Cognitive behavioural therapy (CBT) is often the treatment of choice for the outpatient treatment of anorexia nervosa. However, little is known about which elements of the therapy bring about change. This study explored two potential change processes: early therapeutic alliance and early behavioural change. In Study 1, the temporal relationship between therapeutic alliance and weight gain during CBT for anorexia nervosa was examined in a cohort of 65 adults with a diagnosis of anorexia nervosa (or atypical anorexia nervosa). Patients completed a measure of alliance at session 6 (early therapeutic alliance) and at the end of treatment. Early behavioural change was defined as weight gain over the first six sessions. Early therapeutic alliance was associated with neither the likelihood of completing treatment norwith subsequent weight gain. Thus, no evidence was found that therapeutic alliance is a process that brings about change during CBT for this client group. The data indicated that it was vice versa: behavioural change (measured by weight gain) was predictive of subsequent alliance strength. Treatment completers had made more early behavioural changes (measured by weight gain) compared to those who prematurely discontinued treatment, but early weight gain was negatively associated with later weight gain. In Study 2, 100 clinicians who deliver CBT for anorexia nervosa completed a survey that explored beliefs and clinical practice related to therapeutic alliance and early behavioural change. Responses indicated that clinicians consider both processes to be important change processes, with particular emphasis placed on early therapeutic alliance. The gap between the clinicians' perspective and the empirical findings of Study 1 are discussed, with reference to the potential influences of the existing evidence base and information processing errors.

Background: Despite the increasing interest in the treatment of anorexia nervosa, no model of treatment has been shown to be consistently effective. Traditionally, treatment has been offered on an in-patient basis; however, more recently day treatment has been developed as a cost-effective alternative. Although day hospitalisation represents a potentially effective means of treatment, little has been published in the field in comparison to other models of care. St. George's Eating Disorder's Service additionally adopts two approaches to treating patients within the in-patient and day-patient settings: harm reduction and recovery. While recovery focuses on weight restoration, harm reduction assists patients in reaching a safe but low weight with the aim of improving quality of life. At present little is known about the effects of low-weight discharge on psychological outcome. Objectives: To compare the effectiveness of two models of treatment: in-patients and day-patients, by examining differences in eating disordered and general psychopathology at discharge, weight outcome, and patient satisfaction. Secondly, to compare the effectiveness of the harm reduction and recovery programmes. Methods: 52 participants meeting DSM-IV criteria for anorexia nervosa were recruited to compare treatment outcome. Results: No significant difference was detected at discharge between in-patients and day-patients on measures of eating disorder psychopathology, treatment satisfaction or weight outcome. In-patients, however, had more positive outcomes than day-patients regarding general psychopathology. Recovery patients demonstrated significantly better outcomes on levels of restraint than harm reduction patients, however, no other differences were observed regarding eating disorder outcome. Conclusions: While no significant difference was detected between groups on the majority of outcome measures, the small sample size limits the formation of reliable conclusions. There is preliminary evidence to suggest, however, that in-patients may facilitate better outcomes than day-patients regarding levels of general psychopathology and furthermore that weight restoration may have some benefits regarding improvements in restrictive eating behaviour for patients with anorexia nervosa.

Background: Anorexia nervosa is a serious psychiatric condition, and is associated with low levels of quality of life, and high mortality rates. Reported treatment drop-out rates for anorexia nervosa are high, and have remained so over the course of time, across different treatment settings and modalities. Past research into this area has focussed on the examination of service user characteristics as predictors of drop-out, yet there has been little replicated evidence to support this stance. Instead, service user attitudes and responses to treatment may provide a better insight into treatment outcome. Objectives: To investigate the levels of motivation, alliance, and behaviour change exhibited over the first four weeks of hospitalised treatment for anorexia nervosa. Participants were allocated to treatment outcome groups depending on whether they completed treatment as planned, or prematurely left treatment. Methods: 90 participants meeting DSM-IV criteria for anorexia nervosa were recruited at four specialist eating disorder treatment centres. Self- report data was collected at admission to treatment, and repeated after four weeks of treatment. Weight data was collected over this same time period to measure fluctuations in weight curves. At end of treatment, participants were categorised into completer or premature termination groups. Those in the premature termination group were subsequently also categorised regarding who initiated termination (service user or staff), and the timing of discharge. Results: The overall rate of premature termination was 57.8%. Those who prematurely terminated treatment left at a lower BMI (p <.0005), demonstrated less weight gain (p <.0005), and spent less time in treatment (p <.0005) than those who completed. Only first impressions of therapeutic alliance proved different between broad outcome groups at admission (p = .011). When examining sub-categorisations of treatment drop-out, initial perceptions of alliance predicted self-discharge (p = .006), and slow rate of weight gain predicted staff-initiated discharge (p = .005). Premature discharge that took place in the early weeks of treatment could be predicted by initial impressions of alliance (p = .016). Conclusions: Premature termination of treatment is a common yet complex event in the course of treatment for anorexia, with a number of interacting factors that may influence both timing and manner of discharge. Therapeutic alliance in particular appears to be an important factor in this area.

Anorexia nervosa has been reported to occur in children (Bostic, Muriel, Hack, Weinstein & Herzog, 1997; Nielsen, Lausch & Thomsen, 1997), which presents a challenge to clinical consensus that puberty is an important trigger for the development of the disorder (Crisp, 1967: 1980; 1983; deCastro & Goldstein, 1995; Koff & Rierden, 1993; Nicholls, 2007). There has been limited research conducted into anorexia nervosa presenting in pre-menarcheal children and none of the existing studies have directly investigated the young person's perspective. The study aimed to explore how the young person who developed anorexia nervosa prior to the menarche understands the disorder using Interpretative Phenomenological Analysis (IPA: Smith, 1996; Smith, Flowers & Larkin, 1997). The use of semi-structured interviews allowed for the exploration of: what their understanding of anorexia nervosa is; what it means to them; what led to the development of anorexia nervosa; what they feel the impact of having the disorder had been and how they feel about their size. Seven girls who developed anorexia nervosa prior to the menarche from two, inner- London, NHS Child and Adolescent Eating Disorder Services participated in semi- structured interviews. IPA of the interviews led to the development of four themes. There were similarities and differences in how each theme was described and some novel findings emerged. Although there were some similarities between the findings and existing theoretical models, other important issues arose which have implications for clinical practice.

Anorexia Nervosa (AN) is widespread, difficult to treat effectively and often has a poor prognosis. Body Image Disturbance (BID) is prevalent in the spectrum of eating disorders and is a core factor in the development, maintenance and relapse of AN. Establishing a therapeutic alliance (TA) has been associated with improved outcomes in AN, although this is under-researched area. The existing research suggests that developing a therapeutic alliance with clients with AN can be challenging. Previous research has mainly focused on the TA with psychotherapists and has overlooked other important members of the treatment team, particularly nursing staff. The study aimed to use a qualitative design to explore the experiences of nursing staff working with body image disturbance in adult anorexia nervosa. Little is known about the impact of working with body image disturbance. Nursing staff may lack confidence and skills associated with body image disturbance, which could potentially impact on the therapeutic alliance. The study aimed to explore nursing staffs understanding of BID, the psychological consequences of working with BID in AN and the potential impact on the TA with clients with AN. Eight members of the nursing team from an adult inpatient eating disorder ward were interviewed using a semi-structured interview. The data was analysed using interpretative phenomenological analysis (Smith, Flowers & Larkin, 2009). Five master themes emerged from the data: knowledge and understanding of BID; the challenge of uncertainty; the negative impact on the self and the TA; identifying with clients; and resilience and resourcefulness.

No description available.

This study aims to explore recovery in AN from the perspective of individuals who have experience of it and examine if there are implications for practice. A Grounded Theory methodology was used and semi structured interviews employed to collect the data. The sample consisted of 12 individuals who had experience of AN, either as currently ill or self-defined as recovered from AN. All interviews were recorded and transcribed and the constant comparison method employed to analyse the data. The findings show that recovery for the person involves the successful integration of the four major dimensions of recovery; deciding to recover, sustaining recovering, doing the necessary tasks and building a life without AN. Each of these dimensions represents a series of tasks, which the person must complete, to varying degrees, if they are to recover. The grounded theory that emerged makes explicit that recovery from AN is conditional on the individuals' decision to recover and to take an active part in making it happen. Integrating the four dimensions is a spiralling process where the change in one is dependant on and is influenced by change in the others. They have to improve their physical condition or no recovery is possible because of the effects of starvation. They must tackle the issues that contributed to the AN and take on new roles if they are to move away from the AN identity. They must reconnect with others, asking for and accepting their help because recovery is not achieved alone. If they invest the substantial physical and emotional energy needed to sustain their recovery then they are transformed. They explore and build a life separate from the AN through the integration of the four dimensions. As a result the limited identity of AN is replaced by a more complex identity where individuals are stronger, more connected with others and in control of their lives. This study supports greater attention to the role of self-development tasks and models of treatment that promote autonomy in the person.

This study reports on the analysis of the Mental Health Discourse Corpus. This dataset is comprised of four sub-corpora that contain patients' online discussions of anorexia nervosa, patients' online discussions of depression, general practitioners' discussions of anorexia, and general practitioners' discussions of depression, respectively. The methodology integrates quantitative corpus linguistic approaches with qualitative analysis drawing on Hallidayan functional grammar, discourse analysis and discursive psychology. By interrogating corpora of health communication across communicative modes and participants, the study offers novel insights into the verbal presentation of anorexia and depression by patients and professionals, and examines their respective uptake of medical explanations of mental illness. Common patterns in the online patient interactions are linguistic choices which realise the externalisation and personification of anorexia and depression, the discursive construction of individual helplessness, and the representation of psychological distress in terms of medical pathology. The uptake and proliferation of biomedical explanatory models of anorexia and depression serves to reduce illness stigma for individuals and, notably, is also used to perform local interactional tasks. In the practitioners' talk, participants draw on medical and social explanations of depression and anorexia. Doctors construct depression as a categorical medical diagnosis while also expressing doubt towards its medical treatment and advocating non-medical interventions. When discussing anorexia, clinicians emphasise the bureaucratic role which body mass index scores occupy in managing anorexia and repeatedly highlight the difficulty of overcoming patients' resistance. In both cases, participants highlight the bureaucratic and communicative challenges of working with anorexic and depressed patients and construct a range of unfavourable moral identities for the chronically ill. The practical implications of the research for users of online support groups and general practitioners working with depressed and anorexic patients are identified. In particular, I emphasise the centrality of communication to primary mental health care and the utility of studying online support groups to illuminate the experiences and beliefs of patients. A critical evaluation of the study's methodology is offered, along with recommendations for future research.

Eating disorders are difficult to treat: there is still no NICE-approved first-line treatment for anorexia nervosa. In part this could be due to a lack of a compelling theoretical model to account for the development and dogged persistence of the illness. Sociocultural factors implicating western preoccupation with thinness and attractiveness are likely to play a contributory role, but cannot be by themselves causal in societies where such ideals are dominant. Recent theoretical models in neuroscience predict that predisposing neurobiological factors in early brain development may render some young people more vulnerable than others to universal psychosocial pressures, especially during adolescence. This dissertation reviews the existing evidence for abnormal neurobiological functioning in eating disorders, acknowledging that it is difficult to distinguish between the acute effects of starvation on the brain and possibly pre-existing underlying factors. Nevertheless, such empirical studies do support the development of a novel hypothesis implicating abnormal functioning of a neural network centred on the insula cortex in anorexia nervosa. The insula hypothesis is tested in a series of functional imaging studies using Single Positron Emission Computed Tomography (SPECT) indicating focal abnormalities in the temporal region that persist following weight restoration treatment and correlate with neuropsychological deficits. A subsequent study using higher resolution functional Magnetic Resonance Imaging (fMRI) lends further partial support to the insula hypothesis (in three out of four tasks) and also implicates additional brain structures in the basal ganglia. These findings, if replicated, could contribute to the development of novel therapeutic approaches to the treatment of anorexia nervosa, including realtime fMRI and mindfulness-based approaches, both of which have been shown to modulate insula activation. The studies presented here could hopefully also help to reduce the stigma and shame so often associated with eating disorders, for the benefit of sufferers and their families.

Anorexia nervosa (AN) is an eating disorder characterised by severe emaciation due deliberate restriction of food intake and an intense fear of gaining weight. Theoretical accounts of AN have to date focused predominately on cognitive elements of the disorder, yet resulting treatments have been inadequate and outcome for AN remains poor. Understanding the processes that maintain the disorder is an important step in developing effective strategies to augment existing treatments. With this in mind, the question arises: what processes drive AN? Novel frameworks for AN suggest that particular information processing configurations or “modes” may underpin many symptoms of AN, such as preoccupation with control of eating, weight and shape. More specifically, it is proposed that a ruminative mode of processing may function as an avoidance strategy in AN, enabling individuals to neglect salient and rewarding stimuli, such as food, and thus uphold restrictive eating practices. Whilst empirical studies have examined processes such as rumination, avoidance and reward in depression, they have seldom been studied in AN. The aim of this thesis is therefore to understand the role of rumination and reward processes in AN. Chapter 1 reviews the literature on AN, rumination and reward processing. Chapter 2 presents data demonstrating to what extent the content of rumination in AN differs from rumination in depression and the effect that rumination may have on ED symptoms. The study conducted in Chapter 3 examines whether individuals with AN can be switched out of rumination around meal times and what effect this has on AN psychopathology. Chapter 4 presents neuroimaging data which elucidates the brain regions involved in processing rewarding and aversive food stimuli after recovery from AN. The study reported in Chapter 5 teases apart hedonic (liking) versus motivational (wanting) aspects of food reward in AN. The final study (Chapter 6) provides further evidence using neuroimaging that rumination may be an important process in AN which may override appetitive responses to rewarding stimuli, such as food. The studies reported support the notion that rumination and aberrant reward processing may be involved in the maintenance of AN.