Reduction of High Expressed Emotion and Treatment Outcomes in Anorexia Nervosa-Caregivers' and Adolescents' Perspective

Abstract

High expressed emotion (EE) is common in caregivers of patients with anorexia nervosa (AN) and associated with poorer outcome for patients. In this study, we examined the prevalence of high EE in caregivers of adolescents with AN and analyzed predictors for EE using multivariate linear regression models. We further analyzed whether EE is reduced by the "Supporting Carers of Children and Adolescents with Eating Disorders in Austria" (SUCCEAT) intervention using general linear mixed models and whether a reduction of EE predicts patients' outcomes. Caregivers were randomly allocated to the SUCCEAT workshop (N = 50) or online intervention (N = 50) and compared to a comparison group (N = 49). EE and patients' outcomes were assessed at the baseline, post-intervention, and at the 12-month follow-up. Up to 47% of caregivers showed high EE. Lower caregiver skills, higher AN symptom impact, higher levels of depression and motivation to change in caregivers were significant predictors for high EE. EE significantly decreased in the SUCCEAT groups and the comparison group according to the caregivers', but not the patients' perspective. The level of reduction could partially predict subjective improvement and improvement in clinically assessed AN symptoms and body mass index of patients. Implementing interventions for caregivers addressing EE in the treatment of adolescents with AN is strongly recommended.

Keywords: anorexia nervosa; caregivers; children and adolescents; high expressed emotion; intervention.

Figure 1

Change of high expressed emotion scores in the SUCCEAT workshop, online, and comparison groups from the baseline (light-grey box) to the post-intervention (mid-grey box) and the 12-month follow-up (dark-grey box) assessment: (a) Criticism score (parent perspective), (b) Emotional Overinvolvement score (parent perspective), (c) Criticism score (patient perspective), (d) Emotional Overinvolvement score (patient perspective). The size of the box represents the interquartile range (IQR); the whiskers indicate the minimum/maximum values in case no outliers were observed. Outliers (defined as values > 1.5 x IQR from the 25th quantile and 75th quantile) are depicted as circles. Abbreviations: 12M-FU, 12-month follow-up.

Figure 2

The scatterplot depicting the association (Pearson correlation coefficients) between high expressed emotion change scores (baseline to post-intervention) of parents and patients: (a) Criticism change scores; (b) Emotional overinvolvement change scores. A significant positive correlation indicates that higher levels of change based on the parents’ perspective are associated with higher levels of change based on the perspective of patients.