ابراز احساسات در بی اشتهایی عصبی: در داخل "جعبه سیاه" چیست؟

Objective Expressed Emotion has been called a “black box”, since little is known about contributing factors. The aim of this study was to examine which parental and which patient/illness-related characteristics contribute to maternal and paternal Expressed Emotion levels. Method Sixty adolescent girls with Anorexia Nervosa (AN) and their parents completed instruments that evaluate characteristics of the adolescent's illness and patient/parental psychological characteristics (depression; anxiety; obsession–compulsion; social anxiety and alexithymia). The following illness-related characteristics were recorded: age at AN onset, duration of illness, AN subtype (restrictive AN-R vs. purging type AN-B), current Body Mass Index (BMI) (in kg/m2), minimum lifetime BMI and number of previous hospitalizations, the Global Outcome Assessment Scale total score. Levels of Expressed Emotion were assessed for the two parents using the Five-Minute Speech Sample. Results Less than 30% of the parents in our sample expressed high levels of Critical EE and Emotional Over-Involvement. Our main findings indicate that maternal Criticism (Critical EE levels, Critical Comments, Dissatisfaction) and the sub-dimensions of maternal Emotional Over-Involvement (EOI EE) (Statement of loving Attitudes and Excessive Details about the past) were related both to the severity of the daughters' clinical state and to maternal psychological functioning. Only paternal levels of anxiety explained paternal Dissatisfaction, EOI EE and Statement of loving Attitudes. Discussion Parental psychological functioning and the severity of the daughters' clinical state have an impact on the family relationships. These elements should be targeted by individual treatment for parents where necessary, and by psycho-educational sessions about Anorexia Nervosa for parents generally.

Family relationships in Anorexia Nervosa (AN) are considered as one of the key elements implicated in the evolution of this disorder [1], [2] and [3] and Family-Based Treatment is the most widely practiced treatment in adolescents with AN [4] and [5]. The construct of Expressed Emotion (EE) was originally developed in schizophrenia to assess family relationships [6]. Since 1981, EE has been widely studied in families with a member suffering from AN, and EE appears to be a relevant predictor of treatment compliance, early treatment outcome and long-term clinical outcomes of patients with AN [7]. EE reflects the family climate between a patient and his/her parents, focusing on 2 dimensions: Criticism (Critical EE) expressed by the parent towards their child, and Emotional Over-Involvement (EOI EE), defined as intrusive, overprotective, excessively self-sacrificing behavior or exaggerated emotional response to the patient’s illness [8] and [9]. The underlying mechanisms of EE were for a long time poorly understood. In 1985, Leff & Vaughn were already wondering about the EE dilemma and “the problem of prediction without understanding” [9]. This statement led Jenkins & Karno to refer the EE as a “Black Box” [10]. Recently it was hypothesized that the EE construct may reflect a dynamic interaction between patient and parental dimensions [11], [12] and [13]. For example, Criticism could be a reaction resulting from the way in which parents perceive the patient, as determined by their own emotional state [14] and [15]. However, only a handful of studies have focused on this theme. One study, concerning schizophrenia, found that maternal Critical EE was related to the severity of the patient’s symptoms, while EOI EE was associated with both maternal conscientiousness and patient depression [11]. In AN, parental levels of anxiety and depression and the anorectic behaviors of the patient perceived by the parents as negative/difficult accounted for over 60% of the variance in parental EOI. For parental Criticism, the most significant variable was the negative/difficult behaviours of the patients as perceived by the parents, which accounted for 50% of the variance at the first step of R2 partitioning. At the second and final step patient rejection of caregivers assistance accounted for a further 2% of the variance [12]. Because few studies have sought to determine the contents of the “Black Box” of EE, the aim of the present study is to examine the contributing factors to maternal and paternal EE levels in families of adolescent girls with AN. Thus, we consider the parent and patient-related characteristics, including alexithymia, since difficulties in processing emotional states are implicated in the etiology and maintenance of AN [16]. Furthermore we consider the illness-related characteristics, the socio-economic status of the families and the age of the patient, which have not been taken into account in previous studies, and because all these variables have been found to be related to levels of EE [7]. We consider maternal and paternal EE separately since interactions between parent and adolescent child differ according to the dyad considered (mother/daughter or father/daughter) [17]. Better knowledge of the determinants of EE would enable the definition of potential therapeutic targets.

Low BMI in adolescents with AN is associated with higher levels of maternal criticism. Parental anxiety and paternal alexithymia have an impact on family relationships. It is therefore important to involve parents so that they can gain a better understanding of the disorder and its consequences in terms of symptoms and attitudes, so as to be less critical towards behaviors that they find difficult to understand, but that are in fact symptoms of the illness. It is likewise important to assess the mental state of the parents so as to offer individual support or treatment where necessary. Interventions for parents that target their anxiety would benefit the parents themselves (by reducing anxiety and depression), and could also alter their perceptions of their daughter’s difficulties and enable them to be more empathetic and supportive, and to use warmer and less critical discourse. This could contribute to a better evolution of AN, since communication, mutual respect and understanding would certainly improve their relationship with their daughters. Further research is required to ascertain how far interventions of this nature actually alter parental EE and outcome in AN.