Anorexia nervosa is a serious psychiatric disorder that is estimated to have a prevalence of 0.48 percent among girls ages 15 to 19. Anorexia nervosa combines pathological thoughts and behaviors about food and weight with negative emotions concerning appearances, eating and food. These thoughts, feelings and behaviors lead to changes in body composition and functioning that are the direct result of starvation. As a result, among adolescents the illness severely effects physical, emotional and social development. In addition, there is a fair amount of evidence that suggests that anorexia nervosa often co-occurs with other psychiatric disorders including depression, anxiety disorders, and obsessive-compulsive disorder.

It is not clear what causes anorexia nervosa. The mean age of onset is about 17 and many have suggested that the disorder represents the individual's difficulty negotiating the developmental demands of adolescence. Arthur Crisp's psychobiological perspective suggests that the symptoms of starvation and emaciation are attempts to cope with the demands of adolescence by regressing to an earlier developmental level. Hilda Burch's psycho-dynamic formulation conceives of the patient as overwhelmed by feelings of ineffectiveness, emptiness and a concomitant inability to access his or her own thoughts, feelings and beliefs.

Recent research supports these ideas in the sense that eating problems initially emerge in response to pubertal change, especially fat accumulation. Other associated risks such as teasing by peers, discomfort in discussing problems with parents, material preoccupation with restricting dietary intake and acculturation to the Western values in immigrants also support the idea that adolescence itself is a key aspect of the illness.

Dieting and weight concerns are part of Western culture. Up to 60 to 70 percent of adolescent girls report such concerns. Therefore, it is important to distinguish between these predictable concerns and those that are more pathological. The DSM-IV includes two different types of criteria for anorexia nervosa: medical and psychological. The medical criteria are the easiest to identify. Patients who are below 85 percent of ideal body weight (IBW) or who fail to make expected weight gains meet the weight criteria. The DSM also requires that three consecutive menstrual periods be missed in females who have reached menarche.

Psychological criteria include an intense "fear" of weight gain even though underweight and an overestimation of current body mass - usually called body-image distortion. Additionally, it is possible that anorexia nervosa may be complicated by binge-eating or purging behaviors.

Treatment approach

Treatment of anorexia nervosa requires attention to the possibility of severe medical problems that commonly co-occur with the illness. Changes in growth hormone, hypothalamic hypogonadism, bone marrow hypoplasia, structural abnormalities of the brain, cardiac dysfunction, and gastrointestinal difficulties can occur. In addition, for adolescents there is the potential for significant growth retardation, pubertal delay or interruption, and peak bone mass reduction. Risks of death as a result of complications of anorexia nervosa are estimated at 6 to 15 percent, with half the deaths resulting from suicide. Thus, a therapist working with a patient with anorexia nervosa should ensure that they have adequate medical treatment and motioning.

As might be expected, patients with anorexia nervosa sometimes require hospitalization. In fact, some data suggests that the total percent of time spent in hospitals by patients with anorexia nervosa is only exceeded by patients with schizophrenia. A variety of investigators have published reports on the effectiveness of inpatient hospitalization for acute treatment of anorexia nervosa. These studies demonstrate that inpatient treatment is likely to result in short-term improvement using a variety of clinical approaches, but because of increasing pressure to reduce the use of the modality due both to its high cost and its disruption of the adolescent's usual life, outpatient alternatives are increasingly stressed.

The Maudsley method

However insufficient this data, it appears that for adolescents with anorexia nervosa, a specific form of family therapy developed by Christopher Dare and Ivan Eisler at the Maudsley Hospital in London is the most promising. Studies of the Maudsley method demonstrate that for adolescents, this family-based treatment is superior to individual therapy and that five years after treatment its advantages continue to be evident.

The Maudsley method turns common presumptions about how to treat anorexia nervosa upside down. Historically, many therapists have seen families as pathological and interfacing with the adolescent's ability to develop a sense of self. Thus, clinicians have blamed families, excluded them from treatment, and instead focused on the individual relationship of patient and therapist as the incubus for recovery. The focus of these types of treatments are on the conflict or anxieties about adolescence that anorexia nervosa is helping them to avoid. The hope is that once the patient has an understanding of these problems, the patient will give up self-starvation.

In opposition to this view, the Maudsley method sees a patient in the acute starvation stages of anorexia nervosa as unable to use such insight until after a process of re-feeding has occurred. And perhaps even more importantly, the Maudsley method argues that the family is the best context in which to accomplish this.

The Maudsley method takes an "agnostic" view of the cause of anorexia nervosa, refusing to blame the family for the illness. Instead, the family is seen as the most important resource at the therapist's disposal. The therapist endeavors to empower them to take on the responsibility for nurturing their desperately ill child back to health. Accomplishing this task requires that the family be able to change its approach to the self-starvation that anorexia nervosa has imposed on their child.

In order to accomplish this arduous task, therapists schooled in the Maudsley method endeavor to place the family in a "therapeutic bind". On one side, the family is warned about the necessity for immediate action to prevent their child from succumbing to the illness - a terrifying thought that leads to increasing anxiety, especially on the parent's part. On the other hand, in order to prevent this anxiety from becoming overwhelming, the therapist communicates acceptance, warmth and expertise to support the family.

The Maudsley method owes its major components to variety of clinicians and researchers. For example, family meals are employed in the treatment and used in a way similar to how Minuchin employed them in his treatment. The process of empowering the family to find their own solutions to their problems is based in the non-authoritarian stance of Milan systems therapy as well as feminist theory. In order to assist the family in taking on the problems of anorexia nervosa without attacking their child, the Maudsley method emphasizes separating the patient from the illness, a technique based in part on narrative therapy strategies. Nonetheless, Dare's recipe is ultimately his own.

More research needs to be done examining the Maudsley method and it is also evident that clinicians outside of London need to become more familiar with the approach and be exposed to the techniques involved. Christopher Dare is one of the authors of a recently published treatment manual that provides a detailed description of his treatment approach. The manual provides a systematic account of the scientific literature supporting the use of family-based treatment for anorexia nervosa in adolescents and provides specific instructions in the methods used to engage families in this type of treatment. It also includes transcriptions of therapeutic sessions that illustrate how the treatment operates.

There are limitations to family-based treatment for anorexia nervosa in adolescents. For example, data from the Maudsley studies show that this approach is less effective for older adolescents (>18) or adults, adolescents who are chronically ill or those who binge and purge. In addition, highly critical families may not respond to the whole family treatment model and need alternative versions of family treatment to succeed.

There is a need to continue to evaluate this and other treatment approaches for anorexia nervosa, but family-based treatment based on the Maudsley model is the most promising treatment now available for helping adolescents with anorexia nervosa.

Dr. Lock is a child and adolescent psychiatrist and assistant professor of child psychiatry at Stanford University School of Medicine. He is also Medical Director of the Comprehensive Pediatric Care Unit at Lucile Salter Packard Children's Hospital and Co-Director of the Adolescent Eating Disorder Program.

References:

Bruch H: Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973.

Dare C, Eisler I: Family Therapy for Anorexia Nervosa. In Garner DM, Garfinkel PE (Eds.): Handbook of Treatment for Eating Disorders, (2nd ed.). New York: The Gilford Press, 1997.

Eisler I, Dare C, Russell G, et al.: A five year follow-up of a controlled trial of family therapy in severe eating disorders. Archives of General Psychiatry 1997; 54: 1025-30.

Gull WW: Anorexia nervosa (apepsia hysterica, anorexia hysterica). Transactions of the Clinical Society of London 1874; 7: 222-228.

Lock J, Le Grange D, Agras S, et al.: Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: The Guilford Press, 2001.

Minuchin S, Rosman BL, Baker BL: Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, Mass: Harvard University Press, 1978.

The Maudsley method for family-based therapy for adolescent anorexia nervosa has three clearly defined phases.

• In the first phase, the focus is on engaging the family and empowering them to re-feed their child. The therapist reinforces a strong parental alliance around re-feeding their offspring in order to help ensure success. At the same time, wishing not to abandon the adolescent to this process without support, the therapist attempts to align the patient with the sibling sub-system. The therapist directly expresses the view that parents did not cause the illness and compliments them as much as possible on their efforts.
• Phase two begins once the patient accepts the demands of the parents and steady weight gain is evident. The therapist focuses on encouraging the parents to help their child to take more control over eating herself as is appropriate for her age.
• Finally, the third phase begins when the patient is maintaining a stable weight (near 95 percent of his or her ideal) without significant parental supervision. Treatment focuses on the impact anorexia nervosa has had upon establishing a healthy adolescent identity. Then it is possible to review the central issues of adolescence, work toward increased personal autonomy for the adolescent, and more appropriate family boundaries. It should be noted that families have "learned by doing" in this therapy and are often in much better shape as a result of the changes they have made through their re-feeding efforts.