Anorexia Nervosa: Predicting Levels of Caregiver Stress

The effects of anorexia nervosa (AN) always reach far beyond the patient to family, friends, and other caregivers. Those who care for patients with AN spend a large amount of time seeking and coordinating treatment and support, and additional stress may come with the stigma of the disease. A group of Canadian researchers used a model of measuring stress to identify the variables that increase stress for caregivers and lead to poorer health outcomes.

Dr. Gina Dimitropoulos and colleagues at Toronto General Hospital used self-report measures to examine stressors among 63 family members of inpatients with long-term AN (Int J Eat Disord. 2008;41:739). To study the effects of individual stressors, Dr. Dimitripoulos and colleagues looked at the primary stressor, or “burden,” and secondary stressors, such as family conflicts. To do so, they used a series of questionnaires, including the Burden Assessment Scale, which includes 19 items assessing the subjective and objective aspects of caregiving over the past 3 months. The first 10 questions target objective aspects of burden and the following 9 items measure the caregiver’s subjective feeling and experiences of being a caregiver for a person with mental illness.

The group also utilized the Family Conflict Scale, a 12-item questionnaire that was originally designed for caregivers of people with dementia. This questionnaire measures underlying dimensions of family conflicts. Other questionnaires examined stigma toward the individual and family, perceived support from family members, professional support, general functioning and general overall health.

Primary and secondary stressors

Nearly half of the caregivers were mothers, and the remainder were fathers (27%), siblings (7.9%), partners (all males, 12.7%), and “other” (for example, aunts, 7.9%). Most of the caregivers reported incomes well above the average for Canadian citizens and were well-educated (44% had a college degree). The caregivers reported that 79% of patients were financially dependent on their parents; 11% were financially dependent on their partners. Most of the patients (93%) were female. A majority (76%) were single.

Family function was predicted by a model that included the primary stressor or burden; secondary stressors included conflict about the seriousness of the disorder, family conflicts about attitudes and actions toward the person with the eating disorder and the caregiver, courtesy stigma, and social support. (Courtesy stigma occurs when the caregiver is stigmatized by his or her association with the patient. An example of this occurred during the early days of the AIDs epidemic, when friends and family members were stigmatized by their associations with patients with the AIDS virus.)

Female caregivers reported significantly higher levels of caregiving burden, compared with their male counterparts. A study by Kyriacou et al., which examined the issue of gender differences between mothers and fathers who were caregivers, found that mothers scored higher on both self-related and interpersonal strains than did fathers (Int J Eat Disord. 2007; 41:233).

Burden & stigma

The authors note that although the element of “burden” is increased for caregivers of individuals with AN compared to caregivers of those with psychoses, this is the first study to examine the burden of caregiving as a predictor of family function in families of patients with AN. Also, as hypothesized, secondary stressors predicted family functioning above and beyond burden.

Stigma directed to the family increased stress

Stigma directed toward the family was an important predictor of caregiver outcomes, whereas stigma directed toward the individual with AN was not. Research also suggests that high levels of courtesy stigma lead family members to withdraw from social activities outside the immediate family, to avoid being shamed and blamed for the illness. The self-induced isolation then acts to reduce social support. Social support levels significantly predicted family functioning, over and above primary and secondary stressors, predicting 8.2% of the variance.