12/10 - We Are Family - MSMR: What A Year!

Dr. Lock with his lab team
Back row: Elizabeth LoTempio, Alison Darcy, PhD, Lauren Escott-Pavlis, PhD, James Lock, MD, PhD, Judy Beenhakker, MS, Brittany Alvy
Front row: Alaina Critchlow, Linsey Utzinger, Sarah Forsberg, Kara Fitzpatrick, PhD

Adolescence is a tough time for most people, with puberty and hormonal changes that can make school and home life, not to mention social life, difficult. This is normal and expected. Most children grow out of this stage in life to become mature, responsible young adults. There are some, however, who get caught in the turmoil of adolescence, developing eating disorders such as anorexia nervosa and bulimia nervosa. New research has shown that involving families in the treatment of eating disorders can be very effective in combating these diseases.

Anorexia and bulimia are psychiatric disorders that primarily affect adolescent girls. They often occur with other psychiatric disorders such as anxiety and depression. Although generally grouped together, anorexia and bulimia are quite different disorders. Bulimia is an eating disorder characterized by episodes of binge-eating (eating too much all at once) and purging (generally vomiting, but may also include fasting and over-exercise). Generally purging occurs in secret due to the guilt or shame surrounding this activity. Bulimics may still maintain themselves within a normal weight range even though their fear of gaining weight and/or desire to lose weight causes them to continue cycles of binging and purging.

These binge-purge cycles are characteristic of bulimia. Although bulimia is characterized as a psychiatric disorder, binge-purge cycling may compromise the health of bulimics. Many bulimics have stomach and gastrointestinal tract problems, electrolyte deficiencies, and oral health (teeth) problems. Bulimia is thought to affect about 3% of adolescent girls.

Anorexia is a more severe psychiatric disorder, affecting 0.5% to 0.7% of adolescent girls. Anorexia is characterized by limiting caloric intake while simultaneously over-exercising, resulting in a patient who will continuously lose weight on the path to starvation. Patients with anorexia have a distorted sense of body image so they may still think of themselves as overweight when they are actually severely underweight.

Anorexia nervosa that lasts for a prolonged period of time can have extreme physical consequences as a result of malnutrition, which includes cardiovascular complications such as a heart attack or stroke. Whereas bulimics might tell you (when confronted) that they don’t want to purge themselves or they would really like to be thinner, anorexics will not admit anything is wrong. For this reason, anorexia is an ego-syntonic disorder, meaning that the patient does not realize she or he has a problem. As a result, anorexia can be an extremely difficult disorder to treat. Indeed, there are very few treatments for anorexia nervosa that have been proven to be effective at recovering body weight and altering the patient’s perception of body image.

According to Dr. James Lock of the Stanford School of Medicine, the scarcity of effective treatments for anorexia has to do with a lack of understanding of the causes of the disease. For centuries anorexia was thought of as a choice and was not taken seriously despite data that anorexia is a serious disorder. Furthermore, anorexia has often been characterized as a developmental disease that adolescents will grow out of as they mature. As a result, the research necessary to find treatments for anorexia or other eating disorders has not happened as it has for other psychiatric diseases. The history of anorexia nervosa proves this point. Although anorexia nervosa was first described in the medical literature in the 1600’s, it was not accepted as a psychiatric disorder until 1876. It was another century before the first clinical trial, a key feature of modern medical research, was conducted on the anorexia population.

Dr. Lock was first exposed to patients with eating disorders while a resident in psychiatry. He was interested in these patients, who were very articulate and could talk about their lives and past experiences. But he felt the treatments he could offer them were rather limited. When he finished his residency, he took a job with an organization that provides medical psychiatry services. About half the patients had anorexia and the rest had other psychiatric disorders such as anxiety disorders and depression. Over time, Dr. Lock focused on patients with anorexia, as new therapies and treatments were developed for this psychiatric disorder. At this time, anorexic patients were treated like other medical patients in a hospital setting with psychiatric drugs and individual therapy sessions. These approaches did not seem appropriate to Dr. Lock for the adolescent population he was treating. So he began looking for outpatient options for these anorexia patients and found there was no evidence for any effective anorexia treatment. As a result, he has dedicated his medical career to improving existing treatments for anorexia and finding new ones.

Dr. Lock has focused his research on a treatment method known as Family-based Therapy (FBT). Family-based therapy begins by helping the parents to understand that their child’s condition is not their fault, and that they can, in fact, help their child. Often parents will have already tried to help their child, but because they did not have support, they would give up after a short period of time. This part of family-based therapy treatment is focused on changing the maintaining behaviors of anorexia, namely eating a restricted diet and over-exercising. Parents are given support to take control over the eating and exercising habits of their children so that they regain lost weight. Once this weight has been recovered, the second phase of treatment helps the parents give age appropriate control back to their child. The therapist helps the parents think through this process and evaluate the progress the child is making. Finally, once the child has reached a normal weight and regained control of her or his eating behaviors, the therapy turns to how anorexia has affected the child and what she or he needs to do to get back on track in adolescence.

Family-based therapy directly contradicts the predominant thinking that has surrounded anorexia for so long. For many years anorexia was thought to be caused by over-controlling parents whose children felt they had no control over their lives. As a result, the children would resort to anorexia in order to be able to control some part of their lives. According to this reasoning, if the parents backed off, then the child would no longer need to exhibit anorexic behaviors to gain control, and the child would eat normally again. Thus parents were often alienated from the treatment of their children as instigators of the disorder. "Although a reasonable explanation," Dr. Lock explains, "it’s simply not true." His research has shown that the parents of girls with anorexia are not oppressing their children. By excluding parents from the treatment process, however, this mentality leaves the child to deal with anorexia on her own. Rather than exclude or blame parents, family-based therapy purposefully involves parents in the treatment process, making parents in charge of helping their children get better. Family-based therapy was first reported in 1987 but there were few follow-up studies. Dr. Lock believes the idea of family-based therapy was something that clinicians and other scientists at the time were not ready to hear. He, too, was initially skeptical about the approach. But the researchers had data, and Dr. Lock couldn’t dismiss the study without examining their data.

In 1999, Dr. Lock began a study of 86 children with anorexia to determine the effectiveness of family-based treatment on his patients. Patients were given either 10 sessions of treatment over 6 months or 20 sessions over 12 months. Dr. Lock found that family-based therapy was remarkably effective. By the end of the year, 80% of his patients no longer met the diagnostic criteria for anorexia nervosa. Moreover, Dr. Lock found this result whether the patients had had six or twelve months of treatment. "These are promising results," Dr. Lock remarks.

Nevertheless, he insists that there is a long way to go to improve and develop treatments for anorexia. First, there is still no treatment that has been proven effective for adults. Most recoveries happen within the first five years, so adults who have been struggling with the disease for a longer period of time become harder and harder to treat. It is unclear whether family-based therapy would even be effective for adults because they typically no longer live with their families, and the influence of parents decreases as children age. Second, there is still a population of adolescent patients for whom family-based therapy is not effective. Dr. Lock would like to further study this population to understand how to make the treatment more effective. Lastly, family-based treatment is not an option for patients who have difficult family situations or who do not have a family to support them. Other treatment methods are needed to help these patients.

Third, research on anorexia is complicated by the lack of a definition for the term "full recovery." For a long time clinicians were satisfied with progress where patients were no longer maintaining themselves at very low weights. For Dr. Lock, this is not enough. "For me, a full recovery means someone who is at a normal height and weight for their age and gender and no longer preoccupied the weight/shape worries that predominate anorexia nervosa."

Lastly, anorexia has primarily been associated with adolescent girls, with about 90% of the affected population being female. Yet, as Dr. Lock points out, this may be because the assessment of symptoms for anorexia is focused so much on the weight and shape concerns of young women. One of the key diagnostic criteria for anorexia is a lack of menstruation. This is a characteristic that cannot be applied to boys. Also, girls need a higher proportion of body fat than boys in order to menstruate and maintain proper hormone balance. Boys can have much less body fat and still be physiologically sound. "Since we typically think of anorexia as a girl’s disease," Dr. Lock remarks, "it is quite possible that we don’t identify it in as many boys as we should." This, too, warrants further research.

Educating middle and high school students about anorexia and other eating disorders is an important piece of Dr. Lock’s work. "If you think someone you know might have an eating disorder," he says "the best thing to do is tell a trusted adult."

Dr. James Lock is a Professor of Psychiatry and Behavioral Science and Director of the Stanford Child and Adolescent Eating Disorder Program at Stanford University. He is working to develop an effective treatment program using family-based therapy as well as finding other effective treatments for anorexia. He is a practicing child psychiatrist and regularly sees patients. When not working, Dr. Lock enjoys reading and spending time with his family.

Anorexia.com http://www.anorexia.com

Eating Disorders Research Program, Stanford School of Medicine http://edresearch.stanford.edu

National Institute of Mental Health http://www.nimh.nih.gov/health/publications/eating-disorders/anorexia-nervosa.shtml

National Alliance on Mental Health http://www.nami.org/Template.cfm?Section=By_
Illness&template=/ContentManagement/ContentDisplay.cfm&ContentID=102975

National Association of Anorexia Nervosa and Associated Disorders
http://www.anad.org

Dr. Lock’s webpage
http://med.stanford.edu/profiles/childpsychiatry/frdActionServlet?
choiceId=facProfile&fid=4248

The Training Institute for Child and Adolescent Eating Disorders
http://www.train2treat4ed.com/about.html

Child and Adolescent Psychiatry Department, Stanford University
http://childpsychiatry.stanford.edu

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