Adjusting Cognitive Behavior Therapy For
Adolescents With Bulimia Nervosa:
Results Of Case Series
JAMES LOCK, M.D., Pb,D.
This article reviews the types of adjustments needed to an adult protocol of
cognitive-bebavioral tberapy (CBT) for bulimia nervosa (BN) to make it
more acceptable to an adolescent population. Employing developmental
principles as well as clinical experience as guidelines, tbese modifications
include tbe involvement of parents, recognition of tbe interaction of treat-
ment witb normal adolescent developmental tasks, and allowances for typical
cognitive and emotional immaturity on treatment procedures. Outcomes
from a series of adolescents witb BN wbo were treated witb tbis modified-
CBT approacb sbow results similar to tbose expected in adult populations
treated using CBT.
Psycbological interventions witb youtb work best wben tbey mesb witb
normal developmental processes (Holmbeck et al., 2000; Kendall, 1993),
However, in a recent review of treatment studies of adolescents, Holmbeck
et al. found tbat relatively few (26%) even mentioned adolescent devel-
opment and identified only one study tbat examined age as a moderator of
treatment effects (Holmbeck et al., 2000). Cognitive-Bebavioral Tberapy
(CBT) bas been modified for use witb younger patients witb depression
and anxiety disorders and appears to be effective for tbese conditions witb
patients in tbis age group (Brent et al,, 1997; Kendall, 1994). However,
tbere is no systematic research and no comprebensive descriptions of bow
best to adjust CBT for adolescents witb bulimia nervosa (BN), even tbougb
substantial evidence supports tbe efficacy of tbis form of tberapy for BN in
adults (Agras, Walsb, Fairburn, Wilson, & Kraemer, 2000; C. G. Fairburn
et al., 1991). Tbe purpose of tbis article is to describe bow to adjust CBT
Associate Professor of Child Psychiatry and Pediatrics, Department of Psychiatry and Behavioral
Sciences, Stanford University, Mailing address: Stanford University, Department of Psychiatry and
Behavioral Sciences, 401 Quarry Road, Stanford, CA 94305 e-mail: Jimlock@stanford.edu
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 59, No. 3, 2005
AMERICAN JOURNAL OF PSYCHOTHERAPY
for adolescents witb BN. General principles and illustrations of specific
modifications are provided.
Botb clinical and researcb data suggest tbat adolescents differ from
adults in a number of ways tbat migbt bave an impact on tbe acceptability
and efficacy of psycbotberapy (Feldman & Elliott, 1990). Because of
developmental differences between adults and adolescents, treatments
need to be adjusted to better matcb tbe needs of younger patients (Sbirk,
1999; Kendall, Learner, & Craigbead, 1984), Adolescence is a transitional
developmental period between cbildbood and adultbood tbat is cbarac-
terized by more biological, psycbological, and social role cbanges tban any
otber stage of life except infancy (Feldman & Elliott, 1990). Tbe tbree
main cbanges of adolescence are pbysiologic maturity (puberty), increased
cognitive capacity (abstract tbinking), and increased social maturity
tbrougb role redefinition. Compared witb adults, adolescents bave more
limited abstracting abilities and poorer executive functioning, goal-setting,
and planning abilities (Sternberg, 1977; Sternberg & Nigro, 1980). Tbis
limits tbeir perspectives on tbe bazards of tbeir bebaviors and decreases
motivation to seek and participate in treatment. As a result of tbese
differences adolescents may bave a more limited capacity to utilize tbera-
pies tbat depend on insigbt, emotional processing, self-evaluation and
goal-setting (Izard & Harris, 1995). In addition, autonomy struggles, as
well as tbe bigb value placed on peer relationsbips, can compromise
treatment collaboration, treatment adberence, and ultimately treatment
effectiveness (Savin-Williams & Bernt, 1990; Trickett & Scbmid, 1993).
Adolescents may generalize autonomy struggles from parents to otber
adults, including tberapists, tbus compromising tbe development of a
productive tberapeutic collaboration. In addition, autonomy struggles
(wbicb are often severe enougb to require tberapeutic attention) witb
parents and otber autbority figures make focused psycbological treatments
for BN difficult to maintain. Similarly, adolescents witb difficulties in peer
relationsbips (e.g, dating or otber problems witb social performance and
role) can derail a focused treatment by forcing tberapeutic attention to
tbese problems at tbe expense of time spent focused on tbe eating
Because of tbese types of predictable developmental differences, ado-
lescents are likely to be difficult to engage, motivate, and keep focused in
psycbotberapy. Nonetbeless, tbere are ways tbat psycbotberapeutic strat-
egies can be adapted to be more suitable for adolescents, tbereby increas-
Cognitive Behavior Therapy for Adolescents with Bulimia
ing tbe likelibood tbat tbese treatments will be acceptable and effective.
Key to tbe application of any psycbological treatment to a younger cobort
is developmental expertise in tbe area of adolescence. Tbe following are
key components of sucb a knowledge and experiential base: 1) an under-
standing of tbe biological/pubertal cbanges; psycbological/cognitive
cbanges; cbanges in emotional awareness and processing; 2) an apprecia-
tion of tbe cbanges in and importance of interpersonal relationsbips,
including family relationsbips, peer relationsbips and tbe scbool; 3) an
understanding of tbe developmental tasks of adolescence including tbe
need for increased autonomy, development of individual identity, and an
increased capacity and need for interpersonal intimacy outside tbe family.
On tbe otber band, one of tbe major differences between adolescents and
adults is tbeir continued involvement witb and dependence on tbeir
families in botb an emotional and practical sense. Treatment studies for
adolescent AN suggest tbat family involvement may be beneficial. One
small case series of adolescents witb BN treated witb family tberapy also
supported tbis view (Dodge, Hodes, Eisler, & Dare, 1995; Eisler et al,,
2000; Le Grange, Eisler, Dare, & Russell, 1992; Le Grange, Lock, &
Dymek, 2003; Lock, 2002; Russell, Szmukler, Dare, & Eisler, 1987). An
appreciation of tbese important developmental considerations serves as tbe
foundation upon wbicb tberapists decide bow best to adjust psycbotber-
apy so tbat it is appropriate and acceptable for a particular adolescent's
developmental needs and current trajectory.
We conducted a pilot program of CBT adjusted as described below witb
a series of 34 adolescents witb BN over an 18-montb period. All were female.
Tbese patients ranged in age from 12 to 18 years (mean 15.8 years). Approx-
imately 55% were from divorced families. Approximately 32% were from
minority groups (8% Asian, 10% Hispanic, 4% African-American, and 10%
multi-racial), Comorbid psycbiatric illnesses were common in tbe group
(depressive disorders = 25%; anxiety disorders = 7%). Antidepressants
(selective serotonin reuptake inbibitors) were used to treat tbese co-morbid
conditions in 20% of subjects. Dose levels of tbese antidepressants were not
titrated up to dosages known to be effective for bulimia.
Patients were diagnosed using DSM-IV criteria by tbe autbor of tbis
report using a standard clinical interview of a patients and parents. Witbin
Cognitive Behavior Therapy for Adolescents with Bulimia
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