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ABSTRACT: This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.
Cognitive and Behavioral Practice 02/2012; 19(1):17-30. · 1.33 Impact Factor
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ABSTRACT: Anorexia nervosa (AN) is characterized by its similarity to anxiety disorders, especially obsessive-compulsive disorder (OCD). Family-based treatment (FBT) has shown promising initial results for treatment of AN in adolescents, yet the precise mechanisms of action are unknown. We present a theoretical argument and model, suggesting that FBT may work via exposure (and habituation) to food and its consumption. First, we review the evidence for pathological anxiety in AN, and suggest a framework for identifying specific anxious triggers, emotions (fear and worry) and avoidance strategies. Second, we briefly review evidence indicating that cognitive-behavioural therapy (CBT) and specifically exposure in its various forms is most effective for treating anxiety disorders in youth. Third, we consider distinct approaches to exposure therapy based on the pattern of triggers, anxious emotions and avoidance. We conclude that the interventions utilized in FBT share clear similarities to exposure with response prevention, a type of exposure therapy commonly used with OCD, and may work via facilitating habituation to food and eating in one's natural environment. We also highlight how parents facilitate this process in between sessions by effectively coaching their children and facilitating naturalistic exposure to food and related triggers. Options for future research are considered.
European Eating Disorders Review 01/2012; 20(1):e1-16. · 1.38 Impact Factor
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ABSTRACT: The primary aim was to examine the utility of DSM-IV criteria in predicting treatment outcome in a sample of adolescents with eating disorders.
We (a) descriptively compared the baseline rates of anorexia nervosa (AN) and bulimia nervosa (BN) across multiple reference points for diagnostic criteria, (b) using ROC curve analyses, assessed the sensitivity and specificity of each diagnostic criterion in predicting clinical outcome, and (c) with logistic regression analyses, examined the incremental predictive value of each criterion.
Results show a high degree of variability in the baseline diagnostic profiles as a function of the information used to inform each DSM-IV criterion. For AN, Criterion A yielded the best predictive validity, with Criteria B-D providing no significant incremental value. For BN, none of the measures had a significant AUC, and results from logistic regression analyses showed that none of the indicators were robust in predicting outcome.
For AN, the existing Criterion A is appropriate for children and adolescents, and is sufficient to predict outcome in the context of active refusal to maintain a normal weight as well as multiple informants and behavioral indicators of the psychological aspects of AN. For BN, predictive validity could not be established.
International Journal of Eating Disorders 12/2011; 44(8):692-702. · 2.95 Impact Factor
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ABSTRACT: Across studies, adolescents score lower on measures of eating disorder pathology than adults, but it is unclear whether such findings reflect discrepancies inherent to site/study or true developmental differences. The aim of this study was to determine whether age predicts subscale and diagnostic scores of the Eating Disorder Examination (EDE) in adolescents and adults with anorexia nervosa (AN) admitted to a single research center within the same period of time.
The sample consisted of 16 adolescent and 20 adult consecutive admissions to parallel, age-specific, research-based AN treatment programs. Participants completed a baseline evaluation at admission that included the EDE, depression measures, and global assessment of functioning scales.
Age significantly predicted EDE scores in univariate regression analyses. However, in multivariate models that included severity indices of general and specific psychopathology as covariates, age was no longer a significant predictor of severity of eating disorder symptoms.
This study adds to the growing body of data showing lower scores on the EDE for adolescents with AN relative to their adult counterparts, while eliminating potential site confounds. Results indicate that the higher adult scores may be carried in part by a more overall severe and chronic general clinical profile.
International Journal of Eating Disorders 09/2011; 44(6):567-72. · 2.95 Impact Factor
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ABSTRACT: Appearance-and-performance enhancing drug (APED) use is a form of drug use that includes use of a wide range of substances such as anabolic-androgenic steroids (AASs) and associated behaviors including intense exercise and dietary control. To date, there are no reliable or valid measures of the core features of APED use. The present study describes the development and psychometric evaluation of the Appearance and Performance Enhancing Drug Use Schedule (APEDUS) which is a semi-structured interview designed to assess the spectrum of drug use and related features of APED use. Eighty-five current APED using men and women (having used an illicit APED in the past year and planning to use an illicit APED in the future) completed the APEDUS and measures of convergent and divergent validity. Inter-rater agreement, scale reliability, one-week test-retest reliability, convergent and divergent validity, and construct validity were evaluated for each of the APEDUS scales. The APEDUS is a modular interview with 10 sections designed to assess the core drug and non-drug phenomena associated with APED use. All scales and individual items demonstrated high inter-rater agreement and reliability. Individual scales significantly correlated with convergent measures (DSM-IV diagnoses, aggression, impulsivity, eating disorder pathology) and were uncorrelated with a measure of social desirability. APEDUS subscale scores were also accurate measures of AAS dependence. The APEDUS is a reliable and valid measure of APED phenomena and an accurate measure of the core pathology associated with APED use. Issues with assessing APED use are considered and future research is considered.
Addictive behaviors 05/2011; 36(10):949-58. · 2.25 Impact Factor
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ABSTRACT: Obesity has become a leading global health concern affecting both physical and mental quality of life. This article reviews the psychological interventions currently utilized in confronting the obesity epidemic. It examines obesity in both the pediatric and adult populations, specifically considering empirical evidence of weight loss interventions through randomized control trials. Behavioral weight loss intervention and family-based interventions emerged as 2 of the more frequently utilized and data-supported approaches. Empirically supported psychological treatments for subgroups of the obese population, such as individuals with binge eating disorder, are considered here as well. Limitations of the current interventions are discussed, including issues with generalizability across demographic variables such as age and severity of overweight status. Despite these limitations, overall, psychological interventions play an important role in achieving and maintaining weight loss.
Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine 09/2010; 77(5):472-87. · 2.00 Impact Factor
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ABSTRACT: This article describes the successful application of family-based treatment (FBT) for a 17-year-old identical twin presenting with a 4-month history of clinically significant symptoms of anorexia nervosa (AN). FBT is a manualized treatment that has been studied in randomized controlled trials for adolescents with AN. This case study illustrates the administration of this evidence-based intervention in a clinical setting, highlighting how the best available research was used to make clinical decisions at each stage of treatment delivery.
Journal of Clinical Child & Adolescent Psychology 02/2009; 38(1):176-83. · 1.92 Impact Factor
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ABSTRACT: Family-based treatment (FBT) is emerging as a treatment of choice for adolescent anorexia nervosa (AN) and bulimia nervosa (BN). This paper reviews the history of FBT, core clinical and theoretical elements, and key findings from the FBT for AN and BN treatment outcome literature. In addition, we address clinical questions and controversies regarding FBT for eating disorders, including whether FBT is clinically appropriate for all adolescents (e.g., older adolescents, patients with comorbid conditions), and whether it indicated for all types of families (e.g., critical, enmeshed, and non-intact families). Finally, we outline recently manualized, innovative applications of FBT for new populations currently under early investigation, such as FBT as a preventive/early intervention for AN, FBT for young adults with eating disorders, and FBT for pediatric overweight.
International journal of child and adolescent health. 01/2009; 2(2):243-254.
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ABSTRACT: Cluster-analytic studies of clinical populations of eating disordered women who binge eat have yielded two subtypes--pure dietary restraint and mixed dietary restraint-negative affect--consistent with etiologic and maintenance models of binge eating. This study aimed to replicate this subtyping scheme in university women. The scores of 623 undergrad females on the TFEQ-restraint and BDI scales were submitted to a cluster analysis and revealed three subtypes, "healthy" (47.4%), restrained (36.3%) and mixed (16.3%). In addition, comparisons between subtypes on bulimic behaviors showed that the mixed and restrained subtypes were characterized by greater likelihood than the healthy group to engage in fasting, purging and exercise to control weight, as well as in disinhibition of eating. The mixed subtype revealed higher scores than the restrained subtype on eating disinhibition and purging, and the restrained group was more likely than the mixed subtype to exercise to control weight. These findings provide further support for the reliability and validity of this subtyping scheme, in which the confluence of even mild levels of negative affect and dietary restraint differentiated a more "disturbed" group of undergraduate females. Findings also put into question the dietary restraint theory of eating pathology and suggest the need to control negative affect when studying eating behavior.
Appetite 05/2008; 51(3):727-30. · 2.59 Impact Factor
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ABSTRACT: There is a paucity of evidence-based interventions for anorexia nervosa (AN). An innovative family-based treatment (FBT), developed at the Maudsley Hospital and recently put in manual form, has shown great promise for adolescents with AN. Unlike traditional treatment approaches, which promote sustained autonomy around food, FBT temporarily places the parents in charge of weight restoration. This aim of this open trial was to investigate the feasibility and effectiveness of delivering FBT at a site beyond the treatment's origin and manualization.
Twenty adolescents (ages 12-17) with AN or subthreshold AN were treated with up to 1 year of FBT using the published treatment manual. Outcome indices included the percentage of ideal body weight, menstrual status, the Eating Disorder Examination (EDE) subscales scores, and the Children's Depression Rating Scale-Revised score.
Of the 20 patients recruited, 15 (75%) completed a full course of treatment. Intent-to-treat analyses showed significant improvement over time in the percentage of ideal body weight (t = -4.46, p =.000), menstrual status (p =.002), EDE Restraint (z = -3.02, p =.003), EDE Eating Concern (z = -2.10, p =.04), but not in EDE Shape Concern or Weight Concern subscales or Children's Depression Rating Scale-Revised score.
This open trial provides evidence that FBT can be successfully disseminated, replicating the high retention rates and significant improvement in the psychopathology of adolescent AN seen at the original sites.
Journal of the American Academy of Child & Adolescent Psychiatry 08/2007; 46(7):792-800. · 6.44 Impact Factor
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ABSTRACT: The onset of eating disorder psychopathology is most common in the adolescent age group. Acute psychopathology or subsyndromal eating disorders are perhaps less intractable in these young patients. Subsyndromal eating disorders in children and adolescents are not only clinically significant in their present state, but may represent legitimate candidates for preventive efforts in light of: (i) a risk of progression from subthreshold anorexia nervosa (SAN) to AN or subthreshold bulimia nervosa (SBN) to BN; (ii) the detrimental effects on outcome of delaying treatment; and (iii) the refractory, severe nature of eating disorders once the diagnostic threshold is crossed. Moreover, children and adolescents with SAN and SBN may in fact be exhibiting early 'caseness' of these disorders. Given that AN is notoriously difficult to treat, and there are limited efficacy data for adolescent BN, attempts to disrupt these disorders in what is arguably their early phases is an important goal in preventing more chronic and treatment-resistant forms of these disorders. Future research should address whether the best interventions for SAN and SBN should be derived from the prevention or intervention fields.
Early Intervention in Psychiatry 02/2007; 1(1):27-39. · 0.92 Impact Factor
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ABSTRACT: Although depression is known to co-occur with anorexia nervosa (AN), there are few clear studies of mood in the context of weight gain treatment without the use of medication. Method: Twenty-one patients admitted consecutively to an inpatient clinical research unit normalized weight to at least 90% of ideal body weight (IBW). Depression was assessed at admission and weight normalization (pre-discharge) with the Beck Depression Inventory (BDI).
Multivariate F tests showed BDI scores to be significantly improved across these two time points (BMI: F(2,20) = 166.58, p = 0.000; BDI: F(2,19) = 22.64, p = 0.000). Moreover, improvement in mood was also evident at partial weight restoration (80% IBW).
Patients with AN undergoing nutritional rehabilitation and psychotherapy on an inpatient unit present with significant depressive symptoms as measured by the BDI, and, with weight restoration, demonstrate statistically significant improvement in mood symptoms without the use of adjunctive medication. Data at partial weight restoration suggest that these results cannot be explained by improved mood related to anticipation of discharge.
International Journal of Eating Disorders 12/2006; 39(7):587-9. · 2.95 Impact Factor
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ABSTRACT: The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.
Journal of Consulting and Clinical Psychology 01/2006; 73(6):1097-107. · 4.85 Impact Factor
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ABSTRACT: The current study compared the agreement between the Eating Disorders Examination (EDE) and the Eating Disorders Examination-Questionnaire (EDE-Q) in the diagnosis and assessment of eating disorder pathology in a sample of women with anorexia nervosa.
First, a physician administered a clinical interview to each patient. Then, before hospital admission, all subjects were given the EDE-Q and the EDE interview.
Results indicate that agreement between the EDE and the EDE-Q on the individual items informing the overall diagnosis of anorexia nervosa ranges from low to moderate. Agreement for the overall diagnosis of anorexia nervosa and for the binge/purge subtype was more impressive. Although correlations between subscale scores as well as eating disorder behaviors were strong, higher levels of disturbance were consistently reported on the EDE-Q than on the EDE interview.
The pattern of findings suggests that the EDE-Q may be used in place of the interviewer-based measure when assessing overall diagnosis and subtype, as well as specific, well-defined features (vomiting/laxative use). However, there was a low level of agreement with respect to less-defined features, like binge eating, for which significantly higher frequencies were generated by the self-report questionnaire.
International Journal of Eating Disorders 04/2005; 37(2):92-9. · 2.95 Impact Factor
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ABSTRACT: The purpose of this study was to describe a case series of children and adolescents (mean age = 14.5 years, SD = 2.3; range 9-18) with anorexia nervosa who received manualized family-based treatment for their eating disorder.
Forty-five patients with anorexia nervosa were compared pre- and post-treatment on weight and menstrual status.
After an average of 17 treatment sessions, patients were significantly improved on primary measures of outcome (body mass index and percentage of ideal body weight). Defining outcome categorically (Morgan-Russell outcome criteria), 56% (n = 25) had a good outcome (>85% ideal body weight and menses), 33% (n = 15) an intermediate outcome (>85% IBW and menses intermittent), and 11% (n = 5) responded poorly (<85% ideal body weight and no menses).
Findings provide preliminary support for the feasibility of an outpatient approach with active parental involvement in the treatment of children and adolescents with anorexia nervosa. However, randomized, controlled studies are needed to establish the relative efficacy of this family-based treatment approach.
Journal of the American Academy of Child & Adolescent Psychiatry 02/2005; 44(1):41-6. · 6.44 Impact Factor
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ABSTRACT: There are few reports that describe the manifestation of bulimia nervosa (BN) among adolescents. Moreover, none make reference to the comparative clinical manifestation of adolescent BN and adolescent anorexia nervosa. Nor are any reports available of how distinct partial-syndrome BN cases are from those that meet full diagnostic criteria for BN.
To describe 3 groups of adolescents, those with a full-syndrome eating disorder (BN and anorexia nervosa) or partial-syndrome BN, and to compare these groups along demographic, general psychopathology, and eating disorder variables.
The study population included 120 adolescents with eating disorders who were initially seen at The University of Chicago Eating Disorders Program, Chicago, Ill, for treatment. All participants completed an assessment prior to treatment.
Weight and height were obtained from all participants. Participants also completed a baseline demographic questionnaire (eg, menstrual status, ethnicity, family status), Beck Depression Inventory, Rosenberg Self-Esteem Scale, and the Eating Disorder Examination.
Partial-syndrome BN cases are clinically quite similar to their full-syndrome counterparts. Only objective binge eating episodes and purge frequency distinguished BN and partial-syndrome BN cases. Anorexia nervosa cases, on the other hand, were quite distinct from BN and partial-syndrome BN cases on almost all variables.
Early recognition and swift treatment of eating disorders in adolescents, regardless of whether a diagnostic threshold is met, are imperative because they will lead to early intervention thereby potentially improving eating disorder recovery rates.
Archives of Pediatrics and Adolescent Medicine 06/2004; 158(5):478-82. · 4.14 Impact Factor
