Family Therapy for Adolescents With Anorexia Nervosa: A Brief Review of Family-Based Treatment

Anorexia nervosa is often complicated by devastating medical problems and may result in death. Although studies suggest a multifactorial cause for the disorder, treatment trials have yet to provide clinical guidance about how best to approach anorexia nervosa. However, recent studies have found that for adolescents who have short-duration anorexia nervosa, a specific form of family-based treatment (FBT) shows promise.

Background
Anorexia nervosa is a severe psychiatric disorder that typically has its onset during adolescence and primarily affects young women. The estimated prevalence of anorexia nervosa is 0.48% to 0.7% in females, and males account for about 10% of the total diagnoses.¹ Anorexia nervosa is characterized by overwhelming preoccupation with weight and food, extreme fear of fat or of becoming fat, and refusal to maintain a healthy weight that is often accompanied by a denial of the health consequences of malnutrition, misperception of body shape (ie, body image distortion) by overestimating body size, and loss of menses in postmenarcheal females.

In children and adolescents, the diagnosis of anorexia nervosa is challenging because of limited developmental capacities to report symptoms, as well as difficulties in accurately calculating standardized weight thresholds and determining menstrual status.² Both the psychological and physical effects of these symptoms lead to severe complications.³ Medical complications include changes in growth hormone, hypothalamic hypogonadism, bone marrow hypoplasia, structural abnormalities of the brain, cardiac dysfunction, and GI difficulties. These result in growth retardation, pubertal delay or disruption, and bone loss.

Psychological symptoms lead to social withdrawal, family conflict, guilt, anxiety, and ultimately, in many cases, academic and work failure. In addition, many patients with anorexia nervosa have other psychiatric disorders, particularly anxiety disorders including obsessive-compulsive disorder and affective disorders. An aggregate mortality rate of approximately 5.6% per decade and a crude mortality rate of 5.1% are reported for patients with anorexia nervosa⁴: about one-half of the deaths are due to suicide and one-half are secondary to physical complications of anorexia nervosa, particularly cardiac failure.

Prognostic studies of anorexia nervosa are limited, but those that are available predict that about one-half of the patients recover, one-third have considerable improvement, and the remainder follow a chronic course. Adolescent onset and early treatment appear to improve outcomes. Most of those who will recover do so within 5 years of initial presentation. At the same time, some studies indicate that associated psychiatric and social impairments persist even when anorexia nervosa symptoms abate.

The cause of anorexia nervosa is unknown. Studies find evidence of family aggregation of the disorder, and genetic vulnerability likely accounts for a significant proportion of the risk of anorexia nervosa.⁵ Studies identify neuroanatomical, neurofunctional, neurocognitive, and neurotransmitter differences between patients with anorexia nervosa and controls.^6,7 Social and developmental forces are also implicated in the risk of anorexia nervosa. Adolescents may be at particularly high risk because of social forces that focus on importance of appearance and weight during this period, as well as burgeoning autonomy dilemmas faced by teenagers.⁸

Although progress has been made in understanding the risks of developing anorexia nervosa, treatment for the disorder remains extremely challenging. Studies of adults with anorexia nervosa yield little clinical guidance about how to treat the disorder.⁹ Studies have been plagued by high levels of discontinuation, making definitive conclusions about treatment effectiveness impossible.

Various treatment strategies have been studied for anorexia nervosa, including cognitive-behavioral therapy (CBT), individual supportive therapies, nutritional therapies, antipsychotics (both typical and atypical), and antidepressants. The main conclusion that can be drawn from these studies is that most treatments are not acceptable to adult patients with anorexia nervosa.¹⁰ It also appears that standard nutritional counseling and fluoxetine(Drug information on fluoxetine) do not confer systematic benefit for anorexia nervosa despite the common clinical use of these therapies.^11,12

Hospitalization may be helpful in short-term weight restoration, but long-term benefits have not been identified. A recent study of adolescents found that those randomized to outpatient treatment did as well as those who were treated in a specialized hospital service for 3 months.¹³

In contrast to these disappointing findings in adults with anorexia nervosa, both uncontrolled and controlled outpatient treatment studies of adolescents with anorexia nervosa suggest that family therapy is likely to be helpful with this age group.¹⁴