In a previous post, I explored an article by Sally J. Rogers and Laurie A. Vismara on the state of early interventions for autism. The Rogers and Vismara article was one of a series of articles in a special issue of the Journal of Clinical Child and Adolescent Psychology exploring the evidence base for current child and adolescent mental health treatments. In this post, I explore an article by Pamela K. Keel and Alissa Haedt on the current status of psychosocial treatments for Eating Problems and Eating Disorders.
Details of the studies they reviewed
Keel & Haedt reviewed a total of 12 studies, of which the majority (8) focused on Anorexia Nervosa (AN), with the remaining 4 including a mix of Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS). All of the studies were treatment control studies, meaning the therapy of interest was pitted against another type of therapy or control condition. Common practice for a long time was to pit the therapy of interest against waiting list controls (control participants go on a waiting list to receive therapy after the main group) or no-treatment controls (control participants do not receive a therapy). Interestingly with eating disorder studies, the tendency is to compare the treatment of interest to another potentially viable treatment. This is good for a couple of reasons; a) control group participants receive a potentially helpful intervention (better ethically) and b) the therapy of interest is required to prove itself against other treatment options, rather than just against a no-treatment condition (more rigorous methodologically). In terms of methodological quality, 10 of the 12 studies were classified “Type 2” meaning they were good quality clinical trials with only 1 or 2 components missing denying them “Type 1” status as achieved by the other 2 studies. The quality of trials is important for multiple reasons, but simply put – the better the methodological quality of studies in an area (i.e., plenty of Type 1 and Type 2), the more confident we can be that the effects observed reflect real changes that could be achieved in clinical practice.
Study participants reflected a wide age range from 11.5 to 21 reflecting a child/adolescent/youth perspective and were mostly female (80-100% across the studies). Study sizes ranged from 13 to 86 participants and were generally two treatment comparisons (i.e., treatment vs treatment) with the exception of 1 study which had three treatment conditions. Given the child and adolescent focus the predominant therapy style was Family Therapy, with a few cognitive/behavioural type therapies and a couple of idiosyncratic therapies. Outcome measures were used routinely in all studies but there was significant variation across studies. BMI (Body Mass Index) and quantitative symptom measures were common outcomes along with varied mood and family functioning measures. There were a mix of therapists delivering the treatments. 7 of the 12 studies had psychologists, 5 had social workers followed by a mix of professionals from nursing, psychiatry and occupational therapy, similar to what you would expect in a modern multi-disciplinary CAMHS team.
Keel & Haedt also briefly reviewed 50 studies of treatments in adult populations, given the high proportion of adolescents in these studies, as this was informative on what approaches might are suggested for clients on the cusp of adulthood. In contrast to the 12 child/adolescent studies, the therapy focus in adult studies was cognitive/behavioural treatments with 1/2 of the 50 studies examining some kind of CBT (cognitive behavioural therapy) for BN.
What is suggested in the treatment of Anorexia in adolescents?
Anorexia, defined in the DSM-IV involves a refusal to maintain a minimally normal weight (e.g., weight below 85% of what would be expected), fear of gaining weight or becomming fat, cognitive distortions regarding weight (e.g., experiencing part or all of the body as fat despite emaciation) and loss of menstrual cycles (in menstrual teens). Although it affects less than 1% of the population, it can be severely debilitating and my understanding is the mortality rate from anorexia is the highest of any of the psychiatric illnesses.
Keel & Haedt’s review identified, for adolescents the most studied form of therapy is Family Therapy. There are many “schools” of Family Therapy and I will not pretend to be knowledgable about the distinctions between them. In simple terms though, Family Therapy views the family unit as the client, and through various strategies seeks to alter family dynamics hypothesized to have given rise to the individual’s symptoms. Typical strategies or processes might include: psychoeducation for family around the dangers faced by the client, minimizing blame and fault finding, altering family interactions around eating and the client’s symptoms, sustaining the cooperation of all family members and working with individuals in the family to change how they respond to the eating disorder. In anorexia, the most widely known and reported model of Family Therapy is the Maudsley Model, an intensive outpatient treatment that involves parents/caregivers heavily in the process of re-feeding the adolescent (weight restoration), re-establishing healthy family dynamics around eating and promoting the development of the adolescent’s non-eating-disorder identity. Common to Family Therapy models in eating disorders is the use of hospitalization in order to obtain a minimally health weight prior to commencing therapy. Often the therapy commences during hospitalization so the transition from hospital to home is easier.
Success-wise, for younger adolescents (17 below) the studies suggest 60-90% of patients will achieve good to intermediate outcomes, good being weight maintenance and return of menses, intermediate being weight maintenance only. This appears predicated on successful minimal weight restoration during hospitalization, that is, hospitalization is a critical part of the treatment. As for variation between different Family Therapy models, the literature is still quite young so these kinds of questions are difficult to answer. For example it is not clear whether there is a difference between separated or combined models (referring to whether or not the family are seen at the same time as the adolescent) or short versus long-term therapy models. What is promising is that family interventions following on from successful hospitalization leads to strong effects in the areas of weight gain in particularly.
In older adolescents (17-21), the picture is more varied and a variety of treatment modalities have shown some positive impact on anorexia symptoms. These include cognitive therapy, self psychology, body image therapy and a form of refeeding therapy. In cognitive therapy the focus is on behaviour change – setting goals for weight gain, challenging of core beliefs – particularly beliefs around control, achievement and approval, and relapse prevention – planning for future contingencies. In self psychology, a psychoanalytically driven therapy, eating disordered behaviour is viewed as a consequence of the patient substituting food for people to meet the needs of regulating self-esteem, self-nurturance & vitalization. In body image therapy, techniques such as virtual reality are used to help patients perceive their physical form more accurately. Finally in the refeeding therapy reviewed by Keel & Haedt called KPT (Kyoto Prefectural University of Medicine Behaviour Therapy), therapists use psychoeducation on the physical and metal consequences of starvation as well as the benefits of weight restoration through liquid meals.
As adolescents move into adulthood, current evidence suggests a movement towards as Keel & Haedt call it “nonspecific therapy”. I was a tad confused by this term, so I consulted a colleague of mine who has her finger on the eating disorder pulse. She described to me a model of therapy in which therapists with significant experience and knowledge of AN personalize therapy to the needs of the client. In her words “they did discuss at every appointment issues related to AN such as intake, BMI, etc. But then they picked up on issues that were of priority to the patient”.
In summary, it appears that early presentations of anorexia (late childhood and adolescence) are best addressed through family therapy models, but as the adolescent moves into adulthood, individualized therapy protocols appear more effiacacious.
What is suggested in the treatment of Bulimia Nervosa in adolescents?
Bulimia Nervosa (BN), as defined by the DSM-IV involves the presence of both binge episodes (loss of control over eating and consuming an unusually large amount of food in a short-period) and innappropriate compensatory behaviours such as vomiting, laxative use, fasting, excessive exercise. In BN self-evaluation is unduly influenced by weight. More common than AN, with lifetime prevalence rates between 1.1 and 4.2% in USA, only a small proportion of sufferers actually receive mental health care.
For younger adolescents, similar to AN, Family Therapy (i.e, a version of the Maudsley Model) appears to be a promising treatment, when compared to non-directive supportive psychotherapy. However remission rates associated with the treatment were only in the 29-39% range over 6-months suggesting a large proportion remain symptomatic.
For older adolescents, guided self-help CBT appears to be promising with rates of abstinence from binge eating and compensatory behaviours on par with Family Therapy approaches. Interestingly, in my early training I gained a lot of experience providing guided self-help interventions for women with BN and found it to be a very potent form of intervention, mixing specific strategies (from the self-help book) with interpersonal contact and support.
In early adulthood, the emphasis in the research has definitely been on CBT, such that CBT is recognized as a well-established treatment for Bulimia. In CBT, therapists use a combination of behavioural (e.g., goal setting, behavioural experiements) and cognitive (e.g., thought challenging, cognitive defusion) strategies to reduce identification with eating disorder thoughts/feelings and promote healthy eating habits. It is hypothesized that given the success of CBT in adult samples, the same CBT protocols are probably appropriate for older adolescents (17-21).
In summary, it appears a similar trend exists in the treatment of Bulimia, in that early presentations in late childhood or early adolescence will respond to family interventions, whereas later presentations are more likely to respond to individualized cognitive-behavioural input.
Limitations
I hate throwing out this limitation when talking about reviews, but currently the number of studies in the area of treatment for child and adolescent eating disorder limits firm conclusions. Of the 12 studies found by Keel & Haedt, only 2 studies met full “Type 1” criteria. The field is in need of big high quality controlled trials. There appears to be no child studies in this area and the authors of the review suggest we may need to expand our diagnostic profiles beyond anorexia and bulimia if we hope to capture the syndromes seen in childhood such as food avoidance, selective eating, functional dysphagia (difficulty swallowing) and food refusal. Given that symptoms of eating disorders are appearing in progressively younger populations, this is an important early intervention priority. A long-standing criticism of the eating disorder literature is the fact males are under-represented in the reported studies. Males make up 10-15% of those with eating disorders in the population yet generally constitute less than 5% of participants in treatment control studies.
My thoughts
The over-arching theme emerging from this review in my opinion is the developmental stance therapists should take in choosing treatment options for child and adolescent eating disorder presentations. Early presentations of both BN and AN appear to respond to family interventions, ensuring the family environment is conducive to re-establishing healthy eating habits and normal emotional development. As adolescents draw closer to adulthood, therapists should consider employing structured individualized programs focusing specifically on the thoughts, feelings and behaviours of the adolescent.
It is interesting that these findings parallel how I see the transition of mental health interventions through developmental stages. Interventions with infants, toddlers and young children are typically more family focused. The underlying philosphy here is that if you alter the context in which the behaviour occurs, you alter the function of the behaviour. As a child moves towards adolescence and developmentally towards independence and self-direction, therapeutic interventions are more likely to focus on the adolescent themselves, namely their thoughts, feelings and choices.
Pamela Keel, Alissa Haedt (2008). Evidence-Based Psychosocial Treatments for Eating Problems and Eating Disorders Journal of Clinical Child & Adolescent Psychology, 37 (1), 39-61 DOI: 10.1080/15374410701817832
Filed under: Review Article | Tagged: anorexia, bulimia, CBT, eating disorders, family therapy | 1 Comment »