European Child & Adolescent Psychiatry 12 : 128– 135 (2003) DOI 10.1007/s00787-003-0319-1 ORIGINAL CONTRIBUTION ECAP 319 Andreas Karwautz Gerald Nobis Maria Haidvogl Gudrun Wagner Andrea Hafferl-Gattermayer Cicek Wöber-Bingöl Max 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 Adolescence University of Vienna Medical School Eating Disorders Unit Währinger Gürtel 18–20 1090 Vienna, Austria Tel.: +43-1/4 04 00-30 57 Fax: +43-1/9147317 E-Mail: andreas.karwautz@univie.ac.at ■ Abstract The family relation- ships of patients with anorexia ner- vosa (AN) have been extensively studied over recent years. However, using case-control designs with un- related controls is subject to vari- ous cultural and familial biases. Studying subjective differential perceptions of family relationships in sister-pairs discordant for the disorder may overcome some of these limitations. The aim of the present study was therefore, to in- vestigate subjective perceptions of family environments in a clinically ill sample of female adolescent pa- tients with acute AN and in their healthy sisters using the Subjective Family Image Test.We found sig- nificantly lower perceived individ- ual autonomy and higher perceived cohesion in patients compared with their sisters but no difference in perceived emotional connected- ness. Lower perceived individual autonomy of the ill children re- sulted mainly from their relation- ships with mothers but also in part from their relationships with fa- thers. This observed pattern might contribute to the maintenance of the disorder and should be ad- dressed in individual and family interventions. ■ Key words anorexia nervosa – sister-pairs – subjective perception – family relations – Subjective Family Image Test Introduction Research over the past decades into the family environ- ments of anorexia nervosa (AN) patients has revealed many and in part conflicting results.Various aspects of family 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 focus of attention. However, the subjectivity of the individual’s perception of individual relationships within the family has not been the focus of research in general as the in- struments most widely used [e. g. Family Adaptability and Cohesion Evaluation Scale (FACES), Family Assess- ment Device (FAD), Family Environment Scale (FES)] ask about the family as a whole rather than individual relationships. Where multiple informants have been used 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 on the perceptions of individual relationships, which, to our knowledge, have been used in only six studies in eat- ing disorders. Woodside etal. [49, 50] used the Family Assessment 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. The remaining three studies used the Subjective Family Im-