Effectiveness and efficacy studies, herein called outcome studies, are critical for establishing guidelines for evidence-based care. Outcome studies use measures to examine which treatments are effective, based on the degree of recovery from an ED on certain criteria. Recovery is usually measured as the remission of ED symptoms [ 20 ].
In a systematic review of patient outcome studies on AN, Steinhausen [ 20 ] concluded that remission from all essential clinical symptoms could be considered as recovery; however, he also noted substantial variation in outcome criteria between studies. In sum, outcome studies generally frame recovery around clinically relevant changes in ED symptoms, or remission. Simultaneously, a growing body of literature in the ED field highlights that ED symptom change remission is not sufficient for understanding, capturing and measuring ED recovery and emphasizes the importance of additional criteria, related to mental health, such as quality of life, well-being, psychological, social and emotional functioning [ 16 , 23 , 24 , 25 , 26 ].
This study aims to identify fundamental criteria for recovery from eating disorders focusing on criteria related to clinical symptoms and additional criteria, related to mental health and well-being. Psychologists have lobbied for decades to convey that health is not merely the absence of disease i. The emergence of positive psychology, for example, is based on re-focusing the exclusive attention on absence of pathology as a marker for health only, to positive aspects of mental and social functioning as markers for well-being as well [ 30 ].
He did not define health and well-being as a fixed state, but operationalized it as a syndrome consisting of several criteria, where upon people can develop, meeting certain thresholds for optimal well-being [ 37 ]. Well-being is theoretically divided into psychological, emotional and social well-being [ 31 , 37 , 38 ]. Psychological well-being PWB was conceptualized by Ryff [ 38 ] and consists of six key dimensions: self-acceptance, autonomy, environmental mastery, purpose and meaning in life, personal growth and positive relationships with others [ 34 , 38 ].
This is the model used when we refer to PWB throughout this article. Emotional well-being includes happiness, positive affect and avowed life satisfaction. Social well-being encompasses social contribution, integration, actualization, acceptance and coherence [ 36 ]; see for instance [ 38 , 39 , 40 ] for an overview of well-being and its theoretical and philosophical background.
Recent studies show that psychopathology and well-being are separate but complementary aspects of mental health and reflect two related continua, instead of being opposites on one continuum [ 29 , 37 , 40 ].
Focus on anorexia nervosa: modern psychological treatment and guidelines for the adolescent patient
In addition, a bi-directional relationship between psychopathology and positive mental health over time is found [ 41 ]. The complete mental health model emphasizes the importance of positive functioning for mental health, however, this is widely neglected in research on eating disorders [ 42 ]. While several studies have focused on positive mental health in terms of quality of life or subjective well-being, only one study examined all PWB dimensions among eating disorder patients [ 1 , 3 , 23 , 42 , 43 , 44 ].
Also, these studies examined the presence of PWB among eating disorder patients, it has not been examined as a criterion for recovery. In qualitative research examining recovery criteria from eating disorders, there are many recovery themes that are related to the dimensions for well-being.
Bowlby and Anderson [ 45 ], for instance, found several themes for recovery in a sample of therapists who were recovered from an eating disorder. Most of these themes matched the descriptions of the well-being dimensions. In a survey examining criteria for recovery from eating disorders, Noordenbos and Seubring [ 25 ] found high consensus between ex-patients and clinicians on all of the proposed 52 statements, divided into five themes: eating behavior, physical, psychological, emotional, and social functioning.
However, patients labeled self-esteem, a positive body attitude and expressing emotions as more important, while therapists accentuated eating behavior and physical recovery [ 25 ]. Emanuelli and colleagues [ 26 ] replicated this study in a sample of patients and clinicians, and concluded that recovery included general criteria e. The researchers did not find weight and weight gain as central criteria for defining recovery [ 26 ].
Dawson, Rhodes and Touyz [ 24 ] used a different approach, and conducted an extensive Delphi study with ED professionals to determine criteria for recovery from Anorexia Nervosa AN. They also concluded that, in addition to the minimal criteria i. While these studies show the importance of additional criteria, they have several limitations, making it difficult to understand which criteria are most fundamental besides the ED pathology based criteria remission. Noordenbos and Seubring [ 25 ] and Emmanuelli and colleagues [ 26 ] used a pre-fixed set of statements, making their study susceptible to missing criteria which might have been endorsed by ex-patients or clinicians had they been articulated in the design of the study.
Several qualitative studies show criteria for recovery that were not present in the consensus studies with the pre-fixed statements [ 25 , 26 ], such as improved self-acceptance, identity development, feelings of purpose and meaning in life, self-management and empowerment [ 45 , 46 , 47 ].
Other studies only focused on AN or did not take the perspective of recovered individuals into account. The importance of exploring the perspectives of those with lived experience on their recovery cannot be understated in this regard. Studies have shown that the orientation of patients towards recovery can change over time and during treatment [ 48 , 49 ]. In conclusion, outcome studies tend to follow criteria for recovery that are based on changes in ED symptoms remission , rather than aiming to ascertain health and well-being. It remains inconclusive which recovery criteria should be considered as fundamental.
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We argue that knowledge from individuals who have recovered from an ED should be leading and incorporated into the establishment of fundamental criteria for recovery. Qualitative studies examining the personal experience from recovered individuals highlight the importance of taking additional recovery criteria into account, which are closely related to the dimensions of well-being.
However, the results of these qualitative studies have never been systematically reviewed. Responding to this knowledge gap, we carried out a systematic review and meta-analysis of existing qualitative studies of ED recovery. The aim of this study is to identify fundamental criteria for recovery according to recovered individuals by performing a qualitative meta-analysis.
Qualitative meta-analysis can be explained as the aggregation of studies to discover the essential elements of a phenomenon, and translating these results into a more comprehensive description or clear end-product [ 50 , 51 ]. An integrative interpretation of findings from multiple qualitative studies is therefore more substantive than those resulting from individual investigations [ 50 , 52 ]. To our knowledge, this is the first study to use a qualitative meta-analysis to further identify fundamental criteria for ED recovery over all ED types, among people who were considered recovered.
The first step was to perform a systematic search in two electronic databases, Medline and PsycInfo final search date 04— Terms were searched within all fields. There was no limitation for the year in which the study was published. The second step was an additional search in which the reference list of two comprehensive qualitative studies of eating disorder recovery [ 45 , 46 ] were screened.
Eating Disorders: New Directions in Treatment and Recovery by Barbara P. Kinoy
The third step was to screen all articles in the Google Scholar search engine that had cited [ 45 , 46 ] search date: 06— Duplicates were removed as follows: duplicates between PsycInfo and PubMed, 5 duplicates between study [ 45 ] and [ 46 ] and 49 duplicates between the first PsycInfo and PubMed and the additional search. In total unique studies remained for screening. Studies which only or primarily included patients who were not considered recovered were excluded, as we were interested in understanding the markers or criteria for recovery, as opposed to future perspectives on recovery from those actively experiencing eating disorders.
Unpublished reports and dissertations were not included to avoid studies that have not been peer-reviewed for quality and also to ensure that studies were not duplicating results [ 55 ]. The first and second author screened all eligible studies separately in two phases. In the first phase, selection was based on title and abstract. In the second phase, all selected articles were independently screened by the first two authors based on full text. Inter-rater agreement kappa coefficient between authors in the second round of screening was 0. When there was no agreement, the first two authors discussed decisions to include or exclude studies until agreement was reached.
Finally, the reference lists of the included studies were cross-checked on eligible studies. This did not result in extra studies. In total 18 studies were included in the meta-analysis see Fig.
A qualitative meta-analysis requires both 1 an assessment of the quality of the studies i. The CASP method is a standardized tool to help researchers to systematically examine qualitative studies. CASP is a commonly used method within qualitative meta-analysis, or -synthesis studies to assess credibility, value and relevance of the selected studies [ 47 , 57 , 58 , 59 ].
CASP method applies the following 10 criteria: 1 a clear statement of the aims, 2 methodological design is adequate to aims, 3 research design is appropriate to address aims, 4 recruitment strategy is appropriate to aims, 5 data collection in a way that addresses research issue, 6 relationship between researcher and participant is considered, 7 ethical issues are considered, 8 sufficiently rigorous analysis, 9 clear statement of findings, 10 importance of research. In contrast to meta-synthesis analysis, this method allows for extracting themes and an evaluation of their frequencies [ 50 , 60 ].
The following strategy was used: 1 extract relevant themes from each study, 2 reduce these themes into abstract findings and 3 calculate effect sizes. Themes that were included were: themes that were stated by all participants and themes endorsed by an unknown number of participants, but wherein the theme was part of a main category.
Themes that specifically addressed aspects of the process of recovery i. The themes were identified independently by the first and second author and stored in their original content.
To obtain one dataset for the second step abstract findings , results were first discussed per study for half of the included articles. For the other half of the studies, the data set of the first author was used by the second author to look for further differences in themes.
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Differences in found statements were discussed until agreement was reached. This resulted in a dataset with statements which was audited by the third and fourth author. In the second step, the reduction into abstract findings, the labels were established. For the additional themes, the well-being dimensions were used since they seem to relate closely to the themes that are described in qualitative research on eating disorder recovery.
The following additional labels were used; emotional, psychological and social well-being with their underlying dimensions as stated in earlier work [ 31 , 36 , 38 ]. All themes were read carefully by the first two authors to examine whether they could be labeled corresponding the concept labels. Some of the well-being dimensions were very strictly or narrowly described in the literature [ 31 , 37 , 38 ], A minor adjustment in the description of three labels was necessary for the purpose of labeling the themes see Table 1 for the adjustments.
Then, all original themes were labeled separately by the first and fourth author. Inter-rater agreement kappa coefficient for the labeling process between the authors was. See Table 1 for an overview of the final list regarding the labels and descriptives. In the third step, frequency and intensity effect sizes were calculated for all labels. The frequency effect size shows how frequent labels are mentioned across studies and is calculated by dividing the number of studies containing the same finding by the total number of studies [ 60 ]. Although these cut-off points are rather arbitrary, we decided to use quartiles as cut off for ease of interpretation and pragmatic value for those seeking evidence on recovery criteria.
The intensity effect size gives a clear measure for how fundamental recovery criteria are compared to each other. The intensity effect size is calculated as the number of findings for a criteria produced in all studies, divided by all findings [ 60 ]. See Table 2 for an overview of the included studies and quality rating. The 18 included studies covered participants women and 17 men , with an average age of The average duration of the eating disorder was 8. The average length of recovery was 9. However, for many studies this was unknown.
See Table 3 for the intensity and frequency effect sizes of the criteria for recovery. Substantial to moderate evidence was found for improved body evaluation Insufficient evidence was found for happiness Examining the effect sizes of the overall mental health dimensions; psychological well-being accounted for Physical improvement was primarily about weight recovery and improvement of physical complications.
Intensity effect sizes of criteria for recovery. Circles represent criteria for recovery and are based on the intensity effectsizes. The larger the circle, the larger the intensity effectsize.
Related Eating Disorders: New Directions in Treatment and Recovery (2nd Edition)
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