Quality of Life and Family Relations in Patients With Anorexia Nervosa.

Introduction

Eating disorders (EDs) are a family of psychopathologies characterized past a persistent disturbance of eating or eating-related behavior that results in the altered consumption of food, and significantly impairs physical health or psychosocial functioning (1). The core psychopathology tin can be conceptualized every bit an exaggerated, or exclusive, evaluation of self-worth in terms of torso shape and weight and the ability to control them, which leads to pathological behaviors such as self-starvation and purging behaviors (2). Three fundamental ED diagnoses are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), all of which tend to be of persistent nature and have potentially significant and even life-threatening medical consequences (1).

Over the years, studies have shown detrimental consequences of EDs and psychopathology non simply for patients themselves, but also for their families (three).

The Office of the Family unit in the Etiology and Treatment of EDs

The role of the family in EDs has long been a subject of interest for clinicians and researchers alike. Over the years, family dynamics were studied as a possible gene in the etiology, maintenance, and treatment of EDs. Classic conceptualizations such as Minuchin's model of the "psychosomatic family" accept viewed EDs every bit an expression of an underlying pathological family unit structure, characterized by specific interaction patterns such equally parental overprotection, rigidity, poor disharmonize resolution skills, and conflict avoidance (four). These familial processes were seen as playing a causal part in the development of EDs. Indeed, some studies supported the beingness of such patterns in families with ED patients (5, 6). Withal, a systematic review of the subject institute that although families with ED patients reported worse family operation than controls, no typical pattern of family dysfunction emerged (7). Furthermore, in a position newspaper, the Academy for Eating Disorders renounced the use of whatever etiologic model of EDs in which the primary cause of the disorder is family conduct (5). In spite of the clinical dispute regarding the causal influence of family on EDs, it is widely agreed that interest of one'south family unit in the treatment of EDs is recommended, and appears to be useful in reducing psychological and medical symptoms (five).

Effects of EDs on Family Members

EDs significantly bear on not only the individual, but his or her family system as well (three). The intensity and extensive nature of EDs projection greatly on family unit life, influencing members' personal lives, family unit relationships and the family's daily dynamics. Near of the literature on these implications focuses on EDs' impact on caregiving parents. In a systematic review, parents' levels of psychological distress, anxiety, and depression, as measured by a variety of instruments, were plant to be above clinical cutting-off (8).

However, the experiences of siblings in these families, and EDs' touch on on their well-existence, seem to be neglected, in both research and the clinical field. We aim to fill up this gap in literature by conducting a kickoff-always review of the literature focusing specifically on siblings of those suffering from EDs. Such exam could aid in identifying unique difficulties in need of more research, and promote the development of preventative interventions and early on detection of psychopathology in this group.

Siblings of Those Coping With Mental Illness

Looking at the field of psychiatry at big, i may find studies examining siblings of individuals with other astringent mental illnesses, including schizophrenia and bipolar disorder. Participants reported their siblings' illness greatly affected their sense of self and their relationships with family members (9). Siblings described a variety of negative emotions such every bit grief, guilt, fear, and worry (10), leading to significant emotional burden. Accordingly, it has been found that siblings of individuals with mental disease are at elevated take a chance for emotional, behavioral, social, and developmental impairments (eleven).

Although psychopathology is commonly regarded every bit an individual, personal experience by researchers and clinicians alike, studies have consistently shown that symptoms tin manifest in those shut to the individual, peculiarly his or her family. The most widely studied psychopathology in this regard is Post Traumatic Stress Disorder (PTSD). Studies have shown those in close proximity to trauma survivors come to develop similar psychological symptoms, without having been direct exposed to the traumatic effect (12). Examples of such transmissions were establish in children and spouses of Holocaust survivors (13), children of survivors of the Armenian genocide (fourteen), and children and spouses of veterans (15, 16). Similarly, studies found transmission of depression symptoms between parents and their not-genetically-related children (17), and between spouses (18). Finally, transmission of psychotic symptoms and specific delusional beliefs was identified between parents and children, between partners, and betwixt more distant cohabiting family unit members (19).

Thus, there is empirical prove for symptom manual in a variety of psychiatric disorders. However, while the association betwixt mothers' EDs and EDs among their children has gained some attention (twenty), its presence in other familial sub-systems such equally siblings has been scarcely studied.

As the same findings suggest, there is reason to presume siblings of individuals with EDs may be at risk for psychopathology in full general, and EDs in item. Like to other disorders, the continuous stress and burden may harm siblings' well-existence and serve as catalysts for the evolution of psychopathology (21), alongside other possible pathogenic environmental and genetic factors shared with the siblings coping with EDs (2). Nevertheless, studies apropos siblings' well-being and psychopathology are scant.

The Present Review

In almost studies involving siblings of individuals with EDs the siblings are referred to solely equally a control group, with an intention to sympathize EDs adventure factors and characteristics beyond genetic predisposition (e.g., 22). Studies directly concerning siblings' feel, characteristics, and well-being have been few and far between. The following paper aims to review both qualitative and quantitative existing literature concerning this group, in order to gain a improve understanding of their personal experience, means of coping, and levels of psychopathology. Better insight into these factors could facilitate more than authentic identification and early on interventions for those in need of clinical attention.

Method

Enquiry Databases and Search Strategy

PubMed and PsycNet databases were searched to identify relevant English language-language studies, with no publication date restrictions. The search included a term regarding an ED diagnosis ("eating disorders" or "anorexia" or "bulimia" or "binge eating disorder"), and a term defining the relevant participants ("siblings" or "sisters" or "brothers"), with the Boolean operator "AND" used betwixt the terms. All possible combinations were used. Study titles and abstracts were screened, and if deemed potentially relevant underwent full-text review. In improver, each paper's reference list was searched for additional relevant papers.

Report Selection

Inclusion Criteria:

(1) Studies including participants with siblings diagnosed with AN, BN, BED, or Eating Disorder Not Otherwise Specified.

(2) Studies that were written in English.

(three) Studies that provided qualitative or quantitative information regarding non-ED siblings. Quantitative studies included a control group other than the diagnosed siblings.

Exclusion Criteria:

(1) Studies concerning eating-related disorders which are not psychiatric (east.g., diabetes).

(2) Example reports, commentaries, book chapters, briefing papers, and incomplete studies.

Data Assay

Studies were first categorized into the post-obit mutual themes addressed in studies: emotional well-being, psychopathology, eating-related behaviors and symptoms, social consequences, positive consequences, family dynamics, relationship with family members, family unit office, interaction with health professionals, coping strategies, moderating factors of impact on well-beingness. Side by side, we summarized the findings of these studies by highlighting mutual features in each cluster, besides as data unique to each written report.

Results

The search conducted in electronic databases initially yielded i,346 papers. Afterward emptying of duplicates, and exclusion of studies that did not encounter inclusion criteria, 26 papers were included in the concluding review (Run across Table 1).

Table 1 Core characteristics of reviewed studies.

Mental Wellness and Well-Beingness Among Siblings of Individuals With EDs

Emotional Well-Being

Overall, studies indicated that the ever-present strain and demands of living with a sibling suffering from an ED may have an effect on i'due south emotional well-existence. In a report examining non-ED siblings' quality of life, while most subjects did not reach an "at take chances" score on the quality of life measurement, 80% of siblings did study a subtract in quality of life brought about by the disorder (32). Non-ED siblings besides described the physical outcome the disorder has had on them, feeling sick more ofttimes, experiencing sleeping problems, having lower energy levels, and experiencing difficulties with attention and concentration (31, 42, 44). Siblings besides reported a refuse in scholastic functioning, and a decrease in motivation for social activities (28). Additionally, siblings of individuals with EDs described various negative emotions. Feelings of fear and worry about the future were a recurring theme throughout many qualitative studies (25, 28, 31, 32, 43, 47). In ane written report, 81% of siblings reported they were afraid their sister suffering from AN will never get better, and 43% were agape she will dice (37). Interviews indicated that the diagnosed siblings' negative behaviors, the inability to help and brand them recognize their own disorders, and the feeling that they practise not wish to go better have led to feelings of helplessness, sadness, and anger (25, 31, 42, 43, 47). Guilt was also a prominent emotion amid non-ED siblings. Some felt responsible for the onset of the ED due to their past remarks or deportment, some blamed themselves for not helping their siblings as much as they could, and for some the divide loyalty, to their patents on 1 manus and to their siblings on the other, evoked a persistent sense of guilt (25, 31, 32, 43, 46). Moreover, in-depth interviews with not-ED siblings revealed a sense of grief and sacrifice, as well as a feeling they lost their family unit, their normal babyhood, their good human relationship with their sibling, and their individual identity (32, 42, 43).

Psychopathology

Overall, findings regarding siblings' psychopathology have been inconsistent. Some quantitative studies indicated non-ED siblings did not differ from controls on levels of psychological distress, depression, obsessive symptoms, or issues with peers (24, 34, 35, 38, 40, 44). One study even found parents' reports of non-ED siblings' conduct issues were lower than population norms (44). Withal, other studies have establish siblings' self-report of emotional difficulties, obsessive-compulsiveness, and low was college than controls' (33, 40, 44). Studies of familial aggregation of psychopathology showed siblings of ED patients were i.4 more likely to attempt suicide in comparing to controls (45). They were also significantly more likely to exist diagnosed with affective disorders (OR = one.69), feet disorders (OR = i.54), obsessive-compulsive disorder (OR = 2.04), and personality disorders (OR = 1.62) (41).

Eating-Related Behaviors and Symptoms

Findings pertaining to the furnishings of EDs on the non-ED siblings' eating behaviors and EDs symptoms were also inconsistent. Some studies showed not-ED siblings did not face an increased hazard for the evolution of EDs in comparison to controls. A family aggregation study found that siblings of AN or BED probands were non more than probable than controls to be diagnosed with an ED (26). Other quantitative studies have found that non-ED siblings had no pathological ED symptoms, were similar to controls in their attitudes towards food and eating behaviors, and did not differ from controls in their body image (23, 29, thirty, 33, 34, 48). Several qualitative studies supported these findings, as some not-ED siblings denied influence of the siblings' ED on these psychological aspects, and fifty-fifty claimed to have developed a more than positive relationship with their bodies and with food (32, 42). In some interviews, siblings too mentioned holding negative attitudes towards dieting, and becoming more aware of the importance of salubrious eating and living (28, 42, 47). Nevertheless, other studies indicated a higher inclination to sub-clinical levels of ED symptoms in non-ED siblings, with some studies reporting that 9.5–12% of siblings scored within the clinical range of EDs (23, 36). In addition, there were studies in which not-ED siblings were constitute to take a higher level of dissatisfaction with their body equally compared to controls (24), and experienced a negative impact of the disorder on their trunk image (43). In some qualitative studies non-ED siblings reported having issues with eating themselves, becoming more self-witting of their eating habits, experimenting with different eating behaviors, and holding themselves to their siblings' standards regarding eating habits and body (25, 32, 37, 43, 47). Using computer simulation for perceived and desired trunk images, one report plant that male siblings of ED patients perceived themselves as having more than fat than muscle in comparing to controls (30). Accomplice studies too identified an increased risk for EDs amid siblings of ED patients. Twoscore three percent (43%) of sisters of BN patients endorsed a lifetime diagnosis of some ED, and a lifetime diagnosis of AN was four times more common in siblings of patients with AN compared to controls (26, 41). Partial AN and BN were diagnosed in three.6 and 4.0% of siblings of persons with these diagnoses, respectively (27).

Social Consequences

Overall, studies indicated that having a sibling with an ED affected non-ED siblings' inter-personal relations and social life. While in some studies siblings reported turning to their friends for help and comfort (25, 31, 42), others plant siblings avoided disclosing their feelings and experiences exterior the family (39). This secrecy sometimes stemmed from parents' wish to conceal the diagnosed sibling'southward status (32), or alternatively from the non-ED sibling's own sense of embarrassment and shame, or from fearfulness of stigma and of beingness perceived as weak (32, 39, 42). As was constitute in several qualitative studies, non-ED siblings felt socially isolated at times. They described a trend to withdraw from social contact and seldom invited friends over, in an endeavor to avert questions and comments well-nigh their siblings (25, 42, 47).

Positive Implications of Having a Sibling With an ED

Interestingly, alongside the significant difficulties, non-ED siblings described some positive consequences of the disorder on both themselves and their family. In-depth interviews indicated that some siblings reported an increased sense of family solidarity and cohesion (31, 32, 37, 39), a closer relationship with the diagnosed sibling (31, 42, 43), and an improvement in family eating habits (42). In addition, many described the experience as contributing to the formation of a more resilient, mature, and responsible character, and as rendering them more than empathic towards psychological difficulties (43, 47). In a phenomenological study, all 12 interviewees reported elevated sense of compassion and understanding towards others post-obit their siblings' disorder (31).

Effects on the Family Environment

Family Dynamics

A mutual theme addressed by siblings in several qualitative studies was the authority of EDs in family everyday life. While this theme does not refer direct to the non-ED sibling, but rather to the family as a whole, we did include it in the review as it is based on siblings' reports. Thus, we believe it should be viewed as role of their experience as siblings, and every bit family unit members. Studies have shown that the ED is described past siblings as omnipresent, affecting every aspect of daily life and reigning family unit routine and conduct (25, 32, 43). Siblings often reported feeling family life revolved effectually the diagnosed sibling and the disorder, leaving little room for other problems, and creating a constant atmosphere of abnormalcy (28, 31, 43, 47). In interviews regarding family dynamics many said the disorder brought about a strained and volatile family climate, in which they had to constantly "walk on eggshells" (25, 28, 43). Siblings further described that the intense preoccupation with the diagnosed sibling'due south mental and physical health often gave rising to arguments, notably between parents, as well as between the diagnosed sibling and the parents (25, 31, 32, 43, 47). Every bit could be expected due to the nature of EDs, non-ED siblings saw mealtimes as the main arena for arguments and disharmonize, and some felt mealtimes dominated family life (28, 31, 32, 42).

Siblings' Relationships With Family Members

Human relationship With Diagnosed Siblings

A number of qualitative studies examined the result EDs may accept on the non-ED siblings' relationships with each family member. Commencement, almost studies constitute not-ED siblings' relationships with diagnosed siblings significantly changed due to the disorder (43, 46, 47). While some studies reported that non-ED siblings experienced stronger and closer relationships with their siblings (25, 28, 43, 46, 47), others described their relationships weakened, or increased in strain and tension (25, 28, 32, 46). Generally, non-ED siblings described an ambivalence towards their relationships with their siblings, which included both close and appreciating interactions, and conflictual and distancing communication (43). Nevertheless, one study found that when asked to quantitively rate their relationship with their sisters, non-ED sisters showed a negative correlation between positive and negative aspects of the relationship, suggesting a more split than ambivalent relation. Such correlation was not found for control participants, for whom the two scales did not exclude one some other (40).

Qualitative studies found various factors straining this relationship. The most prevalent of those was difficulty in understanding diagnosed siblings' feelings, thoughts, and behaviors (25, 32, 47), and at times viewing those as a manipulative and preconceived mode of seeking attention (25, 32, 46). In several studies, non-ED siblings reported feeling neglected and underprivileged in comparison to their siblings, and expressed frustration over their experience of differential parental handling (31, 43). However, it was likewise establish that diagnosed siblings reported college levels of jealousy towards their non-ED siblings than vice versa (36). In addition, some non-ED siblings described feeling uncomfortable around their siblings due to the disorder's symptoms, especially the emaciated advent, obsessive symptoms, and rampage and purge cycles (31, 32, 47). Another reported difficulty had to practice with not-ED siblings' feeling that their eating habits and body were criticized by their siblings (32). Nevertheless, many as well noted that their prominent feelings towards their diagnosed siblings were those of compassion, responsibility, and wish to protect (32, 42). Siblings' relationships were improved when non-ED siblings had more than knowledge of the disorder, and when they tended to encounter it every bit carve up from the diagnosed sibling (39).

Human relationship With Parents

Every bit indicated by several qualitative studies reviewed, relationships between non-ED siblings and their parents were besides often afflicted by the disorder. Again, while some not-ED siblings seemed to benefit from sharing their experiences and talking to their parents, and reported an comeback in their relationship (31, 32, 47), many described that the ED created an intricate and at times strained relationship. Not-ED siblings oft felt parents were preoccupied with the diagnosed sibling and were thus less available, both emotionally and practically, leaving them feeling unnoticed and rejected (25, 39, 42, 43). In a study interviewing 12 siblings of chronic AN patients, non-ED siblings reported that they felt their diagnosed siblings received more parental attention and more than practical and fiscal assistance, both in everyday life and particularly during hospitalizations (31). Not-ED siblings also often reported that their parents demanded them to be independent and helpful at a young historic period, either in an indirect way or by explicitly asking them for consideration and compromise (25, 31, 43). These expectations, in plough, evoked at times feelings of anger and resentment (31, 43). Using semi-structured interviews, Dimitropoulos et al. (31) examined the ways parents handled the disorder and their result on their relationship with not-ED siblings. The study showed that non-ED siblings described parental denial of the disorder as undermining their communication with their parents, leaving them feeling unacknowledged and their worries unvalidated. Participants also shared that parental accommodation of the disorder, such equally allowing binges of food intended for the whole family, cleaning after purges, and preparing meals with nutritional restrictions, gave rise to feelings of parental inadequacy and acrimony towards them.

Siblings' Family Role

The reviewed studies indicated that the changes in family unit relationships and everyday life brought about a modify in non-ED siblings' perceived roles in the family as well. As reported in several qualitative studies, non-ED siblings unremarkably assumed responsibleness over their siblings' health and well-being, especially when they were the older siblings (25, 32, 43, 46). Non-ED siblings described a dual and at times conflicting role, in which they were both supporters of the diagnosed siblings and the caring parents' collaborators (25, 31, 32). They tried to balance protecting their siblings, collaborating with them, and keeping their secrets, with gathering information regarding their eating habits for their parents' surveillance and care (25, 32, 43, 46), at times in response to parents' direct requests (25, 31). Not-ED siblings reported serving every bit mediators betwixt the diagnosed sibling and the parents, either when they felt close to both sides or when they felt their parents were ineffective in their coping with the disorder (31, 43). Some other common role not-ED siblings assumed is that of support and care for the parents, peculiarly when parents were living apart (31, 42, 46). Non-ED siblings reported feeling worried for their parents' well-beingness and feeling responsible for them (43). They besides reported parents saw them every bit a source of help and knowledge and consulted them about the disorder (31). A tertiary mutual role non-ED siblings assumed is that of "the salubrious kid," emphasizing their achievements and coping, and hiding their difficulties (49). Non-ED siblings reported deliberately concealing their own needs, worries, and distress from their parents in an attempt to avert burdening them (25, 31, 32, 39). These efforts to conceal difficulties may be successful at times, as 1 study found parents' report of non-ED siblings' levels of emotional difficulties were similar to the norm, while the not-ED siblings' self-written report indicated higher levels of distress (44).

Interaction With Health Professionals

In qualitative studies, siblings' opinions regarding their own inclusion in the disorder'southward management and treatment were mixed. Some siblings did not want to exist included at all, nonetheless many wished to exist more than involved and informed (42). Frequently siblings felt left out of the therapeutic process, even when they participated in family unit sessions (32, 43). In a written report interviewing siblings after participation in family therapy, many siblings reported they initially attended family sessions, merely their attendance reduced over time, partly because they felt they were non a function of the treatment process. Other common reasons for the subtract in attendance were boredom and preferring to participate in social interactions and other commitments (46). In another written report, some siblings reported they did non understand why they were supposed to nourish family unit sessions, and found the experience uncomfortable (47). Nevertheless, in both studies siblings reported that, in retrospect, family therapy has been a beneficial experience for them. Nearly siblings wished they had attended more than sessions, and found that therapy gave them hope and a better agreement of the situation (46, 47).

Another mutual finding was non-ED siblings' demand for individual counseling (31, 43). Many siblings likewise expressed a wish to meet with others in a similar situation to their own, and to attend siblings' support groups (31, 42, 43)

Coping Strategies

Non-ED siblings described a wide variety of ways of coping with the disorder's ramifications. A recurring strategy in many qualitative studies was distancing oneself from the stress and conflict generated by the disorder (25, 31, 32, 47). Thus, non-ED siblings ofttimes attempted to maintain a normal everyday life despite the difficulties at home, taking "time-out" from the strained atmosphere (39, 42). Some turned to friends, neighbors, or romantic partners for back up, and saw them every bit an haven of normalcy (25, 31, 39, 42, 47). In 1 written report, some participants said they took comfort in the anticipation of moving out and living independently in the futurity, a thought they found liberating (25). Some other coping strategy that siblings found to be helpful was learning almost EDs and their siblings' feel (25, 39, 43, 47). A better agreement of EDs seemed to aid siblings distinguish the disorder from the sibling him/herself, and improved their relationships with them (31, 39). Additionally, some siblings used rationalization, every bit they expressed understanding and credence for receiving less attention due to the situation (47).

Factors Moderating the Effect of EDs on Siblings' Well-Being

Only five of the reviewed studies examined possible moderating factors of the disorder'due south impact on not-ED siblings, concentrating on several familial and situational factors. Non-ED siblings living with the diagnosed siblings were found to be more vulnerable to the detrimental effects of the disorder (39). In improver, in families characterized by lower levels of performance and less social support, and in which parents were ineffective or in denial regarding the disorder, non-ED siblings were exposed to more negative emotions and reactions (31, 36). Disease elapsing was likewise plant to be related to the not-ED siblings' level of well-existence (44). Female and older siblings were found more likely to take an agile part in caregiving, and thus were more exposed to the disorder's furnishings (43).

Word

The aim of this newspaper was to review the existing literature concerning siblings of individuals suffering from EDs. To our knowledge, this is the first attempt at exploring and organizing the existing findings on this group. This endeavour comes at a time where researchers and clinicians akin are showing growing interest in the effects of psychopathology both on the family equally a whole, and on non-diagnosed siblings specifically. Over the years, attention to family members of individuals suffering from psychopathology was mostly directed at parents and offspring. This oversight is surprising considering the importance of the sibling human relationship to one's evolution, and the risks siblings are exposed to as a upshot of their unique familial position. Siblings often experience the burdens of living with a family fellow member suffering from psychopathology, and may strongly feel its effects on parental and family unit dynamics. Their lives are oftentimes greatly afflicted by the state of affairs, and as sibling relationships are usually the longest relationships individuals continue throughout their lives, it is a struggle likely to accompany them for years to come. Thus, it is of great importance to gain farther insight into siblings' experiences and needs in context of EDs.

Studies on the effects of other psychopathologies on the family (e.thou., 50) reveal consequences for private family members, in terms of personal well-being and manifestations of psychopathological symptoms, as well as for the family arrangement as a whole. As illustrated in this review, EDs similarly touch not-ED siblings, in various ways.

While in that location is wide agreement that patients' EDs may have an effect on non-ED siblings, findings regarding the nature and magnitude of this consequence remain mixed. Overall, it appears that many siblings' quality of life is impaired due to the disorder, and difficult feelings such every bit fear, guilt, sadness, and anger were common in most studies. Withal, studies remain divided every bit to the effect of EDs on not-ED siblings' level of psychopathology. As is the case with family studies in other disorders (e.g., PTSD; 16), findings on EDs and siblings may be divided into manifestations of specific ED-related symptoms, and generalized psychopathological symptoms and distress.

With regards to EDs symptoms, while some studies reported no differences between non-ED siblings and controls in body paradigm and eating-related behaviors and beliefs, others indicated a higher inclination to sub-clinical levels of EDs, and an experience of difficulty around food amid the former. This warrants farther research as the former findings are not in line with existing literature, which indicates ED symptoms tend to spread amid peer groups, in both normative and hospitalized populations (51, 52). In social club to understand the moderating factors accounting for the differences found in non-ED siblings' level of ED symptoms, there is need for enquiry concerning the mechanisms underlying the spread of ED symptoms in these families. As this review indicates studies in this group are scant, nonetheless the study of the spread of EDs among other peer groups has gained some attending. On the behavioral level, numerous studies found people tend to unwittingly mimic their companions' food intake (53). This is a potential mechanism for the spread of EDs, peculiarly because such mimicry is more prevalent amidst women, and fifty-fifty more so because lean individuals are more than likely to be mimicked (53). Additionally, exposure to weight loss-encouraging talk, which is frequent amid individuals with EDs, can strengthen unhealthy food and body related cognitions. Such conversation patterns, termed "Fat Talks," were constitute to exist related to negative affect, depression, and feelings of guilt (54), likewise as to ED-related behaviors and cognitions such every bit body dissatisfaction and bingeing and purging behavior (55).

Findings regarding psychopathologies other than EDs were also highly mixed, ranging from no reported differences between not-ED siblings and controls, to reports of higher levels of low, obsessive beliefs, and even suicide. Alongside the dandy burden of living with a family fellow member suffering from psychopathology, non-ED siblings are repeatedly exposed to the variety of negative emotions and mental states experienced by their siblings. This exposure may put them at elevated take chances for the development of various psychopathologies, since studies conclude that people in close relationships oftentimes come up to share a similar baseline level of both positive and negative emotions and a similar mental health state (56).

Looking beyond psychopathological symptoms, studies show that family unit relationships and dynamics are also greatly affected when a family fellow member suffers from an ED. These findings are in line with existing literature regarding siblings of individuals with other psychopathologies, indicating non-diagnosed individuals may experience their siblings' psychopathologies cause stress in the family unit, disrupt household routines, and impact relationships (57). Non-diagnosed siblings in such families depict feelings of grief over the loss of the relationships they had with their siblings before the psychopathology onset (58), and experience similar degrees of grief as parents exercise (59). Changes in the relationships with parents are also common among siblings, and similarly to siblings in the reviewed studies, many study feeling that due to their parents' preoccupation with the diagnosed sibling, they themselves receive less parental attention, and feel invisible, abandoned, or forgotten by their families (49, 60).

Studies in this review likewise found that non-ED siblings' position and part in the family may change on account of the disorder. The common roles described in this review are similar to those reported by studies concerning other psychopathologies, including serving as "go-betweens," or mediators, betwixt diagnosed siblings and parents, and playing a supporting role for parents (49). In addition, non-ED siblings often deport the part of "the good for you child" in the family unit, frequently emphasizing their achievements, and concealing their struggles. Due to this combination, their difficulties could frequently be masked and neglected. The darkening and secrecy typical of EDs might strengthen not-ED siblings' tendency to take on these roles, and aggravate the take chances of overlooking their difficulties.

Interestingly, non-ED siblings also describe some positive consequences their siblings' disorders have on them and their families. Some mention a contribution to their personal development and graphic symbol, and a positive bear upon on family solidarity and cohesion. It should be noted that such furnishings, showing that adversity may in fact contribute to 1'south personal growth, were likewise found in other areas of psychopathology (61). These salutogenic furnishings may testify to be important, and warrant further enquiry.

Siblings coping strategies reported in the reviewed studies were ordinarily in the realm of acquiring knowledge about the disorder, and accordingly many expressed their promise that professionals would provide more than information on the subject. Some other common strategy was distancing oneself from one's dwelling house and siblings, thereby fugitive existence in bear upon with the disorder and its implications. Both strategies were besides found common and effective for siblings of those suffering from psychopathologies other than EDs (11).

Methodological Limitations of Existing Studies

Our review too raises several methodological concerns in this area of inquiry. First, at that place are no clear and consequent inclusion criteria of the written report group across studies. Participants' age and birth lodge were varied, and seldom controlled for, and the criteria according to which a specific sibling in families with multiple children was chosen for the report were rarely mentioned. Furthermore, even though gender is a notable moderating cistron for EDs and for caregiving behaviors (62, 63), many studies included both male and female subjects without accounting for differences, thus limiting the test of the effect of gender on EDs' impact on siblings. In add-on, no study has focused exclusively on male siblings—a topic that conspicuously warrants further research.

Another inconsistency beyond the reviewed studies concerns the ED type and characteristics. EDs are a varied family of disorders, and each might give rising to dissimilar challenges and consequences for non-ED siblings (64). The only ED diagnosis to receive specific attention was Anorexia Nervosa, while other studies included siblings of patients with various EDs. In these studies results were not analyzed separately for each ED, mayhap due to small sample sizes. The lack of studies specifically examining EDs other than AN precludes comparison and insight into the unique touch of each ED on non-ED siblings. In addition, co-morbidities, which are highly common amongst ED patients (1, 63), were not controlled for in any study, thus preventing any articulate conclusions as to the unique role of the EDs in siblings' distress (as opposed to, for case, co-occurring low or anxiety symptoms).

An additional aspect of EDs which was not accounted for is the disorders' duration and current treatment status. Chronic conditions and newly diagnosed EDs accept different expressions and different prognoses (65), perhaps affecting the disorder's bear upon on siblings. Additionally, most studies recruited participants whose siblings were hospitalized or were out-patients in ED clinics. Thus, there is a gap in noesis regarding participants whose siblings refuse treatment, or rather are in a more than stable state. Similarly, some studies obtained patients' consent for the participation of their siblings, and were therefore exposed to selection bias based on the nature of the siblings' relationships.

A serious methodological limitation in some of the reviewed studies lies in the omission of siblings with by or nowadays ED diagnosis or symptoms. It is reasonable to assume that these studies excluded the most vulnerable group amid siblings. This may impede identification of the factors distinguishing non-symptomatic, sub-clinical, and ED-diagnosed siblings, thereby limiting our understating of risk and resilience factors among siblings.

Another pregnant limitation of previous studies has to practise with variable pick. Every bit shown in this review, studied factors moderating EDs' impact on siblings' well-existence and psychopathology were to date mostly situational (e.g., nascence order, living status). To our knowledge, no report to engagement has examined the effect of intrapersonal variables on non-ED siblings' resilience or risk to psychopathology. Every bit evident from other psychopathologies, some intra- and interpersonal factors may return family members more vulnerable to these disorders' effects. A notable aspect found to impact one's susceptibility to the transmission of symptoms within the family are patterns associated with the regulation of interpersonal altitude, such as attachment, family unit borders, and differentiation of self (e.g., 66). These variables may be especially relevant in families with a member suffering from an ED, as clinicians and researchers suggest that difficulties in separation and individuation often play a significant office in the etiology and maintenance of EDs (67). Indeed, several studies of clinical and non-clinical samples found low levels of differentiation were predictive of elevated ED symptomatology (68, 69)

Theoretical and Clinical Implications

Siblings of individuals suffering from EDs are a scarcely studied, all the same considerably at-risk group. To our knowledge, this is the commencement paper aimed at reviewing the existing literature on the subject, and it reveals the express state of cognition related to this upshot. As with other psychopathologies and conditions, the report of siblings has just recently started developing and expanding. Only half of the studies reviewed in this newspaper pertain specifically to siblings and their experiences, while the rest compare them to controls equally a ways to expand knowledge regarding EDs. Research focusing on siblings of those with EDs can join and enrich the growing body of noesis on the spread of psychopathological symptoms in families. Thus far, studies have concentrated mainly on spouses and offspring, and dealt with psychopathologies other than EDs, for instance low and PTSD (e.one thousand., fifteen, 18). Examining siblings in the context of EDs in the family could help place unique and shared characteristics or mechanisms of symptomatic spill-over in the family across different disorders and kinship.

This review clearly indicates that more studies are called for in order to broaden our understanding of non-ED siblings and their experiences. Every bit the existing qualitative and quantitative findings reveal contradictory pictures at times, information technology appears at that place is need for enquiry methodologies that could integrate them to create a more multilayered agreement. Mixed methods studies, of which there was simply one in the reviewed studies, could prove a beneficial way to study the complexity and provide a more intricate description at both the symptomatic and subjective levels. Furthermore, futurity studies are encouraged to take into consideration the great heterogeneity in previous piece of work, either by narrowing inclusion criteria, or past accounting for different moderating factors. Such variables could be related to the disorder itself, examining the effects of ED blazon and elapsing, treatment status, and co-morbidities. They could besides pertain to characteristics of not-ED siblings themselves, such every bit gender and interpersonal relating patterns. In order to place potentially significant factors, we encourage researchers to draw at to the lowest degree some knowledge from studies of other psychopathologies, which have looked at a wider assortment of psychological variables. Uncovering possible moderating factors for psychopathology in siblings of individuals with EDs may assist in constructing a more comprehensive model of risk and resilience factors in this group. For such a model to be accurate and externally valid, future studies should also avoid exclusion of participants with past or nowadays diagnoses of psychopathology.

This review also holds clinical significance. The literature covered in this newspaper indicates that siblings of patients with EDs may be seen as facing an increased gamble of developing ED symptoms, and are a risk group in need of attention. This may be attributed to shared genes and environment—factors which were beyond the scope of this paper, only likewise to intense siblings' continuous exposure to EDs, which may be somewhat "contagious." Understanding non-ED siblings' experience and needs can aid in early detection of psychopathology, and in the identification of those siblings who are particularly at risk of developing EDs, which is crucial equally early on diagnosis and intervention potentially pb to a more positive prognosis (seventy). In addition, as qualitative studies indicate, siblings of persons with EDs tend to avoid disclosing distress to their parents or seek professional help. Hence, mental health professionals are encouraged to more than effectively and proactively identify the needs and challenges faced by this vulnerable population.

Furthermore, it appears siblings of ED patients receive picayune clinical attending. Despite family therapy being a common and recommended treatment for EDs (5), to our knowledge piddling has been written almost non-ED siblings' involvement and experience in it (46, 47). Near references to non-ED siblings in this context have to do with their contribution to their siblings' recovery, thus failing to address the needs of the not-ED sibling (71). The relative silence of clinicians and researchers around this subject stands in contrast to not-ED siblings' common wish for more professional help. Therefore, it would be benign for professionals to more closely monitor siblings' well-being and accomplish out to offer support and personal therapy as needed. Since, as mentioned, mutual treatments of EDs are family unit-oriented, family therapists are likely to exist in a position to play this role. Moreover, a more than accurate recognition of siblings' needs could be translated into helpful psychoeducation for parents and into a ameliorate mode to appoint siblings in therapy. In addition, interventions particularly designed for non-ED siblings have been almost entirely absent-minded in empirical and clinical literature. Better insight into non-ED siblings' experiences could contribute to the development of specialized interventions for this grouping.

Conclusion

This review leads to conclusions on theoretical, methodological, and clinical levels. It can be concluded that expansion of the scarce knowledge existing regarding non-ED siblings is necessary. Equally has been done with other psychopathologies, meliorate agreement of non-diagnosed siblings' experience and psychopathology can shed light on pathological family dynamics, and the phenomena of symptoms spill-over in the family. Methodologically, such studies should be more meticulously designed, possibly including both quantitative and qualitative data. As can exist surmised from the present review, non-ED siblings are also in need of more clinical attention. We encourage clinicians in both family and personal therapy settings to be aware of the possible gamble factors of this group, in order to identify distress at an early stage and intervene accordingly.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can exist directed to the corresponding writer.

Author Contributions

All authors took part in conceptualizing the ideas in the review. IM wrote the beginning draft of the paper and conducted the literature review. DH and YG contributed in editing and revising the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absenteeism of any commercial or financial relationships that could be construed every bit a potential conflict of interest.

References

i. American Psychiatric Association. Diagnostic and statistical transmission of mental disorders (DSM-5®). Washington, DC (2013). doi: 10.1176/appi.books.9780890425596

CrossRef Full Text | Google Scholar

3. Martín J, Padierna A, Aguirre U, Quintana JM, Las Hayas C, Muñoz P. Quality of life amidst caregivers of patients with eating disorders. Qual Life Res (2011) 20(9):1359–69. doi: 10.1007/s11136-011-9873-z

PubMed Abstract | CrossRef Full Text | Google Scholar

4. Minuchin S, Rosman BL, Baker Fifty. Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, MA: Harvard University Press (1978).

Google Scholar

5. Le Grange D, Lock J, Loeb G, Nicholls D. Academy for eating disorders position newspaper: The part of the family in eating disorders. Int J Eat Disord (2010) 43(1):i–five. doi: ten.1002/swallow.20751

PubMed Abstract | CrossRef Full Text | Google Scholar

7. Holtom-Viesel A, Allan S. A systematic review of the literature on family functioning across all eating disorder diagnoses in comparison to command families. Clin Psychol Rev (2014) 34(1):29–43. doi: 10.1016/j.cpr.2013.10.005

PubMed Abstract | CrossRef Full Text | Google Scholar

8. Zabala MJ, Macdonald P, Treasure J. Appraisal of caregiving burden, expressed emotion and psychological distress in families of people with eating disorders: A systematic review. Eur Eat Disord Rev (2009) 17(v):338–49. doi: 10.1002/erv.925

PubMed Abstract | CrossRef Full Text | Google Scholar

9. Lukens EP, Thorning H, Lohrer Due south. Sibling perspectives on severe mental illness: reflections on self and family. Am J Orthopsychiatry (2004) 74(iv):489. doi:  10.1037/0002-9432.74.four.489

PubMed Abstract | CrossRef Full Text | Google Scholar

ten. Greenberg JS, Kim HW, Greenley JR. Factors associated with subjective burden in siblings of adults with severe mental illness. Am J Orthopsychiatry (1997) 67(ii):231–41. doi: 10.1037/h0080226

PubMed Abstract | CrossRef Full Text | Google Scholar

11. Kinsella KB, Anderson RA, Anderson WT. Coping skills, strengths, and needs as perceived past developed offspring and siblings of people with mental illness: A retrospective study. Psychiatr Rehabil J (1996) 20(two):24. doi: 10.1037/h0095388

CrossRef Full Text | Google Scholar

12. Figley CR. Traumatic stress: the function of the family unit and social support systems. In: Figley CR, editor. Trauma and its Wake: Traumatic Stress, Theory, Research and Intervention. Pennsylvania: Brunner/Mazel, Old York (1986), pp. 39–54.

Google Scholar

13. Yehuda R, Halligan SL, Bierer LM. Relationship of parental trauma exposure and PTSD to PTSD, depressive and anxiety disorders in offspring. J Psychiatr Res (2001) 35(five):261–70. doi: x.1016/S0022-3956(01)00032-2

PubMed Abstract | CrossRef Full Text | Google Scholar

14. Karenian H, Livaditis G, Karenian S, Zafiriadis K, Bochtsou V, Xenitidis Yard. Collective trauma transmission and traumatic reactions among descendants of Armenian refugees. Int J Soc Psychiatry (2011) 57(4):327–37. doi: 10.1177/0020764009354840

PubMed Abstract | CrossRef Full Text | Google Scholar

15. Dekel R. Posttraumatic distress and growth among wives of prisoners of war: The contribution of husbands' Mail-Traumatic Stress Disorder and wives' own attachment. Am J Orthopsychiatry (2007) 77(3):419–26. doi: x.1037/0002-9432.77.3.419

PubMed Abstruse | CrossRef Full Text | Google Scholar

16. Renshaw KD, Allen ES, Rhoades GK, Blais RK, Markman HJ, Stanley SM. Distress in spouses of service members with symptoms of combat-related PTSD: secondary traumatic stress or general psychological distress? J Fam Psychol (2011) 25(4):461–9. doi: x.1037/a0023994

PubMed Abstruse | CrossRef Total Text | Google Scholar

17. Harold GT, Rice F, Hay DF, Boivin J, Van Den Bree M, Thapar A. Familial transmission of depression and antisocial beliefs symptoms: disentangling the contribution of inherited and environmental factors and testing the mediating role of parenting. Psychol Med (2011) 41(6):1175–85. doi: x.1017/S0033291710001753

PubMed Abstract | CrossRef Full Text | Google Scholar

22. Taborelli East, Krug I, Karwautz A, Wagner Chiliad, Haidvogl M, Fernandez-Aranda, et al. Maternal anxiety, overprotection and anxious personality equally hazard factors for eating disorder: A sister pair written report. Cognit Ther Res (2013) 37(4):820–viii. doi: 10.1007/s10608-012-9518-8

CrossRef Full Text | Google Scholar

23. Maloney MJ, Shepard-Spiro P. Eating attitudes and behaviors of anorexia nervosa patients and their sisters. Gen Hosp Psychiatry (1983) 5(four):285–8. doi: 10.1016/0163-8343(83)90008-7

PubMed Abstract | CrossRef Full Text | Google Scholar

26. Stein D, Lilenfeld LR, Plotnicov K, Pollice C, Rao R, Strober Grand, et al. Familial aggregation of eating disorders: results from a controlled family written report of bulimia nervosa. Int J Eat Disord (1999) 26(2):211–five. doi: 10.1002/(SICI)1098-108X(199909)26:ii<211::Help-EAT11>three.0.CO;2-0

PubMed Abstract | CrossRef Total Text | Google Scholar

27. Strober K, Freeman R, Lampert C, Diamond J, Kaye W. Controlled family unit study of anorexia nervosa and bulimia nervosa: evidence of shared liability and manual of fractional syndromes. Am J Psychiatry (2000) 157(iii):393–401. doi: 10.1176/appi.ajp.157.3.393

PubMed Abstract | CrossRef Total Text | Google Scholar

28. Latzer Y, Ben-Ari A, Galimidi N. Anorexia nervosa and the family: Effects on younger sisters to anorexia nervosa patients. Int J Adolesc Med Health (2002) 14(4):275–82. doi: 10.1515/ijamh.2002.14.4.275

PubMed Abstract | CrossRef Full Text | Google Scholar

32. Areemit RS, Katzman DK, Pinhas L, Kaufman ME. The experience of siblings of adolescents with eating disorders. J Adolesc Health (2010) 46(6):569–76. doi: 10.1016/j.jadohealth.2009.12.011

PubMed Abstruse | CrossRef Full Text | Google Scholar

33. Amianto F, Abbate-Daga G, Morando S, Sobrero C, Fassino S. Personality development characteristics of women with anorexia nervosa, their healthy siblings and healthy controls: What prevents and what relates to psychopathology? Psychiatry Res (2011) 187(3):401–eight. doi: 10.1016/j.psychres.2010.ten.028

PubMed Abstract | CrossRef Full Text | Google Scholar

34. Rozenstein MH, Latzer Y, Stein D, Eviatar Z. Neuropsychological psychopathology measures in women with eating disorders, their good for you sisters, and nonrelated healthy controls. Compr Psychiatry (2011a) 52(half-dozen):587–95. doi: 10.1016/j.comppsych.2011.01.006

PubMed Abstruse | CrossRef Full Text | Google Scholar

35. Rozenstein MH, Latzer Y, Stein D, Eviatar Z. Perception of emotion and bilateral advantage in women with eating disorders, their salubrious sisters, and nonrelated healthy controls. J Affect Disord (2011b) 134(1-three):386–95. doi: 10.1016/j.jad.2011.06.009

PubMed Abstruse | CrossRef Full Text | Google Scholar

36. Dimitropoulos G, Freeman VE, Bellai Thousand, Olmsted Thou. Inpatients with severe anorexia nervosa and their siblings: not-shared experiences and family performance. Eur Eat Disord Rev (2013) 21(4):284–93. doi: ten.1002/erv.2230

PubMed Abstract | CrossRef Full Text | Google Scholar

37. Halvorsen I, Rø Ø, Heyerdahl S. 9-year follow-upwardly of girls with anorexia nervosa and their siblings: Retrospective perceptions of parental bonding and the influence of illness on their everyday life. Eur Eat Disord Rev (2013) 21(1):20–7. doi: 10.1002/erv.2191

PubMed Abstract | CrossRef Full Text | Google Scholar

38. Degortes D, Zanetti T, Tenconi E, Santonastaso P, Favaro A. Childhood obsessive–compulsive traits in anorexia nervosa patients, their unaffected sisters and good for you controls: A retrospective study. Eur Consume Disord Rev (2014) 22(4):237–42. doi: ten.1002/erv.2295

PubMed Abstract | CrossRef Full Text | Google Scholar

39. Withers A, Mullan B, Madden S, Kohn Thou, Clarke S, Thornton C, et al. Anorexia nervosa in the family: a sibling'due south perspective. Adv Eating Disorders: Theory Res Pract (2014) two(ane):53–64. doi: 10.1080/21662630.2013.839187

CrossRef Full Text | Google Scholar

40. Latzer Y, Katz R, Berger Thousand. Psychological distress amongst sisters of immature females with eating disorders: The role of negative sibling relationships and sense of coherence. J Fam Bug (2015) 36(5):626–46. doi: 10.1177/0192513X13487672

CrossRef Full Text | Google Scholar

41. Steinhausen HC, Jakobsen H, Helenius D, Munk-Jørgensen P, Strober M. A nation-wide study of the family aggregation and risk factors in anorexia nervosa over iii generations. Int J Consume Disord (2015) 48(1):i–viii. doi: x.1002/swallow.22293

PubMed Abstract | CrossRef Full Text | Google Scholar

43. Jungbauer J, Heibach J, Urban K. Experiences, burdens, and back up needs in siblings of girls and women with anorexia nervosa: Results from a qualitative interview study. Clin Soc Work J (2016) 44(one):78–86. doi: 10.1007/s10615-015-0569-7

CrossRef Full Text | Google Scholar

44. Langenberg T, Sawyer SM, Le Grange D, Hughes EK. Psychosocial well-being of siblings of adolescents with anorexia nervosa. Eur Eat Disord Rev (2016) 24(6):438–45. doi: 10.1002/erv.2469

PubMed Abstract | CrossRef Total Text | Google Scholar

45. Yao S, Kuja-Halkola R, Thornton LM, Runfola CD, D'Onofrio BM, Almqvist C, et al. Familial liability for eating disorders and suicide attempts: testify from a population registry in Sweden. JAMA Psychiatry (2016) 73(3):284–91. doi: 10.1001/jamapsychiatry.2015.2737

PubMed Abstract | CrossRef Full Text | Google Scholar

46. Van Langenberg T, Duncan RE, Allen JS, Sawyer SM, Le Grange D, Hughes EK. "They don't actually get heard": A qualitative written report of sibling involvement across two forms of family-based handling for adolescent anorexia nervosa. Eat Disord (2018) 26(four):373–87. doi: 10.1080/10640266.2018.1453632

PubMed Abstruse | CrossRef Total Text | Google Scholar

47. Fjermestad KW, Rø AE, Espeland KE, Halvorsen MS, Halvorsen IM. "Practice I exist in this world, really, or is it just her?" Youths' perspectives of living with a sibling with anorexia nervosa. Consume Disord (2020) 28(1):lxxx–95. doi: 10.1080/10640266.2019.1573046

PubMed Abstract | CrossRef Full Text | Google Scholar

48. Weinbach North, Bohon C, Lock J. Set-shifting in adolescents with weight-restored anorexia nervosa and their unaffected family members. J Psychiatr Res (2019) 112:71–6. doi: 10.1016/j.jpsychires.2019.02.022

PubMed Abstruse | CrossRef Full Text | Google Scholar

49. Sanders A, Szymanski Thousand, Fiori Chiliad. The family roles of siblings of people diagnosed with a mental disorder: Heroes and lost children. Int J Psychol (2014) 49(4):257–62. doi: ten.1002/ijop.12020

PubMed Abstract | CrossRef Full Text | Google Scholar

50. Galovski T, Lyons JA. Psychological sequelae of gainsay violence: A review of the impact of PTSD on the veteran'due south family unit and possible interventions. Aggress Violent Behav (2004) nine(5):477–501. doi: 10.1016/S1359-1789(03)00045-4

CrossRef Full Text | Google Scholar

51. Allison S, Warin M, Bastiampillai T. Anorexia nervosa and social contagion: Clinical implications. Aust New Z J Psychiatry (2014) 48(2):116–20. doi: 10.1177/0004867413502092

CrossRef Full Text | Google Scholar

53. Vartanian LR, Spanos S, Herman CP, Polivy J. Modeling of food intake: a meta-analytic review. Soc Influ (2015) x(three):119–36. doi: 10.1080/15534510.2015.1008037

CrossRef Full Text | Google Scholar

54. Stice E, Maxfield J, Wells T. Adverse effects of social pressure to be sparse on young women: An experimental investigation of the effects of "fat talk". Int J Swallow Disord (2003) 34(1):108–17. doi: 10.1002/consume.10171

PubMed Abstract | CrossRef Full Text | Google Scholar

55. Approach A, Segrin C, Harwood J, Bonito JA. Co-rumination of fat talk and weight control practices: An application of confirmation theory. Health Commun (2017) 32(4):438–50. doi: 10.1080/10410236.2016.1140263

PubMed Abstract | CrossRef Full Text | Google Scholar

56. Eisenberg D, Golberstein E, Whitlock JL, Downs MF. Social contagion of mental wellness: evidence from higher roommates. J Health Econ (2013) 22(viii):965–86. doi: ten.1002/hec.2873

CrossRef Full Text | Google Scholar

58. Chen WY, Lukens E. Well being, depressive symptoms, and burden among parent and sibling caregivers of persons with astringent and persistent mental disease. Soc Work Ment Wellness (2011) 9(6):397–416. doi: 10.1080/15332985.2011.575712

CrossRef Full Text | Google Scholar

59. Judge K. Serving Children, Siblings, and Spouses: Agreement the Needs of Other Family Members. In: Lefley HP, Wasow M, editors. Helping families cope with mental disease, vol. 2. London. (2013). p. 161–94.

Google Scholar

60. Leith JE, Stein CH. The part of personal loss in the caregiving experiences of well siblings of adults with serious mental illness. J Clin Psychol (2012) 68(10):1075–88. doi: ten.1002/jclp.21881

PubMed Abstract | CrossRef Full Text | Google Scholar

61. Silverstein MW, Lee DJ, Witte TK, Weathers FW. Is posttraumatic growth trauma-specific? Invariance across trauma- and stressor-exposed groups. Psychol Trauma (2017) 9(5):553–60. doi: 10.1037/tra0000236

PubMed Abstract | CrossRef Full Text | Google Scholar

63. Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, grade, consequences, and risk factors. Curr Opin Psychiatry (2016) 29(six):340–5. doi: 10.1097/YCO.0000000000000278

PubMed Abstract | CrossRef Full Text | Google Scholar

65. Treasure J, Stein D, Maguire S. Has the time come for a staging model to map the course of eating disorders from high hazard to astringent enduring affliction? An examination of the evidence. Early Interv Psychiatry (2015) 9(3):173–84. doi: 10.1111/eip.12170

PubMed Abstruse | CrossRef Full Text | Google Scholar

66. Solomon Z, Dekel R, Zerach G, Horesh D. Differentiation of the Self and Posttraumatic Symptomatology Among ex-POWs and Their Wives. J Marital Fam Ther (2009) 35(1):60–73. doi: 10.1111/j.1752-0606.2008.00102.ten

PubMed Abstract | CrossRef Full Text | Google Scholar

67. Bruch H. The gilt cage. Cambridge, MA: Harvard Academy Press (1978).

Google Scholar

68. Friedlander ML, Siegel SM. Separation-individuation difficulties and cerebral-behavioral indicators of eating disorders amid college women. J Couns Psychol (1990) 37(1):74. doi: 10.1037/0022-0167.37.1.74

CrossRef Full Text | Google Scholar

69. Rothschild-Yakar L, Bashan-Levi Y, Gur E, Vorgaft I, Stein D. Dependent and democratic interpersonal styles and level of differentiation among male patients with eating disorders. Psychoanal Psychol (2016) 33(2):243. doi: x.1037/pap0000026

CrossRef Full Text | Google Scholar

lxx. Currin L, Schmidt U. A critical analysis of the utility of an early intervention approach in the eating disorders. J Ment Health (2005) 14(6):611–24. doi: 10.1080/09638230500347939

CrossRef Total Text | Google Scholar

71. Hughes EK, Burton C, Le Grange D, Sawyer SM. The participation of mothers, fathers, and siblings in family-based treatment for boyish anorexia nervosa. J Clin Kid Adolesc Psychol (2018) 47(sup1):S456–66. doi: 10.1080/15374416.2017.1390756

PubMed Abstract | CrossRef Full Text | Google Scholar

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Source: https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00604/full

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