Abstract
As part of a prospective, long-term treatment study, 30 in-patients with bulimia nervosa (BN) were divided into groups with high and low expressed emotion (EE) family backgrounds according to the Camberwell Family Interview, and followed for a period of six years. The high EE group initially showed significantly more psychopathology than the low EE group. No group x time interactions were found, but the high EE group showed a worse outcome on the “conflict” and “organisation” subscales of the Family Environment Scale. They also showed significantly more eating disorder pathology according to the Eating Disorder Inventory (EDI) and the Structured Interview for anorexia nervosa (AN) and BN before treatment, at discharge, after two years and, to some degree, even after six years. Depth of depression (Beck Depression Inventory) was significantly higher in the high EE group at admission (moderate depression), discharge and after the 6-year follow-up (still slight depression). The Parental Bonding Instrument (PBI) showed no differences between the high EE and low EE groups, but the individuals with “affectionless control” according to the PBI had more negative scores on three of the subscales of the Family Environment Scale (FES). In brief, the high EE individuals with BN were initially sicker and did not fully catch up over time in comparison with the symptomatic recovery of the low EE individuals. These data suggest that EE status upon admission to in-patient treatment is a relevant predictor of the severity and course of BN and depressive symptoms.
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Fichter M.M., Quadflieg N.: Six-year course of bulimia nervosa. Int. J. Eat. Disord., 22, 361–384, 1997.
Keel P.K., Mitchell J.E.: Outcome in bulimia nervosa. Am. J. Psychiatry, 154, 313–321, 1997.
Fichter M.M., Quadflieg N.: Comparing self- and expert rating: a self-report screening version (SIAB-S) of the Structured Interview for Anorexic and Bulimic Syndromes for DSM-IV and ICD-10 (SIAB-EX). Eur. Arch. Psychiatry Clin. Neurosci., 250, 175–185, 2000.
Johnson C., Flach A.: Family characteristics of 105 patients with bulimia. Am. J. Psychiatry, 142, 1321–1324, 1985.
Dolan B.M., Lieberman S., Evans C., Lacey J.H.: Family features associated with normal body weight bulimia. Int. J. Eat. Disord., 9, 639–647, 1990.
Ordman A.M., Kirschenbaum D.S.: Bulimia: Assessment of eating, psychological adjustment, and familial characteristics. Int. J. Eat. Disord., 5, 865–878, 1986.
Shisslak C.M., McKeon R.T., Crago M.: Family dysfunction in normal weight bulimic and bulimic anorexic families. J. Clin. Psychol., 46, 185–189, 1990.
Waller G., Slade P., Calam R.: Family adaptability and cohesion: Relation to eating attitudes and disorders. Int. J. Eat. Disord., 9, 225–228, 1990.
Blouin J.H., Carter J., Blouin A.G., Tener L., Schnare-Hayes K., Zuro C. et al.: Prognostic indicators in bulimia nervosa treated with cognitive-behavioral group therapy. Int. J. Eat. Disord., 15, 113–123, 1994.
Head S.B., Williamson D.A.: Association of family environment and personality disturbances in bulimia nervosa. Int. J. Eat. Disord., 9, 667–674, 1990.
Moos R.H., Moos B.S. Family Environment Scale Manual. 2nd ed. Palo Alto, Consulting Psychologists Press, 1986.
Graber J.A., Brooks-Gunn J., Paikoff R.L., Warren M.P.: Prediction of eating problems: An 8-year study of adolescent girls. Dev. Psychol., 30, 823–834, 1994.
Carney C.P., Yates W.R., Cizadlo B.: A controlled family study of personality in normalweight bulimia nervosa. Int. J. Eat. Disord., 9, 659–665, 1990.
McNamara K., Loveman C.: Differences in family functioning among bulimics, repeat dieters, and nondieters. J. Clin. Psychol., 46, 518–523, 1990.
Walsh B.T., Roose S.P., Glassman A.H., Gladis M., Sadik C.: Bulimia and depression. Psychosom. Med., 47, 123–131, 1985.
Villejo R.E., Humphrey L.L., Kirschenbaum D.S.: Affect and self-regulation in binge eaters: Effects of activating family images. Int. J. Eat. Disord., 21, 237–249, 1997.
Boumann C.E., Yates W.R.: Risk factors for bulimia nervosa: A controlled study of parental psychiatric illness and divorce. Addict. Behav., 19, 667–675, 1994.
Grissett N.I., Norvell N.K.: Perceived social support, social skills, and quality of relationships in bulimic women. J. Consult. Clin. Psychol., 60, 293–299, 1992.
Reiss D., Johnson-Sabine E.: Bulimia nervosa: 5- year social outcome and relationship to eating pathology. Int. J. Eat. Disord., 18, 127–133, 1995.
Parker G., Tupling H., Brown L.B.: A parental bonding instrument. Br. J. Med. Psychol., 52, 1–10, 1979.
Leung N., Glyn T., Waller G.: The relationship between parental bonding and core beliefs in anorexic and bulimic women. Br. J. Clin. Psychol., 39, 204–213, 2000.
Calam R., Waller G., Slade P., Newton T.: Eating disorders and perceived relationships with parents. Int. J. Eat. Disord., 9, 479–485, 1990.
Steiger H., Van der Feen J., Goldstein K., Leichner P.: Defense styles and parental bonding in eating-disordered women. Int. J. Eat. Disord., 8, 131–140, 1989.
Fairburn C.G., Welch S.L., Doll H.A., Davies B.A., O’Connor M.E.: Risk factors for bulimia nervosa. A community-based case-control study. Arch. Gen. Psychiatry, 54, 509–517, 1997.
Kent, J.S., Clopton, J.R.: Bulimic women’s perceptions of their family relationships. J. Clin. Psychol., 48, 281–292, 1992.
Leff J., Vaughn C.: Expressed emotion in families. Its significance for mental illness. New York, Guilford Press, 1985.
Kavanagh D.J.: Recent developments in expressed emotion and schizophrenia. Br. J. Psychiatry, 160, 601–620, 1992.
MacMillan J.F., Gold A., Crow T.J., Johnson A.L., Johnstone E.C.: Expressed emotion and relapse. Br. J. Psychiatry, 148, 133–143, 1986.
Mintz J., Mintz L., Goldstein M.: Expressed emotion and relapse in first episodes of schizophrenia. Br. J. Psychiatry, 151, 314–320, 1987.
Vaughn C., Leff J.: The measurement of expressed emotion in the families of psychiatric patients. Br. J. Soc. Clin. Psychol., 15, 157–165, 1976a.
Hooley J.M., Orley J., Teasdale J.D.: Levels of expressed emotion and relapse in depressed patients. Br. J. Psychiatry, 148, 642–647, 1986.
Miklowitz D.J., Goldstein M.J., Nuechterlein K.H., Snyder K.S., Doane J.A.: Expressed emotion, affective style, lithium compliance, and relapse in recent onset mania. Psychopharmacol. Bull., 22, 628–632, 1986.
O’Farrell T., Hooley J., Fals-Stewart W., Cutter H.S.G.: Expressed emotion and relapse in alcoholic patients. J. Consult. Clin. Psychol., 66, 744–752, 1998.
Fichter M.M., Glynn S.M., Weyerer S., Liberman R.P., Frick U.: Family climate and expressed emotion in the course of alcoholism. Fam. Process, 36, 203–221, 1997.
Chambless D.L., Steketee G.S.: Expressed emotion and the outcome of treatment for agoraphobia and obsessive-compulsive disorder. Annunal Conference of the Association for Advancement of Behavior Therapy. Miami, FL, 1997.
Chambless D.L., Steketee G.: Expressed emotion and behavior therapy outcome: A prospective study with obsessive-compulsive and agoraphobic outpatients. J. Consult. Clin. Psychol., 67, 658–665, 1999.
Butzlaff R.L., Hooley J.M.: Expressed emotion and psychiatric relapse. Arch. Gen. Psychiatry, 55, 547–552, 1998.
King S., Dixon M.J.: The influence of expressed emotion, family dynamics, and symptom type on the social adjustment of schizophrenic young adults. Arch. Gen. Psychiatry, 53, 1098–1104, 1996.
Peter H., Hand I., Wilke C.: Einfluß der Paarbeziehung auf Symptomatik und Therapieeffekte bei Agoraphobie: Eine empirische Studie unter Anwendung des Camberwell Familiy Interview. [Influence of relationships on symptoms and therapy outcome in agoraphobia: An empirical study using the CFI.] Verhaltenstherapie, 3, 120–130, 1993.
Szmukler G.I., Eisler I., Russell G.F.M., Dare C.: Anorexia nervosa, parental ‘Expressed Emotion’ and dropping out of treatment. Br. J. Psychiatry, 147, 265–271, 1985.
Le Grange D., Eisler I., Dare C., Hodes M.: Family criticism and self starvation: A study of expressed emotion. J. Fam. Therapy, 14, 177–192, 1992.
van Furth E., van Strien D.C., van Son M.J.M., van Engeland H.: The validity of the five-minute speech sample as an index of expressed emotion in parents of eating disorder patients. J. Child Psychol. Psychiatry 34, 1253–1260, 1993.
Dare C., Le Grange D., Eisler I., Rutherford J.: Redefining the psychosomatic family: Family process of 26 eating disorder families. Int. J. Eat. Disord., 16, 211–226, 1994.
Vaughn C.E., Leff J.P.: The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients. Br. J. Psychiatry, 129, 125–137, 1976.
van Furth E.F., van Strien D.C., Martina L.M.L., van Son M.J.M., Hendrickx J.J.P., van Engeland H.: Expressed emotion and the prediction of outcome in adolescent eating disorders. Int. J. Eat. Disord., 20, 19–31, 1996.
Flanagan D.A.J., Wagner H.L.: Expressed emotion and panic-fear in the prediction of diet treatment compliance. Br. J. Clin. Psychol., 30, 231–240, 1991.
Fischmann-Havstad L., Marston A.R.: Weight loss maintenance as an aspect of family emotion and process. Br. J. Clin. Psychol., 23, 265–271, 1984.
Fichter M.M., Elton M., Engel K., Meyer A.E., Mall H., Poustka F.: Structured Interview for Anorexia and Bulimia Nervosa (SIAB): Development of a new instrument for the assessment of eating disorders. Int. J. Eat. Disord., 10, 571–592, 1991.
Garner D.M., Olmsted M.P., Polivy J.: Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int. J. Eat. Disord., 2, 15–34, 1983.
Fichter M.M., Quadflieg N.: Six-year course and outcome of anorexia nervosa. Int. J. Eat. Disord., 26, 359–385, 1999.
Fichter M.M., Quadflieg N., Gnutzmann A.: Binge eating disorder: Treatment outcome over a 6-year course. J. Psychosom. Res., 44, 385–405, 1998.
American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 3rd ed., revised. Washington, APA, 1987.
Fichter M.M.: Bulimia nervosa: Basic research, diagnosis and therapy. Chichester, John Wiley & Sons, 1990.
Fichter M.M.: Psychological therapies in bulimia nervosa. In: Fichter M.M. (Ed.), Bulimia nervosa: Basic research, diagnosis and therapy. Chichester, John Wiley & Sons, 1990, pp. 273–293.
Rief W., Stock C., Fichter M.M.: Das Anti-Diät Programm als integrativer Therapiebaustein bei anorektischen, bulimischen und adipösen Patienten. [The anti-diet-approach as an integrative therapeutic element with anorectic, bulimic and overweight patients.] Verhaltenstherapie, 1, 47–54, 1991.
Fichter M.M., Herpertz S., Quadflieg N., Herpertz-Dahlmann B.: Structured Interview for Anorexic and Bulimic Disorders for DSM-IV and ICD-10: Updated (third) revision. Int. J. Eat. Disord., 24, 227–249, 1998.
American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4th ed. Washington, APA, 1994.
Beck A.T., Ward C.H., Mendelson M., Mock J., Erbaugh J.: An inventory for measuring depression. Arch. Gen. Psychiatry, 4, 561–571, 1961.
Hiller W., Zaudig M., Mombour W.: Development of diagnostic checklists for use in routine clinical care. Arch. Gen. Psychiatry, 47, 782–784, 1990.
Hiller W., Zaudig M.: MDCL — Münchner Diagnosen-Checklisten für DSM-III-R und ICD-10. Handbuch und Checklisten (MDCL — Munich Diagnostic Checklists for DSM-III-R and ICD-10. Handbook and checklists. Bern, Huber, 1992.
Moos R.H., Moos B.S.: Family environment scale manual. Palo Alto, Consulting Psychologists Press, 1981.
Schneewind K.A., Beckmann M., Hecht-Jackl A.: Familiendiagnostisches Testsystem. Das FKTestsystem. Testmanual. [Testing system for family diagnosis. The FES.] Forschungsberichte aus dem Institutsbereich Persönlichkeitspsychologie und Psychodiagnostik 8.1. Munich, Germany, Universität München, 1985.
Welch S.L., Doll H.A., Fairburn C.G.: Life events and the onset of bulimia nervosa: A controlled study. Psychol. Med., 27, 515–522, 1997.
Bailey C.A.: Family structure and eating disorders: The family environment scale and bulimic-like symptoms. Youth & Society, 23, 251–272, 1991.
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Hedlund, S., Fichter, M.M., Quadflieg, N. et al. Expressed emotion, family environment, and parental bonding in bulimia nervosa: A 6-year investigation. Eat Weight Disord 8, 26–35 (2003). https://doi.org/10.1007/BF03324986
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DOI: https://doi.org/10.1007/BF03324986