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     Treating Adolescent Anorexia Nervosa: A Family Affair?

 

 

 

 

 

 

 

 

Jennifer Cialone

September 2006

 

 

What is Anorexia Nervosa?                                            

Anorexia nervosa is an eating disorder characterized by a fear of fatness that leads one to self-starvation. According to DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), diagnostic features of the disorder include a body weight below 85% of one’s normal body weight and loss of menses in females (http://www.poppink.com/dsmiv/7.html). While this disorder is not restricted to a particular age group or gender, it is most prevalent among adolescent females. In fact, roughly 85% of the eating disorders begin during this developmental period (http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_adap0701_ENU_HTML.htm). Since most of the people diagnosed with anorexia nervosa are young women, this paper will focus on female adolescents.

While the most obvious effect of anorexia nervosa is the excessively thin appearance of the patient, this disease also causes serious problems for one’s mental health and internal systems. Indeed, anorexic patients often suffer from cardiovascular disease, renal dysfunction, and osteoporosis (http://www.poppink.com/dsmiv/7.html) as well as depression and social withdrawal (http://www.webmd.com/content/article/118/112907.htm).

 

Is there a Cure?                                 

 

 

 

 

 

 

Although researchers have spent decades exploring the effectiveness of treatments for this complex disorder, many questions remain regarding the most useful therapy. With a success rate of only 50% following treatment and a death rate of 6% to 20% (http://www.mayoclinic.org/clinical-update/21-2-05-anorexia.html), scientists are ardently diving into the literature and conducting new studies to learn more about the problem.  Since anorexic patients—especially adolescents who are already dealing with issues of maturation—often have a plethora of issues underlying their fear of fat, treatment goals must encompass physical, emotional, and mental improvements. Treatments most commonly employed may come in the form of medicine, in-hospital care, or therapy sessions (http://www.webmd.com/content/article/118/112907.htm). More recently, researchers have looked at new approaches to psychotherapy in which families take a more active role in the treatment of the adolescent. While data on the effectiveness of this treatment as compared to more traditional individual therapy is scarce, it is important to evaluate the benefits and drawbacks of this method to determine which approach is best for treating adolescents suffering from anorexia nervosa.

 

 

 

 

 

 

 

An Active Role: What is Family-Based Treatment?

 

Family-Based Treatment (FBT) takes the family role in treatment further than either individual or family therapy by actively involving them in the patient’s path to wellness. Individual treatments such as Cognitive-Behavioral Therapy addresses underlying family and social issues to emphasize changing one’s perspective on food and weight through a combination of mental and behavioral modifications (http://www.webmd.com/hw/mental_health/aa32608.asp). Typical family therapy perceives the family to be "the source of the problem for the identified patient and aims its interventions at the family system” (Kotler et al., 436). FBT, on the other hand, does not place blame on the family; rather, it regards the family as an important tool in the treatment of the young girl. FBT was pioneered by Dare and Eisler of London’s Maudsley Hospital in the 1980s and deemed “the Maudsley model.”

In their 2003 review of new psychotherapies for eating disorders, Kotler et al. (2003) describe the treatment program at Maudsley Hospital and evaluate the studies that test the approach. Divided into three phases, the Maudsley model begins with the goal of improving the immediate physical issues of the underweight teenager. Through successive therapy sessions that include a supervised family meal, families accept the task of re-feeding the adolescent. These sessions emphasize a lack of blame so that the family neither feels guilty for the situation nor lays guilt on the child. Kotler et al. note that such an approach contrasts that of traditional family therapy in which the therapist regards the family as the root of the problem.

Once the adolescent’s weight creeps closer to normal levels and better eating patterns emerge, she may enter phase two of the Maudsley model. This phase is dedicated to reinstating the patient’s autonomy in eating. The change may not be immediate, but the family slowly hands this power over to the patient through the course of several sessions.

The final stage is brief but imperative to the success of the program. Once the patient has reached her normal weight and achieved age-appropriate autonomy in her eating choices, the sessions begin to focus on the general adolescent issues that she may face. Lock and le Grange (2005) explain in their review of the treatment that while these issues are often evaluated in the context of the patient’s anorexia nervosa, they also encompass “challenges on adolescent tasks [such as] sexuality, autonomy, and leaving home” (S65).

 

 

 

 

...But Does it Work?

To evaluate the effectiveness of the Maudsley model, Russel et al. (1987) performed a year-long controlled clinical trial to study the effectiveness of FBT for weight restoration and restart of menstruation. At the end of the treatment, they compared outcomes following either FBT or individual therapy and found that FBT was less effective in producing significantly improved outcomes for those with late-onset of the disease. However, they found significant improvement for patients who had early-onset anorexia nervosa with only a short history of the illness. Results from a five-year follow up were promising for these early-onset and short history patients. Compared to the 55% of patients with good or intermediate outcomes from individual therapy, FBT resulted in 90% of its patients having these positive outcomes five years after cessation of treatment (Eisler et al., 1997).

While other case studies have been performed to evaluate the effects of FBT on adolescent anorexic females, there is a lack of conclusive evidence. As Lock and le Grange (2005) note in their review of the empirical data on FBT, many of the studies are conducted with small samples and non-standardized outcomes. In addition, most of these studies have taken place at the Maudsley Hospital, leading one to question the usefulness of FBT as a general treatment elsewhere. However, Lock and le Grange highlight future approaches aimed at improving the validity and applicability of the research. These studies may shed light on the future role of FBT in adolescent anorexia nervosa.

A Cause for Concern: Does FBT Undermine or Promote the Patient’s Path to Autonomy?

 

 

 

 

Although preliminary results seem promising, supporters of individual therapy question the effectiveness of FBT in improving the patient’s development through her adolescent years. The family plays a vital role in childhood development, particularly during this identity-forming time. In particular, family relationships are associated with the adolescent’s behavioral and emotional maturation (http://findarticles.com/p/articles/mi_m0902/is_1_29/ai_73085014). Those who prefer individual therapy reason that the family’s strong influence on the adolescent may adversely affect the recovery of the fragile girl.

Adolescence is a time for children to obtain a sense of autonomy during their transition into adulthood. Karwautz et al. (2003) conducted a self-reporting study that emphasized the importance of an adolescent’s perception of herself as highly autonomous in her family unit after observing a connection between family relationships and development of the disorder. The study focused on the different perceptions of sisters (one who suffered from anorexia nervosa and the other who was healthy) regarding their autonomy in the family and relationships with their parents. Results indicated that anorexic adolescents suffer from a perceived loss of autonomy as compared to their healthy sisters. In addition, Karavasilis et al.(2003) designed a questionnaire-based study which revealed that “low psychological autonomy has been related to the intrusive parenting thought to undermine children’s emerging…view of self” (Karavasilis et al, 156). With this connection between parenting and autonomy, one must question the effect parental involvement would have on the treatment process for anorexia nervosa. If parents play an obvious role in the adolescent’s autonomy—and thus her view of self—would they help or hinder treatment?

            Although no direct relationship has been confirmed between parenting style and development of the disorder, some regard trends of family relationships and autonomy loss as indicative of a causal relationship. Those that support this causality are more likely to prefer either individual or family therapy over FBT because these approaches deal more directly with family problems. They perceive resolution of family issues that may contribute to the disorder as imperative to the healing process. The Maudsley model, on the other hand, does not blame the family for the adolescent’s illness or perception of her autonomy. Rather, it empowers the family to actively help the patient regain her identity and independence. This attempt at empowerment is evident in phase two of the treatment. With preliminary results suggesting a correlation between autonomy loss and anorexia nervosa, one could see how parents may play a key role in restoring their adolescent’s perception of self and autonomy. The Maudsley model contends that, if parents do not involve themselves in the treatment, adolescents will not have the family support necessary to develop a healthy identity (Kotler et al., 2003).

 

 

 

 

 

So What's the Best Treatment?

 

Unfortunately, there does not appear to be a clear answer from the existing data. Limited information on the effectiveness of available treatments and conflicts over the causes of anorexia nervosa make it difficult to determine the appropriate treatment. From the data, I gather that the ideal universal treatment does not exist currently. Instead, each patient must be reviewed on a case-by-case basis to determine what type of therapy would be most effective for her. As the data stands today, psychotherapy is an important component to the treatment of adolescent anorexia nervosa. Whether individual or family-based treatment is more effective, however, may be a question of the patient’s preference or the family’s potential for successful intervention. I hope that more research will clarify the issue and help clinicians improve the quality of treatments available. Perhaps through more effective treatments, we can one day raise the meager success rate for curing this deadly disease.

 

 

 

 

 

 

 

How Can I Learn More About FBT?

DSM-IV-TR(2000). “Anorexia Nervosa.” http://www.poppink.com/dsmiv/7.html.

Eisler, I. et al. (1997) “Family and Individual Therapy in Anorexia Nervosa. A 5-Year Follow-

up.” Institute of Psychiatry. London, England.

Haines, C. (2005) “Mental Health: Anorexia Nervosa.” Web MD.

(http://www.webmd.com/content/article/118/112907.htm

Karavasilis, L. (2003). “Associations Between Parenting Style and Attachment to Mother in

Middle Childhood and Adolescence.” International Journal of Behavioral Development. 27 (2):154-164.

Karwautz et al. (2003). “Perceptions of Family Relationships in Adolescents with Anorexia

Nervosa and Their Unaffected Sisters.” European Child and Adolescent Psychiatry. 12:128-135.

Kotler, L. et al. (2003). “Emerging Psychotherapies for Eating Disorders.” Journal of Psychiatric

Practice 9:6 p. 431-441.

Lock, J. & Le Grange, D. (2005). National Eating Disorder Information Centre. “Family-Based

Treatment of Adolescent Anorexia Nervosa: The Maudsley Approach.”

Mayo Foundation for Medical Education and Research (2001). “Family-Based Therapy for

Anorexia Nervosa.” http://www.mayoclinic.org/clinical-update/21-2-05-anorexia.html

Pavlidis, K. & McCauley, E. (2001). “Autonomy and Relatedness in Family Interactions with

Depressed Adolescents.” Journal of Abnormal Child Psychology.

http://findarticles.com/p/articles/mi_m0902/is_1_29/ai_73085014.

Russell et al. (1987). “Family Therapy Versus Individual Therapy for Adolescent Females with

Anorexia Nervosa and Bulimia Nervosa.” Arch Gen Psychiatry 44:1047-56.

Spears, B. & Myers, E. (2001). “Nutrition intervention in the treatment of anorexia nervosa,

bulimia nervosa, and eating disorder not otherwise specified (EDNOS).” J AM Diet Assoc

2001;101:810 (http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_adap0701_ENU_HTML.htm

Web MD (2005). “Anorexia Nervosa.” http://www.webmd.com/hw/mental_health/aa32608.asp

 

 

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