Lived experience perspectives on labeling and defining long-standing anorexia nervosa

Improving eating disorder care for underserved groups: a lived experience and quality improvement perspective

Improvements to eating disorder (ED) care are urgently needed in the United Kingdom (UK) and around the world. Informed by my lived experiences, independent research, and involvement in the underappreciated field of quality improvement (QI), I have written this article to offer ideas on how to improve individuals' access to and experiences of ED care. As I live in the UK, my lived and QI experiences are of the UK's National Health Service (NHS). However, much of this article's content can be applied broadly to healthcare providers around the world, as similar ED care improvements are needed internationally. Furthermore, this commentary is informed by the latest international research.In this paper, I will identify and discuss 12 groups of individuals whom I believe are more likely to be underserved in ED care. The 12 'underserved groups' (USGs) are as follows: [USG. 1] People with longstanding EDs and/or older-age ED sufferers; [USG. 2] Younger children/preadolescents; [USG. 3] People with under-recognised/underappreciated EDs; [USG. 4] People with higher weights; [USG. 5] People with comorbidities; [USG. 6] People with neurodevelopmental conditions (neurodiverse people); [USG. 7] Digitally excluded people; [USG. 8] Socioeconomically and/or sociogeographically disadvantaged people; [USG. 9] Ethnic/racial minorities; [USG. 10] Sexual and gender-diverse people; [USG. 11] Males; [USG. 12] Caregivers/loved ones.ED sufferers/caregivers are also an underserved group as a whole in general mental health care, so broader considerations for improving ED care will be explored in a future publication; these include stigma, research biases, inadequate clinical monitoring and diagnosing, poor-quality treatments, disorganised service transitions, systemic problems/inefficiencies, and underfunding/under-resourcing. Specific recommendations for USGs 1-12 must be considered alongside these and other broader issues. Throughout both articles, I advocate a humanistic care model/approach based on the inexpensive principles of compassion, hope, empathy, appreciation (of identity), and patience ('CHEAP').

Two identical twin pairs discordant for longstanding anorexia nervosa and OSFED: lived experience accounts of eating disorder and recovery processes

Research into the risk of anorexia nervosa (AN) has examined twin pairs to further the understanding of the contributions of genetics, trait inheritance, and environmental factors to eating disorder (ED) development. Investigations of twin experiences of EDs have been biologically-based and have not considered the qualitative, phenomenological aspects of twin experiences. A gap in the literature exists regarding understanding of discordant twins with EDs. This research was developed in response, with the aim to deepen understanding of AN in discordant twins and to create novel ideas for further research and testing. The case studies presented in this article provide lived experience insights of two identical discordant twin pairs: one twin pair discordant for longstanding AN and one twin pair discordant for 'atypical' AN (the twin with AN has recovered). The perspectives and experiences of each co-twin (one with AN and one without) explore a number of factors that may have contributed to twin discordance in these cases, and how each twin has responded to the impact of AN in their lives. Through use of first-person accounts in case study presentation, this article centres social justice values of lived experience leadership and involvement in research. This article aims to extend current knowledge and understanding of EDs in discordant twins, particularly regarding risk for ED development, ED duration, diagnosis and treatment, and recovery processes.

"I don't know how, if, it's ever going to end": narratives of caring for someone with an enduring eating disorder

BACKGROUND

Families and carers are pivotal in supporting loved ones experiencing eating disorders. This role can bring immense distress and burden, yet the experience of caring for someone with an enduring eating disorder has had minimal research focus. Thus, the purpose of this study is to give voice to carers empowering their stories to increase awareness and understanding, which could inform support to carers and consequently people with a lived and/or living experience of eating disorders.

METHODS

Semi-structured interviews were conducted with 9 carers supporting individuals who had been experiencing an eating disorder for 7 or more years. Data were collected and analysed using narrative inquiry approach.

RESULTS

Carers' narratives revealed feelings of guilt and personal failure; a profound sense of disillusion with current treatment approaches; and immense grief and anguish. As they negotiated a tenuous relationship with hope and the uncertainty of their loved one's future, carers spoke to a complex myriad of feelings of acceptance, letting go, and forging on.

CONCLUSION

Carers deserve to have their voices heard where they are too often silenced. Their narratives provide an urgent call for transformation in our treatments for eating disorders and further involvement of carers within the treatment journey, and their lived experience perspectives have great potential to guide this endeavour.

LEVEL OF EVIDENCE

Level V, qualitative interviews.

Clinical care for severe and persistent eating disorders in pediatric populations: Perspectives of health professionals

OBJECTIVE

Models of treatment for adults with severe and enduring eating disorders focus on harm reduction and improving quality of life. However, there is a notable gap in the pediatric literature in this area. The current study set out to assess the perspectives of health professionals regarding clinical care for young people (e.g., ages 10-25 years) with severe and enduring eating disorders, and to explore perceptions about appropriate treatment options for these presentations.

METHODS

Health professionals were invited to complete a two-stage online survey about their experiences with clinical care for pediatric eating disorders through Canadian and Australian professional eating disorder networks. Survey 1 included questions about their experiences in supporting individuals with severe and enduring presentations. Participants who completed Survey 2 reviewed clinical vignettes and shared their perspectives about treatment recommendations and models of care, including for a severe and enduring presentation.

RESULTS

A total of 85 clinicians responded to questions on Survey 1 about severe and enduring eating disorder presentations. A portion of these respondents (n = 25) also participated in Survey 2. The majority of respondents to Survey 1 reported providing clinical care for pediatric severe and enduring eating disorder presentations. Amongst respondents to Survey 2, there was low consensus amongst respondents for the clinical care that would be most appropriate for young people with a severe and enduring eating disorder presentation. Numerous challenges in models of care for severe and enduring presentations in pediatric settings were raised in responses on Survey 2, with clinicians sharing their awareness of models focusing on quality of life, while also raising concerns about the appropriateness of these models for young people.

CONCLUSIONS

The preliminary results of this study demonstrate that the majority of clinicians report that they have provided care to young people with severe and enduring presentations. There is a clear need for establishing guidance for clinicians working in pediatric eating disorder settings around models of care focused on quality of life. Engagement with interested parties, including those with lived experience, can clarify the development of terminology and clinical pathways for severe and enduring presentations of pediatric eating disorders.

Ethical implications of defining longstanding anorexia nervosa

The label severe and enduring anorexia nervosa (SE-AN) is widely used in the literature on longstanding anorexia nervosa (AN). However, the process of constructing the criteria and the use of the label SE-AN has ethical implications that have not been taken into account. Through combining existing literature and lived experience perspective, this paper addresses to what extent the current criteria do and do not reflect the lived experience. Arguments are presented on why the process of constructing the criteria for SE-AN and the application of the label can be both identified as, and give rise to, epistemic injustice. Epistemic injustice is an injustice that is done to a person as an individual with the capacity of acquiring and sharing knowledge. This type of injustice can occur at any stage of an interaction between people in which knowledge is shared with one another. The paper concludes by giving suggestions on how to pursue epistemic justice in the process of defining longstanding AN.

Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality

Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.

Anorexia nervosa through the lens of a severe and enduring experience: 'lost in a big world'

BACKGROUND

Severe and enduring anorexia nervosa (SE-AN), is a serious and persistent illness, despite 'state of the art' treatment. Criteria have been theoretically proposed, but not tested, and may not adequately capture illness complexity, which potentially inhibits treatment refinements. The clinical reality of death as an outcome for some people who experience SE-AN (1 in 20) and broadening access to voluntary assisted dying, further complicates the field, which is undeveloped regarding more fundamental concepts such as nosology, treatment, recovery definitions and alternative conceptualisations of SE-AN. The present paper is in response to this and aims to build upon qualitative literature to enhance phenomenological understandings of fatal SE-AN.

METHOD

A published book, being the legacy of a 32-year-old professional artist offers a rich account of a life lived with AN, for 18 years with continuous treatment. A polysemous narrative via the interrelationship between the languages of the artist's words and visual art is translated via interpretative phenomenological analysis (IPA), offering rich insight into the SE-AN experience.

FINDINGS

The process of analysis induced three superordinate themes (1) Disappearing Self (2) Dialectical Dilemma (3) Death and Dying: Finding Meaning. Two cross cutting themes traversed these themes: (a) Colour and (b) Shifting Hope, where the former produced a visual representation via the 'SE-AN Kaleidoscope'. Collectively the themes produce a concept of SE-AN, grounded in the data and depicted visually through the artist's paintings.

CONCLUSIONS

The picture of SE-AN revealed in the analysis extends upon conceptualisations of SE-AN, highlighting key processes which are thus far under explored. These factors are implicated in illness persistence eliciting opportunities for further research testing including diagnostic considerations and treatment directions. In SE-AN, distorted body image extends to a global distortion in the perception of self. Additional criteria for the severe and enduring stages of illness related to (1) self and identity processes (2) measures of 'global impoverishment' across life domains are proposed for consideration in the future testing of putative defining features of SE-AN.

Computational analyses identify addiction help-seeking behaviors on the social networking website Reddit: Insights into online social interactions and addiction support communities

INTRODUCTION

Although social connection to others with lived addiction experiences is a strong predictor of long-term recovery from substance use disorders (SUD), the COVID-19 pandemic greatly altered global abilities to physically connect with other people. Evidence suggests online forums for people with SUD may serve as a sufficient proxy for social connection, however efficacy of online spaces as addiction treatment adjuncts remains empirically understudied.

PURPOSE

The purpose of this study is to analyze a collection of Reddit posts germane to addiction and recovery collected between March-August 2022.

METHODS

We collected (n = 9,066) Reddit posts (1) r/addiction; (2) r/DecidingToBeBetter, (3) r/SelfImprovement, (4) r/OpitatesRecovery, (5) r/StopSpeeding, (6) r/RedditorsInRecovery, and (7) r/StopSmoking subreddits. We applied several classes of natural language processing (NLP) methods to analyze and visualize our data including term frequency inverse document frequency (TF-IDF) calculations, k-means clustering, and principal components analysis (PCA). We also applied a Valence Aware Dictional and sEntiment [sic] Reasoner (VADER) sentiment analysis to determine affect in our data.

RESULTS

Our analyses revealed three distinct clusters: (1) Personal addiction struggle, or sharing one's recovery journey (n = 2,520), (2) Giving advice, or offering counseling based on first-hand experiences (n = 3,885), and (3) Seeking advice, or asking for support or advice related to addiction (n = 2,661).

DISCUSSION & CONCLUSION

Addiction, SUD, and recovery dialogue on Reddit is exceedingly robust. Much of the content mirrors tenets for established addiction-recovery programs, which suggests Reddit, and other social networking websites, may serve as efficient tools to promote social connection among people with SUD.

Creating a care pathway for patients with longstanding, complex eating disorders

BACKGROUND

Recovery rates for people with eating disorders are low; fewer than half recover and approximately 20% develop a longstanding eating disorder. Patients with longstanding eating disorders are often referred to as "SEED" (severe and enduing eating disorders) although this remains controversial and is not acknowledged in the British treatment guidance. This project aimed to generate recommendations for a longstanding eating disorder care pathway by identifying what proportion of patients have longstanding eating disorders and how to best identify and support them.

METHODS

Initially, a literature review was completed, followed by interviews with service-users who consider themselves to have longstanding eating disorders, and focus groups with staff members. The results were combined to create a definition of a longstanding eating disorder which was used to establish how many service-users could benefit from the pathway. The qualitative data was used to produce recommendations for a tailored pathway for those with longstanding eating disorders.

RESULTS

The results highlighted that, although "SEED" is often used, participants preferred to be referred to as "longstanding" or having no label. Qualitative analysis identified four themes in relation to supporting this population group which described how to structure the service and individualise care, as well as patients' relationship to the service, and how to build a life after eating disorder services.

CONCLUSIONS

Recommendations included promoting a hopeful message, focusing on quality of life and introducing peer support. Crucially, accessing the pathway should not result in being labelled "SEED", nor should it prevent access to recovery focused interventions including weight restoration. The full list of recommendations are included as well as the implications of the project and limitations.

Establishing consensus for labeling and defining the later stage of anorexia nervosa: A Delphi study

OBJECTIVE

Varied perspectives on the later stage of anorexia nervosa (AN) have left the field of eating disorders without a consistent label or definition for this subpopulation. As a result, diverse criteria when recruiting participants have led to incomparable results across research studies and a lack of guidance when assessing and treating patients in the clinical context. The aim of the current study was to develop consensus-based guidelines on the labeling and defining of the later stage of AN.

METHOD

Utilizing the Delphi methodology, a professional panel of experts (N = 21) participated in three rounds of questionnaires. Five open-ended questions (Round 1) were analyzed using content analysis to form statements relating to a classification system for labeling and defining the later stage of AN. A total of 80 statements were rated in terms of panelists' level of agreement (Rounds 2 and 3).

RESULTS

Consensus was achieved for 28.8% of statements and a further 16.3% of statements reached near consensus in the second and third round of questionnaires. Two labels were identified with five defining features achieving consensus.

DISCUSSION

Findings from the study suggest an alternative approach to labeling be adopted with consensus-based guidelines established for defining the later stage of AN. Implications that may occur from a unified classification system are explored with longitudinal research required to assess the impact on patients experiencing the later stage of AN.