Family therapy for anorexia twice as effective as individual therapy, researchers find

"This research was desperately needed," said James Lock, MD, PhD, one of the study's two lead authors and a professor of psychiatry and behavioral sciences at Stanford. "Anorexia nervosa is a life-threatening illness, and it's really remarkable how little information we have about how to treat it. There are serious cons to not knowing what to do."

The research will be published Oct. 4 in the Archives of General Psychiatry.

Patients with anorexia nervosa inaccurately believe they are fat, and use food restriction and exercise to maintain dangerously low body weights. The disease, which affects about 0.5 to 0.7 percent of adolescent girls, kills about one in every 10 patients.

Lock's team at Stanford collaborated with researchers at the University of Chicago to test family-based therapy against individual psychotherapy therapy in 121 male and female anorexia patients aged 12 to 18. In family-based therapy, the clinician trains the patient's parents to help ensure that their child eats enough and does not overexercise. Individual psychotherapy, in contrast, focuses on resolving the patient's underlying anxiety and emotional problems, with only minimal involvement from the family. In order to control for differences between clinicians, all therapists in the study had patients in both treatment groups.

The researchers evaluated each patient's condition at the start and end of the one-year treatment period, and then again six and 12 months after treatment ended. Patients were considered in full remission if they reached 95 percent of normal body weight and had a normal score on a standardized psychiatric assessment of attitudes about eating. At the end of the study, 49.3 percent of family-based therapy patients were in full remission, whereas 23.2 percent of individual psychotherapy patients were in full remission. The two treatments were equally effective in helping patients achieve partial remission, characterized by reaching a body weight of 85 percent of normal.

"Although both treatments were helpful to a proportion of patients, this study strongly suggests that as first-line treatment, in general, family-based interventions are superior," said Lock, who is also psychiatric director of the Comprehensive Eating Disorders Program at Packard Children's.

"For the first time, we can confidently present parents with a treatment we consider the gold standard for this patient population," added Daniel Le Grange, PhD, the other lead author of the study and a professor of psychiatry and behavioral neuroscience at the University of Chicago.

Lock noted, however, that individual psychotherapy works better in some cases, and that he and his colleagues at Packard Children's routinely offer both types of therapy. The scientists are now further analyzing the data to see if they can figure out how to identify which types of patients should be directed toward each therapy.

Although the study did not determine exactly why family-based therapy was more effective, Lock speculated that the treatment might have worked better because "it's a more direct approach."

"Restrictive eating and overexercise contribute to the maintenance of anorexic thinking," he said, noting prior research has shown that even healthy individuals develop anxious, obsessive, ritualistic thinking patterns about food when they are starving. "If you disrupt the maintaining behaviors of anorexia and get the patients eating, you disrupt that sequence of thinking. The traction of the thinking itself becomes less."

Prior to the study, Lock said, the investigators had speculated that individual psychotherapy might have better long-term results because it attempts to resolve the psychological problems that may underpin the disorder. "The interesting thing to me is that relapse was a lot greater in the individual psychotherapy group," he said. "It suggests that the behavioral components of anorexia nervosa are very powerful at maintaining the disease."

Lock also noted that family-based therapy obtained better long-term results than previous trials in which patients have been hospitalized for anorexia nervosa. Although the earlier trials showed that hospitalized patients gained weight, they often lost much of the weight soon after they returned home.

"In contrast, patients receiving family-based therapy had to learn to eat enough in the context of their real life," he said. "They didn't face a step off the cliff into the real world."

Lock hopes the study's results will encourage those who treat adolescent anorexia nervosa to learn to use family-based therapy.

"I would like clinicians to see that parents can be helpful," he said. "The model of putting kids in the hospital, which excludes parents, or of professionals expecting young adolescents to manage their own eating without their parents' help when they're immersed in anorexic thinking, really should be reconsidered."

Future research will be needed to test whether teens treated with family-based therapy continue to do well after they move away from home, Lock noted.

Lock's collaborators at Stanford were Stewart Agras, MD, professor emeritus of psychiatry and behavioral sciences; senior scientific programmer Susan Bryson; and Booil Jo, PhD, assistant professor of psychiatry and behavioral sciences.

The researchers have written two books on family-based therapy. With Le Grange, Lock wrote a book for parents called Help Your Teenager Beat an Eating Disorder (Guilford Publications, 2005). Lock, Le Grange and Agras are co-authors of a book for clinicians called Treatment Manual for Anorexia Nervosa: A Family-Based Approach (Guilford Publications, 2002).

The research was funded by grants from the National Institutes of Health.