Cover Story

After years of investigation, researchers are finally homing in on ways to help young women overcome two dangerous psychiatric disorders: anorexia nervosa, the rare disease of self-starvation, and bulimia nervosa, the condition marked by binge-eating, purging to avoid weight gain, low self-esteem and depression.

While mental health professionals have tried to understand and treat anorexia nervosa since the 1970s, their efforts have met with little success. The mainstay of treatment has been hospitalization for weight regain, sometimes followed by psychotherapy, and it's often ineffective at helping patients recover physically and psychologically over the long term, those studying the disorder say.

But new research reveals there may be a more effective treatment for anorexia: a form of family therapy that enlists parents' aid in getting their teen-age daughters to eat again and helps to strengthen the young women's autonomy. The treatment, which originated in England, challenges current anorexia treatment because it's relatively short-term, relies mostly on outpatient treatment and boasts lasting success, those involved say.

"Overall, patients appear to do remarkably well on this treatment," says James Lock, MD, PhD, a child psychiatrist at Stanford University who's testing the treatment in the United States on a five-year National Institute on Mental Health (NIMH) grant. "I'm amazed at its ability to help patients overcome the acute symptoms of anorexia nervosa."

Meanwhile, the largest controlled study on bulimia nervosa so far supports what earlier research has found: Tailored cognitive behavioral therapy and, to some extent, interpersonal psychotherapy can help young women stop bingeing and purging, accept their appearance, and develop healthier ways of coping with stressful situations. In addition, the antidepressant Prozac appears to help bulimic patients who don't benefit from cognitive behavioral therapy or interpersonal psychotherapy, other studies find.

"Bulimia nervosa is a serious clinical disorder for which we have demonstrably effective treatments," says eating disorders expert G. Terence Wilson, PhD, who chairs the psychology department at Rutgers University. "It's important that we get the message out to patients and families that this is a disorder that can be treated successfully."

A NOVEL APPROACH TO ANOREXIA

The findings on anorexia are particularly bright because the disease--first identified in 1689 but not treated as a mental health or medical disorder until recently--has vexed clinicians for decades.

Anorexia affects about 1 percent of young women ages 12 to 25, and if left untreated, may lead to osteoporosis, cardiac problems, infertility, depression, relationship difficulties, suicide and death from medical complications. Men and boys fall prey to anorexia nervosa and other eating disorders, too: Recent estimates find that as many as one in eight people with an eating disorder is male.

Treatment for the disorder has stagnated, partly because patients with the condition are difficult to treat and partly because insurance won't pay for long-term treatment (see Pressing for better insurance coverage for eating disorders).

"This is an illness that has defied an awful lot of imaginative people," says Lock. "We know a lot about how bad it is psychologically and medically, but we really haven't known what to do about it."

The anorexia treatment now showing promise and being studied by Lock was developed by two British therapists, child psychiatrist Christopher Dare, MD, and child psychologist and family therapist Ivan Eisler, PhD, of the Maudsley Hospital in London, well-known for its eating disorders unit. The two designed the treatment based on the work of innovative family therapists such as Philadelphia psychiatrist Salvador Minuchin, MD, and on their own ideas.

The treatment elicits the parents' aid in getting the patient to eat, gradually returns control of eating to the client then works with the family to help the client navigate the developmental challenges of adolescence, explains psychologist Daniel Le Grange, PhD. He directs the Eating Disorders Program at the University of Chicago and is conducting studies on the treatment. Clinicians who practice the treatment encourage parents to work together as a team to address their child's health problem. They emphasize the severity of the illness, coaching parents to assume the role of a nurse in an inpatient unit whose aim is to restore the girl's weight to normal.

In an office session early on in treatment, clinicians invite the family to share a picnic meal so they can observe the quality of family meal patterns and help parents find a way to get their child to eat more, Le Grange notes. In future weekly sessions, clinicians help parents discuss the details of their efforts, including what they fed their daughter and what is working especially well in their approach.

Unlike other treatments, the method targets the obsessive anorexic mindset as the villain rather than the patient or family, notes Le Grange. "This approach sees the eating disorder as controlling the adolescent, thereby interrupting normal development," he says. "The family is not to blame for the eating disorder, but is seen as a valuable ally in treatment."

A study on the treatment by Le Grange, which compared two forms of the family therapy, was replicated by Eisler, Dare, Le Grange and colleagues in a larger study of 40 patients. The study found that two-thirds of all patients regained weight within a normal range without needing to be admitted to the hospital, that most showed striking improvements in psychological functioning, and that parents became less critical of each other and of their daughters by the end of treatment.

Lock is one of the first to recognize the treatment's potential value for those affected in the United States. When he received the NIMH grant to test the treatment, he and Le Grange first wrote a comprehensive 300-page treatment manual (Guilford, 2001) that's detailed in an article in the fall 2001 issue of the Journal of Psychotherapy Practice and Research (Vol. 10, No. 4). In the article, the researchers note that a group of therapists successfully applied the manual with patients, an important step because clinicians often resist manualized treatment, they say.

Now Lock and Stanford colleague Stewart Agras, MD, are comparing how people with anorexia fare when they receive six or 12 months of the treatment. They plan to recruit 86 patients in all, the largest study of anorexic teen-agers to date. Numbers in these studies are small because there are so few anorexics in a given location and treatment is so intensive, Lock notes. In fact only 10 randomized controlled treatment trials have been conducted on this population, compared with dozens of studies on people with bulimia nervosa.

Preliminary results on the first 19 patients in Lock's ongoing trial, also reported in the fall 2001 article in Psychotherapy Practice and Research, are promising. At six months, the patients' weight had climbed up to 92 percent of their ideal body weight on average, and their concerns about shape and restrictive dieting had lessened considerably. By 12 months, the researchers were finding even greater gains in patients' self-esteem and self-acceptance. The next step, says Lock, is to compare other forms of psychotherapy with the treatment. He also wants to refine the treatment by looking more closely at what might be its optimal length and intensity, for example.

There's yet another positive development in the treatment of anorexic patients who have regained their weight. While drug treatments such as antidepressants have had little effect combating the symptoms of anorexia, researchers are now finding the medication can help if the patient's weight has returned to normal. In a study by University of Pittsburgh psychiatrist Walter Kaye, MD, and colleagues, two-thirds of anorexics who took Prozac after they'd recovered their weight didn't relapse, compared with 16 percent who took a placebo. With an NIMH grant, psychiatrist B. Timothy Walsh, MD, of Columbia University and Allan Kaplan, MD, of the University of Toronto are now replicating that study.

Meanwhile, one group of patients continues to worry clinicians and researchers: adults with anorexia, estimated to make up about 35 percent of anorexic patients. Those who have had the disease for a long time are often foiled by an unfortunate mix of circumstances, including a history of inadequate treatment, a lack of treatment trials that would otherwise have guided clinicians and a dearth of specialty inpatient units, says Le Grange.

"Most clinicians are trying to figure out how to treat these patients on their own," Le Grange says. "I say to my students, if you want to go into research, here's an area that's ripe for a lot of hard work."

BULIMIA: A POSITIVE PROGNOSIS

The treatment picture for bulimia nervosa has been promising for a while, and the largest controlled study on the disorder underscores that success.

The study, reported in the May 2000 issue of the Archives of General Psychiatry (Vol. 57, No. 5), randomly assigned 220 patients with bulimia nervosa to one of two types of psychotherapy. One is a form of cognitive behavioral therapy designed to address bulimic symptoms; the other is interpersonal psychotherapy, which helps patients tackle relationship issues. Cognitive behavior therapy works with the unrealistically negative thoughts people with bulimia nervosa have about their appearance and guides them in changing eating behaviors by, for instance, helping them normalize their diet. Interpersonal psychotherapy targets problems in current relationships, helping clients address conflicts head on and improve the quality of those relationships, while also helping them expand their social network.

The same clinicians conducted both types of therapy, held during 19 sessions over a 20-week period. The research was conducted both at Stanford and Columbia universities and replicated a smaller study by Oxford University psychiatrist Christopher Fairburn, MD, that found both cognitive behavioral therapy and interpersonal psychotherapy effective. The study's authors are Agras of Stanford, Walsh of Columbia University, Wilson of Rutgers University, Fairburn of Oxford University and Helena Kraemer, PhD, of Stanford University.

The results confirm Fairburn's earlier findings. Immediately after treatment, a significant number of cognitive behavioral therapy patients had stopped bingeing and purging and showed positive changes in psychosocial eating-disorder symptoms such as preoccupation with shape and weight, depression and self-esteem. Also, similar to Fairburn's original findings, the interpersonal psychotherapy patients did worse than cognitive behavioral therapy patients at first, but at a one-year follow-up, showed similar improvements.

"The findings reinforce what we knew: that cognitive behavioral therapy is an effective therapy, but that interpersonal therapy might be, too," Wilson says.

The study also suggests a way to tailor treatment for women with bulimia nervosa who don't respond well to treatment, Wilson notes. Patients who benefited from cognitive behavioral therapy tended to do so in the first six or eight sessions. "So, if you don't see an early response to cognitive behavioral therapy, you might think about changing treatment strategies."

He and others have recently studied what might work for these "nonresponders." In a study in the August 2000 American Journal of Psychiatry (Vol. 157, No. 8), Walsh and colleagues including Wilson randomized patients who didn't improve with either cognitive behavioral therapy or interpersonal psychotherapy, to either Prozac or a placebo. Those who took Prozac showed much greater symptom reduction than those given a placebo.

"The findings strongly suggest that antidepressant medications can be very useful if someone doesn't succeed with one or the other of these treatments," says Wilson.

Le Grange has just received a five-year NIMH grant to study treatment options for adolescents with bulimia nervosa. Oddly, this group has never been studied, he says, perhaps because clinicians tend to assume that the typical age of onset for the disease is between 18 and 24. However, "when you take a history of these women, it turns out they were 15 or 16 when they started bingeing and purging," he notes.

The study, which began a year ago, will compare the effects on 90 bulimic patients of a tailored version of the family treatment used with adolescent anorexics and a form of individual psychotherapy.

Le Grange is hopeful the treatment will apply to this population, too. "Because family therapy for adolescent anorexics seems to be working so well, maybe it will work equally well for adolescent bulimics," he says.

Tori DeAngelis is a writer in Syracuse, N.Y.