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INDEX
1. Abstract _______________________________________________________________2
2. Background ____________________________________________________________4
2.1. Definitions………4
2.2. EDs and co-morbidity………...7
2.3. Anorexia and Epidemiology ………9
2.4. Models of treatment ………...11
2.5. Problems in treatment of DCA patients………..16
3. Experimental Part ______________________________________________________18 3.1. Objective, research query and experimental design………...18
3.2. Materials and Methods………...18
3.2.1. Sample………..18 3.2.2. Measures………...19 3.2.3. Method………..21 3.3. Results____________________________________________________________22 3.3.1. Changes T1-T2……….22 3.3.2. Pearson’s correlations………...22
3.3.3. Correlations among trends T1-T2……….25
3.4. Discussion_________________________________________________________26
3.5. Conclusions________________________________________________________30
4. Figures_______________________________________________________________32
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ABSTRACT
Objective
Evaluate the entity of changes in a group of patients affected by anorexia nervosa restrictive subtype, consecutively admitted between 2011 and 2013 at ED’s unit of O.U. 3 of IRCCS Stella Maris Foundation, and insert in a group of rehabilitative treatment for 9 months.
Method
Sample consists of 20 subjects (18 females and 2 males).
The measures of assessment for the initial evaluation used in this study are: self-assessment questionnaires EDI-3 e YSR, parent’s CBCL and K-SADS administered by clinician with the aim of co-morbidity evaluation. Among all internistic parameters will be used BMI as index for somatic changes.
At the initial Kiddie-SADS assessment appears co-morbidity of mood disorders and anxiety disorders.
It’s been performed a T-Test of Student statistical analysis for paired samples, with the aim to individuate significant difference between scores obtained from T1 and T2 questionnaires. They’re been performed Pearson correlation between scores. For data analyses it’s been used SPSS for Windows.
Results
The comparison between evaluations on T1 and T2 shows changes both for BMI both for other measures used. About BMI, we have noted a significant enhancement among avarage value of BMI evaluated at onset of treatment (15,25) and average value at the end (17,94). We have found statistically significant enhancement in the sub-scales Drive to Thinness, Eating Disorder General Risk, Maturity Fear of’EDI-3 in the scale Somatic complaints in father’s CBCL. Statistically significant worsening appears in the scales Activities in YSR, Social and Total Competence in father’s CBCL, Social Competence and Attention Problems in mother’s At Analysis of correlations about parameters above-mentioned, we have observed statistically significant correlations both on T1 both on T2 .
In our study, we noticed that the entity of drive for thinness at T1 is significantly related with over controlling features (perfectionism tendency and ascetism) of subjects both at the begin that at the end of the treatment, and the improvement of drive for thinness noticed at T2 it’s strictly related also with the significant decrease of somatic complaints as referred by the fathers. Another important data concern the fact that the increase of BMI results strictly predictive for ineffectiveness. Parent refer a greater tendency of their children to social withdrawal (social groups, meet with friends, general behavior with friend and parent).
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Conclusions
In our group of patients there’s an improvement of the disease insight and of the motivation to recovery, as shown by the acceptance at nutritional program and by the consecutive increase of weight in the course of treatment itself. We observed a decrease of the adaptive function assumed by anorexia nervosa: the strong need to control and avoid of every forms of emotion (in particular the negative ones).
We noticed a worsening of the aspects of ineffectiveness, insecurity, emotional and
behavioral instability, distrust in personal relations. These features not only are indicative for a huge difficulty of these patients in communication and ability to create attachment bonds, but also revealed typical problems of adolescence’s developmental junction.
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Background
1) Definitions
Eating disorders are characterized by altered relations with food and with own body, in a way that become compromising for quality of life and social relationship (Luxardi e Ostuzzi, 2003).
An abnormal evaluation of oneself body and its dimensions could lead at a sensation of inappropriateness and dissatisfaction that could have a strong influence in own self-esteem. During developmental the body dimension acquire for the adolescent a central role in the pairs group, as tool for communication, approval, identification, acceptation within the group itself and mirror for own evaluation and so for possible problematic and
psychopathologic paths.
In this setting insert eating disorders (EDs) itself, that seems related with adolescence and familiar and generational conflicts and with lack of interpersonal communication.
Relation with food become ambivalent, made of desire and reject, and is invested of emotional valences, connected with adolescent’s internal world and with his/her relational manners with environmental factors around.
The multiform nature of EDs, in which psychological features mix up with physical and behavioral symptoms, have lead a great number of researchers and clinicians to question own selves about which could be the critical parameters to do a correct diagnosis.
By now, the nosographyc field of psychopathology of feeding, use as systems of psychiatric classification, DSM 5 and ICD-10, International Classification of Desease, that define the diagnostic criteria for the discrimination between different disease.
The more typical forms of Eating Disorders are Anorexia Nervosa (AN) and Bulimia Nervosa (BN); next to these forms we find Eating Not Otherwise Specified (EDNOS). Feeding and Eating Disorders diagnosed for the first time in youth or early childhood (e.g. Rumination disorder in early childhood, Pica, Eating disorders of childhood or early childhood)
are parts of Feeding and Eating Disease of fanno parte della sezione Disturbi della
Nutrizione e dell’Alimentazione dell’Infanzia o della Prima Fanciullezza, che, nel DSM-V viene definito Disturbo dell’Assunzione di Cibo Evitante/Restrittivo (vedi Tab 1)
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Anorexia Nervosa is a complex and multiform disease, characterized by a significant loss of weight in consequence of abnormal eating behaviors, pathological worries for weight and body forms, disperception and difficulties in auto and hetero physical perception.
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Furthermore, there’re alterations of neuroendocrinological features (amenorrhea or delay of pubertal events sequences) when the onset of the disease take place in pre-puberal age, with a consequential stop of development; alterations of hypothalamic termoregulation, hormonal alteration (decrease of basal gonadotropinic levels and decreased LH reaction at
stimulation’s tests, decreased TSH reaction to TRH and decrease of T3 and IGF-1; increase of cortisol and GH strictly related to caloric restrictions, that quickly normalized theirs levels within the ingestion of caloric foods) and alterations of neurotransmitters (dopamine,
serotonin, norepinefrine that change within loss of weight).
Furthermore, between 31% and 80% of AN patients shows excessive levels of physical activity (motorrhea or hyper-exercise), that become compulsive if associated with subjective sensation of necessity or impulse towards her, with characteristics of priority on other tasks and hobbies (e.g. scholastic or recreational ones). Hyperactivity have function of controller of weight and body forms, it’s use to burn calories or caloric excess, or eventually to modulator of emotive states.
The physical exercise addiction strengthens EDs’ psychopathology because it incentivizes obsessive traits toward body weight and form, reinforce caloric restriction and increase social impairment of patients.
Other negative consequences of high levels of physical activity are a major risk of injury, fractures and cardiac events. Furthermore, the available studies on this argument suggest that excessive and compulsive physical activity could predict a worse prognostic clinical course because of the more prolonged hospitalization, insufficient answer to treatment and a major risk of physical and psychiatric complications and of chronicizzation.
Hyperactivity is often associated with early onset forms of AN, usually neglected by patient, difficult to restrain without a strict behavioral control and so could represent a significant feature of interference for treatment compliance.
This is the psychiatric disease associated with the higher mortality rate, consequence both of multiple internistic complications (predominantly the endocrine and cardiologic ones) both of psychiatric co-morbidity.
The Standardized Mortality Ratio (SRM) for anorexia nervosa is 5.9, as recently published meta-analyses showed . Severe somatic complications related to poor outcome of anorexia nervosa (eg. osteoporosis, renal insufficiency) have been observed in the long-term course. These somatic complications result from the anorexia inherent symptoms, such as permanent underweight, amenorrhea or purging behaviors.
Furthermore the DSM 5 identifies two subgroup of Anorexia Nervosa: Restrictive type and Binging/Purging type.
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Anorexia Nervosa Restrictive type is characterized by a decrease of weight because of dieting behavior, starving, physical exercise: there’s so a strong control of food introduction, without compulsive binges or purging behavior (vomiting or lassative use) during the last three month of life. Binging/Purging type of AN instead present in the last three month crises of binges, compulsive episodes towards food which take place consequently food restriction and could lead the subject at a loose of control toward food and toward binging behavior; there’re possible to follow further elimination behaviors, in other words purging behaviors used as compensations tools, eg self induced throw up or laxatives, diuretics and enemas use.
In several cases purging behaviors are actuated also for the ingestion of little amount of food, in absence of bulimic crises.
2) EDs and co-morbidity
Anorexia nervosa has high rates of co-morbidity with other psychiatric disorders, especially major depressive and anxiety disorder. Indeed, several studies have found that major
depressive disorder is the most common co-morbid diagnosis in these patients (Herzog et al., 1992; Kaye, 2008), with lifetime rates ranging between 50% and 75% (American Psychiatric Association, 2006). In the existing literature, clinical depression has been linked with worse anorexia nervosa outcome (Lowe et al., 2001), higher rates of suicide attempt (Bulik et al., 2008; Franko et al., 2004) and suicide- related mortality (Crow et al., 2009).
In anamnesis it’s often referred the presence of affective and anxious diseases preceding the onset of symptoms related with EDs (American Academy of Pediatrics, 2010; Dalle Grave, 2011; Dalla Ragione, 2012).
It is important to understand whether such depressive and anxiety symptoms are ascribable to coexisting clinical depression that could predispose to eating disorder, or whether they are caused by malnutrition interacting with the eating disorder psychopathology. If depressive symptoms are an integral part of anorexia nervosa, co-morbid affective disorders like major depression might facilitate a switching between clinical phenotypes. Psychiatric
co-morbidities have been shown to be linked to increased symptom severity, and thus affect outcome.
Temperament dimensions, mainly Harm Avoidance (HA) and Novelty Seeking (NS), had an effect on the level of depressed mood at the beginning. Depression or anxiety in EDs is a symptom associated with temperamental traits and consequently with serotonergic (Harm Avoidance) or dopaminergic dysfunction (Novelty Seeking). Interestingly, these effects were
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mediated by the feeling of ineffectiveness, very common in EDs, and by the problem with impulse control as measured by the EDI.
The association of HA and NS with the initial level of depression and the mediating effect of Ineffectiveness suggest that, in the therapeutic program for patients with EDs, it is critical to enhance self-esteem, independence and effectiveness.
In a study by Tozzi and colleagues, certain co-morbidities have been elucidated to play a role in the diagnostic crossover from AN to BN and from BN to AN. Patients with instable ED diagnoses had lifetime more frequently than patients with stable ED diagnoses. While the presence of psychiatric comorbidities are linked to ED symptom severity, personality dysfunction co-morbidities in particular may affect diagnostic crossover within ED. The relationship between diagnostic crossover and ED outcome remains unclear.
Depressive symptoms and personality disorders may trigger ED symptom fluctuations. Interestingly, a role of major depression in body weight instability and abnormal food intake has been evidenced. Anxiety disorders are very common in ED patients, but the role of anxiety disorders on the diagnostic instability is still unclear.
Comparing pre-puberal with post-puberal groups, no statistically significant differences are found, both in the clinical features of the eating disorder and in the associated
psychopathological characteristics, in particular in the mood and anxiety symptoms.
Cooper and al.’s study confirm such considerations, pointing out that in a third of early onset AN patients it’s demonstrable the presence of a depressive disorder and that in 75% of cases the onset of Eating Disorders proceeded the onset of mood disorder itself.
Nevertheless we may observe that with the progression of pubertal development and
probably, with increased illness awareness, there appear more dissatisfaction with one’s own body and weight, as well as important depressive symptoms and suicidal thoughts. On the other hand, in the pre-puberal group there is a discrepancy between the evaluation by the parents (CBCL) and self-evaluation by the adolescent (YSR); this could be related to the low awareness of the younger girls’ emotional distress associated to the eating disorder.
As far as concern the co-morbidity of anxious symptomatology, the Generalized Anxious Disorder (GAD) seems to be the more represented, both in pre-puberal subjects that in the post-puberal ones; immediately after in prevalence order, it’s present the Separation Anxious Disorder (SAD), more frequent in pre-puberal age. The other anxious disorders seems to be more uncommon that the previously nominated. It’s possible that the presence of obsessive-compulsive disorders is significantly associated with a longer duration of the ED. Some studies underline the important role of obsessive-compulsive traits for the course of ED. Anderluh and colleagues reported retrospectively that obsessive-compulsive traits in childhood were linked to a longer duration of underweight status, longer episodes of severe
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food restriction, and shorter duration of binge eating. It is possible that rigidity (as obsessive-compulsive disorder or as trait) may contribute to an increased fixation of the ED symptoms and, thereby, reduced diagnostic instability.
The co-morbidity with Personality Disorders (PD) is, according to some authors, more common between ED patients that all the other diagnosis od psychiatric diseases of Axis I (Bornstein, 2001; Grilo et al., 2003).
Several past studies showed the presence of pre-morbid conditions and temperamental tendencies that, when accentuated in familiar conditions, could promote, in adolescence, the crystallizations of typical traits of personality, as the perfectionism, the obsessivity, the rigidity, that could be precluding for co-morbidity, in other words Personality Disorders (PD) (Costa e Montecchi 1996; Caretti et al., 2000). Personality dysfunctions possibly result in greater emotional impairment, increased rates of suicidal features, higher family
dysfunction and frequent hospitalizations.
Other typical traits of AN subjects, in common with PD, concern the low compliance to the first visit, the “non search” for help with the personal conviction to make it by oneself, the little or null insight, the opposition to the constituted authority, the wrong perception of reality, the opposition toward therapies, the tendencies to ascetism and to idealization, that often express their self with a pronounced sense of justice (Costa et al., 2009).
3) Anorexia and Epidemiology
Epidemiologic data shows that the major risks concern all the socio-economic categories and all the ethnical and cultural groups. Anorexia Nervosa in the past seemed to prefer the upper-middle social class, but during the last three decades all the eating disorders had a fair re-distribution, in all the different social grades, hitting the more those families where it’s predominant the tension towards a social improvement.
EDs are frequent in all industrialized countries, their incidence grow up with economic development and cultural westernization.
Cultural norms of thinness and weight control are accepted in their excess in a so diffuse way that attitudes and behaviors required for ED’s diagnosis are not see by people as infrequent or pathologic. Their diffusion in East Europe, in the Third World and between immigrants from poor nations in rich ones, seems to be related to the economic conditions improvement and, more of that, to the process of acquirement of western cultural models. The sex more involved in this disease is the female’s one, although during the last years had suffer an improvement of cases between male sex’s subjects.
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Female/male rate of cases is 15:1 in AN, 30:1 in BN, 3:2 in EDNOS. However, the
prevalence between the two genders change in relation with age: pre-puberty or first phases of puberty 1:1, middle-adolescence 1:10, late adolescence or early adulthood 1:20 (Gonzales et al., 2007). The age of onset falls generally between 10 and 30 years: the medium age of onset is 16/17 years both for AN that for BN, with a peak of onsets between 12 and 17 years. BED usually present a more tardive age of onset. Recent studies on general population indicate an higher frequency for AN in male patients when compared to previous researches (Hudson et al.,2007; Raevuori et al., 2009, American Academy of pediatrics, 2010; Dalla Ragione, 2012).
We’re now attending to a drop of age of onset of anorexia: studies regard the 8-14 years’ age group show an elevated presence of abnormal eating behavior since very premature ages, as much as at today are more and more recurring diagnosis at pre-menarche age up to girls of 8-9 years’ cases.
In industrialized countries, including Italy, every 100 girls in risk range of years (12-25 years), suffer of some eating behaviors disturbs: 1-2 in serious clinical forms of the disease (anorexia and bulimia), but the other ones are equally affected even if in lighter and often transient forms of partial disease. The 25% of preschoolers have an ED.
EDs, as a whole, represent a serious problem, spread out especially between adolescents and young women, constantly increasing because of the increase of incidence of less severe (EDNOS).
Between young women, prevalence of bulimia (1-3%) is higher than anorexia’s one (0,5-1%). EDNOS, that’re represented in particular among adolescent and young adult female, have a prevalence of 6-8% (Sigel, 2008; American Academy of pediatrics, 2010, Watson et al., 2012).
BED in general population have a prevalence of 0,7 and 4,6. Lifetime prevalence of >18 years old subjects, is in female 0,9% for AN; 1,5 for BN; 3,5 for BED. Among male gender, they are 0,3%- 0,5% e 2% (Hudson et al., 2007).
Incidence for AN in female gender seems to be about 8 cases for 100.000; for BN the number of cases is about 12 for 100.000.
Several cases report a little decrease of BN incidence during last years (Currin et al., 2005); otherwise for AN it seems to be stable.
The number of cases that comes to clinical observation is about 40-50% for AN; 11-40% for BN. A huge number of these cases reach clinicians after a long duration of untreated disease (DUP): for AN is 39 months; for BN is about 56 months.
Recent assessments indicate that about the 50% of cases of anorexia nervosa could remain un-diagnosticated, because of screening and valuation tools not yet totally perceptible and
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because of the diagnostic difficulty based on the poor insight, as well as negation and treatment refusal features that are characterizing for every ED.
4) Models of treatment
Treatment of EDs patients’ needs a multidisciplinary team able to deal in a multidimensional way the complexity of these diseases, that involves both psychiatric and behavioral and somatic set of problems (Nicholls et al, 2011; Dalla Ragione, 2012).
The care provider equipe must to be composed by childhood neuropsychiatrists/psychiatrists, pediatricians/internists, psychologists, nutritionist, nurses, but can be integrated with
different “external” specialists according to the single patient needs (eg. Cardiologist) and also non-health figures (eg. Educators, ballet masters or handcraft experts etc) (NICE 2004; Sigel, 2008; American Academy of Pediatrics, 2010, Nicholls et al., 2011; Della Ragione, 2012).
The care provider team must reinforce in every single patients the attitude at elaborating a coherent and shared project, which could reinstate the serious tendency to scission operating in these subjects mind and body. This is an extremely important factor even from a
prognostic point of view, because relapsing is more frequent if patient is been treated in a generic ward rather a EDs’ specialized centre (Keel & Brown, 2010).
During pediatric age, another fundamental factor to look for concerns the patient’s family, that had to be involved in cure’s path to support parents to transform the heavy conflict with their daughter, of which feeding refusal is the epiphenomenon, in flexibility and renovated ability to negotiation (Nicholls et al., 2011).
One common goal of treatment for AN is weight restoration or ’refeeding’, with treatment typically beginning with nutritional rehabilitation (Fairburn 2003). In addition, a range of psychological
and pharmacological therapies have been employed to augment, or follow, the refeeding phase. There are three principal phases to the treatment process. In the first phase, there are Educational interventions (for example, nutritional interventionsand dietetics), in which the principal focus is on refeeding and weight gain. This is achieved by placing responsibility for the child’s eating patterns in the hands of the parents and emphasising the adolescent’s inability to control his or her eating patterns due to the effects of starvation. The second phase focuses on problem-solving regarding family and psychological issues that interfere with refeeding. Psychological interventions are, for example, cognitive behavioral therapy and its derivatives, cognitive analytical therapy, interpersonal therapy, supportive therapy, psychodynamic therapy, play therapy, other). The final phase centers around more general
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family and psychological issues, particularly those related to increasing autonomy for the adolescent and family boundaries.
This is generally achieved through working with the adolescent and family members in joint family therapy sessions. Several recent reviews found little evidence to support the efficacy of any specific psychological interventions, including cognitive behavioral therapy,
interpersonal therapy, cognitive analytic therapy, behavioral therapy, or psychodynamic therapy, for patients with AN(Bulik 2007;Hay 2003; le Grange 1992). Nevertheless, specific types of psychological intervention may be effective in specific populations, for example, cognitive behavioral therapy may reduce relapse rates in adults who have already achieved restoration of a normal body weight
(Bulik 2007), while family therapies may be effective in treating adolescents with the disorder (Bulik 2007; le Grange 2005).
The main types of family therapy considered were: 1. Structural family therapy
2. Systems family therapy 3. Strategic family therapy
4. Family based therapy and its variants (including short term, long term, and separated) and
behavioral family systems therapy (these two therapies were grouped together, given the
similarity of approach)
Behavioral family systems therapy, has a number of similarities with the family based
therapy; also has three stages to treatment, which are highly similar in nature to those utilized in family based therapy (Robin 1994; Robin 1995; Ball 2004). The major principles of this therapy includethe acknowledgment that the adolescent lacks control over their weight and eating habits, work to address cognitive distortions andproblems with the family structure, as well as work to overcomecognitive distortions of the patient, and in later stages, to promote autonomy (Robin 1994; Robin 1995).
The focus of structural family therapy (Liebman 1974; Minuchin 1978) centers on individual physiological vulnerability, dysfunctionaltransactional styles, and the role the sick child plays in facilitatingconflict avoidance. A second approach, derived from structural therapy, is systems therapy, including Milan and Post-Milanfamily therapy. This approach attempts to elicit changes in thefamily dynamic by presenting information that encourages familymembers to reflect on their own behavior within the familydynamic (Selvini 1978). In these approaches the family is not
included in the therapy process until after weight restoration has been achieved (Selvini 1978; Minuchin 1978).
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Rather than considering the impact of the family dynamic on the onset of the illness,
strategic family therapy acknowledges the effect of the illness on all family members and
focuses on inducing change in the eating disorder symptoms. This is often achieved through highlighting paradoxical intentions of family members (Madanes 1981). Like strategic family therapy, the Maudsley model, termed family based therapy, disregards the notion that the family dynamic is a direct causative agent in the pathogenesis of the disorder (Lock 2005). It emphasises behavioral recovery, rather than insight or understanding, and empowers family members to support the recovery of their child in the home setting. Families are helped tomanage the eating behaviors of their child by providing education about AN, encouraging parents to generate strategies for increasing food intake and limiting physical activity. Emphasis is also placed on applying these strategies consistently and calmly (Dare 1997; le Grange 1992).
A recent narrative review suggested that family therapy may be effective at increasing weight and improving psychological functioning in younger, non-chronic individuals with AN (Bulik 2007).
It is important to determine whether family involvement in therapy, of any description, is beneficial to those with AN and what effect this involvement might have. There remain issues that need
to be addressed, including determining the efficacy of different models of family therapy and understanding the impact of age and chronicity on outcome, and emergent characterological traits.
These issues would be best investigated in a systematic review and meta-analysis of all the relevant studies in this area.
Although there are a number of different forms of family therapy, it seems that the therapy most often tested in trials is family based therapy. There is some evidence to suggest that family therapy may be effective compared to treatment as usual in the short term.
However, there is not enough evidence to determine whether family therapy is effective compared to other psychological interventions for rates of remission. There is no differences in relapse rates, symptom scores, weight measures, or the number of drop outs between those treated with family therapy versus any other comparison group. Mortality was not measured or reported sufficiently to determine whether it is reduced for those treated with family therapy compared to other interventions. There were very little data about general or family functioning.
There was some evidence in the trial by Russell 1987that family therapy may be more effective than individual supportive therapy in patients with a shorter duration of illness in terms of remission, cognitive distortion and weight.
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Longer is time among onset of DCA and treatment, worse are prognostic results (Keel & Brown, 2010). Pharmacological therapy has limited indications evidence based and it could not been used at onset or as monotherapy (Watson & Bulik, 2012). So, the use of
psychotherapy should be evaluated case by case, considering the experience of therapeutic
equipe and associated comorbidithies. At now there aren’t in Italy specific medicines for
AN.
There is a lack of evidence to support the use of antidepressant (Claudino 2006) or antipsychotic (Court 2008) medication in AN.
Cognitive behavioral theorists are also of the opinion that clinical depression should be treated with full-dose antidepressants prior to launching the psychological treatment
(Fairburn et al., 2008). However, some clinicians have suggested that it is, instead, preferable to focus initially on the treatment of eating disorders, the goal being to normalize weight and food intake before assessing and prescribing any treatment for co-existing psychiatric disorders (Garner, 1993; Mattar et al., 2012). The rationale behind this recommendation is based on the observation that many of the symptoms postulated to be a sign of psychiatric co-morbidity, including clinical depression, may actually result from low bodyweight and calorie restriction (American Psychiatric Association, 2006). It has been shown that treatment of eating disorder psychopathology with cognitive behavioral procedures and strategies produces a lasting improvement in both eating disorder psychopathology and depressive symptoms without needing to resort to psychopharmacological intervention or to postpone treatment until the mood has been stabilized.
It may be that inpatient CBT exerts a direct effect on the depression scores by normalizing the weight and eating habits, improving the socialization, and reducing the over- evaluation of shape and weight, which are specific targets of the intervention.
It may also be that the program has an indirect effect on depressive symptoms by improving eating disorder psychopathology, which in turn may increase the feeling of self-efficacy and hope. Third, it is possible that the procedures and strategies addressing mood intolerance included in the “enhanced” CBT protocol may have a positive effect on depressive symptoms. Finally, the improvement of depressive symptoms without the aid of specific psychotherapy for depression and antidepressant medications may be the direct result of weight restoration, rather than specific CBT procedures and strategies.
Pharmacotherapy is used in more resistant type and in those associated to psychiatric disorders. In particolar, fluoxetine is used after acute phase, when patients put on weight but they have difficulties to preserve their new BMI and/or there are depressive, anxious, obsessive symptoms.
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Fluoxetine is more effective for obsessive ideation than ritualistic behavior in anorexia nervosa. After weight gain and physical anhancement, fluoxetine it could be effective for reduce long term relaps. In patients partially responsive to other treatment and with more dispercettive symptomatology and/or hyperactivity, olanzapine could be effective to augment appetence and weight gain.
In binge/purge subtype first election medicines are SSRI (fluoxetine, sertraline,
fluvoxamine), that are used for almost 4-6 weeks and they could reduce frequency of binge episodies.
Some guidelines (NICE, 2004) show that ambulatorial livel is more appropriate as treatment setting. In early childood there is a greater risk for complicances and it is necessary to recover the patient in hospital. (Nicholls et al., 2011); in table V there are criteria for hospedalization (Bertelloni et al., 2010; Nicholls et al., 2011). It is important to remember that AN is psychiatric disorder associated to more frequent risk for suicide (Arcelus et al., 2011).
Table V.
Anorexia nervosa: indications for hospedalization.
Parametro
Criteri medici Criteri psichiatrici
Frequenza cardiaca: Sintomatica o < 50 Ideazioni suicide Pressione arteriosa: < 80/50 (o ipotensione posturale)* Incapacita ad un’alimentazione autonoma per via orale
Ipoglicemia: Sintomatica o <54 Co-morbilita psichiatrica severa
Potassiemia: ridotta (<3 mEq/L) Problematiche familiari gravi (es. abusi)
Fosfatemia ridotta Scarsa adesione al trattamento ambulatoriale o insuccesso
Temperatur: Ipotermia Peso: Rapido decremento° o mancato incremento(in trattamento domiciliare)
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5) Problems in treatment of DCA patients
Resistance to treatment and reluctance to recovery represent key-problems in the treatment of individuals affected by AN. In fact, in AN willingness to improve is one of several factors required to achieve recovery, but patients’ apparent strong wish for treatment often not resulting in any improvement because of the profound resistance related to the distress triggered by changing, which is a allmark of Eating Disoreders. Patients are reluctant and ambivalent about changing and they can unconsciously oppose a strong resistance to their therapist’ efforts towards improvement. Reluctance to recover is sustained by ego-syntonic symptoms that reinforce the illness, and relaps is common also because patients often perceive consequences of AN as positive and adaptive.
Eating psychopatology is underpinned by several entangled biopsychosocial elements, personality, general psychopatology, low self-esteem and mood intolerance, perfectionism, body experiences, interpersonal relationships, cognitive inflexibility and avoidance of experience and emotion, poor problem solving abilities, scarce social support and reduced relational abilities, environment and treatment itself, that may have a role in both increasing and lowering patients’ willingness to recover. Patients themselves often describe AN as a means of obtaining identity, avoiding negative emotions, and satisfying a strong need for control.
To earn a resistant patient’s trust it is first necessary to recognize the defensive nature of the eating disorder symptoms being also aware of their adaptive function to achieve the
mitigation of a profound distress. Hidden by the hyper control of body and food, the main elements are demoralization, anger, low self-esteem and a great hunger of approval and reassurance.
The peculiar defense mechanisms AN, denial and intellectualization, can become resistance to treatment when patients are asked to face both changes and negative effect.
Many studies have highlighted how insight, motivation to change and subjective meaning of the illness can be useful tools to manage the resistance to treatment.
The combination of mature and immature defense mechanisms and the lack of insight of illness maintains the disorder. In fact, the majority of treatment resistant patients show a clear denial of illness rather than scarce insight.
Some authors support that duration of illness correlates with greater insight rather than with a more severe disorder.
The restricting AN subtype is strongly characterized by lack of insight of illness that correlates with cognitive flexibility.
BN patients are usually more motivated to seek treatment and change than both AB and sub threshold AN individuals, mostly if chronic. Denial of illness is an intrinsic factor of the first
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phases of AN and the improvement of insight of illness could be an index of a good
therapeutic alliance. It is likely that denial of illness is both a psychosis-like symptom and a rigid and disadaptive defense mechanism helping patients to protect themselves by anxiety and depression and to avoid treatment or negative emotions. In sum, denial of illness correlates with the phenomenon of treatment resistance.
A longer duration of illness, index of poor motivation to change, is a negative prognostic factor in AN.
A lower motivation to change was found to correlate with lower BMI, lower compliance to dietary recommendation and slow weight gain, pathology-full diagnosis, purging behaviors, and worse quality of life. Two studies indicated that the rapidity of weight restoration is the only significant prognostic factor over the short and medium term and can indirectly point out an anhanced motivation to treatment.
Maintaining factor for AN are AD-specific factors (thoughts about eating, weight, body shape, hyperactivity) and non ED-specific factors like low self-esteem, interpersonal
problems, emotional intolerance, perfectionism, cognitive rigidity, inadequacy, high ascetism and matutity fear, impulsivity, sexual problems). Several studies consider personality
disorder as ED maintining factors.
Moreover, willingness to recover or the ability to recognize the negative effects of illness can be confused with motivation to change and this misinterpretation could lead therapist to enhance resistance throught its underestimation.
Resistance to treatment should be considered within the therapist patient interaction
involving on one hand patients’ and illness features and on the other therapist related factors and their interaction.
In this interaction it is crucial for the therapist to achieve a firm empathy because an
empathic understanding of the patient is not enough; firm boundaries are of vital importance to counterbalance empathy in the therapeutic relationship. The treatment enables patients to perceive their therapist as both holding and handling their self-harming attempts. This balance between the two elements, firmness and empathy, can promote changes in patients personality and coping through interiorization. Certain pathological behaviors should not be allowed or clearly prohibited.
Therapist may also incur the risk to consider only patients conscious meanings of illness and to underestimate those inconscious, deeper and even more distressing. In this sense,
conscious meaning can over the long hide useful elements in treatment and therefore contributing to treatment resistance.
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Experimental Part
1) Objective, research query and experimental design
The aim of this study is to evaluate the entity of changes in a group of patients affected by anorexia nervosa restrictive subtype, insert in a group of rehabilitative treatment for 9 months. The research query concerns the identification of more sensitive changing areas and more resilience areas, during the disease evolution.
In particular will be analyzed if improvement of BMI will be related with:
1. an improvement of psychopathological and of ED’s risk evaluation indexes in the questionnaires administer to patients;
2. an improvement of parent’s CBCL investigated areas
3. an improvement of patients self-awareness level and self-perception of the eating disorder itself (insight) in self-assessment questionnaires.
The study is an analytical observational study, with an inception cohort without a parallel cohort.
2) Materials and Methods
1) Sample
The studied population were select among all patients consecutively admitted between 2011 and 2013 at ED’s unit of O.U. 3 of IRCCS Stella Maris Foundation – Scientific Institute for Childhood and Adolescence Neuropsychiatry (Pisa), having a diagnosis of ANR according to DSM-5, complete and partial form.
Exclusion criteria were the presence of psychotic symptoms, IQ<80 at the Wechsler Full Scale, the presence of internistic symptoms not Ed’s related, and recurring or prior episodes of substance abuse. We excluded also ED’s forms like Bulimia Nervosa (BN) and Binge Eating Disorder (BED) because poorly represented in our clinical records.
20 subjects (18 females and 2 males) were studied, with a co-morbidity of mood disorder at the initial Kiddie-SADS assessment: 11 subjects had a Major Depressive Disorder (MDD), 3 had a Minor Depressive Disorder (mDD) and 6 had a Dysthymic Disorder (DD). As far as concern Anxiety Disorders, 8 patients of the group fulfil criteria of Generalized Anxiety Disorder (GAD) and 6 show symptoms of Social Phobia.
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Later Kiddie-SADS evaluation, assessed after 9 months, appears a significant global
improvement of anxious-depressive symptomatology; in particular, only 3 subjects still show a Major Depressive Disorder (MDD), 1 a Minor Depressive Disorder (mDD) and 5 a
Dysthymic Disorder (DD), whereas a Generalized Anxiety Disorder (GAD) persist in 4 subjects, and social phobic aspects last in 5 patients.
2) Measures
Among all the measures of assessment for the initial evaluation will be used in this study: self-assessment questionnaires EDI-3 e YSR, parent’s CBCL and K-SADS administered by clinician with the aim of co-morbidity evaluation. Among all internistic parameters will be used BMI as index for somatic changes.
Child Behavior Checklist (CBCL)
Parent’s fill up questionnaire, that allow the evaluation of social competence, behavioral characteristic and emotional problems in children and adolescents between 6 and 18 years old, by attributing a score (0-2) to a 118 items series.
Emotional-behavioral problems are evaluated by:
“Empirically Based Syndromes” Scales, that could give indications about different syndromic medical case (Anxiety/Depressed, Withdrawn/Depressed, Somatic Complaints; Social Problems; Through Problems; Attention Problems, Rule-breaking Behavior, Aggressive Behavior) and define two groups with a broad spectrum symptoms defined Internalizing (In) and Externalizing (Ex). “DSM-oriented” Scales, that could guide the clinician throw which diagnosis
formulate according to DSM-4-TR criteria, defining eight syndromes (Affective Problems-Dysthymia + Major Depressive Disorders, Anxiety Problems-GAD + SAD + Phobia, Somatic Problems-Somatization and Somatoform Disorders; Attention Deficit/Hyperactivity Problems; Oppositional Defiant Problems; Conduct Problem; Pervasive Development Disorders.
Behavioral scales allow the evaluation of a total score, with the presence of a internalizing score that concern emotive disorder characterized by inhibition and over control, whereas externalizing score suggest the presence of attention problems, oppositional problems, antisocial problems and aggressive problems. A cut-off of 70 is defined to discern clinic case from non-clinic ones.
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Literature reported a good reliability and validity for each of these two scales.
Only 2 symptoms of anorexia nervosa are included in CBCL (n. 24 Doesn’t eat well; n.53 Eat too much) but aren’t included in neither models, internalizing or externalizing scales.
Youth Self Report (YSR)
Self-assessment questionnaire for the evaluation of behavioral and emotional functioning of 11-18 years old adolescents.
It’s formed of 2 sub-areas: the first one formed of 20 items that investigate subject’s participation at sport, hobbies, games, activities, courses, group’s relations, and the second one formed of 112 items splitted in 8 sub-scales evaluating the presence of somatic
complaints, anxious and depressive symptoms, social problems, through problems, attention problems, aggressive and delinquent behaviors.
The first 3 sub-scales are named “internalizing”, the following 2 are named “externalizing” and the remaining other neither internalizing nor externalizing. The period of evaluations involve present time and the last 6 months both for CBCL that for YSR.
Eating Disorder Inventory – 3 (EDI-3)
EDI-3 is a self-assessment questionnaire for clinical evaluation of symptomatology associated with eating disorders. It’s organized in 12 primary scales. 3 eating-disorder specific (Drive for Thinness, Bulimia and Body Dissatisfaction) and 9 general psychological constructs (Low Self-Esteem, Personal Alienation, Interpersonal Insecurity, Interpersonal Alienation, Interoceptive Deficits, Emotional Dysregulation, Perfectionism, Asceticism, and Maturity Fears).
Developed to assessment of symptoms and psychopathological features typical for eating disorders in subjects from 11 to 53 years old, this test supply a specific score of eating disorder risk (EDRC: Eating Disorder Risk Composite score), 4 specific psychological integrative scores (Ineffectiveness, Interpersonal Problems, Affective Problems,
Overcontrol), a score indicating the General Psychological Maladjustment (GMPC) and 3 response style index: Inconsistency (IN), Infrequency (IF) and Negative Impression (NI). It’s formed by 91 total items and each question is on a 6 point scale (ranging from 'always' to 'never'), rated 0-4.
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It’s not a diagnostic toll, but supply information about sympthomathologic and psychological features that are relevant for each patient eating disorder development and maintenance. Administered in different temporal moments, this test is been used to supply data and to evaluate clinical condition and treatment response. The disadvantage of this test it’s that it is highly influenceable by patient’s defense mechanisms, by disease and symptoms negation, and by refusal to care.
Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS)
the K-SADS is a psychiatric semi-structured interview for evaluation of Affective Disorders and Schizofrenia in schoolers and adolescences according to DSM-4-TR diagnostic criteria.
3) Method
Just after been enrolled, every patients have completed: 1) psychiatric evaluation for the ED’s description (EDI-3 “Eating Disorders Inventory”) and for evaluation of psychiatric co-morbidity (K-SADS-PL, “Kiddie Schedule for Affective Disorders and Schizofrenia for School-Age Children – Present and Lifetime Version”, CBCL/6-18, “Child Behavior Checklist” and YSR/6-18, “Youth Self Report”) 2) complete pediatric evaluation including auxological data (weight, height, body mass index – BMI-, puberal stage according to Tanner method), blood pressure evaluation and heart rate, general clinical cardiac assessment (ECG; cardiac Ecodoppler) and hematic ED’s protocol of screening 3) according with the interference of hyperactivity symptom with the clinic case of the patients, hyperactivity has been evaluated by the use of item 40 of SIAB-EX, “Structured Interview for Anorexic and Bulimic Disorder-Expert Form”, in a clinical observed contest, and by the answers to the inherent items of each questionnaire.
At the end of the assessment, every subject received a diagnosis of ANR according the DSM-5, complete or partial form, and inserted in a multidisciplinary treatment 36 weeks lasting.
At the end of treatment cycle it was reapplied the initial protocol of assessment (T2). It’s been performed a t test of Student statistical analysis for paired samples, with the aim to individuate significant difference between scores obtained from T1 and T2 questionnaires. They’re been performed Pearson correlation between scores, with the aim to identify
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predictive measures of changes between T1 and T2. For data analyses it’s been used SPSS for Windows.
4) Results
1) Changes T1-T2
The comparison between evaluations on T1 and T2 shows changes both for BMI both for other measures used.
About BMI, we have noted a significant enhancement (p: 0,000) among avarage value of BMI evaluated at onset of treatment (15,25) and medium value resulted at the end (17,94). Tab. 1
We have found statistically significant enhancement in the sub-scales of’EDI-3 about:
Drive to Thinness - DT (p value: 0,002)
Eating Disorder General Risk - EDRC (p value: 0,004)
Maturity Fear - MF (p value: 0,006). Tab. 2
A statistically significant enhancement appears also in the scale:
Somatic complaints in father’s CBCL (p value: 0,045) Tab. 3
Statistically significant worsening appears in the scales:
Activities in YSR (p value: 0,045).
Social Competence in father’s CBCL (p value: 0,011)
Total Competence in father’s CBCL (p value: 0,030)
Social Competence in mother’s CBCL (p value: 0,007)
Attention Problems in mother’s CBCL (p value: 0,020). Tab. 3-4-5
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At Analysis of correlations about parameters above-mentioned, we have observed statistically significant correlations both on T1 both on T2 .
BMI value is meaningfully related: On T1 with:
o Scales on T1:
Personal alienation - PA (p value: 0,025) Drive for Thinness - DT (p value: 0,008)
Eating Disorder General Risk - EDRC (p value: 0,009). On T2 with:
o Scales on T1:
Social competence in YSR ( p value: 0,048). Tab. 6-10, 12-17
Specifically, Propulsion to skinniness-DT correlates meaningfully: On T1 with:
o Scales on T1:
Body dissatisfaction-BD (p value: 0,005) Asceticism - A (p: 0,004)
Overcontrol - OC (p value: 0,001)
Eating Disorder General Risk - EDRC (p value: 0,000) BMI (p value: 0,008). o Scales on T2: Overcontrol - OC (p value: 0,017). On T2 with: o Scales on T1: Bulimia - B (p value: 0,006)
Body Dissatisfaction - BD (p value: 0,000)
Eating Disorder General Risk - EDRC (p value: 0,004) Somatic complaints reported by father (p value: 0,045)
Social competence reported by mother ( inverse correlation-p value: 0,015).
o Scales onT2:
Body dissatisfaction-BD (p value: 0,000)
Eating Disorder General Risk-EDRC (p value: 0,000) Somatic complaints reported by father (0,019)
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Tab. 6-8, 16-17Eating Disorder General Risk-EDRC scale correlates meaningfully: On T1 with:
o Scales on T1:
Drive for Thinness -DT (p value: 0,004) Body dissatisfaction-BD (p value: 0,000) Asceticism-A (p value: 0,004)
Overcontrol-OC (p value: 0,008)
Internalizing Problems in YSR (p value: 0,012). BMI (p value: 0,009).
o Scales on T2:
Drive for Thinness -BD (p value: 0,000),
Eating Disorder General Risk-EDRC (p value: 0,033). On T2 with:
o Scales on T1:
Body Dissatisfaction-BD ( p value: 0,012 )
Eating Disorder General Risk-EDRC (p value: 0,033) Internalizing problems reported by mother (p value: 0,043) Total problems reported by mother (p value: 0,010) o Scales on T2:
Body Dissatisfaction-BD (p value: 0,000) Drive for Thinness-DT (p value: 0,000) Bulimia (p value: 0,002)
Low self esteem-LSE (p value: 0,033) Asceticism-A (p value: 0,012)
Internalizing problems in YSR (p value: 0,031)
Internalizing problems reported by mother (p value: 0,022) Total problems reported by mother (p value: 0,030). Tab. 6-8, 16-20
Maturity fear scale correlates meaningfully: On T1 with:
o Scales on T2:
Overcontrol-OC (inverse correlation, p value: 0,039) on T2 with:
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o Scales on T1: Perfectionism-P ( inverse correlation, p value: 0,004) Attention problems reported by mother (p value: 0,048) Somatic complaints reported by father (p value: 0,004). o Scales on T2:
Personal alienation-PA (p value: 0,018) Interpersonal insecurity-II (p value: 0,034) Interocettive Deficit-ID (p value: 0,048) Emotional Dysregulation-ED (p value: 0,029) Body dissatisfaction-BD (p value: 0,000) Tab. 6-8, 16-17
Activities scale evacuate in YSR correlates meaningfully: On T1 with:
o Scales on T1:
Eating Disorder General Risk-EDRC (p value: 0,022) Total Competence reported by father (p value: 0,000) Activities reported by mother (p value: 0,040)
Somatic Complaints reported by father (p value: 0,028) On T2 with:
o Scales on T1:
Somatic complaints reported by mother (p value: 0,047) Activities reported by father (p value: 0,014)
Somatic Complaints in YSR (inverse correlation, p value: 0,008) o Scales on T2:
Total Competence in YSR (p value: 0,003)
Total Competence reported by mother (p value: 0,002) Social problems in YSR (p value: 0,020).
Tab. 9-17
3) Correlations among trends T1-T2
BMI increase observed among T1 e T2 correlates with entity of Inadequacy -IC felt by patients on T2 (p value: 0,041). Moreover, BMI increase correlates meaningfully with
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Social competence (inverse correlation, p: 0,18) e Total Competence (inverse correlation, p: 0,005) reported by father on T2.
Other trends correlated in a way statistically significant are noted among:
BMI increase and Social Competence (p value: 0,006) e Total Competence scales (p value: 0,001) reported by father
Total competence scale reported by father and BMI (p value: 0,001)
Total competence scale reported by father and scale Social Competence reported by father (p value: 0,002).
Drive to Thinness-DT e Eating Disorder General Risk-EDRC scale (p value: 0,000) and viceversa (p value: 0,000).
Maturity fear-MF and scale Somatic complaints reported by father (inverse correlation, p: 0,001) e viceversa (inverse correlation, p value. 0,001). Tab. 21-23
4) Discussion
In the analyzed group we found an improvement of clinical condition, as demonstrated by the substantial improvement of BMI after the treatment cycle (18 patients of 20). This prove that the subjects proceeded the proposed diet, modifying their eating behaviors. At the same time we observe an improvement of some ideational features of eating disorders, as
underlined by the significant decrease of mean scores of Drive to Thinnest, Eating Disorder General Risk and Maturity Fears Scales. Even Perfectionism and Ascetism decrease during treatment, even if not significantly.
Eating Disorder General Risk is strictly connected with the strong will to lose weight, that represent one of the pivotal points of ANR (according with classification systems, DSM-5 and ICD-11) and it’s considered a critical criterion for diagnosis. Furthermore, the high scores of Drive to Thinness and Maturity Fear, as well as the high Body Dissatisfaction, present at the beginning of the observation, confirm the presence of ego-syntonic symptoms, and describe the symptomatological constellation, typical for anorexia nervosa restrictive subtype.
In our study, we noticed that the entity of drive for thinness at T1 is significantly related with over controlling features (perfectionism tendency and ascetism) of subjects both at the begin that at the end of the treatment. Such a correlation don’t exist at T2, and this fact prove that with the partial improvement of clinical case even the tendency of overcontrol could decrease. So it could be hypnotized that some pathologic features supporting anorexic ideation in the subject (the tendency to denial by controlling corporal needs,
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criticism, the need of not disappoint other person, ascetism express with a steely dieting as a form of purification and renunciation of physical gratifications, the fasting lived as
atonement and thinness considered as a virtue) could form transitorily aspects, rather than constitute a more stable trait in this patients personality.
The improvement of drive for thinness noticed at T2 it’s strictly related also with the significant decrease of somatic complaints as referred by the fathers, and with the improvement (even not statistically significant) of body dissatisfaction of internalizing problems as referred by both patients and their mothers at T2.
These data could be indicative for a small improvement of patients discomfort relatively with their weight and body form, and so represent a positive prognostic factor for AN.
Another important data concern the fact that the increase of BMI results strictly predictive for ineffectiveness feelings registered by patients themselves at the end of treatment. The Ineffectiveness scale of the EDI-3 include scores that are relatives at Low Self-Esteem and Personal Alienation scales: both those scales are significantly related, at the beginning and at the end of the observation, to other psychological indexes underlining the eating disorder. In particular, both self-esteem that personal alienation, noted ad T2, are related with each other and influence the aspects of interpersonal insecurity, ineffectiveness, emotive instability and general psychological maladjustment observed at T2.
So, for ours patients, increasing their weight means an increase of ineffectiveness feelings. To confirm this data, we observe that low self-esteem seems to be related at T2 even with Drive for Thinness, Body Dissatisfaction and Eating Disorder General Risk. The level of low self-esteem, moreover, when noticed at T1 and at T2, it’s predictive for aspects of emotive deregulation at the end of the treatment.
As much as until here described demonstrate that in subjects affected by anorexia nervosa the self-esteem regulation is strictly related with weight control, body form and achievement of the thinness, that constitute landmarks for infer of their personal value.
As consequence, at the increase of BMI, these subjects could undergo feelings of emotive nothingness, past of loneliness, low ability to self-understanding (personal identity deficit) associated with the sensation of loss of every control on things and above all on own body. Such difficulties of patients associated with the increasing of the weight, had to be confront with a restraining and supportive approach, that could supply the reassurances that they need. Moreover, in this phase, it’s extremely important to follow patients in theirs feeding features, supplying an external systematic control of meals, with the aim to avoid that they acquire more weight of what established, losing their control on food.
Another interesting aspect is worsening perceived by patients in activities scale of YSR, that explores social and relational activities.
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This result underlines the close bond among features and feelings of ineffectiveness in interpersonal relations, social problems, difficulty in identification and managing of own emotional state, often perceived as out of own control.
To confirm that, patients of our group recognize a worsening, even if not statistically significant, of their behavior, speaking of impulsiveness, discontrol and a greater eterodirect aggressivity. It’s fascinating to observe that patients recognize an improvement (statistically not significant in mean scores of YSR) of theirs internalizing problems (anxious-depressive pasts, tendency at depressive withdrawing, somatization). This data are confirmed at the evaluation of co-morbidity, by using K-SADS at the end of the observation: it’s been referred from the patients an attenuation of depressive and anxious symptomatology (8 patients) or the resolution of the initial clinical case (9 subjects), while the in other patients last symptoms observed at the beginning.
It’s possible to hypothesize that our patients begin to effect mainly their emotions, externalizing the disease, especially in the familiar background.
In fact, what is reported by patients accords with what results by parent evaluations about you’re their children emotional life both behavior, even if differences statistically significant don’t appear among evaluations on T1 and T2.
Contrarily, parent refer a greater tendency of their children to social withdrawal (social groups, meet with friends, general behavior with friend and parent).
It appears from significant Social competence e Total competence impairment reported by mothers and from significant impairment reported by father at the end of treatment. Fathers, observe also a global impairment about their children competences, not only about social life relational aspects of their children but also about academic performance and involvement in activities of major interest.
These competences appear meaningfully correlated to BMI increase on T2.
Mothers refer, moreover, an impairment about attention problems of their children. Fathers, refer an improvement in Somatic complaints (nightmares, dizziness or daze sensation, excessive, somatic pains, headache, fatigue, nausea, gastralgia, vomit, general discomfort, eyes trouble).
This improvement seems predict meaningfully maturity fear reduction, that on T1 appears related to overcontrol.
Moreover, maturity fear has been predictor of many treatments results, as reported in vary studies. (Fassino et al. 2001).
So, our patients, with BMI increase, could feel ineffective because they perceive somatic change and they have difficulties to accept it and they have discomfort to be in social
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context: they reduce their interests and social motivations, they have distrust in relationship and feel misunderstood.
Limited control feels about own body and emotions are associated to this aspects, as so as impulsive and deregulate actions to show own discomforts: patients have difficulties in communication, in own thoughts and feels externalization, and this reinforces their social isolation.
This psychological personal aspects don’t show significant changes during treatment. In fact, we didn’t see significant correlations among BMI increase and improvement about psychological problems referred both patients both their parent.
Contrarily, weight gain is associated to fear reduction associated to psychosessual maturity and to insurgence of adolescent development typical conflicts.
It could denotes that eating disease has been a tool for these patients to reduce their worries about own physical and emotional development, and it anchor them in a typical infant safety condition and it avoid for them biological and psychological conflicts in the natural
development.
Treatment cycle effected consists first of all in a nutritional rehabilitation schedule, aimed to normalize feeding and body weight: patients meal have been daily assisted by specialized operators.
It has been possible to keep individualized caloric daily scheme for each patient.
At the end of cycle of treatment we have observed patients behavioral improvement and so BMI increase.
Moreover, treatment consists of:
-psycho pedagogical intervention in group activities, aimed to not only encourage relationships among peers, but also to incite patients to reflect about own psychological problems and to express own discomfort. Patients have done graphic-expressive activities self-sown and related to specific thematic; manual activities (fimo, painting) to excite patient creativity.
-Individual psychotherapeutic intervention, aimed to excite patients to experience feels and emotions previously removed or managed in a dis-adaptive way.
-Family therapy, during which there is a family communication oversight by a psychologist; it’s possible to talk about themes and problems related to familiar relationship, with
particular attention to personal significant situations and motives for eating disorder onset and maintenance.
Anorexic patients are often ambivalent in the relationship and have a dis-adaptive attachment style: this is the relationship pattern defined by dependency and others thoughts fear.
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-Pharmacological therapy for these patients with major initial endangerment about depressive and anxious symptoms.
After improvements observed in our patient sample, we can deduce that psycho pedagogical and individual psychotherapeutic intervention, through self-meditation, help patients to attenuate some eating disorder ideations.
It’s interesting, moreover, to see that improvement about eating disorder and some
associated depressive e/o anxious aspects connects to major behavioral reactivity, and that own emotions externalization, in particular with parent, connects to more syntonic
emotionality, typical of adolescent development.
Familiar therapy has led to a major patients relational deploy with their parent and viceversa, and it could have moderate austere familiar values, so it has extenuate patient pressing and expectances, that could have promote patient overcontrol, perfectionism, drive to greater performances (often directly referred by family and teachers).
Our study limits are:
-sample scarce numerousness (20 patients)
- treatment period (9 months) insufficient to evaluate patients greater clinical change -clinical evaluation absence aimed to which compare results derived from measures used by patients and parent.
5) Conclusions
In our group of patients there’s an improvement of the disease insight and of the motivation to recovery, as shown by the acceptance at nutritional program and by the consecutive increase of weight in the course of treatment itself. We observed a decrease of the adaptive function assumed by anorexia nervosa: the strong need to control and avoid of every forms of emotion (in particular the negative ones). These aspects are strongly bonded to treatment endurance, and they’re supported by the two principal defense mechanisms, negation and intellectualization, usually adopted by anorexic patients.
Several studies have indeed demonstrated that not only the loss or the lack of disease insight, but also the combination of defensive mechanism, mature and immature, could maintaining anorexia nervosa. Other studies underline as the velocity of BMI recovery could be a reinforce feature for treatment response.
From this data we’re able to gather that in our patients could primarily take place the weakening of some predictive factors for disease maintenance and for treatment endurance. However, there isn’t a significant improvement of the other ideational features of eating disorder (e.g. Body dissatisfaction, Ineffectiveness) or of the real motivation to changing,
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because the main psychological problems doesn’t improve in a significant way. This fact suggest that the will to recovery or the ability to identify the negative aspects of the disease couldn’t be considered indexes of the will to change.
Furthermore, during the observation, we noticed a worsening of the aspects of ineffectiveness, insecurity, emotional and behavioral instability, distrust in personal relations. These features not only are indicative for a huge difficulty of these patients in communication and ability to create attachment bonds, but also revealed typical problems of adolescence’s developmental junction. The identity consciousness of the patients, earlier centered on food and own body control, is weakening until total collapse, and this is a pivotal role in theirs developmental process and for the therapeutic management. Therefore it’s essential to pursue the psychotherapeutic interventions, especially the individual ones, with the aim to incite the patients toward the real changing of themselves. They need to be supported in the comprehension and in the critique to the subjective meaning given to the eating disorder; need to be helped in the rescue of the awareness of their personality and of their experiences both emotional that food and body related. The therapeutic relational strategy had to be finalized to development of a personal own identify, not yet acquired by our patients.
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Tabelle
Tab. 1: T-Test BMI
Inferiore Superiore
Coppia 1 BMI INGRESSO - BMI
ATTUALE
-2,57750 2,48235 ,55507 -3,73927 -1,41573 -4,644 19 ,000
Test per campioni appaiati
Differenze a coppie
t df Sig. (2-code)
Media Deviazione std.
Errore std. Media
Intervallo di confidenza per la differenza al 95%
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Tab. 2: T-Test EDI-3t1 t2
M Sd M Sd P Value
Drive to Thinness (DT) 16,30 9,34 8,30 8,86 0,002
Bulimia (B) 2,75 4,25 1,15 2,60 0,146
Body dissatisfaction (BD) 18,80 11,46 13,85 11,49 0,087 Eating Disorder General Risk (EDRC) 37,85 19,94 23,05 20,03 0,004
Low self-esteem (LSE) 10,05 6,56 7,50 6,16 0,105
Personal alienation (PA) 8,15 6,29 7,20 5,69 0,555
Interpersonal in security (II) 10,45 6,10 9,65 6,91 0,609
Interpersonal alienation (IA)
8,05 4,29 7,90
3,83
0,910
Interceptive deficit (ID) 11,15 6,52 8,55 8,67 0,061
Emotional dysregulation (ED) 6,35 5,98 5,40 6,13 0,519
Perfectionism (P) 6,10 3,90 5,50 4,75 0,510
Ascetism (A) 8,00 5,03 6,45 5,83 0,154
Fear of maturity (MF) 16,50 5,17 11,70 6,77 0,006
Incompetence (IC) 18,20 11,90 15,50 10,75 0,369
Interpersonal problems (IPC) 18,50 9,15 19,30 10,75 0,783
Affective problems (APC) 17,50 10,71 14,55 13,65 0,211
Overcontrol (OC) 14,10 7,15 14,70 14,94 0,820
General psychological maladjustment(GMPC) 83,20 31,18 76,30 41,81 0,453
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Fig. 2: EDI36
Tab. 3: T-Test father’s CBCLt1 t2 M Sd M Sd P Value Activities 38,13 10,44 34,94 8,37 0,299 Social Competence 40,69 9,44 29,25 13,87 0,011 Total Competence 36,69 15,19 23,50 15,01 0,030 Anxious/Depressed 65,88 11,93 64,19 10,23 0,471 Withdrawn/Depressed 67,81 13,57 67,44 11,23 0,866 Somatic Complaints 59,25 6,52 55,00 5,17 0,011 Social Problems 59,56 9,45 59,81 6,15 0,907 Thought Problems 63,38 10,19 61,44 9,32 0,396 Attention Problems 55,00 6,26 58,75 7,44 0,094 Rule Breaking Behavior 54,94 5,69 55,25 4,53 0,841 Aggressive Behaviour 58,75 8,12 58,94 8,36 0,919 Internalizing Problems 65,13 10,02 63,31 9,13 0,337 Externalizing Problems 56,31 9,03 56,94 7,99 0,765 Total Problems 59,73 9,96 60,00 8,67 0,909
