Perceptions of family relationships in adolescents with anorexia nervosa and their unaffected sisters

European Child & Adolescent Psychiatry12:128–135 (2003) DOI 10.1007/s00787-003-0319-1 ORIGINAL CONTRIBUTION

ECA

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Andreas KarwautzGerald NobisMaria HaidvoglGudrun WagnerAndrea Hafferl-GattermayerCicek Wöber-BingölMax H. Friedrich

Perceptions of family relationships in adolescents with anorexia nervosa and their unaffected sisters

Accepted: 15 April 2002

A. Karwautz, MD, Prof. (�) · G. Nobis · M. Haidvogl · G. Wagner · A. Hafferl-Gatter-mayer, MD · C. Wöber-Bingöl, MD, Prof. · M. H. Friedrich, MD, Prof.University Clinic of Neuropsychiatry of Childhood and AdolescenceUniversity of Vienna Medical SchoolEating Disorders UnitWähringer Gürtel 18–201090 Vienna, AustriaTel.: +43-1/4 04 00-30 57Fax: +43-1/9 14 73 17E-Mail: [email protected]

■ Abstract The family relation-ships of patients with anorexia ner-vosa (AN) have been extensivelystudied over recent years. However,using case-control designs with un-related controls is subject to vari-ous cultural and familial biases.Studying subjective differentialperceptions of family relationshipsin sister-pairs discordant for thedisorder may overcome some ofthese limitations. The aim of thepresent study was therefore, to in-vestigate subjective perceptions offamily environments in a clinicallyill sample of female adolescent pa-tients with acute AN and in theirhealthy sisters using the SubjectiveFamily Image Test. We found sig-nificantly lower perceived individ-

ual autonomy and higher perceivedcohesion in patients comparedwith their sisters but no differencein perceived emotional connected-ness. Lower perceived individualautonomy of the ill children re-sulted mainly from their relation-ships with mothers but also in partfrom their relationships with fa-thers. This observed pattern mightcontribute to the maintenance ofthe disorder and should be ad-dressed in individual and familyinterventions.

■ Key words anorexia nervosa –sister-pairs – subjective perception– family relations – SubjectiveFamily Image Test

Introduction

Research over the past decades into the family environ-ments of anorexia nervosa (AN) patients has revealedmany and in part conflicting results. Various aspects offamily environments in AN (reviewed in: 18, 39, 44, 46,51) have been studied. Beside family size, family struc-ture, birth order, family functioning [29], parental con-cerns, family climate [24, 36, 37], role allocations [10]and parental bonding [1, 7, 31, 38, 42, 43], family rela-tionships [2, 3, 11, 15, 17, 18, 23, 47] have been the focusof attention. However, the subjectivity of the individual’sperception of individual relationships within the familyhas not been the focus of research in general as the in-struments most widely used [e. g. Family Adaptabilityand Cohesion Evaluation Scale (FACES), Family Assess-

ment Device (FAD), Family Environment Scale (FES)]ask about the family as a whole rather than individualrelationships. Where multiple informants have beenused the focus has generally been to establish interrater-reliability of assessments of family relations (e. g. 16, 17,45). These generally conclude that there is a “good de-gree of convergence in their perceptions of family mem-bers” [18].

There are three self-report instruments that focus onthe perceptions of individual relationships, which, toour knowledge, have been used in only six studies in eat-ing disorders. Woodside et al. [49, 50] used the FamilyAssessment Measure (FAM-III, 41) in patients with bu-limia nervosa (BN) and Casper and Troiani [2] in pa-tients with AN, while Houben et al. [14] used the Rela-tionship Inventory (RI, 25) in patients with AN. Theremaining three studies used the Subjective Family Im-

A. Karwautz et al. 129Subjective perceptions of family relations in anorexia nervosa

age Test (SFIT; 26, 40, 48), which is the instrument ofchoice in our study and is described in detail later.As hasbeen shown in these studies, psychiatric patients in gen-eral and anorexia nervosa patients in particular perceivethe relationships within their families as low in auton-omy [26, 40, 48]. Emotional connectedness is perceivedas low in a mixed psychiatric sample [26], moderate in asample of recovered AN patients [48] and high in thelargest reported sample of AN patients [40].

Nevertheless, it has been stressed that the subjectiveexperience of parental characteristics may be more im-portant than objective characteristics in the develop-ment and maintenance of psychiatric disorders and eat-ing disorders [14]. In particular, the study in adolescentAN by Houben et al. [14] centred its attention on the sub-jective perception of empathy, directivity, transparency,positive regard and unconditionality in the relations ofeach family member separately. In terms of the receivingperspective, anorexic patients’ perceptions of their fa-thers’ relationships towards them did not differ fromcontrols in any respect, whereas mothers were describedby the patients as more empathic than in the controls.Fathers, on the other hand, feel a more directive intru-sive and authoritarian attitude of their anorexic daugh-ters towards them compared with controls. Mothers’perceptions did not differ between the groups. In termsof the sending perspective, anorexic daughters did notdiffer from controls in their perceptions regarding theirrelationships towards fathers and mothers. Fathers didnot differ from controls in their perceived relations to-wards their daughters but mothers of patients perceivedthemselves to be more intrusive and authoritarian to-wards their anorexic daughters than did mothers in thecontrol group. This study, however, focused on familytrios and did not include siblings.

To study sisters who are discordant for the conditionof interest offers a unique research opportunity for anumber of reasons: (a) they do not differ greatly in ma-jor social variables, e. g. family structure, socio-eco-nomic status, schools and neighbourhoods, thus lessen-ing this possible bias present in case-control studieswith unrelated samples [4]; (b) siblings reared in thesame family for many years have many of their experi-ences in common, which tends to make them similarrather than different [13, 22, 34]; (c) what makes siblingsdifferent in phenotypes is non-shared experience, e. g.experiencing different life-events or perceiving the samesituations differently [5, 33, 35]. In particular, subjectiveperceptions of family issues are of a non-shared natureand may be relevant for differences in the phenotypewhich is, in the present study, whether an eating disor-der is present or not [20].

In the present study, which combines a focus on sub-jective perceptions of family environments and thestrength of a discordant sister-pair design, we aimed toclarify the question of whether eating disordered pa-

tients and their healthy sisters report different percep-tions regarding their relationships with their fathers andmothers. Delineated from the results of SFIT studies todate, we specifically hypothesised, that the anorexia ner-vosa patients perceive themselves as low in autonomyand highly emotionally connected compared with theirunaffected sisters.In addition,we wanted to look at puta-tive differences between the father-mother relationshipsfrom the viewpoints of both sisters.We hypothesised thatthese relations will not be seen as different by the sisters,thus these relations would not contribute to differencesin the family trios. To assess subjective perceptions infamilies consisting of two parents, an eating disorderedadolescent (trio A) and a non-eating disordered adoles-cent (trio B) gives the unique opportunity to control forthe bias when unrelated controls are used instead of sib-lings reared in the same family,and to look at individual-specific perceptions of their family relations which couldcontribute to the maintenance of the eating disorder.

Methods

■ Subjects

We included all consecutively admitted female adoles-cent patients with AN of both subtypes presenting to theEating Disorder Unit of the University Clinic of Neu-ropsychiatry of Childhood and Adolescence, Universityof Vienna Medical School, admitted between 1994 and1998 who had a sister who did not have a current or pasthistory of any eating disorder. After obtaining informedconsent, patients and their sisters were interviewed per-sonally to assess eating disorder diagnoses and theycompleted questionnaires within one week of admissionto the outpatient or inpatient clinic to avoid biasing theresults due to treatment. Patients were only included inthe study when severe starvation effects were absent(through clinical interview by the first author) whichcould affect the patients’ ability to complete the instru-ments reliably.

■ Clinical description of the sample

We included 31 adolescent patients (aged 13–18 years)with a mean age of 15.7 (SD 1.3) years and their closest-in-age sisters (n = 31) [age range: 11–21 years, mean age16.2 (SD 2.8)]. The sister-pairs did not differ in theirmean age (t = 0.93, df = 30, p = 0.36), with a mean age dif-ference ranging from 1 to 6 years. All participating sub-jects were Caucasian. Diagnosis was made by consensusof two experienced clinicians (AK, CW-B). Patients ofboth the restricting (DSM-IV: 307.1; ICD-10: F50.00)(n = 24) and the binge-purging (DSM-IV: 307.1; ICD-10:F50.01) (n = 7) subtype of the disorder were included.

130 European Child & Adolescent Psychiatry, Vol. 12, No. 3 (2003)© Steinkopff Verlag 2003

On admission, the patients had a BMI below 85 % of thatexpected for age. The sisters differed significantly intheir mean current BMI, which was 15.6 kg/m2 (1.6) inthe patient group and 20.5 kg/m2 (2.7) in the healthy sis-ters (n = 28) (t = 8.11,df = 27,two-tailed p-value < 0.001).In the patient group the mean lowest BMI before admis-sion was 14.9 kg/m2 (1.5) (range 12.3–17.5) with meanage at onset 14.7 years (1.4) (range 12–17 years of age).To avoid the possible effect of chronic illness on thecompletion of the instruments, patients were includedin the study only if they were in the first episode of theirillness with no prior inpatient treatment and a short du-ration of illness [mean 12.2 (8.9) months]. Healthy sis-ters were screened for eating disorder history and cur-rent eating behaviour disturbances by interview(SIAB-part 1) and administration of the Eating Atti-tudes Test (EAT-26; 12) and were only included if: (a)there was no current or past eating disorder history and(b) they had an EAT-26 score of less than 20.

■ Measures

Eating disorder diagnosis

Diagnosis of an eating disorder was made using the“Structured interview for anorexia and bulimia nervosa– part 1: psychopathology” (SIAB-P; 8) for which excel-lent reliability and validity data are available [9]. All pa-tients fulfilled both the DSM-IV criteria for AN and theICD-10 criteria for both subtypes. For our adolescentsample, we adapted the weight criterion of the ICD-10for adolescents (as described in detail in 19).

Eating disorder related traits

The Eating Attitudes Test (EAT-26 [12]; German transla-tion in [28]) was used in the healthy sisters for screeningpurposes regarding eating disordered behaviour. Cron-bach’s alpha is reported as 0.85.

Perception of family environments

The self-rating instrument Subjective Family Image Test(SFIT; 27) was used to assess subjective perceptions ofthe family environment. This measure is based on thedevelopment-cohesion model of family relations,grounded in the dialectical interrelations of individualautonomy (IA) and emotional connectedness (EC),which are crucial for child and adolescent development[26]. Explanations for all abbreviations used are given inan appendix.IA = Individual autonomyEC = Emotional connectednessMFIA = Perceived IA within the relationship of mother

to father (perception by patient or sister)

MFEC = Perceived EC within the relationship of motherto father (perception by patient or sister)

FMIA = Perceived IA within the relationship of fatherto mother (perception by patient or sister)

FMEC = Perceived EC within the relationship of fatherto mother (perception by patient or sister)

FSIA = Family sum of IA (excluding the marital rela-tions) (perspective patient or sister)

FSEC = Family sum of EC (excluding marital relations)(perspective patient or sister)

CD = Positive conditions of development (FSEC plusFSIA)

CO = Cohesion (FSEC minus FSIA)MCIA = Perceived IA within the relationship of mother

to child (perception by patient or sister) – re-ceiving perspective

FCIA = Perceived IA within the relationship of fatherto the child (perception patient or sister) – re-ceiving perspective

CMIA = Perceived IA within the relationship of child tomother (perception patient or sister) – send-ing perspective

CFIA = Perceived IA within the relationship of child tofather (perception patient or sister) – sendingperspective

MCEC = Perceived EC within the relationship of motherto child (perception by patient or sister) – re-ceiving perspective

FCEC = Perceived EC within the relationship of fatherto the child (perception patient or sister) – re-ceiving perspective

CMEC = Perceived EC within the relationship of child tomother (perception patient or sister) – send-ing perspective

CFEC = Perceived EC within the relationship of child tofather (perception patient or sister) – sendingperspective

This instrument has good reliability and validity [26,27]: a clear 2-factor (IA and EC) structure has beenreplicated in various populations, the internal consis-tency for individual relations regarding IA and EC wasacceptable (mean alpha = 0.76), the 2-weeks re-test reli-ability in a child psychiatric population was 0.66 for IAand 0.78 for the EC scales, the criterion validity compar-ing with the FACES was as expected.The SFIT asks aboutvarious relationships from the perspective of each fam-ily member, focusing particularly on the subjective andindividual-specific view of each family member ratherthan “objective data” (e. g. family climate or family func-tioning). Six pairs of adjectives are rated on a 7-pointLikert scale (–3 to + 3) to quantify a relationship be-tween a subject and her family member, as well as to de-scribe how she perceives the other family member actsin the relationship with her.Each individual relationshipis described with one value on the scale “individual au-tonomy – IA” (derived from the adjective pairs: inde-


pendent-dependent; decisive-indecisive; confident-anx-ious), and one value on the scale “emotional connected-ness – EC” (derived from the adjective pairs: interested-disinterested; warmhearted-cool; understanding-intolerant). Each of these two scales (IA, EC) has valuesbetween –9 and + 9.

In a second step, there are several possibilities to cal-culate more comprehensive values such as “familysums”.These are measures of perceived global family re-lationships and are calculated by summing all perceivedrelationships from the viewpoint of one person (in thiscase the patient or the sister).Although there are a num-ber of “family sums”that can be calculated (which wouldinclude all relationships and all reciprocal relationshipsbetween all family members), here we use just four rela-tionship scores for each subject: “sum of patient’s views”= relationships between patient–father, father–patient,patient–mother and mother–patient; “sum of sister’sviews” = relationships between sister–father, father–sis-ter, sister–mother and mother–sister, resulting in valuesfor these (further called simply “family sums” and ab-breviated FS) between –32 and + 32.

In a third step, two further scales are calculated. Pos-itive Conditions for Development (CD) is calculated as“family sum EC” plus “family sum IA”. Cohesion (CO) iscalculated as “family sum EC” minus “family sum IA”.

The test was given to patients with AN and their sis-ters and subjects were asked to rate how they perceivedthe relationship between (a) their mother towards father(MFIA, MFEC) and (b) their father towards mother(FMIA, FMEC), (c) their own relationship towards theirmother (CMIA, CMEC), (d) that of their mother towardsthem (MCIA, MCEC), (e) their own relationship towardstheir father (CFIA, CFEC), and (f) that of their father to-wards them (FCIA, FCEC).

In addition, the test was given to fathers and mothersas well, in order to have the opportunity of looking atwhether certain perceived relations were similarly ordifferently perceived by the adolescents (in particularthose which were found to be different between the sis-ters).

■ Statistics

Differences between the patient and the healthy sisterswere tested for normal distribution using Kolmogorov-Smirnoff Tests. The groups were compared using pairedt-tests and Wilcoxon Signed Ranks Tests where appro-priate. Pearson correlations between the perceptions ofthe sisters were calculated. Effect sizes were calculatedusing Cohen’s method. All significance tests were two-sided. We corrected for multiple testing using the Bon-ferroni-Holm method. The analyses were performed us-ing SPSS version 10.0.

Results

The mean values (SD) of both perceived IA and EC in therelationships between parents and adolescents withintrio A (patient’s perspective) and trio B (healthy sister’sperspective) are given in Figs. 1 and 2, the mean values(SD) of the higher-order factors and the test statisticsare given in Table 1.

■ Differences between the sister-pairs regarding the marital relations

Sisters did not differ in their perceptions of the maritalrelationship between mother and father; all means (SD)of these relations are between 4.16 and 6.68, which is ina normal range according to norm tables for adult peo-ple. The correlations for paired samples (perceptions ofboth sisters) are for MFIA 0.64, p < 0.001; for MFEC 0.69,p < 0.001; for FMIA 0.13, p = 0.50; and for FMEC 0.65,p < 0.001.

■ Differences between the sister-pairs regarding the relationships within both trios

As a second step, we excluded the marital relationshipsfrom the calculation of the family sums using only theperceived relationships of the patients and the sisters to-wards their parents and the relationships of both par-

Fig. 1 Means (SD) of individual autonomy perceived by both children (F = father,M = mother, C1 = child with AN, C2 = child without AN)


ents towards their children. Comparing the perceivedfamily sums of patients and sisters regarding EC and IArevealed no difference in EC but a significantly lowerperceived IA in the patient group (Table 1) with amedium effect size. In addition,Pearson correlations be-tween the sisters’ perceptions are reported in Table 1.Sisters showed medium size correlations for FSEC andlow correlations for FSIA.

In the third step, we calculated the scales CD and COand compared the sisters on these. Patients had a non-significant trend towards lower CD and significantlyhigher perceived CO (with a large effect size) comparedwith their healthy sisters. Sisters had medium size cor-relations for CD and low correlations for CO.

In the fourth step, we looked at the specific contribu-

tions of individually perceived IA between patients/sis-ters and their parents (“sender’s perspective”) and thecontributions of perceived IA between parents and pa-tients/sisters (“receiver’s perspective”). There were nodifferences in the receivers’ perspectives, but thesenders’ perspectives of the children contributed mostto the differences in perceived IA in these families. Inparticular, the patients perceived that they were non-au-tonomous towards their mothers [CMIA: 3.71 (4.6) inpatients vs. 6.26 (2.8) in healthy sisters; t = –3.5,p = 0.001; mean difference: –2.55 (4.1), CI lower: –4.0, CIupper: –1.1] and their fathers (although, for the latter,this trend just failed to reach significance).

■ The parents’ perceptions of relationships

Comparing the mothers’ and fathers’ perceptions of therelationships found to contribute to differences in indi-vidual autonomy, we found similar perceptions by themothers regarding lack of autonomy in the relations oftheir anorexic daughters towards them (CMIA mothers’view) [patient mean 2.79 (5.41) vs. sister mean 6.21(3.59); Wilcoxon-Signed-Ranks Z = –3.64, p < 0.001], butno difference in autonomy in the relationships of themothers towards their daughters, the fathers towardstheir children, and the daughters towards their fathers.The finding of a lack of autonomy within the relation-ship of patients towards their mothers reported by pa-tients is, therefore, corroborated by the mothers’ percep-tions.

Discussion

In this study we have used the strengths of a discordantsister-pair design to investigate individual-specific sub-jective perceptions of family relations of patients withAN and their healthy sisters. We were particularly inter-ested in differences between the perceptions of the rela-tionships towards their parents and their parents to-

Fig. 2 Means (SD) of emotional connectedness perceived by both children (F = fa-ther, M = mother, C1 = child with AN, C2 = child without AN)

Table 1 Means (SD) of the SFIT measure higher-order factors in the AN group’s perception and the healthy sisters’ perception; t-tests and two-tailed levels of significance(p), Bonferroni-Holm (BH) correction for multiple comparisons, mean (SD) differences (Mdiff), and 95% confidence intervals [lower (CI-low) and upper (CI-upp) percentile]for paired samples (df = 30), Pearson correlations between the sisters’ ratings. Cohen’s d as effect size estimation

Code AN (n = 31) Sister (n = 31) T P BH Mdiff (SD) CI lower CI upper Correlation Effect sizeMean (SD) Mean (SD) between the sisters Cohen’s d

FSIA: Family sum 18.19 (10.34) 24.71 (7.56) –3.28 0.003 sig. –6.52 (11.1) –10.57 –2.46 0.268 (ns) –0.719individual autonomy

FSEC: Family sum 23.65 (11.46) 22.13 (10.83) 0.99 0.33 n. s. 1.52 (8.5) –1.61 4.64 0.709 (p < 0.001) 0.136emotional connectedness

CD: Positive conditions 41.84 (19.38) 46.84 (15.82) –1.74 0.092 n. s. –5.00 (16.0) –10.87 0.87 0.603 (p < 0.001) –0.282for development

CO: Cohesion 5.45 (10.05) –2.58 (9.93) 3.87 0.001 sig. 8.03 (11.6) 3.79 12.27 0.330 (ns) 0.8037


wards these adolescents in an AN group compared withtheir sisters regarding the two developmentally impor-tant areas of perceived individual autonomy and emo-tional connectedness [26].

We found no significant differences between the sis-ters discordant for an eating disorder in their percep-tions of the marital relationships of their parents. Therewas a significant difference with a medium effect be-tween patients and their healthy sisters, in particulardue to differences in perceived autonomy (patients lessautonomous). The sisters did not differ in their per-ceived relationships with parents regarding emotionalconnectedness. The patient group perceived signifi-cantly higher cohesion with quite a large effect. This dif-ference resulted mainly from the lower perceived auton-omy of the ill children towards their mothers and in partfrom lower perceived autonomy towards their fathers.

The main clinical implication of these findings is thatthe sisters with AN are in a weaker intra-familial posi-tion than their healthy sisters, lacking, in particular, in-dividual autonomy within their families. This has to bepredominantly considered in individual and/or family-based psychotherapy, as a focus has to be set at strength-ening individual autonomy and reducing cohesion inthe patient-parents relationship to decrease these possi-ble maintaining factors in order to contribute to a goodoutcome.

There are similarities and differences between the re-sults of the present study and those of others using theSFIT. The SFIT has been used in adolescents with vari-ous disorders and in healthy probands reporting on thesubjective perceptions of family environment [26].However, there are only three studies which have re-ported on patients with AN. Wewetzer et al. [48] com-pared 22 recovered AN patients with 24 controls. Con-sistent with their results,we also found a lower perceivedautonomy in global family environment (excludingmarital relationships) but not in all individual relation-ships (e. g. low autonomy towards mothers but not to-wards fathers) and no differences in EC either in globalfamily environment or in individual relationships.In ad-dition, our finding regarding the lower autonomy in ANpatients’ relationships towards their mothers is in keep-ing with their finding in the recovered patients. Consis-tent with the second report by Mattejat [26] on 19 ANpatients, we also found similar levels of EC and IA in therelationships of the mothers towards their daughters(patients’ receiver’s perspective). However, we could notcorroborate the trends towards lower EC and lower IA inthe relationships of fathers towards their daughters(from the perspective of the patients). Instead, we foundlower IA in the relationships of the anorexic adolescenttowards her mother to be the most important finding.

The third, and most recent report on 65 German-speaking patients with eating disorders [40] showed areversed family hierarchy with dominance of the index

patient (high values of EC and low levels of IA), whichwas in part supported by our study.

It is difficult to compare the results with those fromstudies using other measures like the Parental BondingInstrument [32] that assesses paternal and maternalcare and protection. However, fathers are perceived asless caring and empathic [43] and mothers as more em-pathic [14]. If emotional connectedness (warmhearted-ness, interest and tolerance) is a similar construct to pa-ternal care and empathy,our findings differ from both ofthese studies.

The dimension “positive conditions of development”was similar in the sisters, whereas they differed in cohe-sion. We found significantly higher CO perceived by theAN patients compared to their sisters. However, there isa conceptual difference between cohesion as Mattejat[26] defines it for the SFIT and how it is defined by Ol-son et al. [30] for the FACES, which also makes a directcomparison impossible.

It has been proposed in the “development-cohesionmodel” (Mattejat [26] pp. 67–81) that the optimal pre-requisite for healthy development is a family where theadolescent perceives herself highly autonomous andhighly emotionally connected, whereas the more patho-logical pattern would be a family where she perceivesherself as non-autonomous and unconnected to theother family members. In our study, the sister-pairs per-ceived themselves similarly highly emotionally con-nected to their parents while the patients perceivedthemselves as non-autonomous in these relationships,thus lying somewhere in the middle between best andworst perceived family conditions for development.Thiscan be seen as a sign of the family being perceived as afused family (type-2 family according to Mattejat [26])from the perspective of the patient at the beginning of aperiod of severe illness.

In a study of the family relationships of AN patientswhich also included siblings, Casper and Troiani [2] re-ported that restricting AN did not differ significantlyfrom healthy controls whereas patients of the binge-purging subtype of AN perceived themselves as signifi-cantly more impaired than controls. Siblings of patientsof both subtypes rated their parents as functioningwithin the normal range, thus differing from the af-fected sibling. A comparison of subtypes was not sensi-ble in our sample as it included only seven patients of thebinge-purging subtype. When selecting the AN/R pa-tients only (n = 24) and re-calculating the comparisonsbetween the sister-pairs regarding the main variables,the differences between the sisters found for the wholesample in FSIA and CO remained significant, those inFSEC and CD remained non-significant.

In general,differences between healthy probands andpsychiatrically ill patients are more prominent on thedimension of IA than on the dimension of EC (Mattejat[26]: p. 265, p. 283). Patients perceive a trend towards


emotionally negative relationships and themselves asnon-autonomous. This proposed pattern is broadly sup-ported by the present data in AN patients. However, theEC dimension did not differ. This difference can be ex-plained as we compared the relationships of patientswith their healthy sisters living in the same family, thusreporting individual-specific perceptions rather thandifferences between patients and unrelated healthy con-trols. Our findings differ from those by Mattejat [26],who used a mixed group of psychiatric patients, in thatwe did not find any emotionally problematic relation-ships with the mothers and no problems within the au-tonomy dimension in the father-daughter relationships.

There are a number of limitations that we would ac-knowledge. For example, the sample size was relativelysmall. This did not allow us to explore possible differ-ences between subtypes of AN. However, when exclud-ing the patients of binge-purging subtype from the mainanalyses, the differences found between the sisters re-mained similar. It also means the representativeness ofour sample is open to question, particularly in relationto those from the general population [6,36,37] although,as clinicians, we are primarily interested in those whoseek our help in deriving clinically useful models. Thestudy is also cross-sectional and we cannot determinewhether the differences are of aetiological importanceor, indeed, whether they have implications for recovery.Differences in perceptions of relationships may havebeen the result of having an ill sister or, indeed, the

anorexia itself may have actually affected the whole fam-ily system. Many of the unaffected sisters who partici-pated in this study had also not passed the age of peakrisk, although this would have reduced any differencesthat might have emerged. The fact that we were inter-ested in perceived differences in relationships precludedus from using information from patients, parents andsisters as corroboration from multiple informants ex-cept for those relations perceived differently by the sis-ters. Nevertheless, we were interested in perceived rela-tionships rather than objective family relations althoughthe fact that patients and sisters did not differ in theirperceptions of the relationship between parents sug-gests, at least, that any influence that AN has on percep-tions of relationships is not a global one. Finally, thespecificity of the differences found to AN requires futurestudies to include additional control groups such asthose where one proband has some other psychiatric di-agnosis such as bulimia or is unaffected of psychiatricdisturbance [21].

■ Acknowledgements This study was supported in part by a grantby the European Commission Framework 5 (QLKT-1999–00916)given to AK. We would like to thank all patients and families whoparticipated, Prof. M. Schemper, Department for Biostatistics andComputing, University of Vienna for helpful statistical advice, Dr.Nick Troop, London Metropolitan University, London, UK, for cor-recting the English text, and Prof. Fritz Mattejat, University of Mar-burg/Lahn for helping to deal with some revision requirements of themanuscript.

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Documents

Perceptions of family relationships in adolescents with anorexia nervosa and their unaffected sisters