Stanford Report Online

Stanford Report, November 15, 2000
New anorexia therapy makes family a key to recovery


Due to attention in the popular press, the public knows more than ever about eating disorders such as anorexia nervosa. But among child and adolescent psychiatrists who typically treat patients with the disease, there are many more questions than answers about the cause of the condition and the best form of treatment. Stanford physicians are hoping that the family-focused treatment program they are testing will help patients conquer the illness before it causes long-term physical problems.

"This is a field with a lot of opinions, but not a lot of actual research," said James Lock, MD, PhD, assistant professor of psychiatry and behavioral sciences and medical director of the comprehensive pediatric care unit at LPCH. "There have been only 8 randomized, controlled clinical trials in psychotherapy for anorexia," said Lock. He aims to enroll 86 patients and their families in his trial, making it the largest psychotherapy study yet of adolescents with anorexia.

The family-based treatment plan that Lock and his colleagues are using was pioneered in England, where Lock worked with Christopher Dare, MD, a psychotherapist at the Maudsley Hospital in London, to learn Dare's approach to the problem.

The clinical trial being conducted at Stanford and LPCH is the first U.S. study of this family-therapy plan. What makes the approach different from the traditional treatment plan for anorexia is that it attempts to address the patients' eating problems first, before tackling any underlying psychological problems. The reasoning behind the approach is that a patient's behavior is usually so severe, and his or her thought processes so distorted, that any attempts to address the psychological issues first will likely fail. "We don't really know what causes the illness, but the approach usually advocated is that it's a family and/or a psychological development problem," said Lock. "This turns that idea on its head -- the perspective is reversed."

In traditional family and individual therapy, Lock explained, therapist and patient talk about issues of adolescent development, focusing on childhood, up-bringing and family life. The therapist will ask the patient how she feels about herself and her family (90 to 95 percent of anorexia patients are girls), in the hope that the eating disorder will be solved by resolving underlying conflicts. The psychiatrist looks to address problems within the family in the hope that the patient's behavior will change as a result, said Lock.

The new therapy approach looks upon the family primarily as a resource for treatment, not as a cause of the disorder. "We tell them, 'We don't know what causes it but you know her best and can be a resource to her as she's fighting an illness that's really not her anymore'," said Lock. "The whole tone is different. The illness is seen as an external factor -- the family's not to blame and neither is the adolescent. The initial emphasis is on the hazards of the illness and the need to address it."

According to Lock, the percentage of patients that die from psychiatric or medical consequences is greater for anorexia than for any other psychiatric illness. Heart disturbances and suicide are the most common causes of death, but serious medical problems include bone breakage, infertility, depression, and a specific kind of low blood pressure. Most anorexia patients are female, in part because of a cultural preoccupation with female body image, and also because diagnostic indicators such as cessation of menstruation mean females are more likely to be officially diagnosed, said Lock. However, males also can develop the disorder. Boys may actually suffer from the underlying psychological aspects of anorexia for longer than girls do before medical problems appear, because -- due to basic differences in physiology -- males can tolerate a more severe reduction in body fat, for longer periods.

The family-based therapy, like any anorexia treatment plan, aims to help and ultimately cure the patient before the medical effects of the disease take their toll. "We don't have any drugs for anorexia. The only medication is food -- food really does change your state of mind," said Lock.

Lock has written a reference book about the technique so that other psychotherapists can adopt it. The book, "Treatment Manual for Anorexia Nervosa -- A Family Based Approach," published by Guilford Publications, was released in October. According to Lock, it is the only existing manual for treatment of anorexia nervosa in adolescents.

Lock is still looking for volunteers to take part in the Stanford clinical trial. Participants must be 12 to 18 years old and have been diagnosed with anorexia nervosa. Patients will be randomly assigned to a six-month or 12-month treatment program. Some of the 30 patients currently in the study have already completed their treatment but overall results will not be revealed until the trial is complete, which is expected to be in 2002. Those interested in participating should call (650) 723-5473.