Feb. 10, 2015
Anorexia nervosa, which affects about 2 percent of young women and 1 percent of adolescent males, has challenged clinicians for decades. The disorder profoundly alters the lives of patients, interfering with growth, development and fertility and commonly co-occurs with substance use and mood and anxiety disorders. The mortality rate — an estimated 20 percent — is the highest of any psychiatric illness.
Yet traditional psychodynamic models such as adolescent-focused individual therapy (AFT), which stresses autonomy, self-efficacy and individuation, have met with little success. Less than half of patients treated with AFT recover physically and psychologically over the long term; the rest continue to experience symptoms of varying severity throughout life.
Several factors account for these poor outcomes, according to Leslie A. Sim, Ph.D., L.P., a psychologist specializing in eating disorders at Mayo Clinic's campus in Rochester, Minnesota. "Many of these kids are very ill; they aren't thinking clearly or flexibly and aren't capable of engaging in traditional psychotherapy," she says. "Then, too, as clinicians, we're trying to reduce their control over weight and eating, which in many cases they have incorporated into their identity as a moral value. So in essence, we are asking a child to stop the behavior that in her eyes makes her a good person."
Family-based therapy (FBT) also known as the Maudsley approach, was developed as an alternative to traditional interventions. It is an intensive outpatient program that seeks to avoid hospitalization and instead actively engages parents in the process of restoring their child to a healthy weight at home. FBT treats anorexia first and foremost as a medical illness and uses food as a therapeutic agent.
"Children and teens with anorexia aren't capable of making good choices about their health. Their brains are hijacked by starvation, so the parents have to step in and make those choices for them," Dr. Sim explains. "The choice they make is that kids have to eat. We don't have any good pharmacology for anorexia; food is the medicine, and we know that it works."
Results of the first randomized controlled trial to demonstrate the effectiveness of FBT appeared in JAMA Psychiatry (formerly Archives of General Psychiatry) in 2010. In that study, researchers found that FBT was superior to AFT on most clinically significant measures, including relapse rate from full remission — 10 percent and 40 percent, respectively. Subsequent studies and clinical experience have confirmed those findings.
Feast or famine
FBT is a challenging and labor-intensive process that requires loving support and remarkable patience and persistence from parents, one of whom must be present to monitor each meal and snack, no matter how long a child takes to eat it.
"There is no one right way to do it, but the key is not to let children out of the demand that they consume a certain amount of food at every meal," Dr. Sim says, adding that the goal is to regain weight quickly and aggressively — an outpatient rate of 2 pounds a week — so high-fat, calorie-dense foods are encouraged.
Once parents see the physical and psychological changes in their children — which can occur quite quickly — they feel much more empowered, Dr. Sim says. "There is nothing worse than seeing your child starve and not be able to do anything about it," she points out.
Children's reactions vary. Some, especially older teens, are angry and aversive. Others are relieved to be able to relinquish control over food to their parents. And many adjust to the regimen once they start feeling better. A relatively brief hospital stay may be needed for the small subset of patients for whom the outpatient program isn't working.
"Weight restoration and normalizing eating are the first and most important instruments of change," Dr. Sim says. "Later we work on handing control back to the child, and we help parents with that process. The third and final phase involves handling normal adolescent issues such as independence and sexuality that have been derailed by anorexia and establishing a healthy parent-adolescent relationship, where illness is no longer the focus of life."
Mayo Clinic has one of the few FBT programs in the country. At least 80 percent of treated patients make a full recovery — defined as achieving normal or near-normal weight — though younger patients with a shorter history of the disorder have a better chance of success. "Parents are our allies; we couldn't do it without them," Dr. Sim says.
For more information
Sim LA. Family-Based Therapy for Anorexia Nervosa in Adolescents. Medical Professional Video Center. Mayo Clinic. 2014.
Lock J, et al. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. JAMA Psychiatry. 2010;67:1025.