent of participants in the dissertation research.

Conflict of interests

The authors declare no conflict of interests.

Ethical aspects

The study was approved by the Commission on Bioethical Expertise and Research Ethics of the National Medical University named after O.O. Bogomolets (protocol №127 dated 02.12.2019).

Connection with scientific programs

The study is performed within the research work of the Department of Medical Psychology, Psychosomatic Medicine and Psychotherapy of the National Medical University named after O.O. Bogomolets "Dynamic biopsychosocial model of medical and psychological care (diagnosis, therapy, rehabilitation, prevention) of patients of multidisciplinary hospitals in a rapidly changing associative-crisis society" (registration №0119U103910).

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How to Cite

1.
Sak Л. Modern approaches to the examination of patients with anorexia nervosa. PMGP [Internet]. 2020 Oct. 11 [cited 2024 Mar. 29];5(4):e0504270. Available from: https://e-medjournal.com/index.php/psp/article/view/270