INTRODUÇÃO: Os transtornos alimentares (TA) incluem os diagnósticos de anorexia nervosa (AN), bulimia nervosa (BN) e transtorno alimentar não-especificado (TANE). Apresentam altas morbidade e mortalidade. Acometem indivíduos jovens, afetando amplamente o seu desenvolvimento. Na infância e adolescência, os TA possuem peculiaridades epidemiológicas, diagnósticas e clínicas que ainda são pouco conhecidas em pacientes jovens brasileiros. As comorbidades psiquiátricas podem interferir no curso do tratamento e na evolução dos TA, podendo aumentar sua letalidade. Outros fatores prognósticos dos TA também têm sido investigados e seu papel permanece indefinido. Os objetivos deste estudo foram investigar o perfil sociodemográfico e clínico dos pacientes com TA; identificar a prevalência de comorbidades psiquiátricas; investigar o impacto de comorbidades psiquiátricas e de outros fatores de risco na resposta ao tratamento de pacientes com TA que receberam o mesmo tratamento. MÉTODOS: Estudo realizado em um serviço multidisciplinar especializado no tratamento de crianças e adolescentes com TA (PROTAD IPq/HCFMUSP). A amostra consistiu de 100 pacientes de ambos os sexos, com idade até 18 anos e diagnóstico de TA, síndromes totais e parciais, segundo critérios do DSM IV - TR. Os dados foram coletados à entrada e à saída do tratamento. Os três tipos de resposta ao tratamento foram Alta Clínica, Abandono e Falha de Tratamento. Foram testados, também, quais fatores preditivos influenciaram no tempo de tratamento até a alta clínica dos pacientes pela análise de sobrevida. O nível de significância considerado em todos os testes estatísticos foi de 5%. RESULTADOS: A idade média dos pacientes foi de 15,41 anos, a média de idade de início dos TA foi de 13,5 anos e o tempo médio de duração do TA foi de 21,06 meses. Características da amostra: 82% de mulheres, 84% brancas, 64% das classes econômicas A e B; 69% de famílias tradicionais; 43% com diagnóstico de AN, 17% de BN e 41% de TANE; 56,8% admitidos na internação; 66% com tratamentos prévios; 88% cuidados pela mãe durante o tratamento; 75,7% com transtornos do humor (TH) que, em 81% dos casos, iniciaram durante os TA, e 54% com transtornos ansiosos que, em 75% das vezes, começaram antes dos TA; 60% com grande impacto dos TA, segundo a Escala de Avaliação Global de Crianças. Os pacientes do grupo AN eram mais jovens, pesavam menos, tinham menos tempo de TA, procuraram mais tratamentos prévios, apresentavam menos obesidade prévia, usavam mais os exercícios físicos excessivos como compensação e tinham mais amenorreia do que aqueles do grupo BN. Os sujeitos da enfermaria apresentaram menor índice de massa corporal, mais tempo de TA e maior impacto dos TA do que os do ambulatório. Na análise de sobrevida, os pacientes sem TH tiveram quase 3 vezes a chance de alta clínica do que aqueles que tinham TH. Os pacientes cuidados por suas mães apresentaram 4 vezes a chance de alta clínica do que os indivíduos que foram cuidados por outras pessoas. Pacientes do grupo abandono eram 12 meses mais velhos do que os dos outros grupos de resposta ao tratamento. O grau de instrução dos responsáveis pelos grupos abandono e falha de tratamento era maior do que do grupo alta clínica. Os outros fatores prognósticos investigados não tiveram impacto no tipo de resposta ao tratamento. CONCLUSÃO: Os pacientes jovens brasileiros com TA apresentaram características epidemiológicas e sintomatológicas muito semelhantes aos dados da literatura científica na mesma população, inclusive da alta prevalência de comorbidades psiquiátricas. A maior frequência das síndromes totais dos TA, o predomínio de quadros de início precoce, o longo tempo de duração até iniciar tratamento especializado e a maior gravidade dos pacientes da enfermaria, evidenciados nessa amostra, chamaram atenção por serem indicadores de maior gravidade em TA. A presença de TH e ausência de cuidados maternos aumentaram significativamente o tempo de tratamento até a remissão dos pacientes com TA. A idade mais avançada dos pacientes e maior nível educacional dos responsáveis estiveram associados com maior risco de abandono de tratamento. Os outros fatores preditivos investigados não tiveram impacto na resposta ao tratamento e no tempo de tratamento até a remissão. Os resultados podem contribuir para a estruturação de novos serviços direcionados às crianças e aos adolescentes brasileiros com TA e para o desenvolvimento de estratégias mais racionais e eficazes de diagnóstico e tratamento / INTRODUCTION: Eating disorders (ED), which present high morbidity and mortality, include anorexia nervosa (AN), bulimia nervosa (BN) and nonspecific eating disorder (EDNOS), and affect youth, greatly impacting their development. ED in childhood and adolescence, which involve epidemiological, diagnostic and clinical peculiarities, have been little studied among young Brazilians. Psychiatric comorbidities may also interfere with the treatment and progress of ED, and may increase their lethality. Other prognostic factors for ED have also been investigated, and their role remains undefined. The objectives of this study were to 1) investigate the sociodemographic and clinical profile of ED patients, 2) to identify the prevalence of psychiatric comorbidities, 3) to investigate the impact of such comorbidities on patient treatment response in comparison to that of patients without comorbidities under the same treatment conditions, and 4) to determine the impact of other risk factors on patient response to ED treatment. METHODS: The study was conducted at a multidisciplinary service specializing in the treatment of children and adolescents with ED (PROTAD IPq/HC-FMUSP). The sample consisted of 100 patients of both genders up to 18 years old who had been diagnosed with ED (either total or partial syndromes) according to DSM IV - TR criteria. The data were collected upon admission and at discharge from treatment. The three types of treatment response were: clinical discharge, abandonment and treatment failure. Based on the survival analysis, the patients were also tested regarding which predictive factors influenced patient treatment time until clinical discharge. A significance level of 5% was adopted for all statistical tests. RESULTS: The mean patient age was 15.41 years; the mean time since ED onset was 13.5 years and the mean duration of ED was 21.06 months. Sample characteristics: 82% female, 84% white, 64% from socioeconomic classes A and B; 69% from traditional families; 43% diagnosed with AN, 17% with BN and 41% with EDNOS; 56.8% admitted via hospital admission; 66% had previous treatment; 88% were assisted by the mother during treatment; 75.7% had mood disorders (MD) which, in 81% of the cases, began during the ED, and 54% had anxiety disorders that, in 75% of the cases, began before the ED ; 60% of patients had a great impact by the ED. Patients in the AN group were younger, weighed less, had less time of ED, had sought previous treatment more frequently, presented less previous obesity, more frequently resorted to excessive physical exercise as compensation and had more amenorrhea than those in the BN group. The patients from the hospital ward had a lower body mass index, longer time with ED and were more impacted by the ED than patients from the clinic. In the survival analysis, patients without MD were almost three times as likely to receive a clinical discharge as those with MD. Patients assisted by their mothers were four times as likely to receive a clinical discharge as those assisted by others. Patients from the abandonment group were an average of 12 months older than those in the other treatment response groups. The educational level of guardians in the abandonment and treatment failure groups was higher than that of parent/guardians in the clinical discharge group. The other investigated prognostic factors had no impact on treatment response type. CONCLUSION: Young Brazilian patients with ED present epidemiological and symptomatic characteristics very similar to those found in the scientific literature regarding similar populations, including a high prevalence of psychiatric comorbidities. The higher frequency of total ED syndromes, the predominance of cases with an early beginning, the long delay in beginning a specialized treatment and the more severe state of patients from the hospital ward attracted attention because these factors differed from what has been reported in reference studies and indicated greater ED severity. The presence of MD and the absence of maternal care significantly increased treatment time for ED. Greater patient age and higher guardian educational level were associated with higher risk of treatment abandonment. The other predictive factors investigated had no impact on treatment response or on treatment time until discharge. These results can contribute to the structuring of new services for Brazilian children and adolescents with ED and to the development of more rational and efficient strategies for diagnosing and treating ED

Trata-se de um estudo qualitativo, que teve como objetivos explicitar as representações de familiares de indivíduos portadores de transtornos alimentares acerca da anorexia e bulimia nervosas e analisá-las na perspectiva das ações e de cuidado que desenvolvem no convívio cotidiano com seus familiares doentes. Teve como cenário o Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, que é centro de referência no atendimento de pacientes com transtornos alimentares. A coleta de dados foi realizada com os familiares, mediante entrevista semi-estruturada, gravada e transcrita literalmente. Os princípios éticos de participação voluntária, esclarecida e consentida foram respeitados. A teoria das representações sociais foi utilizada como referencial teórico e os dados foram submetidos à análise de conteúdo. Os depoimentos permitiram o conhecimento das representações que orientam as ações dos familiares na convivência com o familiar portador de transtorno alimentar. Nos depoimentos, a representação desse adoecer psíquico, ancorada principalmente nas perspectivas psicológica e social, é caracterizada por singularidades que mostram uma fragilidade psíquica, a qual, tanto favorece o aparecimento do transtorno, como se estrutura no curso do mesmo. Tal fragilidade tornaria as adolescentes vulneráveis aos processos de massificação e importação de modelos culturais hegemônicos decorrentes da globalização - o culto à beleza. Vivenciando a exclusão social, pontuada pela erosão nos relacionamentos e isolamento afetivo, esses familiares apontam uma vivência sofrida que lhes impõe carga objetiva e subjetiva, que se traduz numa tarefa difícil e desgastante que é o cuidado possível. / This is a qualitative study, aiming to show the representations of eating disorders patients\' relatives, regarding anorexia nervosa and bulimia nervosa, as long as to analyze these representations on the context of the daily actions and quotidian taking care of their sick relatives. The research has been developed at the Psychiatric Institute of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, which is the center of reference to the assistance of eating disorders patients. The data collection has been made within the relatives, submitted to semi-structured interviews, recorded and literally transcribed. The ethics principles of voluntary, cleared and consented participation have been respected. The social representation theory have been used as a theoretic referential and the data have been submitted to the content analysis. The declarations made possible the knowledge of the representations which guides the family relatives\' actions living with the person who suffer from eating disorder. In the declarations, the representation of the psycho becoming sick process, mostly based on the psychological and social perspectives, is characterized as singularities that show psycho fragility which makes easier for the eating disorder to appear and which structures it self in the illness length. This fragility would make the female teenagers vulnerable to the massing process and importing of hegemonic cultural models resulted from the globalization - the cult of beauty. Living the social exclusion, marked by the erosion at the relationships and affective isolation, these family relatives mentioned above, indicate a suffering living that impose objective and subjective load, translated in a hard and tiresome task: the possible care.

Orientador: Egberto Ribeiro Turato / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T05:36:27Z (GMT). No. of bitstreams: 1 Seidinger_FlaviaMachado_M.pdf: 3514258 bytes, checksum: e2c1eb6f42762328f4418b07c0f0199e (MD5) Previous issue date: 2014 / Resumo: O abandono do tratamento, questão cara à saúde pública, constitui preocupação nos transtornos alimentares, pelos altos índices, bem como pelos resultados insatisfatórios no tratamento e pela gravidade do quadro. O presente estudo teve por objetivo compreender o fenômeno do abandono do tratamento ambulatorial nos transtornos alimentares a partir dos significados atribuídos por pacientes que vivenciaram tal experiência. Utilizando-se do método clínico-qualitativo, entrevistas em profundidade orientadas por roteiro semiestruturado foram colhidas, gravadas e transcritas na íntegra. Oito pacientes com ?18 anos que abandonaram o tratamento especializado em ambulatório de hospital universitário público compõem amostra fechada por critério de saturação dos dados. Foi pressuposto que o abandono do tratamento guardasse relação com aspectos psicológicos próprios a esses transtornos. A fundamentação teórica foi ancorada no referencial psicodinâmico, e os achados também são analisados à luz de revisão da literatura científica atual. Foram identificadas oito categorias de conteúdo originadas por enunciação, apresentadas em três grupos. Encontradas como denominadores comuns a todas as demais categorias, enquanto significados psicológicos do abandono para os participantes, as seguintes categorias dizem respeito à psicodinâmica ligada ao abandono, sendo, portanto, categorias centrais: 1.a) "Uma escravidão ao vício, compulsivamente" ¿ dimensão aditiva da anorexia e bulimia e 1.b) "Me senti abandonada, então abandonei" ¿ acting out da fantasia de abandono. Por sua vez, as categorias secundárias relacionam-se diretamente às centrais e revelam mecanismos que participam do fenômeno do abandono: 2.a) "Não gosto que as coisas saiam do meu controle" ¿ abandono como alívio, 2.b) "Anorexia é uma coisa para a vida inteira" ¿ apego/adesão ao sintoma e 2.c) "Eu me dei alta" ¿ melhora suficiente e cura. Por último, por corresponderem aos significados da faceta "tratamento" implicada no objeto "abandono", as categorias consideradas colaterais por serem relativas ao tratamento: 3.a) "No começo eu não aceitava como doença" ¿ negação inicial e superação, 3.b) "Um tratamento dentro do tratamento" ¿ lugar dado à palavra e 3.c) Da "aliança ao vício" à aliança terapêutica como laço. Os resultados confirmam pressuposto do estudo. Os significados revelam elementos simbólicos que permitem melhor compreensão do fenômeno e apontam proximidade às adicções. Dentre os aspectos psicodinâmicos destacam-se: dificuldades com o controle e no campo interpessoal, impulsividade e condutas atuadas; sugerem a importância do laço a ser construído com a equipe, no manejo clínico, inclusive nas recaídas, frente à dinâmica aditiva. Com possível impacto na adesão e nos resultados do tratamento, o estudo aponta ramificações e possibilidades para a terapêutica desta clínica carente de avanços / Abstract: Dropout, a relevant issue for public health, in the case of Eating Disorders is concerning due to the high rates, severity of disorders and poor outcomes. The present study aims at understanding outpatient treatment dropout in eating disorders from meanings attributed by patients to their dropout experiences. It was assumed that dropout could be related to psychological aspects of these disorders. It was conducted a qualitative study adopting the clinical-qualitative approach. The sample, set according to data saturation criteria included eight ?18 years old patients that dropped out of specialized outpatient treatment in a public university hospital. Eight semi-structured interviews have been collected in-depth recorded and fully transcribed. The theoretical basis is grounded in psychodynamic references and the findings are also analysed under the scope of current scientific literature review. Eight content categories originated by enunciation are analysed, clustered in three groups. Found as common denominators to other categories, as psychological meanings of drop out to participants, the following categories refer to the psychodynamic linked to drop out, thus being central categories: 1.a) "Enslavement to addiction (compulsively)" ¿ addictive dimension of anorexia and bulimia, and 1.b) "I¿ve felt abandoned, so I dropped out" ¿ acting-out the fantasy of abandonment. Secondary categories are directly related to the central ones and reveal mechanisms participating in the drop out phenomenon: 2.a) "I don¿t like if things get out of my control" ¿ dropout as relief, 2.b) "Anorexia is for life" ¿ attachment/adherence to the symptom and 2.c) "I¿ve discharged myself" ¿ sufficient improvement and cure. In a collateral plane, corresponding to meanings related to the "treatment" facet implicated in the object "dropout", there are the categories related to treatment: 3.a) "At first I didn¿t accept it as a disease" ¿ initial denial and overcoming, 3.b) "A treatment inside the treatment" ¿ the place given to the word and 3.c) From "alliance to addiction" to therapeutic alliance as a bond. The results confirmed the study¿s assumption. The meanings points symbolic elements that allow for a better comprehension of the phenomenon, revealing the proximity between addictions and psychodynamic aspects such as: interpersonal difficulties, impulsivity and acting out conduct. These suggest the importance of the therapeutic bond to be built with the treatment team, in clinical management, including relapse, in face of the addictive dynamics. The study signals ramifications and new possibilities to the clinical practice in eating disorders, with possible impact in compliance / Mestrado / Ciencias Biomedicas / Mestra em Ciências Médicas

Orientador: Egberto Ribeiro Turato / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-20T19:17:05Z (GMT). No. of bitstreams: 1 Campos_LiaKeuchguerianSilveira_M.pdf: 8034389 bytes, checksum: a01465db3be6cb1234ecc307cb5b3ab1 (MD5) Previous issue date: 2012 / Resumo: O presente estudo teve como objetivo conhecer as vivências emocionais das mães de adolescentes do sexo feminino, cujas filhas receberam o diagnóstico de anorexia nervosa e que estão em tratamento no Ambulatório de Transtornos Alimentares do Hospital das Clínicas da UNICAMP. Utilizamos o método clínico qualitativo, por meio de entrevistas semidirigidas em profundidade, em uma amostra intencional, fechada pelo critério de saturação, com sete mães de paciente com anorexia nervosa. As entrevistas foram feitas individualmente no Ambulatório de Transtornos Alimentares do HC UNICAMP. Cuidados éticos foram tomados seguindo as normas preconizadas pelo Conselho Nacional de Saúde. A técnica de tratamento de dados foi feita por meio da análise de conteúdo das entrevistas transcritas na íntegra e categorização. Os resultados foram submetidos à validação externa, junto ao Laboratório de Pesquisa Clínico-qualitativo do Departamento de Psicologia Médica e Psiquiatria da UNICAMP e na apresentação em congressos nacionais e internacionais. Os resultados possibilitaram identificar aspectos das mães das pacientes com anorexia nervosa que foram organizados em três categorias: Não diferenciação mãe-filha e falhas na comunicação; Quantidade versus qualidade; e Anorexia e oposição como um ataque. As mães das pacientes com anorexia nervosa propõem uma relação fusional na qual os aspectos da individualidade da filha ficam mal definidos e as tentativas de busca de individuação por parte das filhas são sentidas como um ataque e oposição aos cuidados maternos. As mães apresentam dificuldades em compreender as reais necessidades de suas filhas e tentam compensar deficiências qualitativas com quantidades, especialmente de alimentos e cuidados. Forma-se um círculo vicioso no qual a maternidade fica confundida com padrões rígidos de controle e de expectativas em relação à filha e as atitudes desta filha que sinalizam tentativas de individuação são sentidas como um ataque à mãe e sua devoção, o que leva as mães a recrudescerem os esforços no sentido de controlá-las e adequá-las ao padrão rígido proposto. Concluímos que os achados permitem contribuições para a ampliação dos conhecimentos e tratamentos da anorexia nervosa, ressaltando a necessidade do acompanhamento psicológico e psicoeducacional para as mães dessas pacientes / Abstract: The present study aimed to understand the emotional experiences of mothers of female adolescents whose daughters were diagnosed with anorexia nervosa and who are receiving treatment at the Out-patient Clinic for Eating Disorders at the University Hospital of UNICAMP. The Clinical Qualitative Method was used, through in-depth semi directed interviews, using an intentional sample, closed by saturation, with seven mothers of female patients with anorexia nervosa. The interviews were conducted individually in the Outpatient Clinic of Eating Disorders, HC UNICAMP. Ethical Care was taken following the ethical standards established by the National Council of Health. The technical data processing was done through the qualitative content analysis of the fully transcribed interviews and categorization. The emerging categories were validated by peer-reviewers from the Laboratory of Clinical-Qualitative Research, UNICAMP and presentation at national and international conferences. The findings made it possible to identify aspects in mothers of patients with anorexia nervosa which were organized in three categories: Non-differentiated mother-daughter and failures in communication; Quantity versus quality; e Anorexia and opposition as an attack. Mothers propose a fusional relationship with their daughters, in which the aspects of individuality are ill-defined. The daughters' attempts to become individuals are felt as an attack, and experienced by mothers as injustice and aggression. The mothers have difficulties to understand their daughters' logic and try to remedy a qualitative deficiency with quantity, especially of food and care. A vicious circle is formed, in which motherhood is confused with rigid control standards and expectations for the daughter and every attempt of the daughters to individualize are experienced by their mothers as an attack on the mother and on her devotion, which leads mothers to increase her offensive to make her daughter adapt to the model she is proposing. We concluded that the findings provide important contributions which can improve knowledge and clinical interventions to treat anorexia nervosa, emphasizing the need for psychotherapeutic and psycho-education for the mothers of these patients / Mestrado / Ciencias Biomedicas / Mestre em Ciências Médicas

M.A. / In this project the researcher explores, analyses and interprets the narratives of seven women who have recovered from anorexia and/or bulimia. The investigation is conveyed from the sufferers' point of view, an approach suggestive of a qualitative inquiry, and is formulated within a qualitative theoretical and methodological framework. Linear approaches like the medical model, that endorse a pathological view of mental and emotional problems, are challenged for contributing to the notion of a defect model of mental illness. The dominant view that psychological and emotional problems like physical illnesses should be treated and eradicated, is contextualised within the framework of a defect model of mental illness. The researcher proposes that this position disempowers the recipients of therapy, can become a self fulfilling prophecy, and ultimately furthers the argument that emotionally disturbed people are sick. Concepts from systems theory such as homeostasis and dialectic thinking, are cited to illustrate the rationale behind the notion of a `competency' model of mental illness. The continuance of either anorexic or bulimic behavior is seen as playing a central role in the maintenance of an equilibrium (albeit a painful one) in the sufferer's personal and family system - thus serving a purpose. The researcher subsequently proposes that it can be beneficial to view an eating disorder as a milestone, where from much good can be derived.

Orientador: Egberto Ribeiro Turato / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T23:55:56Z (GMT). No. of bitstreams: 1 GarciaJunior_Celso_D.pdf: 2283312 bytes, checksum: 66dc8e1447486f1382f2809c6b7a2a8a (MD5) Previous issue date: 2015 / Resumo: O presente estudo teve como objetivos compreender as experiências de vida dos genitores masculinos de pacientes adolescentes do sexo feminino em tratamento ambulatorial devido a um Transtorno Alimentar (TA) e entender como esses homens vivenciaram o impacto do TA de suas filhas em suas próprias vidas, desde o início da doença até o desenrolar do tratamento a que elas se submeteram no Grupo Interdisciplinar de Assistência e Estudos em Transtornos Alimentares (GETA) da UNICAMP. Foi utilizado o método clínico-qualitativo, através de entrevistas semidirigidas de questões abertas em uma amostra intencional que foi fechada pelo critério de saturação de informações. Doze indivíduos foram entrevistados individualmente no ambulatório de psiquiatria do Hospital das Clínicas da UNICAMP, onde as atividades do GETA são desenvolvidas. Cuidados éticos foram tomados seguindo as normas preconizadas pelo Conselho Nacional de Saúde. A técnica de tratamento de dados foi feita através da análise de conteúdo das entrevistas transcritas na íntegra e categorização. Os resultados foram submetidos à validação externa, por meio de discussão com os membros do Laboratório de Pesquisa Clínico-Qualitativa do Departamento de Psicologia Médica e Psiquiatria da UNICAMP e na apresentação em congressos nacionais e internacionais. Os resultados permitiram compreender que os entrevistados passaram pela infância e adolescência à deriva, devastados pelo trabalho infantil e buscavam desesperadamente pela atenção do pai distante afetivamente. Esses indivíduos mostraram-se com dificuldades em lidar adequadamente com situações de angústia e conflito e sentiam-se distantes de suas filhas. Os primeiros sintomas do TA foram minimizados pelos participantes. Com o agravamento do quadro, os pais vivenciaram sentimentos de tristeza, frustração, medo da morte da filha, culpa, impotência e desesperança. Os entrevistados foram capazes de reconhecer, com satisfação, os progressos obtidos a partir do tratamento e perceberam que, depois do TA, passaram a conversar mais com suas filhas. Aparentemente, o TA serviu como um caminho de aproximação na relação pai-filha. Nossos achados contribuíram na ampliação dos conhecimentos na área e podem ter aplicação na melhora da prática clínica no campo dos transtornos alimentares / Abstract: The present study aimed to understand life events reported by fathers of female adolescents with eating disorders (ED) in outpatient treatment and understand fathers¿ perceptions about the impact of having a daughter with an ED, since the symptoms onset. The Clinical-Qualitative method was used, through in-depth semi-structured interviews, using an intentional sample, closed by saturation criterion. Twelve participants were interviewed at the outpatient psychiatry unit of the Clinical Teaching Hospital at the State University of Campinas (UNICAMP), where Eating Disorders¿ Clinical and Research Program (GETA) activities are developed. Ethical procedures were taken following the ethical standards established by the National Council of Health. Data analysis was performed through the qualitative content analysis of the fully transcribed interviews and categorization. Peer-reviewers members from the Laboratory of Clinical-Qualitative Research (UNICAMP) validated the emerging categories, as also the attendees of national and international conferences where the results were presented. The findings made it possible to understand that the participants were adrift in their childhood and adolescence, devastated by child labor. They desperately sought attention without achieving a secure, affective contact with their affectively distant, hardworking father. These individuals showed difficulties in dealing adequately with situations of anguish and conflict. They felt distant from their daughters and had the sensation of impotence when faced with their daughter¿ problems. They minimized the early ED symptoms but feelings of sadness, frustration, fear of the daughter¿s death, self-guilty, powerlessness and helpless emerged, as the eating symptoms worsened. The fathers could recognize treatment benefits and perceived that they got able to improve the relationship with their daughter. Apparently, ED has functioned as a path to an improvement of the father-daughter relationship quality. Our findings can contribute to the expansion of knowledge in the area and may have application in improving clinical practice in the field of ED / Doutorado / Saude Mental / Doutor em Ciências Médicas

Bakgrund Ätstörningar är idag vanligt förekommande och betraktas som ett betydande hälsoproblem. Uppskattningsvis lider tio procent av unga kvinnor av någon form av ätstörning. Ätstörningar kännetecknas av att relationen till och synen på mat blivit osund och har ofta ett långdraget sjukdomsförlopp med såväl medicinska som psykologiska komplikationer. Anorexia nervosa är den mest efterforskade typen av ätstörning och den psykiska sjukdom med starkast koppling till förtida död. Behandlingen utförs i multiprofessionella team där sjuksköterskans specifika kompetens och ansvarsområde är evidens- och personcentrerad omvårdnad. I dagsläget saknas nationella riktlinjer för behandling av ätstörningar även om det finns specialiserad ätstörningsvård. Syfte Syftet var att undersöka hur patienter diagnostiserade med anorexia nervosa upplever omvårdnad och behandling. Metod Den metod som användes var en icke-systematisk litteraturöversikt. En sammanställningav relevant befintlig forskning gjordes för att undersöka patienters upplevelser av vården vid anorexia nervosa. Sökningar efter vetenskapliga artiklar genomfördes i databaserna PubMed ochCinahl. En integrerad analys genomfördes och det insamlade materialet presenterades i olika kategorier. Resultat  Tre övergripande kategorier som belyste patienters upplevelser av behandling, behandlare och vårdmötet identifierades. Skapandet av behandlingsallians och patientens möjlighet att påverka behandlingen belystes i flera studier och beskrevs påverka behandlingsutfallet positivt. Flera studier beskrev även behandlarens karaktärsdrag och beteenden samt hur dessa kunde påverka såväl behandling som alliansskapandet. Resultatet kopplades till KASAM då flera möjligheter att stärka patientens upplevelse av meningsfullhet, begriplighet och hanterbarhet beskrivs. Slutsats Det finns ingen entydig faktor som främjar behandlingen vid anorexia nervosa, snarare samverkar ett flertal faktorer i behandlingen. Med mer omfattande kunskap om dessa faktorer kan behandlaren med större framgång stötta patienter i sitt tillfrisknande. / Background Eating disorders are common today and are considered a significant health problem. An estimated ten percent of young women suffer from some form of eating disorder. Eating disorders are characterized by the relationship to and view of food becoming unhealthy and often has a long course of illness with both medical and psychological complications. Anorexia nervosa is the most researched type of eating disorder and the mental illness with the strongest link to premature death. The treatment is performed in multi-professional teams where the nurse's specific competence and area of responsibility is evidence- and person-centered nursing. At present, there are no national guidelines for the treatment of eating disorders, even though there is specialized care for eating disorders. Aim The aim was to explore how patients diagnosed with anorexia nervosa perceive care and treatment. Method The method used was a non-systematic literature study. A compilation of existing, relevant research was made with the aim of studying the care that patients with anorexia nervosa receive. Searches for scientific articles were conducted in the databases PubMed and Cinahl. An integrated analysis was implemented and the gathered material was presented in categories. Results Three main categories emerged that highlighted the patients experiences of the treatment, the caregiver and the encounter with care. The formation of treatment alliances and the patient’s ability to influence the treatment was highlighted in multiple studies and was described as having a positive effect on the treatment outcome. Several studies also described the caregiver’s characteristics and behaviors, as well as how these might affect the treatment as well as the formation of alliances. The result is linked to SOC, as several opportunities to increase the patient’s sense of meaningfulness, comprehensibility and manageability are described. Conclusions There is no unequivocal factor which improves anorexia nervosa treatment, rather a number of interacting factors in the treatment. With more extensive knowledge of these factors, the caregiver can more successfully support patients in their recovery.

Bakgrund: Ätstörningen anorexia nervosa innebär en intensiv rädsla för viktuppgång, som resulterar i att den som insjuknat successivt förlorar kroppsvikt genom att försätta kroppen i svält. Sjuksköterskans centrala roll i omvårdnaden av patienter med anorexia nervosa är att förmedla hopp, samt bemöta patienter med öppenhet, trygghet, respekt och förståelse. Syfte: Syftet var att beskriva kvinnors upplevelser av att leva med anorexia nervosa. Metod: Metoden omfattar en systematisk litteraturstudie där dataanalysen utfördes genom att identifiera kategorier och meningar i resultatartiklarnas textinnehåll, som svarade på studiens syfte. Resultat: Vid granskning av resultatartiklarnas förekommer ett tydligt mönster av återkommande beskrivningar av hur kvinnor med anorexia nervosa upplever sin livsvärld. Kvinnors upplevelser av att leva med anorexia nervosa utgjordes av tre övergripande kategorier: “en strategi för att hantera livets negativa känslor och upplevelser”, “den inre konflikten och inre rösten” och “självhat”. Konklusion och implikation: Ett patientperspektiv skapar förutsättning att utveckla sjuksköterskans medvetenhet och kunskap om ätstörningens psykologiska och emotionella aspekter. Det skapar förutsättning att utföra en personcentrerad omvårdnad utifrån patientens upplevelser, behov och förutsättningar. / Background: The eating disorder anorexia nervosa is an intense fear of gaining bodyweight, causing the patient to successively lose weight by starvation. The central role of the nurse in treatment of anorexia nervosa is to convey hope, and to meet the patient with openness, safety, respect, and understanding. Aim: The purpose was to describe the experiences of women living with anorexia nervosa. Method: A systematic study of literature was conducted by identifying categories and reoccurring phrases in article contents that relate to the study’s purpose. Results: The reviewed articles show a clear pattern of reoccurring descriptions of the experiences of women living with anorexia nervosa. These experiences can be classified into three main categories: “a strategy for dealing with negative feelings and experiences”, “the inner voice and conflict”, and “self-hatred”. Conclusion and implication: A patient perspective creates the conditions for developing the nurse's awareness and knowledge of the psychological and emotional aspect of the eating disorder. It creates the conditions to perform a personcentred care on the patient's experiences, needs and basis.

Laut S3-Leitlinie zur „Diagnostik und Therapie der Essstörungen“ (AWMF, 2019) ist bei PatientInnen mit Anorexia nervosa (AN) eine zeitnahe Aufnahme einer Therapie wesentlich. Dabei stehen die Normalisierung des Essverhaltens sowie des Gewichtes im Vordergrund. Dennoch ist die Heilung von AN meist mit vielen Therapien und Krankenhausaufenthalten verbunden, nicht zuletzt aufgrund der recht hohen Therapieabbruchrate. Kliniker und Forscher sind daher bemüht Prädiktoren für den Therapieverlauf von AN-PatientInnen zu finden, um den Verlauf bei RisikopatientInnen besser steuern und gestalten zu können. Die Ableitung allgemeingültiger Regeln ist aufgrund der meist geringen Stichprobengröße sowie variierender methodischer Vorgehensweisen bislang jedoch noch nicht möglich gewesen. Die vorliegende Arbeit überprüft, inwiefern sich schon diskutierte Prädiktoren im Behandlungsverlauf der AN identifizieren und zur Erstellung eines Prädiktorenmodelles für den Therapieerfolg (BMI≥19kg/m2) bzw. Therapieabbruch eignen. Ein weiteres Ziel der vorliegenden retrospektiven-naturalistischen Studie ist die Evaluation einer stationären psychosomatischen Behandlung von Patientinnen mit Anorexia nervosa in der Klinik für Psychotherapie und Psychosomatik (PSO) des Universitätsklinikums Carl Gustav Carus in Dresden. Dazu wurden die Daten von N = 75 weiblichen anorektischen Patientinnen einbezogen, die im Zeitraum von 2015-2019 länger als zwei Wochen an dem kognitiv-verhaltenstherapeutischen Phasenessprogramm der PSO teilgenommen haben. Es zeigte sich, dass das Phasenessprogramm insgesamt eine hohe Effektstärke bzgl. der Gewichtszunahme aufweist und damit als wirksam eingestuft werden kann. Relativiert wird dieser Effekt durch die vielen vorzeitigen Therapiebeendigungen, wodurch insgesamt bei weniger als der Hälfte der Patientinnen eine Gewichtsnormalisierung realisiert werden konnte. Für den Therapieerfolg konnte im Rahmen dessen ein Prädiktorenmodell erstellt werden, welches eine höhere Therapieerfolgschance je BMI-Punkt bei Aufnahme, sowie beim Fehlen einer komorbiden affektiven Störung vorhersagt. Für einen Therapieabbruch konnte lediglich der BMI bei Aufnahme als Prädiktor identifiziert werden. Das Ableiten eines allgemeingültigen Prädiktorenmodells für den Therapieverlauf bei AN scheint daher nur begrenzt möglich. Es scheint vielversprechender zu sein, individuelle Indikatoren zu suchen, um frühzeitig auf RisikopatientInnen eingehen zu können und gemeinsam adäquate Therapieziele zu entwickeln, um somit langfristig die Motivation sowie die Selbstwirksamkeit der Patientinnen zu stärken und aufrecht zu erhalten. / According to the S3-guideline on 'Diagnosis and Therapy of Eating Disorders' (AWMF, 2019), it is essential for patients with anorexia nervosa (AN) to start therapy as soon as possible. The normalization of eating behavior and weight is of primary importance. Nevertheless, the cure of AN is usually associated with many therapies and hospital stays, not least because of the rather high therapy discontinuation rate. Researchers are therefore trying to find predictors for the course of therapy of AN patients in order to be more able to control and shape the course of therapy, especially in high risk patients. However, the derivation of generally valid rules has not yet been possible due to the usually small sample size and varying methodological procedures. The present study examines the extent to which predictors, that have already been discussed (elsewhere), can be identified during treatment and are suitable for creating a predictor model for the success of therapy (BMI≥19kg/m2) or for discontinuation (drop out) of therapy. A further aim of the present retrospective-naturalistic study is the evaluation of an inpatient psychosomatic treatment for patients with anorexia nervosa in the Clinic for Psychotherapy and Psychosomatics (PSO) of the University Hospital Carl Gustav Carus in Dresden. Data from N = 75 female anorexic patients who participated in the cognitive-behavioral “phase- program” of the PSO for more than two weeks in the period 2015-2019 were included. It was shown that the “phase-program” has a high overall effect strength with regard to weight gain and can therefore be classified as effective. This effect is put into perspective by the many premature terminations of therapy, whereby a normalization of weight was achieved in less than half of the patients. For the success of the therapy, a predictor model was developed which predicts a higher chance of success per BMI point on admission and the absence of a comorbid mood disorder. For a therapy discontinuation, only the BMI at admission could be identified as predictor. Therefore, the derivation of a generally valid predictor model for the course of therapy in AN seems to be possible only to a limited extent. It seems to make much more sense to look for individual indicators in order to be able to respond to at-risk patients at an early stage and to jointly develop adequate therapy goals in order to strengthen and maintain the motivation and self-efficacy of patients in the long run.

As social beings, we are constantly confronted with psychosocial stressors (e.g., social evaluation, exclusion, achievement and / or performance; Dickerson & Kemeny, 2004; Kirschbaum et al., 1993; Pruessner et al., 2003), which significantly affect the neuroendocrine (HPAA) and autonomic (ANS) function (Chrousos, 2009; Foley & Kirschbaum, 2010; Mohammadi et al., 2019). In a prolonged fashion and in the lack of habituation, chronic stress leads to cortisol hypersecretion, posing a risk for the development of Hypothalamic-PituitaryAdrenal Axis (HPAA) hyporeactivity. At the same time, this represents a vulnerability for the development of somatic and psychiatric conditions (Chrousos, 2009; McEwan, 1998, 2004; Fries, et al., 2005; Heim et al., 2000; Herman et al., 2005). In this regard, response parameters of the HPAA (e.g., cortisol) and the ANS (e.g., Heart rate variability) are paramount in studying the relationship between reactivity and health/illness (Chrousos, 2009; McEwen, 1998). For example, individuals with psychiatric conditions, such as eating disorders (EDs), exhibit hyporesponsiveness of the stress networks, which is associated with dysregulated biomarkers (Het et al., 2020; Monteleone et al., 2010; 2018a, 2018b; Støving, 2019). Among EDs, Anorexia nervosa (AN) records the highest mortality rate (Arcelus et al., 2011; Erskine et al., 2016; Moskowitz & Weiselberg, 2017) and displays a range of ANS and HPAA irregularities, e.g., bradycardia, hypercortisolemia (Gibson et al., 2020; Giovinazzo et al., 2019; Katzmann, 2005; Mazurak et al., 2011; Miller et al., 2013; Sauro et al., 2008). Maintenance of underweight and fear of weight gain despite being underweight (BMI < 17.5 kg/m2) are typical characteristics (DSM-V, APA, 2013). Treatment outcomes are poor (Harbottle et al., 2008; Murray et al., 2019; Watson & Bulik, 2013) and the disease burden for patients and health care substantial (Schmidt et al., 2016). Therefore, innovative and effective treatments are urgently needed. Concerning onset and maintenance, psychosocial stress has been frequently investigated (Caglar-Nazali et al., 2014; Monteleone et al., 2011, 2018b; Wierenga et al., 2018). Patients commonly showed deficient social skills and higher negative affect accompanied by hyporesponsiveness to psychosocial stress (Het et al., 2015, 2020; Monteleone et al., 2011; 2018b; Putigiano et al., 2001; Vocks et al., 2007; Zonevylle-Bender et al., 2015). However, experimental and controlled studies on the neuroendocrine and autonomic reactivity are underrepresented and ambiguous in PAN. Accordingly, the following investigations address this research gap. Objectives and Method: In order to expand ED-specific data and foster understanding at the psychological and physiological level, the stress response to a psychosocial stressor was investigated in a sample of patients with anorexia nervosa (PAN) which was age- and gender-matched to healthy controls (HC), under highly14 standardized conditions. For this purpose, biomarkers such as salivary cortisol (Study 1), heart rate (HR) and heart rate variability (HRV; see Study 2/Table 1) were assessed in a crosssectional study design under two experimental conditions: 1) rest and 2) stress (see Figure 1/Study 1-2). In addition, psychological stress indicators (PASA, VAS, TICS) and symptoms were analyzed (e.g., SCL-K-9, BDI, EDI). Based on previous evidence, elevated cortisol levels and bradycardia at rest were expected in PAN (vs. HC). A stress hyporeactivity in the examined biomarkers was hypothesized in PAN (vs. HC). Additionally, a reduced sympathetic (SNS) and pronounced parasympathetic (PNS) activity and reactivity was assumed in PAN (vs. HC). Furthermore, a regulation of the HPAA functionality regarding total cortisol expression (AUCG) and reactivity with weight recovery in PAN was postulated. Secondarily, BMI (kg/m2) was analyzed in relation to the derived biomarkers and psychological measures of concern.