Os transtornos alimentares (TA) são doenças graves de etiologia multifatorial, que cursam com alterações importantes no comportamento alimentar e complicações clínicas como desnutrição e distúrbios hidroeletrolíticos, além de comorbidades psiquiátricas. A hospitalização integral é uma modalidade terapêutica indicada quando o seguimento ambulatorial não atinge resultados satisfatórios associados à piora dos sintomas. O objetivo deste estudo foi descrever as características e resultados da hospitalização dos pacientes com TA atendidos pelo Grupo de Assistência em Transtornos Alimentares do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto-USP. Dados antropométricos, bioquímicos e clínicos foram coletados a partir da revisão de prontuários dos pacientes internados durante o período de 1982 a 2011. Como resultado, observou-se que das 186 pessoas que receberam atendimento pelo serviço, 44,6% deles (n=83) necessitaram de no mínimo, uma internação durante o tratamento. A predominância foi do sexo feminino (95,2%), da raça branca (94%), solteira (76%) e sem filhos (78,3%). Cursavam o ensino médio (50,6%) com idade de 23,3±10,8 anos. O diagnóstico era de anorexia do tipo restritivo (AN-R) para 54,2% (n=45) deles, 31,3% (n=.26) apresentavam anorexia do subtipo compulsão periódica/purgativo (AN-CP) e 14,5% (n=12) tinham bulimia nervosa (BN). A média de internações foi de 1,9±3,9 vezes sendo que 73,5% (n=61) dos pacientes foram internados apenas uma vez, por 41,2±37,6 dias. Para aqueles que precisaram dessa modalidade de tratamento por mais de uma vez, a duração da hospitalização, considerando todas as internações, foi de 70,6±115,9 dias com extensa variação (3 a 804 dias). Não foi observada associação entre o número de internações com o Índice de Massa Corporal (IMC) e com o tempo de sintomas antes do diagnóstico. O IMC dos pacientes mudou significativamente (p<0,05) durante a internação (para o grupo com AN-R: de 13,5kg/m2 para 14,8kg/m2 ; para os com AN-CP: de 15,7kg/m2 para 16,9kg/m2 ; naqueles com BN: de 22,0kg/m2 para 21,0kg/m2 ). A amenorréia esteve presente em 69% (n=45) das mulheres, sendo mais frequente naquelas com AN-R (65,1%). Dos 23 pacientes (27,7%) que realizaram o exame de densitometria óssea, 44,4% (n=10) apresentam osteopenia e 29,7% (n=7) osteoporose. Os valores médios da maioria dos parâmetros bioquímicos avaliados estavam dentro da normalidade, com exceção do beta-caroteno, que encontrava-se elevado, tanto no início quanto no final da internação. A Nutrologia foi a enfermaria na qual a maioria das internações ocorreu (79,5%) e a necessidade de terapia nutricional foi a indicação mais frequente (62,3%). A via de administração de nutrientes preferencialmente utilizada foi a via oral (67,5%), apesar de ter sido observado aumento de 2,3 vezes na escolha da terapia nutricional enteral exclusiva nos pacientes que foram internados mais de uma vez. O acompanhamento multidisciplinar foi evidenciado, pois além do médico, houve a participação maciça de nutricionistas (87,9%) e psiquiatras (72,3%). Como conclusão, a hospitalização integral é uma modalidade bastante indicada no tratamento de pacientes com TA, mas sua duração é prolongada e requer a assistência de diversos profissionais. No entanto, quando indicada a partir de critérios bem estabelecidos proporciona melhora no estado nutricional. Futuros estudos são necessários para ampliar e aprofundar os resultados encontrados possibilitando o aprimoramento de condutas terapêuticas. / Eating disorders (ED) are serious diseases with multiple etiologies that course with major changes in eating behavior and clinical complications such as malnutrition and electrolyte disturbances, and also psychiatric comorbidities. Inpatient treatment is a modality of treatment used when the outpatient follow-up did not reach satisfactory results associated with worsening of clinical status. The aim of this study was to describe the characteristics and outcomes of the hospitalization in patients with ED who were treated by Assistance Group on Eating Disorders from the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP. Anthropometric, biochemical and clinical data were collected from the medical records of patients admitted between 1982 and 2011. It was observed that among 186 patients attended by the service, 44.6% (n = 83) required at least one inpatient treatment. Most patients were female (95.2%) and white (94%). The majority was single (76%), with no children 78.3%) and were high school students (50.6%). The mean age was 23.3± 10.8 years old. According to the diagnosis, 54.2% of patients had anorexia nervosa, restricting subtype (AN-R), 31.3% had anorexia nervosa binge-eating/purging subtype (AN-CP) and 14.5% had bulimia nervosa (BN). The mean age at admission was 23.3 ± 10.8 years (range 8-58 years), 73.5% of patients were hospitalized only once. The mean number of admissions was 1.9 ± 3.9 times and 73.5% (n=61) were hospitalized only once, during 41.2 ± 37.6 days. For those who needed this type of treatment more than once, the length of stay, considering all admissions, was 70.6 ± 115.9 days with extensive variation (3-804 days). No associations were observed between the number of hospitalizations and Body Mass Index (BMI) and duration of symptoms before diagnosis. The BMI of the patients changed significantly (p <0.05) during hospitalization (for the group with AN-R, from 13.5 kg/m2 to 14.8 kg/m2 ; for AN-CP: 15.7 kg/m2 to 16.9 kg/m2 , those with BN: from 22.0 kg/m2 to 21.0 kg/m2 ). Amenorrhea was present in 69% (n = 45) women, most frequently in those with AN-R (65.1%). According to exam of bone densitometry of 23 patients (27.7%), 44.4% (n=10) had osteopenia and 29.7% (n=7) had osteoporosis. The mean values of most biochemical parameters were within normal limits, except for beta- carotene, which was above the normal range, both in admission and discharge. The Nutrology was the infirmary where the majority of hospitalizations occurred (79.5%), nutritional support was the most frequent indication for hospitalization (62.3%). The route of administration of nutrients preferably used was oral (67.5%), although it has been observed an increase at 2.3 times on exclusively enteral feeding in patients admitted more than once. The multidisciplinary team reveals, besides the doctor, the massive presence of dietitians (87.9%) and extensive involvement of psychiatrists (72.3%). It is concluded that inpatient treatment is needed in patients with ED, often shows prolonged duration and requires the assistance of various professionals. However, when indicated based on criteria well established can provide improvement in nutritional status. Future studies are needed to broaden the results enabling the improvement of therapeutic approaches.

The thesis has been prepared in paper based format and includes three papers: paper 1 is a literature review, paper 2 is an empirical study and paper 3 is a critical reflection. Paper 1 has been prepared for submission to Clinical Psychology and Psychotherapy and systematically reviews the qualitative literature pertaining to the process of recovery from anorexia nervosa (AN). A metasynthesis of 12 studies was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles. The metasynthesis identified factors that helped and factors that hindered recovery from AN, in addition to offering an interpretation of how these factors underpin the process of recovery. The strengths and limitations of the review are discussed, as are the implications of the findings for clinical practice. Paper 2 has been prepared for submission to the British Journal of Clinical Psychology and is a qualitative exploration of the nature of the relationship between the self and the eating disorder in individuals with a lifetime history of AN. Semi-structured interviews were conducted with 11 women and the interview transcripts analysed using constructivist grounded theory methodology. The results suggested that the self is shared with AN and separating the self from AN has an important role to play in recovery from the disorder. A theoretical framework explaining the nature of the relationship between the self and AN is presented and discussed. The strengths and limitations of the study are considered, as are the implications of the findings on the content of therapeutic interventions. Paper 3 is not intended for publication and is a critical reflection of the research process as a whole. It evaluates the strengths and limitations of both paper 1 and paper 2, in addition to offering a critical review of completing a qualitative research project. Paper 3 also discusses issues surrounding reflexivity, implications of the research for clinical practice/working as a clinical psychologist and draws overall conclusions.

Bakgrund: anorexia nervosa har under de senaste decennierna ökat i Sverige och liknande trend ses även i andra länder. Sjukdomens mångfacetterade och ibland svårförstådda natur baseras på dess upplevda för- och nackdelar. Behandling mot ätstörningar har förhållandevis hög andel som avslutar den i förtid och det påvisas att många uppvisar motvilja till att delta. Syfte: Syftet med studien var att belysa erfarenheter av att leva med anorexia nervosa. Metod: En litteraturbaserad studie baserad på nio kvalitativa forskningsartiklar. Resultat: Ur analysen av datamaterialet framträdde tre kategorier; Ambivalens mellan gott och ont, Ett pendlande känsloliv samt Att andra människor påverkas och påverkar med fyra underkategorier. Slutsats: Att få kunskap om erfarenheter från de som lever med sjukdomen kan öka förståelsen om dess komplexitet. Därmed kan sjuksköterskor förmedla det stöd som behövs för att ge patienten ökad motivation till att bli frisk. / Background: during the last decades anorexia nervosa has had a rising incidence in Sweden as well as in other countries. The disorder may sometimes be difficult to understand due to its multifaceted nature of experienced pros and cons. Furthermore, reluctance toward treatment is frequent among people suffering from anorexia nervosa and treatment for eating disorders have rather high drop-out rates. Aim: The aim of this study was to highlight experiences of living with anorexia nervosa. Method: A literature based study consisting of nine qualitative research articles. Results: Three categories emerged from the analysis; the ambivalence between good and evil, varying emotions and other people are influenced and influences the person with four subcategories. Conclusion: Emphasis on achieving increased knowledge of the lived experiences of anorexia nervosa to enhance understanding for its complexity, might enable nurses’ support-providing to enlarge the patient’s motivation to recovery.

Bakgrund: I grund och botten är människan utseendefixerad och med ett ständigt informationsflöde utsätts den, medvetet eller omedvetet, dagligen för information som förmedlar signaler och budskap om hur man ska se ut och vara. Syfte: Att beskriva vuxna människors upplevelser av att leva med Anorexia Nervosa och hur undersökningsgrupperna i inkluderade studier beskrivs. Metod: Tio kvalitativa studier har granskats, analyserats och sammanställts till litteraturstudiens resultat. De databaser som använts är Cinahl och PubMed. Huvudresultat: Ett av det starkaste inslaget i sjukdomen är känslan av ambivalens, känslan av att sjukdomen är ens bästa vän som man vill vårda och behålla för att inte mista den trygghet den ger. En trygghet att gömma sig bakom, en tröst och en identitet som är väldigt stark. Samtidigt tampas patienterna med viljan att bli frisk som resulterar i känslor som oro, ångest och depression. Metodologisk aspekt: Alla artiklar presenterade sin undersökningsgrupp. Slutsats: Medvetenheten om AN ökar och dessa patienter kan förekomma överallt inom sjukvården. Som grundutbildad sjuksköterska är det troligt att man kommer att möta denna patientgrupp varför det är av största vikt med kunskap om hur människor med AN upplever sin sjukdom. / Background: People are in general obsessed with their looks. With constant influences from the society, people are always vulnerable for daily information which passes signals and messages about how you should look and be. Aim: To describe the adult experience of living with Anorexia Nervosa and the study groups. Method: A quality review with ten qualitative articles which has been analysed and compiled in the result Result: Ambivalence is one of the strongest characteristics of Anorexia Nervosa. The feeling that the disease is your best friend which you want to nurture and keep to feel safe. A security to hide behind, a comfort and identity which is strong. Meanwhile people with AN have to fight with the desire to be healthy which gives them feelings of worry, anxiety and depression. Methodological aspect: All articles presented their study group. Conclusion: The awareness about AN is increasing and these patients can occur everywhere within health-care institutions. A general nurse will probably meet these patients and it’s important to have knowledge about how people with AN experience their disease.

Os transtornos alimentares se caracterizam por comportamentos inadequados no consumo e padrão alimentar, além de crenças equivocadas sobre alimentação, que ocasionam uma piora da qualidade nutricional. Os Transtornos alimentares são determinados por uma etiologia multifatorial, onde os fatores socioculturais, as diferenças étnicas e psicossociais, associados à vulnerabilidade biológica, tem grande importância no desencadeamento, manutenção e perpetuação dos sintomas alimentares. Na Anorexia Nervosa o medo intenso ou mórbido de engordar representa o aspecto psicopatológico central desta doença. Estes pacientes caracterizam-se por uma excessiva perturbação da imagem corporal e pela busca incessante da magreza. Em função do medo de engordar, são incapazes de manter o peso em medidas ideais, além de apresentarem comportamentos alimentares inadequados na intenção de perpetuar o baixo peso. Para a compreensão dinâmica da personalidade destes pacientes é de extrema importância o conhecimento da personalidade na patogênese e patoplastia deste transtorno. Neste sentido, o Inventário de Temperamento e Caráter avalia fatores de temperamento e caráter aplicados à percepção dos traços de personalidade de pacientes com o transtorno alimentar, no caso, Anorexia Nervosa. Este trabalho teve como o objetivo avaliar os traços de personalidade, segundo o Inventário de Temperamento e Caráter (ITC), em pacientes com anorexia nervosa e compara-los a um grupo controle. Os RESUMO resultados indicaram que estes pacientes apresentam características sóciodemográficas de uma população jovem, com início do transtorno na adolescência, composta por mulheres, de etnia branca e solteiras. Os pacientes com Anorexia Nervosa diferenciam-se do grupo controle devido à presença de sintomatologia depressiva moderada pelo BDI. Além disso, na avaliação de personalidade confirmou-se a presença de elevados traços em esquiva ao dano e diminuídos em autodirecionamento nos pacientes com AN comparados aos controles normais. Houve diferenciação entre o grupo restritivo e purgativo na dimensão busca de novidades. A exclusão de pacientes com sintomatologia depressiva grave não interferiu na análise dos resultados dos traços de personalidade. / The eating disorders are characterized by behavior not good in consumption and dietary patterns, and wrong beliefs about diet that cause a worser nutritional quality. The Eating disorders are determined by a multifactorial etiology, where the sociocultural factors, psychosocial and ethnic differences associated to the biological vulnerability, have been great importance in triggering, maintenance and perpetuation of food´s symptoms. In anorexia nervosa the intense fear or morbid to be fat is the psychopathological central aspect of this disease. These patients are characterized by an excessive disturbance of theirs body image and the incessant quest for thinness. Depending on the fear of fat, are unable to keep the weight on measures ideals, and doing inadequate eat in order to perpetuate the low weight. To understand the dynamics of personality of these patients is very important knowledge of the personality and patoplasty in the pathogenesis of this disorder. In this case the Inventory of Temperament and Character value factors of temperament and character applied to the perception of the personality traits of patients with the eating disorder, in the case, anorexia nervosa. This study have been evaluate how the traits of personality, according to the inventory of Temperament and Character (ITC) in patients to anorexia nervosa and compares them to a control group. The results indicated that these patients present social-demographic characteristics of a young population, beginning the disorder in adolescence, composed of women, which ethnic white and single. Patients with anorexia nervosa are differentiated from the ABSTRACT control group because of the presence of moderate depressive symptoms by BDI. Also, the personality avaliation is confirmed the presence of high traits damage and reduced in selfdirection in patients with AN compared with normal controls. There was differentiation between the restrictive group and purgative in a dimension a search of news. The exclusion of patients with severe depressive symptoms had not been interfered in the analysis of the results in a personality traits.

Esta pesquisa parte da constatação clínica de que os sujeitos anoréxicos apresentam subjetividades uniformizadas e uma propensão à homogeneidade discursiva e atitudinal entre si. Tal identidade levanta a hipótese sobre a presença de um tipo de contágio psíquico entre as pacientes anoréxicas. Consideramos a epidemia anoréxica como um movimento coletivo definido por uma mesma narrativa de sofrimento, que possui uma frequência significativamente relevante, entre mulheres jovens, de aproximadamente 0,4% ao ano. Investigamos o conceito de identificação em Freud e em Lacan, e encontramos comentadores que tratam da identificação na anorexia, sugerindo a presença de um tipo especial de identificação necessário para explicar a noção de epidemia anoréxica. Tal hipótese nos levou simultaneamente a um modelo epidemiológico psicanalítico para certas formas de sofrimento que se propagam, historicamente, sob a forma de um contágio psíquico. Localizamos a epidemia anoréxica na identificação imaginária, do estádio do espelho, e a relacionamos ao discurso do capitalista e a uma comunidade de gozo. O fracasso da identificação narcísica nas anorexias severas mais especificamente as falhas na constituição da unidade da imagem é responsável por um excesso no plano da identificação imaginária entre as anoréxicas, que se identificam com o semblante do sintoma. Os sujeitos nas anorexias severas fazem epidemia para se livrarem do saber inconsciente, e se fixam num gozo autístico, que exclui o Outro. A psicanálise que se propõe a tratar o sofrimento, e não o sintoma aborda o que fica de fora da comunidade de gozo. Como resultado, postulamos que o conceito de identificação na epidemia anoréxica é importante para o tratamento institucional da anorexia, incluindo a fundamentação de projetos terapêuticos / This research is based on the clinical finding that anorexic subjects show, among them, standardized subjectivities and a tendency to homogeneity in discourse and attitude. That identity leads to the hypothesis of the presence of a type of psychic transmition among anorexic patients. We have considered anorexic epidemics as a groupal movement defined by the same suffering narrative, with significantly relevant frequency among young women, of approximately 0.4% per year. We have investigated the concept of identification in Freud and in Lacan theories and found commentators who treat anorexia identification suggesting the presence of a special type of identification necessary to explain the notion of anorexic epidemics. Simultaneously, such hypothesis has led us to a psychoanalytic epidemiologic model for certain forms of suffering historically spread as psychic transmition. We have found the anorexic epidemics in the imaginary identification of the mirror stage and established its relationship to the capitalist discourse and to a joy community. Failure of a narcissist identification in severe anorexics more specifically failures in the constitution of the image unit , is responsible for excess in the level of the imaginary identification among anorexics who identify themselves with the symptom semblance. The subjects in severe anorexia make epidemics to become free from the unconscious knowledge, and stick to an autistic joy which excludes the Other. The Psychoanalysis that proposes treating the suffering and not the symptom, addresses to what is outside the joy community. As a result of this research, we have postulated that the concept of identification in anorexic epidemics is important to the institutional treatment of anorexia and serves as basis for therapeutic projects

Tese de mestrado integrado. Engenharia Metalúrgica e de Materiais. Faculdade de Engenharia. Universidade do Porto

Eating-disorder clients show low motivation, poor follow-through, and inordinate premature dropout rates in treatment. To date, little research has been conducted that might provide clinicians with an understanding of the critical factors that may aid clients' recovery. Such factors may be used by clinicians to better motivate clients to collaborate in treatment. The purpose of this study was to identify some of the critical factors that women with eating disorders believed were crucial in prompting or facilitating their recovery. Identification of these factors was accomplished through a systematic content analysis of semistructured interviews with recovered or recovering bulimics and anorexics. This study may contribute significantly to future research into the development of motivational supplements to eating disorder therapy ( e.g., psychoeducational materials or therapy orientation programs). Of interest were what personal, interpersonal, or environmental factors anorexic and bulimic clients reported increased their motivation to recover, and prompted them to begin the recovery process, maintain recovery, and cope with the threat of relapse. Also, factors that subjects reported hindered their progress in recovery were examined. The anorexic and bulimic subjects reported social support as a critical factor across three stages of recovery, including beginning recovery, maintaining recovery, and coping with relapse. Being "tired" of the disorder and therapy were indicated to be relevant to beginning recovery. Improved self-esteem was deemed significant in helping subjects both maintain recovery and cope with the threat of relapse. Establishing healthy eating habits and attitudes was a necessary factor required to maintain recovery. Subjects shared that developing healthy ways to deal with emotions enabled them to deal successfully with the threat of relapse. Anorexic subjects reported that people and societal expectations, fear of becoming fat, incentive to numb emotions, and poor eating habits and attitudes impeded their recovery. Bulimic subjects indicated that people and societal expectations, incentive to numb emotions, lack of understanding, and poor eating habits and attitudes hindered their recovery.

Public view removed at the authors request. 16/07/2006 / The daily experience of anorexia nervosa sufferers has not previously been studied and yet it is fundamental to understanding anorexia nervosa. This study examined and compared the daily experiences of anorexia nervosa patients and control participants in terms of sense of self, mood states and flow states. Flow is characterised by undivided concentration and interest in an activity for intrinsic benefits. Flow is not always desirable, as some ways of experiencing it may be harmful to the individual and society. Anorexia nervosa participants were recruited from hospitals and private practices of clinicians specialising in the treatment of anorexia nervosa. Exclusion criteria included male gender, chronic anorexia nervosa, drug abuse, and current participation in an inpatient program. Anorexia nervosa participants completed a series of questionnaires at baseline, 3-6 month follow-up and 7-12 month follow-up (stage one, two and three respectively). The questionnaires were designed to measure the severity of their eating disorder. Anorexia nervosa and control group participants completed Experience Sampling Forms (ESF) and a Repertory Grid at baseline and 3-6 months. The ESFs were completed each time a pager was activated. The pager was activated seven times a day, for four days at random times between 8.00am and 10.00pm. The pager signals were a minimum of two hours apart. The Repertory Grid consisted of 23 constructs and 13 elements provided to the participant. Thirty-one anorexia nervosa sufferers and thirty-two control participants completed stage one and eighteen anorexia nervosa sufferers and twenty-seven control group participants completed stage two of the study. Eighteen anorexia nervosa sufferers completed stage three of the study. Control participants were not required to participate in stage three. There was no difference in the severity of anorexia nervosa between completers and drop-outs The analysis of the ESFs at stage one indicated that the anorexia nervosa group participants did not spend more time alone at home or more time alone in any situation than the control group. For both groups, being alone had a negative influence on mood state, but had no effect on sense of self. The anorexia nervosa group felt lonelier and less sociable than the control group. The mood state and sense of self for the anorexia nervosa group was significantly lower over all the ESFs when compared to the control group. They were also more self-critical, experienced higher levels of guilt, were less able to live up to their own expectations, and were less satisfied with their performance in the activity they were doing. The anorexia nervosa group experienced less flow states than the control group at stage one. There was an improvement in mood state, sense of self and self-criticism for the anorexia nervosa group when they were in a flow state compared to when they were not in a flow state. There was an improvement in mood state, sense of self, guilt and self-criticism for the control group when they experienced flow, however these differences were not significant. The anorexia nervosa group had a more positive mood state and sense of self at stage two when compared to stage one. Correspondingly, there was a trend towards a reduced severity of the disorder indicated by a significant improvement on some of the psychological tests (EAT, REDS, BDI, DT). There was also a significant improvement in BMI. However, there was a significant decline in the amount of flow of anorexia nervosa participants experienced at stage two when compared to stage one. This result may be attributed to the significant decline in the response rate on ESFs in the second stage of the study for both the anorexia nervosa and control groups. Anorexia nervosa non-responders at stage two reported more severe symptoms of anorexia nervosa than anorexia nervosa responders, although this was a trend and reached significance only on minor indicators of eating disorder severity. The identification of a factor that predicted severity over a six-month period was not possible. The repertory grid analysis showed that the construct system of the anorexia nervosa participants was tighter and less complex than that of the control group. The anorexia nervosa group construed themselves as dissimilar from the way they would like to be in any context. The control group construed themselves as similar to the way they would like to be when they were alone, but as dissimilar from the way they would like to be when they were with other people. While the most salient element for both the anorexia nervosa and control groups was 'alone at home', it appears that the controls use this time for goal-directed activities. In contrast, this time was dominated by fear of losing control for the anorexia nervosa group. Although there was a trend towards a decrease in the amount of variance accounted for by the first component for the anorexia nervosa group at stage two compared to stage one, the interpretation of this result was complicated by mixed result of the control group. The anorexia nervosa groups' daily experience of life was bleak when compared to the daily experience of the control group, except for periods when the anorexia nervosa participants experienced a flow state. DeVries (1992) has documented the success of therapeutic interventions that involve the identification and replication of activities that resulted in a flow state. This investigation suggests that a similar result may be possible in the treatment of anorexia nervosa.

Thesis (M.A.)--Georgia State University, 2007. / Cynthia Hoffner, committee chair; Jaye Atkinson, Mary Ann Romski, committee members. Electronic text (90 p.) : digital, PDF file. Title from file title page. Description based on contents viewed Dec. 14, 2007. Includes bibliographical references (p. 67-74).