Arthur Lecomte
email: alecomtemed@gmail.com

Assia Zerrouk

Jordan Sibeoni

Simeen Khan

Anne Revah-Levy

Jonathan Lachal

The role of food in family relationships amongst adolescents with bulimia nervosa: A qualitative study using photo-elicitation

Keywords: bulimia nervosa, family relationships, food, qualitative research, photo-elicitation 1. Introduction

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when compared with healthy controls [START_REF] Karwautz | Subjective family image in anorexia nervosa and bulimia nervosa in adolescence: a controlled study[END_REF], and lower emotional connectedness prior to onset of BN disease compared to their healthy sisters in another paper [START_REF] Huemer | Perception of autonomy and connectedness prior to the onset of anorexia nervosa and bulimia nervosa[END_REF]. Studies also found a significant negative correlation between individuation from parents and adolescent BN symptoms, and connection between mothers and adolescents was negatively associated with BN symptoms, while adolescents with increased eating concern were more likely to express a desire for more connection with their family [START_REF] Thomas | Observed connection and individuation: relation to symptoms in families of adolescents with bulimia nervosa[END_REF]. The role of the father-child relationship has also been scrutinised: several studies address the role it is thought to play in the possibility of development of AN or BN, by influencing the child's level of self-determining autonomy, which in turn can impact maladaptive eating attitudes [START_REF] Gale | A review of the father-child relationship in the development and maintenance of adolescent anorexia and bulimia nervosa[END_REF].

Family eating patterns also bore a correlation to BN symptoms: patients diagnosed with BN ate dinner more frequently with their family than those who had AN (the authors offered the hypothesis that patients with AN were subjected to more parental vigilance, and parents of teenagers with BN were less aware of their child's disordered eating, and thus less insistent upon family meals) [START_REF] Elran-Barak | Family meal frequency among children and adolescents with eating disorders[END_REF].

Finally, on the topic of eating disordered patients' perception of family relationships, patients with AN and BN expressed more discord within the family than the healthy control group [START_REF] Ciccolo | Exploring experience of family relations by patients with anorexia nervosa and bulimia nervosa using a projective family test[END_REF]. In another study, many adolescents with eating disorders (AN, BN and Other Specified Feeding and Eating Disorders) reported their family styles to be in the healthy range, but paradoxically, numerous patients and parents (especially those who suffered from depression) expressed dissatisfaction with their family relationships [START_REF] Fisher | Perceptions of family styles by adolescents with eating disorders and their parents[END_REF]. This paper presents the results of a French study, focused on teenagers diagnosed with BN and their families. Being a qualitative study, it aims to form hypotheses in order to better understand the dynamics of these families, starting with the way they interact around food, hoping to find out which specific aspects both individual and familial therapy can be based on to maximise their efficiency. In literature, some authors have suggested the hypothesis of a correlation between the inception of bulimic behaviour and the combination of two factors: a history of violent familial splitting (in particular of the parental couple), and denial of these separations. [START_REF] Igoin-Apfelbaum | Characteristics of family background in bulimia[END_REF] Such conception evokes an atmosphere of open conflict in the family of patients with BN, as opposed to those with AN, where conflict is unutterable and opposition only occurs through food. [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF] Indeed, past studies have differentiated several family profiles depending on which eating disorder is studied; the parents of patients with BN described their families as "more chaotic," and "less cohesive" than those of teenagers with AN [START_REF] Cerniglia | Family profiles in eating disorders: family functioning and psychopathology[END_REF]. This atmosphere results in "high conflict," and bears consequences in regards to the disorder itself: "the greater disorganization in the bulimic families results in greater severity of symptoms" [START_REF] Johnson | Family characteristics of 105 patients with bulimia[END_REF]. More detailed information on the systemic functioning of families is required in order to gain better insight into the proper course of action in terms of family therapy. It seems relevant to try and identify the perpetuating factors for the familial dysfunction that allows the illness to develop and be sustained.

Material and methods

Background

This study is a continuation of previous qualitative studies led by the QUALIGRAMH (QUALItative Group of Research in Adolescent Mental Health) research group; they were designed and directed by Pr Anne Revah-Levy (Paris, France). Those studies aimed to use qualitative research methods (in particular, photo-elicitation) to better comprehend adolescent mental health, and have already examined the question of the role of food in family relationships in several adolescent populations: namely sufferers of obesity, AN, and teenagers without eating disorders. In all three studies, food was found to be a means to regulate proximity and distance to relatives [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF][START_REF] Lachal | Qualitative research using photo-elicitation to explore the role of food in family relationships among obese adolescents[END_REF][START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF][START_REF] Ramalho | A qualitative study of the role of food in family relationships: An insight into the families of Brazilian obese adolescents using photo elicitation[END_REF]. In the AN study, this resulted in failure to gain autonomy; in teenagers without eating disorders, food also played a part in relations to people in other social circles (not limited to the family), thus playing a role in the construction of teenage identity [START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF].

In order to enrich this array of clinical entities, it seemed important to switch the focus, this time, to teenage sufferers of BN and their families.

Sampling and participants

Five families were recruited for the study. Five girls, three couples and two mothers (for a total of 11 interviews) were interviewed over a period of five months, at the local adolescent outpatient care center: the Maison des Adolescents (House for Teenagers) in Metz, a mediumsized city in France. All participating teenagers were patients receiving care at the facility, which is part of the larger public psychiatric care system for the general Metz area. (See Results, Table 1) All participating teenagers were diagnosed with BN, according to the DSM-V criteria [START_REF] Psychiatric Association | DSM-5 -Manuel diagnostique et statistique des troubles mentaux. 5e édition[END_REF]. This excluded cases where bulimic behaviour occurred during an episode of AN. This project is a continuation of the aforementioned series of studies from our research team [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF][START_REF] Lachal | Qualitative research using photo-elicitation to explore the role of food in family relationships among obese adolescents[END_REF][START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF][START_REF] Ramalho | A qualitative study of the role of food in family relationships: An insight into the families of Brazilian obese adolescents using photo elicitation[END_REF] regarding the role of food in family relationships among adolescents with obesity, AN, and without eating disorders, which has received approbation from the Comité d'évaluation de l'éthique des projets de recherche biomédicale (CEERB) -IRB 00006477, from GHU North Paris. The methods and location of interviews were the same as those involved in the AN study [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF], the medical diagnosis of BN instead of AN being the only different parameter, thus remaining within the realm of what the research was approved for.

As part of informed consent, it was explained that participants had a right to withdraw from the study at any time without any consequences on subsequent care in the facility, and that all data would be anonymised: as such, all the names and locations in data have been altered to preserve privacy. Permission to record interviews was obtained.

Data collection

All interviews were based on semi-structured interviews, and on the photo-elicitation method, which is a visual narrative method. It involves using a photograph as a support during a research interview [START_REF] Harper | Talking about pictures: A case for photo elicitation[END_REF] and has been shown to have several advantages in adolescent mental health research: it induces the teenage participants' interest, plays the role of a mediator during interviews, and gives insight into the teenager's perspective [START_REF] Sibeoni | Photo-elicitation with adolescents in qualitative research: an example of its use in exploring family interactions in adolescent psychiatry[END_REF][START_REF] Kirk | Methodological and ethical issues in conducting qualitative research with children and young people: a literature review[END_REF][START_REF] Yi-Frazier | Using Instagram as a Modified Application of Photovoice for Storytelling and Sharing in Adolescents With Type 1 Diabetes[END_REF]. Because photography has become a part of most teenagers' daily lives through social networking [START_REF]Social Media, Social Life: How Teens View Their Digital Lives | Common Sense Media n[END_REF], it provides a familiar medium for research, encouraging participation. In the case of our study, although the picture itself was not used in analysis, we found photo-elicitation to be effective as a starting point in the interviews; it made discussion easier and allowed a progression from factual, descriptive questions, to more personal ones. Conveying data that is otherwise difficult to express with words was also made easier [START_REF] Guillemin | Questions of process in participant-generated visual methodologies[END_REF]. On the premise that food is at the heart of eating disorders, we chose to design our study around it, looking to find out how it interacts with the family, the place it occupies amongst the relationships within the family, and ascertaining key factors that can be manipulated in order to instigate change on a bigger scale.

After a first interview where the study was explained, and consent was received, all participating teenagers were asked to take a photograph, using their mobile phone camera, according to the following instructions:

"Please take a photograph of the table after a family meal. It must be taken before the table has been cleared out, with nobody visible in it, which means it must be taken after everyone has left the table. You can take as many pictures as you like, but you will have to pick a single one, which you will discuss with the researcher during the interview." In the event of the teenager taking more than one single picture, picking one was required of them, because it reinforces the teenage participants' involvement in the research, allowing them to portray what they deem as most relevant to their lived experience. We chose not to have any people present in the picture in order to elicit a narrative from the participant of what happened before, during, and after the meal, rather than limiting the response to what was happening at the specific moment the picture was taken.

The selected photograph was displayed on a computer screen during the interviews and was the basis for the questions asked. The same picture was used for both interviews (with the teenager, and with the parents), which brought additional information through the parents' reaction to discovering which picture their child picked. Throughout the data collection interviews (which took place as soon as possible after a seven-day period of reflection), the researcher followed a pre-determined semi-directive interview schedule, which consisted in a series of open questions, designed to allow the discussion to branch out into neighbouring topics if needed. The photographs were neither stored or published.

The first questions invited participants to describe the photograph provided, and to comment on the meal in question. The following questions then explored the way meals generally unfolded, the significance of food and cooking in their respective families, and the part food played in the way the different family members relate to each other and interact. (Table 2)

All interviews took place in a consultation room located in the Maison des Adolescents, Metz facility. Teenagers were interviewed first; their parents followed either right after whenever possible, or at a later date (a few days later) when they were not available at the same time as their child. Two sets of parents were interviewed as a couple; one set was interviewed separately, considering their long-separated situation; and the remaining two mothers were interviewed each alone.

Table 2:

Outline of the interview schedule -Description of the photograph provided by the participant; how are people seated around the table? -How is the meal prepared? Who decides what to eat, and how? -Can you describe your emotions before, during and after this meal? -Is eating with your family important, and why? -Would you say eating is a pleasure for your family? What is the importance of food to the family? -How does your family react when you eat too little or more than usual? -What are your memories about meals when you were younger? -Could you describe members of your family and your relationship with them? -Does your family talk about food? How? -Is knowing how to cook important? Is the transmission of cooking in families important to you?

Analysis

All interviews were audio-recorded, and then transcribed verbatim in French, using word-processing software. The method used for analysis was the Interpretative Phenomenological Analysis (IPA). It was chosen to conduct this research because of the insight it gives into the participants' inner world: we were looking to better understand the way our sample families viewed the different aspects revolving around the question of food and its role in their family relationships. IPA is based on verbal data and provides examinations of personal lived experience. [START_REF] Smith | Interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain[END_REF] The interview transcripts were read several times each, in order to familiarise with it. Each reading could potentially bring up new insights. The data was annotated by following the text closely: what was interesting or significant in what the participant said was written down. It was then processed using the annotations as a basis, capturing the general ideas into codes. These, in turn, were grouped together, allowing the emergence of themes. Next, the themes were listed, which allowed the researchers to find connections between them, leading up to their clustering into superordinate themes. Each study of the transcripts brought new themes to light, which were then studied in the previously analysed transcripts to make sure the connections were still relevant to the source material, the whole process being one of constant back and forth between the text, codes and themes.

An ordered table of the themes was then produced, listing where all of the instances of each theme can be found in the text. The most relevant occurence of a theme was used to illustrate it during the writing of the article. [START_REF] Smith | Qualitative Psychology: A Practical Guide to Research Methods[END_REF] Interviewing and transcription were performed by the same researcher (AL); two independent coders (AL and AKZ) were conducting the analysis, in order to maximise result validity. Analysis was made using the same word-processing software used for interview transcription.

Extracts of the transcripts have been selected to exemplify the themes described and translated into English for the sole purpose of this article, attempting to convey the original tone of the speaker. Words have been added between brackets to provide context where needed. Three dots mean a pause in speaking; three bracketed dots mean part of the sentence has been taken out. All verbatim accounts have been anonymised. Data analysis found five themes, which can be clustered into two superordinate themes. The first one is centered around the relationship between parent and child. It includes the following themes: the sharing of disarray about food between parent and child; food and the issue of children becoming autonomous from parents; and food as a catalyser of conflict amongst other stressors. The superordinate theme describes relationships in the family as a group. Its themes are the dining table as a likeness of family functioning; and lastly, the meal at a crossroads between sharing and solitude. (Table 3)

Results

The superordinate themes are similar to those found in previous studies, where some of the themes also find their match. Three themes are specific to teenagers with BN: these are displayed in italics in Table 3.

Table 3: Main themes

Super-ordinate themes Themes Theme description

The relationship between parent and child

The sharing of disarray about food between parent and child

Food is a source of suffering to the teenager, and to the parents through their child's illness

Food and the issue of children becoming autonomous from parents

Attempts to grow autonomous from the parents, and the managing of absence

Food: a catalyser of conflict amongst other stressors

Conflict occurs about various topics, food is one of them

Relationships in the family as a group

The dining table as a likeness of family functioning

Seating habits around the table are informative of family functioning

Food at a crossroads between sharing and solitude

Two extremes of interaction that involve food

The relationship between parent and child

The sharing of disarray about food between parent and child

Some of the teenagers interviewed paint their relationship to food in a mostly negative light, barely admitting they can derive pleasure from it, said pleasure being, to them, part of their problem: Interviewer: "And how important is food, in your family?" Sarah: "Well, it's a pretty big deal, because, yeah, I have a family that likes eating, that's it... And um, I also like eating, but I don't want to admit it to myself, and I'm ashamed of it." In turn, parents, perceiving these feelings of shame, adapt their behaviour in the kitchen to try and make things easier for their child, sometimes at the cost of frustration easing itself into what once was mostly a positive activity: Sarah's mother: "Oh, there's been moments, yes, moments I told you "don't cook this" because of Sarah, and you said "ah, what a pain in the ass!" (laughs)" Sarah's father: "Oh yeah, uh, I wanted to cook this, and she'd tell me "well, don't cook that, because..."" Sarah's mother: "Because she'll be tempted, um..." Sarah's father: ""You're gonna tempt Sarah, and all..." What a pain in the ass!" Indeed, loss of control (namely in the form of the binge-purge cycle) becomes a shared fear between parent and child, sometimes to the point that parents won't feel at ease leaving their teen alone, even for a short time:

Manon

.""

This also plays out in the ways parents attempt to help regulate the teen's eating patterns. Some parents, in an attempt to lessen the teenager's unease, comply with their wishes to lose weight and suggest healthier food choices, even though they do not believe their child needs to lose weight.

Sarah's mother: "At some point she wanted to lose weight, and I... well I helped her lose weight, well, since she wanted to lose weight. So I avoided cooking things that could, um, since I knew it would be tempting for her, so there. I avoided cooking them." Food regulation tactics sometimes go as far as to lock up food that might trigger a binge.

Aurélie's mother: "I even had to lock up a pantry, or else she'd empty, um, biscuit boxes, she wouldn't leave any for anyone else." This is, in some cases, done at the teenager's request, when frequent binge-purge episodes drive them to ask their parents to intervene in their food intake.

The loss of control translates, to some of the parents, into a feeling of helplessness, when even grocery shopping, a necessary, everyday act, becomes what they perceive as a danger to their child, and a source of exasperation to themselves.

Aurélie The dynamics around food aren't the same according to who's partaking in the meal. As such, amongst our sample, fixing the evening meal is an almost exclusively parental task with the whole family present when it's time to eat. On the other hand, the midday meal sometimes takes place in the absence of the parents, meaning cooking becomes mandatory for the teenager who eats at home: managing the absence of the parent becomes a way, albeit obligatory in this case, to become self-reliant. This isn't always synonymous with satisfaction, as eating alone seems to be a negative, lonely experience in the eyes of three of the interviewed teenagers: Interviewer: "Do you think eating with your family is important?" Caroline: "Well, I think, um... When you're all alone, it's sad. [...] When nobody's eating with you, it's sad..." Others would rather eat on their own, because their overall painful perception of the act of eating makes longer meals difficult. In this instance, the eating disorder seems to create a distance between teen and parent, because it pushes the teenager to cook on their own in order to avoid long confrontations to food during meals:

Interviewer: "And is eating with your family important to you?" Manon: "No, because it takes a long time. I'd rather eat alone."

The way parental implication is perceived remains a great topic of ambivalence. On the one hand, it is unwelcome and viewed as intrusive: One characteristic of the teenage participants in our sample is that all of them are subjected to great emotional reactivity, which is one of the reasons conflict can't be avoided most of the time, despite their reluctance to it and the way they wish they had a greater proximity and understanding in the relationship to their parents. As such, part of the fighting, be it about food or not, originates in the teenager's tendency to react strongly.

Sarah
In our study, we found that some parents attempt to avoid conflict during mealtimes, but not necessarily outside of them. Outside of meals, food remains a subject of discord, usually in an attempt to confront the teen about her damaging eating habits. Due to the painful nature of the topic in the teenager's mind, these conflicts are a major source of guilt and unease to them. However, some parents don't hesitate to broach the subject of food when they feel it is needed during meals, in an attempt to help the teenager not lose control of their intake, at the cost of a fight oftentimes breaking out:

Sarah
Manon

The dining table as a likeness of family functioning

In our study, we found that the way the family gathers around the table is somewhere in-between the two aforementioned studies. Seating is generally the same, out of practicality in all five families, but in some cases, it is intended to facilitate discussion: Caroline's father: "Practical reasons, I was going to say. I have my back to the stove, so it's more practical to get the dishes, actually. That's it, simply put. Also, the two... Caroline and Justine are seated next to each other. This way I'm directly across from them, it makes chatting easier." The way seats are attributed usually depends on who arrives first in the family, as it constructs or reconstructs. Conversely, family members may also switch places in the occasion of a departure from the household, such as when the older siblings leave to live on their own: Lisa's mother: "And my husband across from me, and afterwards the children, well since, um... As they arrived in the family, they were seated accordingly, I mean. Also, the little one was always right next to me, so that I could help her eat, and so on, I mean, so um... That's how we moved around, actually." On occasion, the seating may vary according to the temporary absence of another family member: . This can stem from the fact that meals fill patients with anxiety, which prevents them from joining the discussion. Another case is when the negative feelings that accompany the act of eating surrounded by other people (more precisely, the possibility of being watched and judged while eating, in the teenager's mind) push the teenager to be done with it as soon as possible, and to subsequently leave the table, limiting the time spent together. Parents do not fail to notice this, and link it to how fast their child is eating: Sarah's mother: "The way she eats, it really is "I'm done with it as soon as possible". It's... I think that's often a chore, to her, the meal." Despite this, the teenager's words echo their longing to spend more time with their family, in contrast to their own behaviour:

Sarah
Sarah: "I'd just like to spend some time with them and chat, um, nothing fantastic, but really just, um, that's it, to be together... Just to be together, yeah."

Regarding exchange and aloofness, one important theme is that most of the participants involved, teenagers and parents alike, feel the need for more communication, which is, during our interviews, expressed through the lens of food and eating disorders.

Interviewer: "You mean you'd like the meals to last longer?" Caroline's father: "Well yeah, I'd like... I'd like to exchange a bit more. But well, at some point, I see that, it's... over... Well, that's it..."

More verbatim accounts can be found in Table 4.

Discussion

The aim of this paper was to better grasp the role of food in family relationships among teenagers diagnosed with BN and their families. The analysis revealed two super-ordinate themes, which are the relationship between parent and child, and the relationships in the family as a group. These superordinate themes were very similar to those found in the previous studies about obesity [START_REF] Lachal | Qualitative research using photo-elicitation to explore the role of food in family relationships among obese adolescents[END_REF], AN [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF] and its continuation comparing the results to those of teenagers without eating disorders [START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF].

The first superordinate theme starts by detailing how the disarray about food, which is characteristic of eating disorders, is shared between parents and child in cases of BN. We found this theme to be specific to the disorder, having not been described in previous studies [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF][START_REF] Lachal | Qualitative research using photo-elicitation to explore the role of food in family relationships among obese adolescents[END_REF][START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF].

Loss of control is feared not only by the patient, but also by the parents. Adding to their feeling of hopelessness, is the violence of the act of binge eating, and especially purging in the form of vomiting. Parents are most often aware of the guilt their child feels because of this behaviour.

As a result, not only the meals, but also their child's eating as a whole, once purely a vector of love and a source of shared pleasure, becomes a source of anxiety, as they sometimes show great care to look for and spot the purging habits, even though they can't change anything about them, adding again to that hopelessness.

Parents usually try to confront their child about the purging, and quickly realise two things: how guilty the teenager feels towards these behaviours, and how confrontation not only is useless, but also adds to that guilt and shame. Parents then tend to stick to trying to help regulating the child's intake, with or without their cooperation: these attempts to help take many forms, in more or less extreme ways, from letting the teenager know when they notice they're eating too much, to locking up anything they might binge on. They might even go along with the child's wishes to lose weight, even though they don't feel it is needed, in order to minimise the risk of binging and purging. This doesn't mean they condone their child's behaviour; they are merely setting clear limits to try and keep things from getting out of control.

Throughout the different interviews we conducted, parental posture remains appropriate and coherent. This is contrary to what was observed in the AN study, where parents couldn't maintain a firm posture, and food betrayed the existence of a disordered dynamic in parent and child roles. [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF] It is worth noting that in our sample, out of five families, three of them included at least one family member with a history of disordered eating (other than the interviewed teenager): Caroline's mother presents with what clinically appears to be past AN, and still displays residual restrictive behaviour; Lisa and her mother discuss the father's decades-long struggle with BN (regrettably, he was not interviewed in the study); and Manon's mother suffers not only from lifelong avoidant restrictive food intake disorder, but also binge eating disorder she developed in her adult years. One of Lisa's older sisters also struggled with overeating, but no sibling in our study was identified as having an eating disorder, in terms of DSM-V criteria. Hence, the painful quality of the relationship to food is another common trait between these parents and their child. That additional reason to share the teen's unease about food has some degree of significance, and falls in line with past studies about the heritability of eating disorders [START_REF] Kassett | Psychiatric disorders in the first-degree relatives of probands with bulimia nervosa[END_REF][START_REF] Thornton | The heritability of eating disorders: methods and current findings[END_REF][START_REF] Bulik | Heritability of binge-eating and broadly defined bulimia nervosa[END_REF]. It goes on to show the suffering, when it comes to food, is shared between the teen and the ill parent, and can be extended to parents without an eating disorder, something that didn't come to light in the study involving the families of teenagers with AN [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF].

Our analysis goes on to show how food is used as a means to regulate dependence on the parent, following one of the most commonly found themes throughout qualitative studies about the role of food in families, eating disordered or not [START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF]. Food is involved in the way teenagers attempt to gain autonomy from or, contrarily, remain dependent on their parents, as is the case in AN [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF]. We found the role of food to be part of the process of becoming autonomous and independent, from the child's perspective, when they associate it with having their own place to live and cooking meals on their own, something that isn't easily done in the context of BN and compensatory behaviour, when it involves trying to restrict their food intake.

While this issue is nothing specific to eating disordered teenagers [START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF], what our sample patients tell us is that disordered eating pushes them to distance themselves from their parents by learning to be more self-sufficient in regard to food, and that gaining autonomy can be a difficult experience to them, the same way it is hard for their parents to watch it happen. [START_REF] Carraz | Anorexie et boulimie : approche dialectique[END_REF] This is congruent with literature that says BN stems in an insecure link to the parent, which then morphs into a dependency-based relationship, to which bulimic behaviour is an answer when independence starts to become a reality [START_REF] Guelfi | Manuel de psychiatrie[END_REF]. The difference between BN and AN, when it comes to how both disorders fail to allow real selfsufficiency, is in the fact that adolescents with BN tend to rush too fast through the independence process; those with AN delay this process.

Even though this divergence in eating establishes a difference between the teen and her family, the parental anxiety and subsequent watchfulness it creates results in the impossibility to distance themselves from one another. Ambivalence is also present in the way these teenagers view the parental scrutiny, which is after all an attempt to help them: though they may suffer from the fact that their parent is attentive to their eating, they tend to see an absence of parental attention as being even worse, because they are in need of limits set by the parent to suppress their own ambivalence. This is different from what can be observed in cases of AN, where the illness creates a state of false well-being, as food obsession oftentimes fills up enough psychic space to mask other sources of anxiety [START_REF] Lloyd | Anxiety and the development and maintenance of anorexia nervosa: protocol for a systematic review[END_REF]: BN doesn't even leave its sufferers that small comfort, as everything about it is painfully lucid and guilt-ridden. This could explain why parental help tends to be better received in this case, though still a source of inner turmoil.

Our third theme showcases how food plays the role of a spark that ignites a fire between family members. It is a trigger for conflict, a specific topic of conflict in itself, and a medium through which wider familial conflict plays out. The fact that these tensions are not limited to the realm of food is a theme that is specific to the teenagers with BN in our study. Though the will to avoid conflict is present, as described by authors [START_REF] Carraz | Anorexie et boulimie : approche dialectique[END_REF], it does not stand long in front of the displays of emotional reactivity from the patient.

Indeed, it was deduced from clinical observation that all patients in our sample present significant impulsive behaviour. This is markedly different from the patients participating in the previous study about AN, in which teenagers didn't display such reactivity; instead, all attempts at opposition played out through the issue of food. [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF] Regarding the way conflict plays out in our own sample participants, politics vary across families: some attempt to exclude disputes from mealtimes, instead choosing to confront each other at other times; others are made to tackle issues during the meal, including when the problem involves food. This is another of the differences our study found between teenagers with BN and those with AN: it was described in the families of AN sufferers that food has the function of crystallising all family conflicts, effectively displacing them and covering them up, in congruence with the idea that these families do not accept the idea of being in conflict with each other. [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF] Contrarily, the families of teenagers with BN do not avoid conflict for various reasons, including food. The nature of the relationship between parents must also be considered. In accordance with literature [START_REF] Igoin-Apfelbaum | Characteristics of family background in bulimia[END_REF][START_REF] Cerniglia | Family profiles in eating disorders: family functioning and psychopathology[END_REF], in four out of the five families interviewed in our sample (see Table 1), BN occurs in families where the notion of parental separation exists, whether past or present, or having been seriously considered at some point, in some cases involving violent conflict.

The last theme revolves around the two extremes of interaction at which food is situated. Eating and cooking with other family members inspires a sense of exchange and sharing, be it through discussion around a meal, or learning to make a favourite dish a long-gone loved one used to prepare. On the other hand, eating alone, whether it's a meal taken in the absence of others, or a binge that will or will not be followed by vomiting, is shrouded in secrecy and loneliness. This duality is also specific to BN. A majority of participants indicate they feel a need for more communication, generally speaking. This seems to indicate how much of a toll that forced exile is taking on family relations.

It should be noted that isolation extends to outside the family. The realm of relationships described by the participants during the interviews doesn't leave much room to include social links outside of the family; the only such ties mentioned are passing comments about the boyfriend of one interviewed teenager, and the boyfriend and best friend of another. No other mention of friends or eating around friends is made.

Our study allowed us to better grasp the inner world of both patients and parents in the participating families. The results confirm that AN and BN are indeed the two polar sides of one single clinical spectrum [START_REF] Andersen | Anorexia nervosa and bulimia: A spectrum of eating disorders[END_REF]. Many of the themes found in studies on AN and BN are the same [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF], but with very different expression of symptoms and family dynamics; we believe these specificities must be taken into account for effective treatment.

Although it was easy to parallel characteristics of our sample BN families with those of teenagers with AN, it was harder to find similar correlations to characteristics found in the families of obese teenagers, because there was not a clear link between them. Indeed, the study centred on the families of obese teenagers shows food as a third party used to manage the distance between parent and child, and the role of nurturance was especially present [START_REF] Lachal | Qualitative research using photo-elicitation to explore the role of food in family relationships among obese adolescents[END_REF], which allows for a certain degree of cohesion in the family, as opposed to the ambient chaos in the families of teenagers with BN we interviewed, where conflict amongst family members is a common occurrence. The conclusion which can be drawn from this, is how different obesity and BN are, in terms of family dynamics and psychopathology, even though they might seem similar at first glance.

Throughout our study, the dining table reveals the functional dynamics of our sample families: they are marked by changes that reflect the presence and absence of family members, namely the vacant spaces left, one by one, by older siblings, as they leave the household to live their life. In most cases and compared to AN, BN appears at a later age in adolescence [START_REF] Foulon | Les conduites alimentaires[END_REF], at the dawn of early adulthood: a stark contrast to the static quality of families with AN [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF].

The previous studies about the role of food in family relations of adolescents presenting AN [START_REF] Zerrouk | Place de la nourriture dans les relations familiales d'adolescents présentant une anorexie mentale : étude qualitative par la photographie, The place of food in family relations of adolescents presenting an anorexia nervosa: A qualitative study by means of photography[END_REF] and those without an eating disorder [START_REF] Sibeoni | Nourriture et relations familiales chez des adolescents avec et sans anorexie mentale : une étude qualitative par Photo-elicitation[END_REF] described the dining table as a representation of family functioning. In the AN group, this appeared in the form of a photograph, depicting a ritual frozen in time, with immutability in the way the family was seated, where change was unwelcome. The non-disordered eating group, on the other hand, exhibited dynamism at mealtimes, which evoked the movement and creativity of a movie, a setting where relationships could evolve. To keep up with the metaphor, in the event of patients with BN, one could evoke a dynamic akin to a comic book, with its relative and brief stillness that still allows for change and dynamism, albeit oftentimes in explosive ways.

Our study shows therapy in bulimia, especially family therapy, should be oriented towards the development of a more secure relationship between parents and teenagers, the latter being oftentimes subjected to the anxious questioning of their interpersonal relations. In return, more perceived emotional security will allow the teenager to operate a slower, more thorough individuation process.

Four out of the five teenagers we interviewed provide examples of how, paradoxically, a rushed autonomisation oftentimes results in dependence to the parent. Sarah has successfully finished high school, but her eating disorder and major depressive episode didn't allow her to start university right away. Caroline's suicidality required changing schools (as she was previously in a boarding school in another city) in order to allow her family to watch more closely over her. Lisa ended up being homeschooled after she developed school phobia, in a context of severe anxiety (which fostered her eating disorder). Manon was the most extreme case of this: her severe bulimia and recurrent suicidal ideation (including several suicide attempts) caused her to quit school, and required her mother to stay by her side at all times to make sure she didn't attempt to take her own life again.

BN is an isolating disorder, especially in families where meals are the only real moment spent together. Creating more occasions of interaction (involving not only the child and parents, but also siblings) that aren't cemented in eating, like some of the teenagers in our study point out, could be a start in the process of breaking that cycle. Our study shows family-based therapy remains a pivotal addition to individual therapy (mostly based on the managing of emotions through means other than food or self-harming behaviours) in the treatment of BN, by eliminating some of the factors that perpetuate the disorder: lessening isolation, re-establishing communication about food in nonharmful ways, fostering more security in the parent-child relationship, in order to help parents help their children.

Study limitations

No male subjects were included in the study, because not one was found amongst the patients receiving care from the practitioners involved at the time of patient recruitment. A subsequent study on the same premises, focusing on male patients, could be an interesting prospect to work with in the future, for comparison.

Furthermore, not every parent could be interviewed, as one father and one father-in-law weren't available at the time; nevertheless, it could be argued that this allows for a better understanding of the point of view of the two mothers involved, because interviewing parents as a couple doesn't yield the same results as talking with them each alone.

Moreover, it can be argued that screening the patients in our sample for personality disorders would have been relevant: these clinical entities are described in literature as frequently comorbid with eating disorders [START_REF] Cassin | Personality and eating disorders: A decade in review[END_REF], and diagnosis would have allowed us to study more precisely the influence of personality disorders on our findings.

One characteristic of the teenage participants in our sample is that all of them are subjected to great emotional reactivity, which is one of the reasons conflict can't be avoided most of the time, despite their reluctance to it and the way they wish they had a greater proximity and understanding in the relationship to their parents. The way seats are attributed usually depends on who arrives first in the family, as it constructs or reconstructs:

Aurélie: "That's how it is. In the beginning, my mother and brother have always been there, and since I used to live at my father's place before, well I took the seat... that seat... the last seat."

Food at a crossroads between sharing and solitude

The teenagers in our sample tend to view these meals as an important moment to be together, albeit not the only one of the day, which makes its significance less strong than what transpires in the parent's view.

Interviewed: "Do you think it's important to eat with your family?" Sarah: "Not necessarily. I think... Yes, it's a bit of a privileged moment, but... You can do without, and spend other moments together, where food is not necessarily involved."

The cooking activity is sometimes another shared slice of time between the family members. In this regard, food is clearly used as a vector of love, from the one who cooks to the one who accepts it, regardless of where parent and teenager are positioned in this equation.

Interviewer: "What is it that makes her cooking different, that makes it your favourite?" Manon: "Well I don't know. But... Maybe it's because she's my mother, actually, but... To me, it's best when she's the one cooking."

Eating alone in the context of BN is all about solitude and secrecy. The interviewed teenagers describe a vicious circle of shame and loneliness, where they isolate themselves from their family so that no one finds out they had yet another fit of binge eating: Sarah: "Usually, I don't have meals alone, actually, the only occasions where I actually eat is when I binge, so... I... I don't keep anything down, in the end, and when I binge I'm alone in my room, sometimes my cats are here... But I try... I isolate myself as much as I can, and I even make sure there's nobody on the floor I am on, so that they don't hear me."

Isolation also occurs when physically present around the dining table. This can stem from the fact that meals fill patients with anxiety, which prevents them from joining the discussion: Sarah: "I see the others are really exchanging a lot, in touch with one another, and I really have trouble taking part in conversations."

The negative feelings that accompany the act of eating surrounded by other people (more precisely, the possibility of being watched and judged while eating, in the teenager's mind) push the teenager to be done with it as soon as possible, and to subsequently leave the table, limiting the time spent together: Lisa: "I know if I take my time eating, I'll stay with them longer, so there's more of a possibility that they'll look at my plate, so I really try to do it as fast as possible, I mean, so um... Sometimes I'll eat in three minutes and it'll be over, I mean."

Teenagers feel victimised by the fact that their parents tend to talk about the disordered eating amongst themselves instead of involving their child in such discussions. To the teenager, it feels as it the parents are making the topic a taboo. This could indicate the patients feel the need, at least on an unconscious level, to discuss these issues with their parents. Sarah: "I wonder why they simply don't... talk about it, um, directly with me, um... Especially since well, it could, I could answer them directly, I could know the mind of my father, who... who doesn't really communicate with me..."

Table 1 : Participants' characteristics Teenager name Sex Ag e BM I Psychiatric comorbidities Parental situation Number of siblings Other eating disordered members of family Parent interviewed

 1

	Sarah	Female 18 23	Borderline	Cohabitating	2	0	Mother and father
			personality disorder,
			major depressive
			episode
	Caroline	Female 16 24	Major depressive	Separated	3	1	Mother and father
			episode				(separately)
	Aurélie	Female 17 23	Marked	Cohabitating	1	0	Mother and father
			impulsiveness
	Lisa	Female 18 22	Histrionic personality	Married	2	1	Mother
			disorder
	Manon	Female 17 33	Borderline	Divorced	2	1	Mother
			personality disorder

  's mother: "Usually, I'm not here. Because she can cope when I'm here, but... All it takes is for me to go out for, I don't know, half an hour, one hour, to go, um... Because I have an appointment, or because... I have to run an errand, but she doesn't want to go out, or, er... Well, it's during that time she, um... she'll eat. So she'll phone me: "mum, I'm not feeling well, I threw up because I ate..

  : "I feel her gaze, um, over me.[...] I know that's not what it is, but I feel it... I feel like she's judging me, but... Well, I know it's just that she cares about me, and she doesn't want me to... but..." Yet at the same time, when the parent chooses to ignore the disordered behaviour for one reason or another, it is a cause for distress on the teenager's part, as if the parent keeping a careful watch on their eating was a way to express love. The link between parental attention and affection at mealtimes is sometimes obvious in the teenager's mind and speech:Interviewer: "For instance, what makes you think they don't care?" Caroline: "Well, because they won't take up, like, um... When I eat, eat, eat, they won't take it up. They won't tell me, "that's enough now, you've eaten too much"."

	Interviewer: "And how can you tell your dad cares?"
	Caroline: "Well, he, um... When I'm snacking, he'll tell me... He'll hold me back, he'll tell me... "Okay, but um, only, for instance, three
	biscuits.""
	Interviewer: "So he says "OK" but gives you limits? How do you feel about that?"
	Caroline: "Yes... I like that better."
	3.1.3. Food: a catalyser of conflict amongst other stressors

  of regulating interactions, for instance between siblings. The configuration of the table allows for diminishing tensions, while the different protagonists remain in their respective role.Aurélie's mother: "Things go off real fast between Aurélie and Simon. Aurélie's father: "That's why I'm seated here. This way, if they wanna fight..." Aurélie's mother: "Because they fight, yes." Interviewer: "You're positioned here so that you can separate them if they fight?" Aurélie's father: "Well I think so, unconsciously, I think that's it. Mélanie is here because this way she can go in the kitchen, as we said... Simon is here, because he's next to his big sis... And I'm here, in the middle of them, so that if they wanna... I hold them back, I push my chair away, and there you go, I keep them from going through." 3.2.2. Food at a crossroads between sharing and solitude Family meals are described by all parents in our sample as a moment of togetherness (sometimes the only moment of the day where the family is reunited), and the preferred time to share and discuss around daily life. Caroline's father: "Listen, to me, meals are, um... There's more dialogue during meals, if you will. A meal, that's a place for dialogue, actually. It's not so much about what's in the plate, it's really about the discussion around it. [...] I mean, everyone speaks up, I police things a little because someone cuts somebody off, and so on..."The cooking activity is sometimes another shared slice of time between the family members. In this regard, food is clearly used as a vector of love, from the one who cooks to the one who accepts it, regardless of where parent and teenager are positioned in this equation. The meal and the whole process of preparation surrounding it (doing the groceries, cooking...) is also the occasion of transmitting family recipes, sharing knowledge, the pleasurable experience of eating, and sometimes remembering those they hold dear.

's father: "Yes, usually, Sarah was on the right, usually that's my seat, but I'm not..." Sarah's mother: "But when you're not here, she sits... Because usually she sits on the right side, but a bit farther. [...] Yes, she's there, she's on the right, but since we're not gonna leave her on the other... at the very back... She gets a little bit closer." Meals are sometimes the only time of the day the whole family is gathered together, and it means there's a potential for tensions and escalation between the different family members; these conflicts are those of everyday life, and the way parents are seated around the table has the function Manon's mother: "That's to say, we'll talk about... For instance, when Bernard cooks something, I'll very well say "Grandma used to cook this, but with, um... With potatoes like that, she'd add Bibeleskäs, or she'd season by adding a... a little chives in it, or..." We talk about people... ancestors, she [Manon] used to know. And thus, she cares very much about these people." On the opposite end of this spectrum, eating alone in the context of BN is all about solitude and secrecy. The interviewed teenagers describe a vicious circle of shame and loneliness, where they isolate themselves from their family. At the same time, loss of control around food, which acts as a way to regulate emotions, most often occurs precisely in those moments of withdrawal: Lisa: "It's often in the evening when I'm all alone in my room, and I can't think of anything else, and it's stuck in my mind, actually, it's... So in these moments, I get something else to eat, then I go again, and then I go again, and well... It won't stop until I go to sleep, I mean, so um..." Isolation also occurs when physically present around the dining table

  Part of the fighting, be it about food or not, originates in the teenager's tendency to react strongly: Aurélie's mother: "Actually, earlier she emptied a box of... a box of biscuits... So um, I saw it earlier, so I lectured her earlier. On that one she didn't say anything at all. She kept her head low, um, she wasn't saying anything." Interviewer: "How do you think she felt?" Aurélie's mother: "Some moments it's, I feel as if she's ashamed... And some moments it's as if she's mocking me, I mean."Conversely, the topic of food and the disputes it creates, can also take a toll on the relationship between parents.Manon's mother: "Well he [Manon's step-father], sometimes, um, well when she throws up, especially, when she makes herself throw up, he makes cheap remarks, um, that it's expensive, that it's a waste, that's it's, um... Those, I'm fed up with... And it's... I understand, that's true. But at the same time... She's not doing it on purpose."

	Relationships in the family
	as a group
	The dining table as a
	likeness	of	family
	functioning
			Lisa: "Since I know I tend to be very irritable in those moments [shared mealtimes], since I'm really
			anxious, well, I still try to... to withdraw so that it doesn't become, um, a big deal, and so that I don't
			ruin the moment, I mean."

Manon's mother: "Before, when they were younger, systematically, it was Manon who went off... Because her brother or father had more food than her, it was... Like if the piece of meat was bigger, or things like that."

Outside of meals, food remains a subject of discord, usually in an attempt to confront the teen about her damaging eating habits. Due to the painful nature of the topic in the teenager's mind, these conflicts are a major source of guilt and unease to them.

Acknowledgements

We would like to thank the adolescents and parents who agreed to take part in this study, without whom this work would have never been possible.

Conflicts of interest

The authors declare they have no conflicts of interest regarding this study, or the writing and publishing of this article.

Appendix Table 4: Additional verbatim accounts

The relationship between parent and child

The sharing of disarray about food between parent and child

Limiting their teenager's food intake goes against the very core of what some parents believe to be the right way to regulate (or not regulate) the teen's eating, as one mother puts it:

Aurélie's mother: "They don't even have to ask me to help themselves to some food, to me it's free access... [...] To me, a bag of sweets, if the child is holding it, they can do whatever they please with it, actually."

Locking up food, in some cases, is done at the teenager's request, when frequent binge-purge episodes drive them to ask their parents to intervene in their food intake: Manon's mother: "She'd asked us to lock everything up so that she couldn't access it anymore." The midday meal sometimes takes place in the absence of the parents, meaning cooking becomes mandatory for the teenager who eats at home: managing the absence of the parent becomes a way, albeit obligatory in this case, to become self-reliant.

Caroline: "Well that depends if, for instance, when she[her mother]'s working, and I'm not working, well I'm the one who cooks." Interviewer: "Okay. And how frequently does that occur, your having to cook?" Caroline: "Well, it's often at noon. But in the evenings, she's often the one cooking."

When the parent chooses to ignore the disordered behaviour for one reason or another, it is a cause for distress on the teenager's part, as if the parent keeping a careful watch on their eating was a way to express love. This is displayed in the following example, in which Manon's mother expresses her views and the way she reacts to her daughter's compensatory behaviours, usually fasting in-between binges: