Hetsätningsstörning är en av de vanligaste ätstörningarna i USA och antalet patienter med hetsätningsstörning ökar konstant. Flertalet patienter väljer att avsluta sin behandling kort efter att de påbörjat den. Anledningen är vanligtvis att relationen mellan sjuksköterska och patient inte fungerat, eller att behandlingen inte är lättillgänglig för patienten. Syftet var att undersöka patientens upplevelse av vård vid hetsätningsstörning. Detta för att öka kunskapen om hur vården uppfattas från patientens perspektiv och för att förbättra vården inom denna sjukdom. Resultatet visade att patienter som drabbats av hetsätningsstörning ansåg att vården var för oböjlig och inte tillräckligt individanpassad. Patienterna menade även på att sjuksköterskan inte alltid verkade förstå deras känslor och tankar de hade kring hetsätningen. Det ansågs positivs att ha en kontaktperson som redan genomgått behandling som komplettering till den standardiserade vården för sjukdomen. Personcentrerad vård och en möjlighet för patienten att sätta upp sina egna mål i behandlingen samt en god kommunikation mellan sjuksköterska och patient ansågs vara de viktigaste åtgärderna för att åtgärda problemen som uppstår när en patient med hetsätningsstörning söker vård. / Binge eating disorder is one of the most common eating disorders in the USA and the number of patients suffering from the disease is constantly increasing. Many patients choose to refrain from treatment shortly after it’s begun. The cause for this is usually due to a poor relationship between the nurse and the patient, or that the treatment is not easily accessible by the patient. The aim of the study was to investigate the patients experience of care when suffering from Binge eating disorder. The purpose of this aim was to increase the knowledge about how care is perceived by the patient as well as improve the care for the disorder. The result revealed that patients afflicted by Binge eating disorder considered the care too non-flexible and not adjusted to individual needs. The patients also mentioned that the nurse did not always understand their feelings and thoughts around binge eating. Having a contact person that had already undergone treatment was considered a positive experience. Person-centered care, the possibility for the patient to set up individual treatment goals as well as the communication between the nurse and the patient were considered the most important aspects when treating patients with binge eating disorder.

This thesis explores the decision making styles demonstrated by people with anorexia. It is presented as three papers: 1) a literature review; 2) an empirical study and 3) a personal reflection on the processes involved in conducting the research and critical appraisal of the issues which emerged. The literature review in Paper 1 systematically explored the existing research that examined decision making in disordered eating populations. Twenty seven papers were reviewed and their findings synthesised to develop a comprehensive overview of decision making across a spectrum of disordered eating populations. Parallels in decision making across diagnostic categories were identified, and the relationship between decision making and clinical, personality and demographic variables was also explored. Methodological quality of studies was reviewed; recommendations for future research were also identified. Broadly, the findings indicated that similar styles of decision making appear evident in anorexia and bulimia. No characteristically different decision making patterns were demonstrated by people with eating disorder-not otherwise specified or by people recovered from anorexia. The evidence regarding nature of decision making in obesity and binge eating disorder was less conclusive. The empirical study conducted in Paper 2 endeavoured to enhance our understanding of the nature of decision making in disordered eating. The study examined a specific decision making bias i.e. the ‘jumping to conclusions’ bias in people with anorexia. The study also explored whether eating disorder related beliefs in anorexia could be considered to be of ‘delusional’ proportions. The results indicated that compared with a healthy control group, people with anorexia did not display a ‘jumping to conclusions’ bias. They did not display a tendency to make decisions on the basis of little evidence. The majority of individuals with anorexia did demonstrate limited insight into their eating disorder related beliefs, though only a minority subgroup held beliefs that could be considered ‘delusional’. Methodological limitations and clinical implications of the findings are discussed. The third paper provides a personal and critical reflective account of the processes involved in conducting both the literature review and the scientific study. It critically appraises aspects of the research process including strengths and limitations of both studies. Implications for clinical practice, replication and directions for future research are also identified. This paper also includes personal reflections on the approaches used and the challenges encountered within these.

The current dissertation is comprised of two studies that examined the relationship between group dynamics, attachment anxiety, and post-treatment outcomes in a sample of women (N = 102) with binge eating disorder (BED) who received Group Psychodynamic Interpersonal Psychotherapy. The first study explored the relationship between the development of group cohesion, the individuals’ level of attachment anxiety, and frequency of binge eating, symptoms of depression, and self-esteem at post-treatment. The second study explored the relationship between the interpersonal learning, individuals’ level of attachment anxiety, and outcomes. Interpersonal learning was conceptualized as the convergence between multiple perspectives of group cohesion: one’s own and the group’s perception of one’s cohesion to the group. Parallel measures of individual self-rated cohesion (CQ-I) and mean group-rated cohesion (CQ-G) were developed based on the original Cohesion Questionnaire (CQ; Piper et al., 1983) for this study. Participants were assigned to homogeneous groups composed of either high or low attachment anxiety to assess the impact of pre-treatment attachment anxiety. Findings indicated significant growth in cohesion over time, and a significant convergence in multiple ratings of cohesion. These processes did not differ significantly based on level of attachment anxiety. Growth in cohesion was related to greater reductions in binge eating for those high in attachment anxiety, while the convergence in ratings of cohesion (i.e., interpersonal learning) was related to improvements in self-esteem for individuals in both attachment anxiety conditions. The findings support the importance of group interventions for BED that are sensitive to individuals’ attachment anxiety, and that emphasize cohesiveness, and interpersonal learning to improve outcomes.

The thesis sought to explore the experience of caring for an individual with an eating disorder. It is comprised of three standalone papers. Paper one and two have been prepared for submission to a journal and in accordance with the journal guidelines. Paper one is a systematic literature review synthesising qualitative studies relating to the experience and impact of caring for, or living with an individual with an eating disorder. Databases were systematically searched and twenty studies were included in the review. Nine core themes emerged from the meta-synthesis. Eating disorders were found to have a pervasive impact on family members mediated by a number of factors. Cognitive appraisals affected the caregiving experience and responses to the individual. The experience of caregiving was continually reappraised leading to a process of adaptation over time. Paper two is a qualitative study which sought to examine caregivers’ accounts of managing Anorexia Nervosa with an emphasis on accommodation responses. Eight participants were interviewed and transcripts were analysed using a grounded theory approach. A theory of the processes by which accommodation responses operate was developed which emphasised the importance of caregivers’ emotional resources in mediating responses. Difficulty managing anorexia nervosa led to low perceived efficacy and diminished resources. Subsequently caregiving aims shifted in line with accommodation responses. Carers recognised accommodation as counterproductive to recovery and experienced internal conflict (dissonance) which was reduced using a number of cognitive and behavioural strategies. The clinical implications of the findings are discussed with reference to existing literature. Paper three is a critical review of the research process, focusing on the experience of undertaking qualitative research. Personal reflections of the process, as well as the implications of the research for the researcher’s professional practice and for the wider profession are discussed.

Forskning tyder på att 200 000 personer i Sverige drabbas av en ätstörning någon gång under livet. Studiens syfte var att utforska behandlingen mot ätstörningar och de erfarenheter som patienter och deras anhöriga upplevt genom bemötande och delaktighet i vården och den inverkan de fått på deras tillfrisknad. Semistrukturerade intervjuer genomfördes med fem tidigare ätstörningspatienter och två anhöriga. Data analyserades med hjälp av tematisk analys. Av resultatet framkom ett övergripande tema: Se hela mig - kropp och själ hör ihop samt sex underteman: styrande stereotypa föreställningar, den stereotypa bildens följder, tillit och misstro, kompetens påverkan relationella band, medbestämmande och samverkan, maktobalans. Deltagarna saknade behandling för de tankar och känslor som upprätthåller ätstörningen. Auktoritära tillvägagångsätt främjade inte arbetsallians eller delaktighet. Deltagarna upplevde att utebliven psykologisk behandling orsakat att de fortsatt levt med negativa tankar och beteenden som mer eller mindre vidmakthållit ätstörda beteenden. Utifrån deltagarnas önskemål och beskrivningar av brister förefaller det behövas kompetenshöjande insatser kring bemötande i behandlingen av ätstörningar.

This study examined some of the procedures used in eating disorder research. Body size estimation procedures, in light of their similarity to procedures in social psychology, were used to create self-focus and selfconsciousness conditions. If the procedures in the present study create self-consciousness effects, it is possible that the results of those studies have been affected by a heightened state of self-awareness. The present research also explored the relationships between self-consciousness, self-esteem, body esteem, body perception, and eating disorder proneness. The research was conducted with a nonclinical sample from a university population, controlling for age and body development factors. Baseline and experimental measures of objective self-awareness and body size perception were taken. The experimental conditions consisted of the presence of a) a VCR and mirror and b) an observer who was rating the subject. The third condition was a control setting that replicated the baseline setting. The sample was also tested at the posttest for self-esteem, body esteem, and eating disorder proneness. The results indicate that the subjects reported no significant changes in self-consciousness or body size estimates, suggesting that something besides the presence of equipment influences whether or not one feels selfconscious. This idea has been borne out in other research that implicates self-esteem as a major consideration in whether or not an individual feels self-conscious in certain situations (that is, that low self-esteem appears to increase one's amenability to induce self-consciousness). Another primary factor is that self-consciousness cannot be induced when the individual is interested in the task. Subjects in the present study indicated that they found the tasks inherently interesting and forgot about the presence of equipment and observers once they began thinking about the questions posed to them. In the present research, selfesteem and body esteem were both found to be negatively related to self-consciousness, while eating disorder proneness was found to be positively related to selfconsciousness. The results are discussed in light of these connections, and suggestions for future research are provided.

This present study examined the session-by-session content of group therapy for eating-disordered clients. The main objective of this study was to identify how therapist-client gender match affects group therapy process , regarding the disclosure of important issues relevant to eating-disordered clients. It was hypothesized that the group therapy process for eating-disordered clients would be qualitatively different if therapy was facilitated by a female as opposed to a male therapist. The evaluation of the research question required using an alternating treatments single-subject research design, in which the presentation of treatment conditions was counterbalanced across two therapy groups. The treatments consisted of three therapist conditions (i.e., male therapist only, female therapist-only, or both therapists) that were systematically presented during the study. All group-therapy sessions were videotaped and coded for verbal content. The results suggested that when a female therapist alone was leading group therapy sessions, eating-disordered clients were more inclined to discuss general emotional issues and specific issues involving negative affect. Furthermore, during the male therapist-only conditions, there was a tendency for female group members to talk more about the physical symptoms of eating disorders (i.e., food-related behaviors, body image issues). The relationship of these results regarding their practical implications on therapist knowledge, training, in-session behavior was discussed.

Background: Eating disorders as term includes several diagnoses that often result in serious conditions related to eating-habits, weight and body image. Early detection, confirmed diagnosis and initiated treatment significantly increases the chance of recovery. There is a lack of knowledge regarding how physiotherapists identify and treat eating disorders in primary care.  Objective: To examine the physiotherapists’ experiences of identifying and treating eating disorders as well as problems related to them, within primary care.  Methods: A qualitative method with semi structured interviews with five participants, based on convenience sampling was used. Qualitative content analysis was used for data analysis.  Results: This study showed experienced difficulty in both identifying and treating eating disorders among physiotherapists. They pointed out that it was important to have an awareness about the diagnoses, and that plenty of different factors can complicate the process of identifying them. They also experienced an uncertainness regarding the role of the physiotherapist. Treatment was described to be individualized and applied with a biopsychosocial approach.  Conclusion: Eating disorders and problems related to them were experienced as complicated and hard to treat. This study shows an uncertainness regarding the role of the physiotherapist when it comes to these patients. Previous research indicates that physiotherapeutic methods could have a positive effect as a part of the treatment. However, further research and knowledge are needed to establish the utility of physiotherapy when it comes to eating disorders in primary care. / Bakgrund: Begreppet ätstörningar inkluderar ett flertal diagnoser och tillstånd som ofta leder till allvarliga tillstånd kopplade till ätbeteende, vikt och kroppsuppfattning. Tidig upptäckt, ställd diagnos och påbörjad behandling ökar chansen för tillfrisknande hos drabbade individer. Det finns en tydlig kunskapslucka i hur fysioterapeuter upptäcker och behandlar ätstörningar inom primärvården.  Syfte: Att undersöka fysioterapeuters upplevelser och erfarenheter av att upptäcka och behandla ätstörningar samt problem relaterade till dessa inom primärvården.  Metod: I studien användes kvalitativ design i form av semistrukturerade intervjuer med fem deltagare utifrån ett bekvämlighetsurval. Databearbetning utfördes genom kvalitativ innehållsanalys.  Resultat: Studien visade att fysioterapeuter upplevde att det var svårt att upptäcka och behandla ätstörningar. De påpekade att det var viktigt att ha en medvetenhet om sjukdomarnas existens och att många olika faktorer kan försvåra identifieringen. De upplevde också en oklarhet i om fysioterapeuten bör ha en aktiv roll i efterföljande behandling. Gällande behandlingen fanns uppfattningen att den bör individanpassas och tillämpas med ett bio- psyko-socialt synsätt.  Slutsats: Ätstörningar och problem relaterade till dessa upplevs i många fall komplicerade och svårbehandlade. Studien visar på en osäkerhet i vilken roll fysioterapeuten bör ta vid mötet av dessa patienter. Tidigare forskning tyder på att fysioterapeutiska åtgärder kan ha en positiv inverkan på behandlingen. Ytterligare forskning och kunskap behövs dock för att tydliggöra fysioterapeutens roll och kompetens gällande ätstörningar inom primärvården.

Research on influences of eating disorders have informed diagnosis and treatment of eating disorders, particularly for White cisgender women. A Perfect Biopsychosocial Storm is a theory of influences of disordered eating development: sociocultural influences of rigid body shape and size ideals, high rates of trauma and violence, experiences of objectification and sexualization, and biological changes (Maine & Bunnell, 2010). For transgender individuals, recent findings suggest disparities and negative mental health outcomes such as elevated prevalence of disordered eating, body image concerns, and self-reported disordered eating. For transgender men and women, researchers found that disordered eating may be related to attempts to masculinize/feminize the body, through effects like suppression of weight and secondary sex characteristics. For nonbinary individuals, motivations are unclear regarding masculinization/feminization. Further, while previous research has implicated experiences of marginalization in reduced body appreciation, impact on disordered eating behaviors in nonbinary individuals have yet to be explored. This study addressed gaps in research regarding experiences of nonbinary individuals with disordered eating. Through Grounded Theory qualitative analysis, I developed a framework to understand disordered eating among nonbinary individuals. Disordered eating was the surface-level manifestations of experiences such as trauma, distress surrounding bodily changes in puberty, and marginalization. Repeated marginalization, like misgendering and identity erasure, created conditions of shame to be associated with identity and self. Shame is a universal emotion that occurs when one does something they perceive as social transgressive and, thus, prevents connection. Shame motivates individuals to reduce socially transgressive behavior to increase connection with others. When one experiences marginalization and repeated shame surrounding identity, identity and self then can be experienced as a social transgression that prevents belonging. For example, participants described feelings of shame in comparison to the stereotypical image of a nonbinary person (White, masculine-leaning/androgynous, thin, tall). Disordered eating facilitated emotional coping, and, for some participants, helped achievement of gender presentation. Disordered eating also was associated with consequences of further shame around eating behaviors, and feelings of lack of control. Recovery and healing was supported through combating shame and disempowerment: being seen and empowerment through choice.

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