Eating disorders (EDs)—anorexia nervosa (AN) and bulimia nervosa (BN) in particular—remain among the most perplexing psychiatric disorders. The lifetime prevalence of an eating disorder among youths (aged 12 to 18 years) in the US is estimated to be more than 6%.1 Despite these high numbers and the associated morbidity and mortality of these disorders, few randomized clinical trials (RCTs) (eg, psychotherapy, pharmacotherapy, or combined) have been conducted on EDs in adolescents.2 As a consequence, relatively little is known about efficacious treatments for this patient population.
Notwithstanding sparse treatment data, recent efforts are beginning to provide clinicians with some clear treatment guidelines. For medically unstable adolescents with AN, a course of inpatient treatment is indicated until vital sign stability is achieved.3 Depending on admission weight, duration of hospital stay typically does not exceed 14 days provided calorie input starts high (~ 2,000 kcal), and is advanced fast (adding 200 kcal every other day).4 For medically stable adolescents with AN, our best efforts demonstrate that about 50% of patients will remit at one year post treatment when receiving a course of family-based treatment (FBT).5 FBT is quite proficient at bringing about weight recovery for a majority of patients, although somewhat less effective at engineering the immediate remission of cognitive symptoms. Unfortunately, data for other treatment strategies have not been able to muster such encouraging evidence.
FBT is therefore the current preferred therapy albeit for a circumscribed subset of the adolescent population. That is, it is an outpatient psychotherapy implemented by mental health providers (eg, psychiatrists and psychologists) for medically stable adolescents with AN. In addition to substantial remission rates in FBT, this treatment is manualized and therefore allows the clinician clear instructions about its implementation.6 Briefly, FBT emphasizes parental capacity for weight restoration of their adolescent offspring, therefore supporting parent to take on the task typically done by nurses had the adolescents been admitted to an inpatient refeeding program. Once weight has been restored, the second goal of this treatment is to support the return of the adolescent to age appropriate developmental tasks.
FBT proceeds through three clearly defined treatment phases, provided in about 15 to 20 treatment sessions over a period of 9 months on average:
• Phase 1. Parents restore weight. This phase (sessions 1 through 10) deals almost exclusively with the reinforcement of parental efforts to support the adolescent in terms of weight restoration. The therapist carefully guides the parents through this process, always with great deference to their capacity to get this job done. At the same time, the clinician is relentless in his/her support for the predicament the adolescent finds him/herself in. The treating psychiatrist should manage comorbid psychiatric diagnoses.
Dr Le Grange is the Director of the Eating Disorders Program at The University of Chicago Medicine, and Professor of Psychiatry and Behavioral Neuroscience at The University of Chicago. He reports that he receives funding from the NIH, NEDA, IBH LLC, The University of Melbourne, and honoraria from the Training Institute for Child and Adolescent Eating Disorders, LLC, Delaware. He also receives royalties from Guilford Press and Routledge.
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