Chapter 15 Peter M. Doyle, Catherine Byrne, Angela Smyth, and Daniel Le Grange Eating disorders are serious psychiatric illnesses that can severely impact both the mental and physical health of affected individuals. Diagnostic categories for eating disorders have changed with the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) to include anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and Other Specified Feeding or Eating Disorder. AN is characterized by a failure to achieve or maintain a minimum weight for age and height, fear of gaining weight although underweight, and disturbance in self-perception of body weight or shape or denial of seriousness of low body weight. Patients are given a diagnosis of BN if they are of normal weight but are engaging in regularly occurring episodes of binge eating (i.e., eating large amounts of food with an accompanying sense of loss of control) coupled with compensatory behaviors (e.g., self-induced vomiting, laxative abuse, excessive exercise). Those who are regularly binge eating but do not engage in any kind of compensatory behaviors would meet diagnostic criteria for BED. Outside of these three primary diagnostic categories, patients who engage in some sort of disordered eating are considered to exhibit an Other Specified Feeding or Eating Disorder. Throughout this chapter, we describe these conditions and current evidence-based treatments available when working with eating-disordered children and adolescents. Rates of eating disorders in the population vary depending on the specific type of eating psychopathology being discussed. By the age of 20, it is estimated that 0.8% of people in the United States will have had AN. Although traditionally thought of as an illness affecting females, approximately 1 to 3 in 10 patients with anorexia are male (Wooldridge, 2012), and that ratio may grow as the stigma of males presenting for treatment of an eating disorder decreases. At this same age cut-off, 2.6% will have had BN, 3.0% will have had BED, and 4.8% to 11.5% will have had an Other Specified Feeding or Eating Disorder (Le Grange, Swanson, Crow, & Merikangas, 2012; Stice, Marti, & Rohde, 2013). The typical age of onset for eating disorders is between 16 and 20 years old. However, increasingly younger cases are being seen in clinics around the country, with some presentations of anorexia nervosa in children as young as 8 years old. While research in the field of eating disorders is ongoing, there have been some treatments that have been found effective in the improvement and recovery of these disorders. Assessment of patients with AN can be complex, as there are high rates of comorbid psychopathology as well as medical complications that need to be evaluated. Anxiety disorders are the most common comorbidity, with as many as 40% of patients with AN meeting criteria for obsessive-compulsive disorder at some time in their life (Wu, 2008). Of greater concern to the treatment team is the potentially life-threatening consequences of AN. The starvation or semistarvation states in AN can impact every system of the body and lead to disruptions in cardiac, hematological, gastrointestinal, neuroendocrine, skeletal, neurological, and dermatological functioning. Medical complications and the need for close medical monitoring are the norm in patients with AN. The illness has the highest mortality rate of any psychiatric disorder, with 10% of patients ultimately dying from complications (Smink, van Hoeken, & Hoek, 2012). As such, empirically supported treatments for AN include a strong focus on stabilizing the patient’s physical health as a means to full recovery. A brief description of these treatments follows. Originally developed at the Maudsley Hospital in London during the 1980s, family-based treatment for anorexia nervosa (FBT-AN) is commonly referred to as the Maudsley method or Maudsley approach. Theoretically, FBT-AN was influenced by different models of family therapy as well as inpatient eating disorder treatment paradigms. What resulted is a treatment focusing primarily on weight restoration and aiming to empower parents and families to elicit change. The treatment is designed to unfold in three distinct phases. Throughout treatment, the primary therapist serves to coordinate the treatment team, which is comprised of the family, therapist, medical provider, and psychiatrist, if psychotropic medication is necessary. The primary therapist remains in regular contact with all members of the team to ensure consistency of message and focus on eating-disorder symptoms. Except under special circumstances (e.g., suicidal or self-harm behaviors), nothing will take precedence over the task of refeeding and the team’s focus on weight restoration. The initial session of FBT-AN is designed to engage the entire family in combating the eating disorder, helping them to conceptualize the eating disorder as separate from the patient, and maximize the family’s anxiety in order to motivate them into action. Session 2 is the “family meal,” in which the family brings a picnic-style meal to the therapy office. Unlike the standard 60-minute session typical of FBT-AN, this session is 90 minutes long. During this session, parents are given in vivo coaching in how to handle the patient’s protestations in a way that is firm but supportive and does not devolve into power plays or arguments. Throughout the family meal, parents are asked to convince their child to eat “one more bite” than he or she is prepared to eat. In order to do so, parents are coached to act together and direct the child to eat in a calm, firm, but supportive manner. Additionally, the therapist will guide the parents on how to persevere until the child eats. The remainder of Phase I is focused on helping parents to problem-solve on a weekly basis in their efforts to help their child gain weight. The primary therapist takes a collaborative stance and works to empower the parents to help them regain trust in their intuition and innate ability to feed their child and make effective decisions in the refeeding process. Instructions regarding food choices or calories are avoided. Instead, parents are encouraged to make these decisions on behalf of their child and to use the weekly weight as data for the effectiveness of their strategies. For example, the therapist will encourage the parents by acknowledging that they have several other children at home who are healthy and have been fed by the parents their whole lives. Additionally, the therapist will support the family in showing them that they had successfully fed their child with anorexia until the anorexia took over. If, for example, the child drops weight in the week before a session, the therapist will encourage the family to identify examples of food that can be added to the child’s daily intake in order to increase calories and make up for the weight loss. The therapist also may help the family discover ways in which the patient could have been deficient on calories in the previous week, such as not fully consuming a daily snack at school. Once the patient has reached at least 87% of expected body weight (EBW) and can engage in meals and snacks with minimum resistance, the transition to Phase II can begin. During this phase, control over food decisions is gradually handed back to the child or adolescent. The final disposition of this transition will vary, depending on the age of the patient. A younger patient may not assume full control of all food decisions regardless of progress, whereas an older adolescent might be expected to function more like an adult in terms of food decisions by the end of Phase II of treatment. When the patient’s weight is 95% to 100% EBW and he or she can maintain weight without extra parental involvement, treatment can transition into Phase III. The final sessions of FBT-AN are devoted to helping the patient and his or her family navigate a return to a normal trajectory of adolescent development. Often the patient’s psychosocial development has been retarded by the presence of AN, and the family must now adjust to what life will look like for a typically functioning preteen or teenager. The therapist reviews the tasks of adolescence and helps the family identify or predict developmental struggles relevant to the patient. These may include peer relationships, sexuality, issues of separation and individuation from parents, and even plans for moving away from home. FBT is currently the only treatment for adolescent AN that is well established by empirical evidence. The efficacy for FBT-AN has been tested in five randomized control trials (RCTs) (Loeb & Le Grange, 2009). Results from these studies have consistently found that at least 50% of patients experience a full remission of symptoms following 12 months of FBT-AN outpatient treatment. Additionally, the literature has demonstrated that such gains are maintained 4 to 5 years after treatment ends (Eisler et al., 1997; Eisler, Simic, Russell, & Dare, 2007; Lock, Couturier, & Agras, 2006). Accordingly, FBT-AN received the highest rating of any eating disorder treatment from the British National Institute for Health and Clinical Excellence when it published recommended treatment guidelines in 2004 (National Collaborating Centre for Mental Health, 2004). The studies discussed consistently show that adolescents with AN respond well to treatment when their parents are included in the treatment process. However, there is still a substantial population for whom FBT-AN is not successful. Adolescent-focused therapy (AFT, discussed later) seems to be a reasonable alternative to FBT when the latter is not feasible. Behavioral family systems therapy (BFST) (Robin, Siegal, Koepke, Moye, & Tice, 1994) also utilizes parental involvement and initial control over eating to help patients overcome AN. There are several obvious similarities with FBT-AN, including a three-phase model, the assumption that an underweight patient is unable to make rational decisions about nutrition and healthy eating, and the subsequent control given to parents in Phase I to make decisions on behalf of the patient in terms of food and eating. However, BFST does not focus on empowering the parents to use their own intuition to facilitate changes to meals and food choice. Instead, parents work with a nutritionist, receive concrete directions regarding calories and food choices from the therapist, and record all the meals for therapists’ review and feedback. Phase I of BFST consists of an initial assessment followed by parent training relating to the implementation of a behavioral weight gain program. Using straightforward behavioral strategies (e.g., stimulus control and behavioral reward systems), the therapist advises the parents in effectively applying these principles to help their child gain weight. Stimulus control might include removal of “diet” foods from the home. As part of a behavioral reward system, rewards are given for successful performance of some desired behavior, such as meal completion. Depending on the specific family, rewards may take the form of tangible products (e.g., music downloads, clothing, etc.), monetary rewards, or special time spent with family or friends doing a certain activity. These rewards can be negotiated ahead of time with the patient or parents can use their knowledge of the child’s preferences to determine rewards. Once the parents are able to consistently achieve weight gain in the patient, Phase II can begin. During this phase, parents continue to maintain control over eating, but the focus of in-session discussions turns to identifying the cognitions that are underlying the patient’s eating disorder (e.g., unrealistic fears of unremitting weight gain or all-or-nothing ideas about “good” and “bad” foods). Cognitive behavioral strategies are employed to label the core beliefs and “hot” cognitions that lead to or maintain anorexic behavior. Distorted thoughts are challenged, and patients are encouraged to use rational responses to their distorted automatic thoughts. The final phase of BFST is initiated once patients are able to successfully and consistently challenge their distorted thoughts and manage their own eating and exercise behaviors. Discussions may focus on the parents’ activities as a couple and the patient’s interests and activities separate from the family. During this final phase of BFST, patients assume responsibility for their own eating and weight maintenance, and the therapist works to help patients individuate and the parents refocus on their marital relationship (something that typically has been deprioritized while their child was acutely ill with AN). In a design similar to the RCTs for FBT, Robin et al. (1999) compared BFST with ego-oriented individual therapy (EOIT, now known as AFT). Results demonstrated significant improvements for both BFST and EOIT, with 67% of patients reaching target weight and 80% regaining menstruation. At 1-year follow-up, patients had continued to improve, with approximately 75% reaching their target weight and 85% having menses. Results indicated that changes in weight and menses were superior for patients in BFST both at posttreatment and follow-up. Improvements in eating attitudes, mood, and self-reported eating-related family conflict were comparable for the two groups. Therefore, as a close relative to FBT, BFST appears to be a promising treatment option for adolescent AN.
Evidence-Based Interventions for Eating Disorders
BRIEF OVERVIEW OF DISORDER/PROBLEM
EVIDENCE-BASED APPROACHES
Anorexia Nervosa
Family-Based Treatment for Anorexia Nervosa
Phase I
Phase II
Phase III
Behavioral Family Systems Therapy
Phase I
Phase II
Phase III
Adolescent-Focused Psychotherapy
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