Title: Attachment and mentalization as predictors of outcome in family therapy for adolescent anorexia nervosa
Funder: Health Education England

Abstract: Background Anorexia nervosa (AN) is a serious condition which typically emerges during adolescence. AN is associated with high rates of psychiatric co-morbidity (Salbach-Andrae et al, 2008) and significantly raised mortality rates (Arcelus et al, 2011).Specialist eating disorder-focussed family therapy has the strongest efficacy evidence in the treatment of adolescent AN (NICE, 2004; Couturier et al, 2013), with low relapse rates (Eisler et al, 2007; Lock et al, 2010) and reduction of the need for hospital admissions by 50% or more (House et al, 2012; Lock et al, 2010). Whilst the majority of patients achieve weight restoration following family therapy (Le Grange and Eisler, 2009), approximately 20-30% of patients have poor outcomes. This subgroup of patients with long-term AN symptoms entails very high NHS treatment costs, primarily due to prolonged hospitalisation (Royal College of Psychiatry, 2012; Goddard et al, 2013). It is known that early weight gain (Lock et al, 2014) and the quality of the therapeutic alliance (Friedlander et al, 2011) are potent predictors of outcome, but further research is needed to understand the factors that underpin this. Recent evidence drawn from the adult literature suggests that attachment and mentalization may be important variables in determining treatment outcome in eating disorders (e.g. Illing et al, 2010; Schulte-Ruther et al, 2012; Rothschild-Yakar et al, 2010). This study would be the first to investigate these variables as predictors of outcome in an adolescent sample receiving family therapy for AN. It is hypothesized that families with insecure attachments and mentalizing difficulties are at increased risk of poor outcome, due to their greater difficulties in establishing a positive therapeutic relationship with their therapist early on in treatment. Aims The aims of this project are to answer the following main research questions: Do parent and child attachment and mentalization at assessment predict treatment outcome? Does the therapeutic alliance between family and therapist mediate the relationship between attachment, mentalization and treatment outcome? Plan of investigation The main study is a prospective observational study of adolescents with AN and their parents recruited as they start family therapy. All consecutive cases referred to the child and adolescent eating disorder service at the Maudsley Hospital within the data collection period will be invited to participate. Self-report measures of attachment, mentalization and therapeutic alliance will be completed by adolescent patients and parents at the following intervals: assessment, 1 month, 3 months, 6 months and 9 months. The primary outcome is categorical treatment outcome, using the Morgan-Russell scales (Morgan & Russell, 1975). The study aims for a sample size of 200. Logistic regression and multi-level modelling will be used to test the theoretical model proposed. The research program also includes a systematic review of extant measures of attachment in middle childhood and adolescence. This will inform clinicians and researchers on the validity and reliability of available measures. Research participants in the main study will also be invited to take part in a sub-study, in which interview-based measures of attachment and mentalization are administered. Using a sample of 50 adolescents and parents, this sub-study will test the hypothesis that interview-based measures are more accurate predictors of outcome than self-report questionnaires. Potential benefits to patients and the NHS If the study hypothesis is confirmed, the findings will result in the early identification of families at risk of poor treatment response. An improved understanding of the factors associated with failure to engage families in effective treatment will inform adaptations to the treatment model for those families at risk of poor outcome. Identifying families at risk of poor outcome and offering a more effective treatment could result in significant savings for the NHS.

Lay abstract: Family therapy for adolescent anorexia nervosa is an effective evidence-based treatment but 20-30% do not respond well and have a poor outcome. Emerging evidence suggests that attachment (the nature of relationships with close others, particularly parents and children) and mentalization (the ability to understand behaviour in terms of mental states such as intentions) may be relevant to treatment outcome. This study will evaluate the specific role that attachment and mentalization plays in family therapy for adolescent anorexia. This study will help services to identify at assessment those families at risk of poor outcome, and inform new adaptations to treatment.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH