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Do mom and dad really know best? 
Family Based Treatment and Adolescent Anorexia

Karen Crow

September 24, 2007

MCj03479130000[1]What is anorexia?

The National Institute of Mental Health (2001) defines anorexia nervosa as,  “a resistance to maintaining normal body weight, an intense fear of becoming fat or gaining weight even if under weight, a disturbance in the way in which ones body shape is experiences and infrequent or absent menstrual periods”. It is also described by the National Association for Anorexia Nervosa and Associated Eating Disorders as being fifteen percent under the ideal body weight (http://www.anad.org/22385/22427.html ).  There are two different categories of anorexia, one in which the patient limits food intake, called the restricting type and one in which the patient also engages in purging behaviors, called the binge-eating purging type. The ANAD also states that 1-2% of the population suffers from anorexia. In a 2003 review of anorexia literature, Hoek and van Hoeken (2003) found 40% of newly identified cases of anorexia are in girls 15-19 years old. A 50 year study in Rochester, Minnesota found that the number of teens ages 15-19 with anorexia has been constantly increasing and this trend has been seen throughout all parts of the nation (Lucas, Beard, O'Fallon, & LT Kurland, 1991).

Although the prevalence of the disease continues to increase, outcomes for people with anorexia remain bleak. Seinhausen (2002) reviewed 119 clinical trials in the twentieth century and found that only forty-four of patients followed at least 4 years after the onset of illness are considered recovered (which means being within 15% of ideal body weight), one-quarter of patients remained seriously ill, and another 5% died. These numbers are grave and indicate the need for further investigation of treatments for greater recovery from the disorder.
What are available 
treatments for anorexia?MPj04015920000[1]

There are many forms of anorexia treatment all with varied outcomes.   Traditional treatment involves recovery time spent within a hospital and therapy sessions.  However, especially among adolescent girls, this treatment is not completely effective.  Seinhausen (2002) indicated that the clinical recovery rate for anorexia is forty-seven percent which is similar to the overall recovery rate.  Hospitalization for clinical treatment is extremely expensive so there is also the option of different types of therapies which are often more financially feasible for some families.  There is individual therapy, cognitive behavior therapy, group therapy, and family therapy ( http://www.medicinenet.com/anorexia_nervosa/page5.htm ).  The therapies focus on a whole self recovery and facing the issues that underlie the cause of the disorder.  Of the treatments, Family Based Therapy has been receiving attention as of late and because of its focus on what often times can be the source of anorexia, the family. While the concept of family therapy is promising, articles need to be explored to determine whether or not family based therapy is effective in dealing with adolescent anorexia.

MPj04227890000[1]What is Family-Based Therapy?

 Family Based therapy is a type of treatment developed in the Maudsley Hospital in London, England.  It is an “out-patient family based treatment” and developed as an alternative to the traditional in-patient treatments (LeGrange, 2005).  It is a relatively controversial form of treatment in that it is an outpatient treatment that first focuses completely on weight taking place outside of the clinic and in a family meal setting.  The treatment takes place in 20 clinical sessions over the course of 1 year.  It is extremely different from older anorexia practices that generally suggest patient hospitalization for treatment and it also focuses on weight gain before bringing in other issues causing the disorder (LeGrange, 2005).  Traditional theories discourage parent involvement in the treatment because they see parents as the cause of the problem.  FBT directly involves the parents and focuses on the fact that FBT is the best form of treatment for the patient.  

FBT takes place in three phases.  In phase one (sessions 1-10) the goal is to restore the child’s weight through supportive interaction with the parent.  Parents are supposed to play an imperative role in their child’s weight gain by providing family meals with nutrient-rich and calorie dense foods (LeGrange, 2005).  In phase I, the parents dictate what the child eats, stresses the seriousness of the condition and the importance of recovery. Phase two (sessions 11-16) begins once the patient is gaining weight and more willing to eat food. In this phase, parents gradually transfer control over eating back to the patient while still monitoring food intake. Phase III (sessions 17-20) begins once the weight gain is significant and the major symptoms and signs of anorexia are gone and during this stage, the parent allows the adolescent to eat without supervision.  It is also during this phase when the factors of the disease outside of weight gain are addressed. There is flexibility in the number of sessions, up to 30 sessions are allowed to complete the total treatment if necessary (cite manual). The criteria for progression from phase I to phase II are “weight at a minimum of 87% IBW, significantly reduced patient resistance to eating, and parental confidence in facilitating weight restoration”.  (Lock, Agras& Dare, 2002)

Is it effective in treating Anorexia Nervosa?

A limited number of studies have shown that FBT is effective in the adolescent treatment of anorexia nervosa. The Maudsley hospital studies were some of the first on family based treatment and compared individual therapy treatments to the family based treatment after in-hospital weight restoration (LeGrange, 2005). There were 80 patients involved in the study and one-fourth of this group was in the adolescent age range (less than 18 years old). The studies showed that after a one year follow up, ninety percent of the patients using FBT had a successful follow-up while only 36 percent in the individual therapy had success in the follow-up. Eighty percent of parents involved in the treatment called the therapy “helpful” and “desirable”.  A later study by Eisler, also instituting family based therapy to patients, found a similar level of effectiveness to the Maudsley studies (LeGrange, 2005).  It described, “75% of patients have a good outcome, 15% an intermediate outcome and 10% have a poor outcome (weight not restored and no menses)” (LeGrange, 2005)  Eisler also found that the treatment was most effective in adolescents who had been suffering from anorexia for less than three years (LeGrange, 2005).

A recent study at Stanford University sought to determine the long term effectiveness of a 10 session shorter version of FBT rather than the 20 session treatment plan (Lock, Courtier, & Agras, 2006).  The first study divided the eighty-six patients into 1 year (20 session) and 6 month (10 sessions) groups.  The study found that there was no real difference between the success rates of patients with 10 sessions versus patients with 20 sessions over the course of four years.  The two studies also showed an overall success of FBT with 89 percent of completing participants being greater than 90% of their idea body weight and returning to normalcy by either being in work or attending school regularly (Lock Courtier, & Agras, 2006). The participants in the experience, however, were not of the normal population and Lock describes them as “”on average higher socioeconomically than expected for the general population” with “”willing and able” families who were recommended to the treatment.  Therefore, the sample in this experiment is not random and does not represent what the outcome of the therapy for the general population.

Loeb et al. (2007) sought to find the effectiveness of the available manual for the treatment in adolescents in a clinical research setting.  The manual became available to the general public on the World Wide Web and there were questions as to whether treatment with the manual alone and without the developers’ involvement would be effective enough for patients.  Loeb et al. (2007) describes the experiment participants: “patients had a mean age of 14.85 (SD 0.6; range 12-17), and a mean duration of illness of 13.8 months (SD 15.3; range 3-72). The majority of the 20 entered patients were female (95%), white (75%), and from intact families (80%), with a full diagnosis of AN (65%)”. The article also states that the parents and siblings of the participants had to consent to the treatment and at least one parent had to participate. Enrolled participants could not have any other diagnosed psychological disorders except concurrent depression and anxiousness. Twenty-one adolescents participated in the study to completion. The study showed that 65% percent had a good outcome, 15% had an intermediate outcome and 20% had a poor outcome (Loeb at al., 2007).  Within this study, there is a small number of a specific kind of patient and it makes it challenging to try to apply these statistics globally to the many different kinds of patients who are treated with anorexia.

These studies show that FBT is most effective in adolescents who had the illness for a short duration (3 years or less) and hospitalization is usually not necessary for full recovery to occur with FBT (LeGrange, 2005).  Even with this information, there is still significant research that needs to be done to prove the complete effectiveness of FBT and family involvement in anorexia treatment. Studies have been based around white female patients with a medium to high socioeconomic status without a BMI less than 85%, with a willing family and without other severe mental disorders. Therefore, there is still literature lacking in its effectiveness when parents are unwilling or unable to participate or the patient comes from a low socioeconomic background. There also needs to be more focus on research on minority populations to determine whether or not FBT is effective for different subgroups. The treatment does prove promising for the specific population it has involved.
MPj04222660000[1]
Is FBT the best form of treatment?

There are no indications that FBT is the best form of treatment for adolescent anorexia.  While success rates are high within the therapy, there are a limited amount of studies done and they focus on one portion of the population dealing with anorexia.  Other therapies, including cognitive behavior therapy and individual therapy without family intervention have also had high success rates in treating the disorder.  Because the disease is so individualized, it is difficult to dictate the best treatment for the whole population suffering from anorexia. In cases where family the family is unwilling or unable to participate in the recovery of its own son or daughter, these non-family based treatments may ultimately prove to be better for the patient.  Where family is available, though, using FBT as a form is a viable option for treating anorexia that needs further exploration.

Citations

 

 

Eisler, I., Simic, M., Russell, G. & Dare, C. (2007). A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. Journal of Child Psychology and Psychiatry, 48, 552.

 

Hoek, H. & van Hoeken, D (2003).  Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34, 383-396.

 

 

LeGrange, D (2005). The Maudsley family-based treatment for adolescent anorexia

nervosa. World Psychiatry, 4(3), 142–146.

 

 

Lock, J., Couturier, J., & Agras, W (2006). Comparison of Long-Term

Outcomes in Adolescents With Anorexia Nervosa Treated With Family TherapyJournal of the American Academy of Child and Adolescent Psychiatry, 45(6), 666-672.

 

 

Lock, J. LeGrange, D., Agras, S., & Dare, C. (2002). Treatment Manual for Anorexia

Nervosa A Family-Based Approach. New York: Gilford Press.

 

Loeb, K., Walsh, T., Lock, J., Le Grange, D., Jones, J., Marcus, S., Weaver, J. & Dobrow,

(2007).Open Trial of Family-Based Treatment for Full and Partial Anorexia Nervosa in Adolescence: Evidence of Successful Dissemination. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7):792-800

 

Lucas, AR., Beard, CM., O'Fallon, WM.,  & Kurland, LT. (1991). 50-year trends in the

incidence of anorexia nervosa in Rochester, Minn.: a population-based study. American Journal of  Psychiatry, 148: 917 - 922.

 

Medicine.net (2007). How is Anorexia Treated? Retreived Setember 20, 2007, from

            http://www.medicinenet.com/anorexia_nervosa/page5.htm

 

National Association for Anorexia Nervosa and Other Eating Disorders (2007).

Retrieved Setember 12, 2007, from http://www.anad.org/22385/22427.html

 

 

National Institute of Mental Health (2001). Eating Disorders: Facts About Eating

Disorders and the Search for Solutions. (NIH Publication No. 01-4901) Retrieved September 18, 2007, from NIH. Access:  http://www.nimh.nih.gov/topics/eating-disorders.shtml

 

Seinhausen, H (2002). The outcome of anorexia nervosa in the 20th century.  The American Journal of Psychiatry, 159(8),

1284-1294.

 

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