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Metasynthesis of studies in anorexia nervosa
Review article
Annals of Clinical Psychiatry 2009;21(1):38-48
Anorexia nervosa treatment from the
patient perspective: A metasynthesis of
qualitative studies
ia
ed
M
h
lt
Cybele Ribeiro Espíndola, MSci
Department of Psychiatry
Federal University of São Paulo/UNIFESP
São Paulo, Brazil
Sergio Luís Blay, MD, PhD
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nl
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Background: Anorexia nervosa is a complex condition that brings great
challenges at each stage of treatment. This study aims to organize the
body
® of information available in qualitative studies about the treatment
of anorexia nervosa through a systematic literature review and metasynthesis.
D
u
l
t
a
h
n
yrig r perso
p
o
C
Fo
Department of Psychiatry
Federal University of São Paulo/UNIFESP
São Paulo, Brazil
Searches were carried out on the following databases for
the years 1990 to 2005: PubMed, ISI, PsycINFO, EMBASE, LILACS, and
SciELO from 1990 to 2005. A meta-ethnographic approach was used to
synthesize the data through second-order and third-order interpretations.
Methods:
The search revealed 3415 studies, of which 16 were selected.
Two concepts for second-order interpretation emerged from the process:
(1) the process of change (phases of recovery, factors favoring recovery,
factors limiting recovery) and (2) perception of the treatment modalities. From the second-order categories, a third-order category was derived—reconciliation, in which personal and environmental acceptance
have a central role.
Results:
Recovery from anorexia nervosa, as a very complex process, goes well beyond conventional treatment. Self-acceptance, determination, and spirituality are equally important elements.
Conclusions:
Correspondence
Sergio L. Blay, MD, PhD
Department of Psychiatry
Escola Paulista de Medicina-UNIFESP
R. Botucatu, 740 CEP 04023-900
São Paulo SP
Brazil
Keywords:
anorexia nervosa, treatment, systematic review, metasyn-
thesis
E-mail
[email protected]
38
February 2009 | Vol. 21 No. 1 | Annals of Clinical Psychiatry
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Annals of Clinical Psychiatry
I n tro d u c t i o n
Various intervention methods are used for treatment of
anorexia nervosa. However, experimental studies testing
the efficacy of these methods have shown limited results,
even considering short-term follow-up.1-5 Frequently,
those who remain in treatment do not adhere to instructions and, when they do adhere, they are at great risk
of relapse. In a follow-up study of women with anorexia
nervosa who participated in interpersonal psychotherapy, Keel et al6 found a 36% relapse index. According to Treasure and Ward,7 about 50% of patients who
participated in multiprofessional treatment achieved
full recovery, 20% remained with residual symptoms,
and 30% presented a chronic course independent of the
treatment used. The mortality varied between 0% and
25%.1 Many individuals with anorexia nervosa display
bulimic behavior, and most bulimic individuals have a
history of anorexia.2
Guidelines for the treatment of patients with eating disorders have recently been launched in many
countries;2,8-10 these guidelines are based on the available scientific evidence. In the case of anorexia nervosa, the guidelines are based on very weak evidence.
For example, in a study titled “The only evidence that
anything works in adult anorexics,” cognitive behavioral
therapy reduced the rate of relapse from 53% to 22%.11
A review of 5512 studies on the same topic found only 6
studies that fulfilled scientific criteria, from which only
2 indicated some effect of treatment.12 In recent years,
progress in terms of anorexia nervosa treatment, and
particularly outcome, has been modest.1
Most of the studies about women’s recovery in
anorexia nervosa have used quantitative methods that
do not focus on women’s diverse experiences of recovery. However, a number of studies using qualitative
methods have been presented recently. The results of
these studies reveal that recovery from anorexia may
depend on more than treatment factors. In a review of
23 studies, Bell13 investigated the opinions of patients
with eating disorders as to which treatment they considered the most useful. Overall, treatments involving
the psychological context of various theoretical and
methodological approaches were viewed as very useful,
whereas medical interventions focused exclusively on
weight were seen as not useful.
From a theoretical point of view, the understanding
of the clinical manifestations of anorexia nervosa has
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been enhanced by psychodynamic and cognitive investigations. The psychodynamic theories were enriched
by the work of Bruch, Boris, Skårderud, Farber et al,
and others.14-17 Among various considerations, anorexia
nervosa is seen as a multidetermined symptom, which
may include attempts to create a new identity, cope
with counter-attacks to the self, give birth to a true
self, devise defense mechanisms to cope with parental
conflicts, manage annihilation anxieties, and develop
“emotional metaphors” to articulate where emotions
materialize in the body. The cognitive theories, including those put forth by Kleinfeld and collaborators,18 are
supported by two basic assumptions. The first is that
avoiding food is primary for the maintenance of the disorder. The second is that anorexia nervosa would have
a positive function in the patient’s life, thus offering a
way out of the difficulties faced at different stages of the
development of the disorder, in addition to the cognitive
distortions that accompany it. In this sense, the disorder to which the patient is attached is constantly being
reinforced. Other important factors may include support
from family, contact with friends, engagement in activities that help the patient focus on something other than
the eating disorders, and experiences that improve selfesteem.19-21 Other cognitive models of anorexia nervosa
are proposed by other investigators. Vitousek and Gray22
proposed a combined theoretical model, in which psychodynamic and cognitive elements participate. For
that purpose, they combine the treatment of anorexia
nervosa with psychodynamic techniques allied to the
approach involving false beliefs, nutritional issues, and
difficulties with family. Fairburn et al23 have created a
“transdiagnostic” model, in which they aim to explain
how anorexia is maintained. Their model is based on
psychological therapies, particularly cognitive-behavioral therapy, and so suggests areas in which clinicians
could provide psychological treatment. The key premise
of this model is that all major eating disorders share core
types of psychopathology that help maintain the eating
disorder behavior. These include clinical perfectionism,
chronic low self-esteem, mood intolerance (inability to
cope appropriately with certain emotional states), and
interpersonal difficulties.
Metasynthesis is a method that involves rigorous
examination and interpretation of the findings of a
number of studies using qualitative methods.24 It relies
on the synthesis of themes and textual quotations from
qualitative reports, and the goal is to produce new and
Annals of Clinical Psychiatry | Vol. 21 No. 1 | February 2009
39
Metasynthesis of studies in anorexia nervosa
integrated interpretations of findings that are more substantial than those resulting from individual investigations.25,26 Synthesizing the findings of qualitative studies
on women’s recovery in anorexia has important implications, both for increasing knowledge of the therapeutic
process for treating these patients and for the possibility
of modifying clinical practice through more advanced
understanding.26
Keeping in mind the difficulty of treating these
patients and the fact that until now, no reviews on this
subject have been published, our goal was to synthesize studies that used qualitative methodology through
a systematic review and metasynthesis of how patients
understand anorexia nervosa treatment and recovery.
Methods
The research encompassed 3 distinct phases: (1) systematic literature review, (2) critical appraisal of the
articles, and (3) metasynthesis.
1. Systematic review
Search sources. An exhaustive electronic bibliographic
search was carried out using the following databases:
PubMed, LILACS, SciELO, ISI, PsycINFO, and EMBASE.
Search strategy for electronic databases. This
research used the following key words: eating disorder,
anorexia nervosa, AND qualitative research; qualitative
study; phenomenology; perspective; perception; experiences; and comprehension—respecting the peculiarities of each database.
Selection of qualitative studies. The selection of
manuscripts is not free from debate. As proposed by
Dixon-Woods et al25 we opted for a quality inclusion
strategy.
Inclusion criteria. (a) Studies were published in
English, Spanish, French, or Portuguese in the 15 years
from 1990 to 2005. (b) Articles had to report qualitative research about patient experiences with anorexia
nervosa, according to DSM-IV criteria.27 We focused
on patients with anorexia nervosa independent of the
degree of severity, and included adolescents and adults
only. (c) Articles had to report the following methodological structure: original study; clear theoretical framework, and purposeful sample with sample size defined
by saturation; analysis based on qualitative methods of
data extraction; and results obtained through text-based
40
transcriptions and interpretations.
Exclusion criteria. (a) Chapters or books, as well as
masters theses or dissertations; (b) studies focused on
psychiatric disorders or comorbidities other than eating
disorders; (c) investigations assessing children or the
elderly; and (d) secondary analyses of previous studies
2. Critical assessment of papers.
The adopted quality criteria were assessed by the standardized form Critical Appraisal Skills Programme
(CASP),28 which traces lines for quality appraisal of
qualitative research. CASP consists of 10 items that
allow classification of articles in categories referring to
methodological structure. The studies were classified as
categories A or B.
Category A studies have a low risk of bias. They
meet ≥9 of the 10 items proposed. Adopted criteria are
as follows: (1) the objective is clear and justified; (2) the
methodological design is adequate to the objectives;
(3) the methodological procedures are presented and
discussed; (4) the sample selection is purposeful; (5)
data collection is described, including specific instruments and saturation process used; (6) the relationship
between researcher and interviewee is considered; (7)
ethical cares are considered; (8) the analysis is dense
and well-founded; (9) the results are presented and
discussed, point to the credibility aspect, and use triangulation; (10) the contributions and implications of the
knowledge generated by the research, as well as its limitations, are discussed.
Category B studies meet ≥5 but <9 of the 10 items
proposed. Assignment of studies to category B status
means that they partially meet adopted criteria, presenting a risk of moderate bias. Case studies and convenience sample belong to this category.
There were no disagreements between the two
researchers as to which studies were deemed to fit the
inclusion criteria for the review.
3. Metasynthesis
Extraction and data synthesis. Metasynthesis is a
method involving induction and interpretation that provides an alternative to traditional synthesis methods by
allowing the researcher to understand and transfer ideas,
concepts, and metaphors across different studies. Metaethnography is one of the most well developed and frequently used methods for synthesizing findings of qualitative studies.29-32 Part of the appeal of meta-ethnography
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to qualitative researchers is its potential to preserve the
properties of primary data and facilitate the identification of themes that run both within and across studies. It
is also one of the few methods to provide explicit guidelines for conducting a synthesis. Unlike traditional review
work, meta-ethnography aims to derive new insights. The
meta-ethnographic method involves selecting relevant
empirical studies to be synthesized and then reading
them repeatedly and noting key concepts. These key concepts become the raw data for the synthesis. The synthesis is achieved through 3 techniques:
1. Reciprocal translation analysis, which entails
examining the key concepts across each study. An
attempt is made to translate the concepts into each other
based on a comparative approach. Judgments about the
ability of the concept of one study to capture concepts of
others are based on the attributes of themes themselves,
including cogency, economy, and scope. The concept
that is considered “most adequate” is chosen.
2. Refutational synthesis, in which the key concepts
and themes in each study are identified and contradictions
between the reports are characterized. The “refutations”
are examined, and an attempt is made to explain them.
3. Lines of argument synthesis, which involves
building a general interpretation grounded on the findings of the separate studies (similar to comparative
analysis of the Grounded Theory).
Although these translations allow comparisons
between different studies, they preserve the structure
of relations between concepts. The translation process
goes through two stages as suggested by Noblit and
Hare.33 The first, called second-order interpretation, is
based purely on original results and is the basis for the
synthesis itself. The contexts and concepts relevant to
each study are registered for a better understanding of
interpretations. Text rereadings are done to standardize
terminology and incorporate new concepts. The start
of the synthesis process translates the findings from an
individual study to provide an understanding of how
the work interrelates with others. Each new concept
is examined through convergent and divergent cases
using a process called reciprocal translation.
The second stage is called third-order interpretation. In this stage, interpretation goes beyond the meaning of the original results and interpretations, advancing
conceptually and deriving a new reading of the original
categories synthesized. As a result, third-order interpretation can constitute a new construction of hypotheses
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or theories concerning the area of study.
The reading and extraction of categories were carried out by two independent reviewers (C.R.E. and
S.L.B.). Categories used in assessment and metasynthesis were obtained through a consensus among appraisers. One of the articles (Woods34) was used as a reference for organizing the comparison process between
the different investigations.
Results
The combined search strategies yielded 3415 documents. The abstracts and titles of the citations were read;
2995 studies were rejected, the majority of which did
not use qualitative methodology or were note written in
the adopted language inclusion criteria. The remaining
420 documents were read in detail. An additional 404
manuscripts were rejected for the following reasons:
the study had other objectives; the study did not focus
on the theme; the sample was outside the age range
(ie, elderly or children); the study was not original; the
study was theoretical; the methodology was insufficiently described or inappropriate; clinical descriptions
were inadequate; or the study included epidemiological studies on clinical samples or in the community. The
final number of investigations was 15. According to the
quality criteria applied, 2 studies were classified as category A and 13 as category B. Tables 1 and 2 illustrate
some of the methodological characteristics of studies
on anorexia nervosa and on mixed disorders, anorexia
nervosa, and bulimia, respectively.
Samples from the 15 studies included 306 subjects
(298 women, 97%; 8 men, 3%), age 12 to 63. Most studies
(10 of 15) examined subjects over age 18. Studies were
conducted in the following countries: 4 in England, 4 in
the United States, 3 in Canada, 2 in New Zealand, 1 in
Australia, and 1 in China. Most of the studies (13 of 15,
86.67%) used semistructured interviews, but other formats included 1 case study, 1 focal group study, and 1
study that used messages on blogs on the Internet. More
than half of the studies were published after 2000.
Most patients were seen in clinics and hospitals
(n=8), whereas others were seen only in outpatient clinics (n=3), or exclusively in hospitals (n=1). Two studies
examined patients in alternative treatment settings,27,28
and no studies were based on commentaries by family
members.
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Metasynthesis of studies in anorexia nervosa
Table 1
Studies of anorexia nervosa (N=10)
Method of Study
Author/year
CountryParticipants/treatment modality
data collection
qualitya
Hsu et al (1992)41
United Kingdom
6 patients (age 17 to 44)/outpatient treatment
Case study
B
New Zealand
7 women/outpatient and hospital treatment
Interviews
B
Tozzi et al (2003) New Zealand
69 women (average age, 32.3)/outpatient and hospital treatment
Interviews,
questionnaires
B
Tan et al (2003)37
United Kingdom
10 women patients (age 13 to 21) and 9 of their mothers outpatient and hospital treatment
Interviews
B
Tan et al (2003)45
United Kingdom
10 women patients (age 13 to 21) and 9 of their
mothers outpatient and hospital treatment
Interviews
B
Williams et al (2003)46
28 women (age 18 to 43)/outpatient treatment
Interviews
B
Chan and Ma (2003)
China
1 patient (age 25) and family/
outpatient treatment
Interviews,
videotapes, family
therapy sessions
B
Colton and
Pistrang (2004)34
19 women (age 12 to 17)/hospital treatment Interviews
A
Lamoureux Canada
and Bottorff (2005)39
9 women patients (age 19 to 48)/ outpatient and hospital treatment
Interviews,
grounded theory
B
Weaver et al (2005)38
Canada
12 women patients (age 14 to 63)/ outpatient treatment
Interviews,
grounded theory
Surgenor et al (2003)
43
19
United States
42
United Kingdom
B
a A: low risk of bias; B: moderate risk of bias (per Critical Appraisal Skills Programme criteria28).
Table 2
Studies with mixed eating disorders/anorexia nervosa and bulimia (N=5)
Method of Study
Author/year
CountryParticipants/treatment modality
data collection
qualitya
Redenbach and
Australia
Lawler (2003)20
5 women (older than 18)/outpatient and Interviews
hospital treatment
A
D´Abundo and
United States
20 women/outpatient and hospital treatment Chally (2004)35
as well as some without treatment
Interviews, focus
group, participant
observation
B
Woods (2004)36
United States
16 women and 2 men (age 18 to 21)/alternative treatment setting; did not accept treatment
Interviews by e-mail
B
Cockell et al (2004)40
32 subjects/outpatient and hospital treatment
Interviews
B
32 women and 3 men (age 13 to 53)/
alternative treatment setting
Internet messages
B
Canada
Keski-Rahkonen
United States
and Tozzi (2005)22
a A: low risk of bias; B: moderate risk of bias (per Critical Appraisal Skills Programme criteria28 ).
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Table 3
Synthesis: Second-order interpretation/
Process of change
Phases of recovery
Centered identity in anorexia21,34,37-39
Self-knowledge20,38,39
Self-acceptance19-21,35,36,38
Determination19-21,35,38
Maintenance20,38,40
Factors favoring recovery
Satisfactory affective relationships19,20,35,36,40,41
Application of cognitive/psychological abilities
and nutritional knowledge38,40
Increasing vital space19,40,41
Spirituality19,35,41
Factors limiting recovery
Fear of change37,42
Lack of motivation20,34
Ambivalence4,43
Lack of social support36,40
Professional rigidity43,45
Media influence36,46
Perception of treatment modalities
Pharmacologic treatment19,21,34
Nutritional treatment21,34
Individual psychotherapy19,34,39,41
Group therapy19,20,34
Second-Order Interpretation
From readings and the saturation process—the point
at which no new information or themes are observed
in the data—two second-order themes were identified
in the studies: (1) the process of change with treatment
(phases of recovery, factors favoring recovery, and factors limiting recovery) and (2) perception of treatment
modalities. (See Table 3 for second-order concepts and
interpretations.)
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The process of change
Phases of recovery. This category includes behavior
and cognition constituting the recovery process, which
is presented in stages.
a) Centered identity in anorexia.21,34,37-39 First, the
identity of the subject is centered on anorexia nervosa,
and subjects believe that the condition is part of their
identity. As a result, fighting against anorexia nervosa is
a difficult fight against one’s own identity.
b) Self-knowledge.20,38,39 The self-knowledge process
expressed in some commentaries allows patients to find
their identity, promoting a better understanding of the
self and the construction of new paradigms about themselves and about life.
c) Self-acceptance.19-21,35,36,38 With the development
of self-knowledge, patients with anorexia nervosa may
change the dysfunctional view they have of themselves
and begin to function in a more integrated manner.
Returning to previously held values and establishing expectations are fundamentals of the process of
change.
d) Determination.19-21,35,38 Later, after developing a
broader understanding of the experience, the patient
adopts determination, ie the movement to have initiative and assume a commitment to the reconstruction of
new behavior.
e) Maintenance.20,38,40 In this category, the patient
tries to maintain and consolidate what was conquered
before. Inasmuch as new habits are maintained, existence without anorexia nervosa becomes possible.
Factors favoring recovery. This category identifies factors that facilitate the recovery process. Studies
focused on the patient’s own perspective on recovery
consider extra-professional help of great importance in
recovery. Satisfactory affective relations, increased living
space, and spirituality are the most common factors.
a) Satisfactory affective relations.19,20,35,36,40,41 Satisfactory affective relationships, whether with partners,
family members, or friends, are emphasized. Acceptance and understanding are central elements in these
relationships.
b) Application of cognitive/psychological abilities
and nutritional knowledge.38,40 Distorted ideas about
food, such as caloric value, are prejudicial; in this light,
knowledge helps patients in modifying inappropriate
food attitudes.
c) Increasing vital space.19,40,41 Power concentrated
in aspects of life other than the body and the disorder
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Metasynthesis of studies in anorexia nervosa
also help in recovery. This process includes concrete
changes. In this way, actions such as moving to a new
house, getting a new job, or taking care of an animal represent useful attitudes and symbolize a new beginning.
d) Spirituality.19,35,41 Having religious belief and faith
were also identified as important aspects in the recovery
process.
Factors limiting recovery. There are various internal and external barriers a person with anorexia nervosa must pass through in the recovery process. Fear
of change, ambiguous feelings, and absence of social
support as well as professional rigidity and indifference are some of the barriers most often mentioned by
patients.
a) Fear of change.37,42 This fear involves life changes
in general, including changes in weight.
b) Lack of motivation.20,34 Treatment will be successful and recovery possible only if the patient is motivated.
c) Ambivalence.34,43 “I don’t want to change my
body shape; I want to be free of disturbance but not of
my body”...“I really want my body reduced as much as
possible.”43 These comments reveal ambivalence about
treatment and recovery. Patients become anxious about
both being free of the disorder as they also desire to
remain thin.
d) Lack of social support.36,40,44 Cockell et al40 and De
la Rie et al44 identified lack of social support as a barrier
to change.
e) Professional rigidity.43,45 “Health professionals
need to understand that people hide behind anorexia;
and the sterner and more rigorous they are, the more
we will hide behind it and so it will get stronger.”43 An
imposing, indifferent manner does not seem to garner
results with these patients.
f ) Media influence.36,46 “I hate TV. It brings all kinds
of bad old feelings back to me. I don’t watch anymore.”46
The problem with media influence is how the message
is received, interpreted, and understood by individuals
with anorexia nervosa.
Perception of treatment modalities. This category
investigates patient perceptions of the different types of
interventions that constitute treatment for anorexia.
a) Pharmacologic treatment.19,21,34 Although without much emphasis, the use of medication is considered
useful in addressing mood problems and reducing anxiety, but it is not considered important for addressing the
central aspects of anorexia, in that it is limited to organic
determinants.
44
Table 4
Synthesis: Third-order interpretation/
Reconciliation
Derived from the second-order interpretations
• Recovery phases (centered identity in anorexia,
self-knowledge, self-acceptance, determination, maintenance)
• Factors favoring recovery (satisfactory affective relationships,
broadening of vital space)
• Factors limiting recovery (fear of change, lack of motivation,
ambivalence)
b) Nutritional treatment.21,34 “An eating disorder does
not disappear just because you start eating right.”21 This
category shows that the treatment of anorexia nervosa
is not exclusively a question of weight and eating habits.
Nutritional treatment designed to increase weight, which
may at times involve the imposition of certain rules, is
understood to be unsatisfactory, in that no consideration
is given to the psychological aspects of anorexia nervosa,
nor does it provide emotional support to the patient.
c) Individual psychotherapy.19,34,39,41 Individual psychotherapy was considered useful by most patients, as
a way of managing the emotional aspects of anorexia
nervosa and in promoting motivation and willpower.
Psychotherapy is also considered a privileged space
where the patient can feel understood and accepted in
an unconditional manner.
d) Group therapy.19,20,34 Individuals’ positions within
a group may bring out the ambiguity that is attributed to
group therapy, which is sometimes considered useful
but also has some caveats. Being together with people
who also have anorexia nervosa may be beneficial in
the sense of promoting support, but it may also entail a
series of negative effects that result in increased stress,
eg, patients may compete for thinness. Being together
with other participants can also mean learning new bad
habits concerning eating disorders, which may make
patients feel even worse at times.
Third-Order Interpretations
The second-order categories allow for the formulation
of a third-order category: the process of reconciliation with oneself. This meta-category was not present
individually in the articles studied but brings together
a great deal of information relative to the treatment of
anorexia nervosa (see Table 4 ).
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The “reconciliation process” includes 3 axes of
understanding. The first is characterized by the acceptance of anorexia nervosa as an affliction, in that one of
the characteristics of the process is a lack of criticism of
the problem. Patients often consider this eating behavior normal and do not perceive it as a behavior problem.
They adopt dietary restriction as a way of life, presenting various arguments and intellectualizations on the
subject. The second axis considers the person’s need to
perceive that they are an object of acceptance by others,
especially a family member or a health care professional.
This process includes the notion of approximation, and
not confrontation, with what the patient is or represents.
Finally, self-reconciliation is achieved (see Table 4 ).
Discussion
Second-order interpretation
Second-order analysis resulted in two concepts: the
process of change and the perception of treatment
modalities. The process of change is complex and long
and is made up of various phases. Initially, a person
with anorexia nervosa lives the affliction so intensely as
to forget about himself or herself. Life becomes anorexia
nervosa, as if the person has been swallowed up. In a
theoretical study, Buckroyd47 argued that, in the process
of change, it is essential to separate anorexia nervosa
from the person and his or her individuality and healthy
qualities.
Regarding factors that facilitate change, the following were identified as contributing to treatment success: satisfactory affective relationships that provide
acceptance and understanding as key elements; broadening life space with involvement in different activities;
development of cognitive abilities through psychoeducational work about inadequate eating habits and their
nutritional aspects; and, finally, spirituality that provides emotional comfort. In a qualitative study based on
interviews, Woods36 affirmed that satisfactory affective
relationships based on understanding and acceptance
by the other are not just supportive, ie, they do not simply serve as support in a helpful manner but, rather, they
serve as true active interventions.
Among factors that limit the process of change are
fear of change, absence of social support, and lack of
motivation. According to a qualitative study by KeskiRahkonen and Tozzi,21 the value of professional help
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is conditioned by the patient’s desire to change. If the
patient is not willing to change, treatment will not be
successful.
Another factor raised by patients that may limit the
process of change is ambiguity of feelings, rigidity, and
lack of sympathy on the part of health professionals.
Gabbard48 argued that establishing a bond with a patient
who has anorexia nervosa is a slow and difficult task,
in that the therapist/physician may be considered the
enemy. In psychotherapy, the therapist must synchronize with the emotional experience of the patient and
give meaning to that patient’s experience. This notion
was supported by Dare et al5 in a study on the effectiveness of psychological therapies, in which a friendly therapist-client relationship appears as the most powerful
element in promoting change.
Regarding the perception of treatment modalities,
it should first be emphasized that treatment of anorexia
nervosa must be understood in a broad sense, considering the subject as a whole, thus including biological, psychological, and social dimensions. However, although
each of these interventions has its role and degree
of importance according to the comments analyzed,
patients have a preference for psychosocial approaches.
Pharmacological approaches can be seen as directed
toward treating anorexia nervosa and not the patient,
ignoring that patient’s intense emotional needs.
Third-order interpretation: reconciliation
Third-order interpretation revealed a meta-category
involving a subject’s self-reconciliation. One of the central questions in this disorder is a conflict or discomfort
with the body itself. This is experienced with intense
suffering in that it involves the subject’s self-image. The
anorexic individual has to experience a process of being
accepted by self and others. This broader acceptance—
inner and outer—is what facilitates recovery, according
to patients. In a study of anorexia nervosa and quality
of life, De la Rie et al44 indicated that 93% of the patients
interviewed felt that caring and belonging are a central
aspect of quality of life.
On the basis of clinical cases on the role of acceptance in this clinical picture, Hycner and Jacob49 consider a primal factor in recovery to be what they call
“confirming the other.” Confirming means a conscious
effort to see the other as a unique, singular being who
has a right to his or her own individuality, respecting it
and accepting it in one’s own capacity to make choices
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Metasynthesis of studies in anorexia nervosa
and be responsible for them.
This synthesis of qualitative research allows the
integration of findings from small studies to be used as a
tool to better understand how individuals with anorexia
nervosa view treatment. Meta-ethnography can be used
to synthesize studies with various qualitative methods—
not limited to ethnographic research—to explore a wide
range of experience while simultaneously increasing
the size and diversity of the total sample.
Clinical consensus has demonstrated that health
professionals should not be limited to weight gain as
an exclusive objective in the treatment of patients with
anorexia nervosa. Difficulties in the treatment field are
enhanced by the frequent association of anorexia nervosa with multiple comorbid factors, personality disorders, family organization, genetics, temperament, body
image, and mechanisms of defense.50-59 All of these
combined factors may be related to the heterogeneity of patients with anorexia nervosa and could have
important psychotherapeutic and prognostic value.
Our analysis showed that, of the studies we identified,
patients had pointed out important treatment experiences that could help the management of patients who
have anorexia nervosa.
Overall, it can be observed that the studies examined in this review support the evidence presented by
the works of Bruch, Boris, Skårderud, Farber et al, Kleinfeld et al, and Bell.13-18 Hence, we postulate that the difficulty in treating patients with anorexia nervosa relies
on the complex psychological mechanisms involved—
mainly, the concept of identity, which is so impaired in
these cases. This concept can partly explain the lack of
therapeutic success frequently reported in experimental studies and systematic meta-analyses. Furthermore,
even when a patient recognizes the existence of the eating disorder, that does not eliminate the simultaneous
presence of a group of other psychological components
that cause patients to minimize the nature of the problem and the risk involved.
These findings can be useful to health professionals who are involved in the treatment of anorexia nervosa. The treatment of anorexia nervosa that exclusively
considers the notion of weight can be frustrating for the
patient. The exclusion of the psychological elements
discussed previously can limit the relationship between
the health care professional and the patient. The consequence is obvious and can jeopardize not only the
enrollment in any kind of therapeutic process (inde-
46
pendent of its therapeutic approach), but can also influence the patient’s involvement with the therapeutic
processes. False assumptions about anorexia nervosa—
both from patients and doctors—can be at the core of
many unsuccessful therapeutic cases. The biggest contribution of the anorexic patient to the investigation
of therapeutic processes might be in emphasizing the
complex nature of this disorder and the need to account
for this complexity in the process of intervention.
This synthesis of qualitative research shows that
several main themes were described as important in the
treatment process: phases of recovery, factors favoring
recovery, factors limiting recovery, perception of treatment modalities, and self-reconciliation. The themes
identified in this synthesis confirm other research in
anorexia nervosa,59,60 but our synthesis expands on
previous work by showing the large spectrum of alternatives faced by patients with anorexia nervosa when
attempting to deal with and treat their symptoms. For
the health care practitioner, the diagnosis of anorexia
nervosa is challenging, as the likelihood of successfully
treating such patients is low. However, an awareness of
the themes indicated by patients is vital, as taking into
account some of these issues may help some patients.
Anorexia nervosa is a heterogeneous entity manifested
by symptoms leading to clinically significant impairment or distress. There are indications that the outcome
may be affected by the following factors: religion and
spirituality,61-63 internal motivation to change, recovery
as a work in progress, the perceived value of the treatment experience, developing supportive relationships,
awareness and tolerance of negative emotion and selfvalidation,60 awareness of the process of change,59 relevant turning points,19,64 fear of change,65 the therapeutic
relationship,66,67 and information.68 Another interesting
factor affecting outcome is media information, such as
television. For Williams et al,46 the media has two main
functions: (1) maintaining the disorder, and (2) helping
to maintain anorexia and dictating rigid aesthetic standards.
This study presents some positive aspects that
should be emphasized. As far as we know, this is the
first metasynthesis study of anorexia nervosa from the
patient’s perspective. Second, the results point toward a
complex phenomenon in which the question of identity
emerges, along with its connection to outcome.
However, the results of this investigation should
be viewed in the light of some limitations. First, most
February 2009 | Vol. 21 No. 1 | Annals of Clinical Psychiatry
Annals of Clinical Psychiatry
of the results come from studies classified as category
B according to the criteria for evaluating qualitative
methodology, leading to cautious interpretation. Second, almost all of the studies consider the experience
of women who have anorexia nervosa. Third, scientific
production is concentrated in a few developed countries, which can lead to cultural bias. Fourth, we relied
on self-report. However, self-report has been found to
be a valid measure in anorexia nervosa and other eating
problems.69-71
Further investigations with qualitative methodology are needed. Increased scientific production
involving more methodological rigor is needed, as are
studies in developing countries and those that include
the male population. n
This study was supported by
FAPESP, Fundação de Amparo à Pesquisa do Estado
de São Paulo (The State of São Paulo Research Foundation), Grant 07/50739-1.
Acknowledgements:
Disclosure: The authors report no financial relationship
with any company whose products are mentioned in this
article or with manufacturers of competing products.
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