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Treating Adolescent Eating Disorders

Anorexia Nervosa and Bulimia Nervosa

Both Anorexia Nervosa (AN) and Bulimia Nervosa (BN) often onset during the adolescent years.[1] For example, Anorexia Nervosa has an incidence rate of 0.48 to 0.7 percent among adolescents, with almost every case having an onset before the age of 25.[2] Similarly, Bulimia Nervosa has an incidence rate of anorexiaone to two percent among adolescents,1 and binge eating and purging often begins during the middle adolescent years.[3] However, most cases of Anorexia Nervosa and Bulimia Nervosa among adolescents are instead diagnosed as Eating Disorder Not Otherwise Specified (EDNOS) as the criteria of the DSM is not developmentally sensitive and focuses on adult cases of the disorders instead.[4] James Lock, M.D., Ph.D. reviews the eating disorders among adolescents, their treatments, and future directions in his article “Treatment of Adolescent Eating Disorders: Progress and Challenges.”1

Anorexia Nervosa is characterized by a restrictive eating pattern that results in significant weight loss and distorted perceptions of body weight and shape.[5] The disorder is often associated with higher levels of anxiety and depression, low self-esteem, and interpersonal and family difficulties.1 One of the more severe psychiatric disorders, the mortality rate is between four and five percent, which is higher than any other psychiatric disorder, except for possibly substance abuse.[6]

Bulimia Nervosa is characterized by misconstrued ideas regarding body weight and shape, as well as unhealthy dieting and eating patterns that include binge eating and purging.5 Physical complications associated with Bulimia Nervosa are esophageal tears, gastric disturbances, dehydration, cardiac arrhythmias, and death.1 Usually, Bulimia Nervosa co-occurs with other psychiatric disorders, including anxiety, depression, personality disorders, and substance abuse.1 Although Bulimia Nervosa is viewed as less concerning than AN, Lock states that recent data suggests mortality rates may be very similar.6

Treatments for Anorexia and Bulimia

There are a handful of treatments currently available for Anorexia Nervosa.1 Family therapy, specifically Family Based Treatment (FBT) is common.1 It is based on the idea that families are able to make accommodations when feeding their child, and the treatment helps to identify and modify the accommodations that are in need of changing.[7] Another treatment, which Lock states is the most commonly used, is an individually-based approach.1bulimia With Anorexia Nervosa, there are developmental challenges involved, and individually-based treatment encourages the patient to gain weight and eat normally in order to increase their self-control.1 Cognitive Behavioral Therapy (CBT) is also useful for adolescents with Anorexia Nervosa.[8] As adolescents suffering from the disorder may have distorted thoughts about body weight and shape, over-valuing thinness, CBT addresses these thoughts through normalizing eating patterns, monitoring food intake, and practicing problem solving.[9] Usually, nutritional advice is recommended as an added treatment of Anorexia Nervosa.1

According to Lock, medicines used in the treatment of Anorexia Nervosa are limited and the results have not been too promising.1 Medicines in many different classes have been studied; however, none have consistently shown efficacy.1 Lock states that there was hope for SSRI antidepressants to help prevent weight loss after some weight has been gained back,1 but a study conducted by Walsh and colleagues has recently stated that is it unlikely.[10] Atypical antipsychotics were also considered as treatment due to their side-effects of weight gain and anxiolytic properties, but studies have been inconsistent in their results.1

Regarding Bulimia Nervosa, Lock states that CBT is the first line treatment.1 For adolescents, the treatment helps to normalize eating patterns and supports cognitive change through problem solving and cognitive restructuring.1 Improvements at six-month follow-ups showed abstinence rates of 30 percent.1 Also, sometimes medicines are recommended for BN treatment, with antidepressants being first choice.1 Lock also states that adolescents diagnosed with EDNOS should be treated with the same approaches they would be as if they had the full disorder.1

Within the last decade, progress has been made regarding effective treatments for adolescents with Anorexia Nervosa and Bulimia Nervosa; however, much still needs to be done.1 Still, new treatment directions have been centered around new findings within the neurosciences. In the area of neuropsychology, studies have found that cognitive processes in individuals with eating disorders may be affected.[11] Studies of adults have identified two common cognitive deficits: cognitive inflexibility and weak central coherence.[12] Recent studies have identified the same deficits in adolescents.[13] It is also known that weak central coherence, a detailed focus that leads to the neglect of the bigger picture, is also seen in other psychiatric disorder, such as obsessive-compulsive disorder and autism spectrum disorders.[14] Treatment of these cognitive deficits include cognitive remediation therapy (CRT), which is found to be effective in improving cognitive processes for individuals with schizophrenia and OCD may also be effective for individuals with Anorexia Nervosa and Bulimia Nervosa.[15] CRT consists of several cognitive exercises that aid in the enhancement of cognitive flexibility, and when used with patients with eating disorders, do not focus on eating or weight but instead explore how to think more flexibly and see the bigger picture.1 In the treatment of eating disorders, CRT would be an added treatment, not a sole treatment.1 It would be especially helpful in treating adolescents as their brains are more flexible and the treatment may be able to intervene early and improve cognitive processes that may help prevent relapse and decrease the potential development of other psychiatric disorders.1

The Future of Treatment for Anorexia and Bulimia

According to Lock, there are several other studies that are focusing on effective treatments of eating disorders in adolescents.1 There is a large study being conducted to compare FBT to Systemic Family Therapy (SFT), helping to clarify the role family plays in treating adolescents with Anorexia Nervosa.1 Other types of FBT, specifically the multi-family group (MFG) model, is being studied in the United Kingdom for efficacy in the treatment of adolescent Anorexia Nervosa.1 Also, a clinical trial that will evaluate the effectiveness of CRT in adolescents and adults is underway at Stanford University.1 Regarding Bulimia Nervosa, a study comparing CBT, FBT, and Supporting Individual Therapy is being conducted at the University of Chicago and Stanford University.1 Other studies are needed to address increased effective treatments for Bulimia Nervosa.1



[1] Lock, J. (2010, Sept.) Treatment of Adolescent Eating Disorders: Progress and Challenges. Minerva Psychiatr. 51(3): 207-216.

[2] Hoek H, Hoeken Dv. Review of prevalence and incidence of eating disorders. Int J Eat Disord. 2003;34:383–396.

[3] Stice E, Agras WS. Predicting onset and cessation of bulimic behaviors during adolescence. Behavior Therapy. 1998;29:257–276.

[4] Workgroup for the Classification of Child and Adolescent Eating Disorders. Classification of child and adolescent eating disturbances. Int J Eat Disord. 2007:40.

[5] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition edition. Washington, D.C: American Psychiatric Association; 1994.

[6] Crow S, Peterson C, Swanson S, Raymond N, Specker S, Eckert ED, Mitchell J. Increased mortality in bulimia nervosa dn other eating disorders. Am J Psychiatry. 2009;166:1342–1346.

[7] Eisler I. The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. Journal of Family Therapy. 2005;27:104–131.

[8] Cooper Z, Stewart A. CBT-E and the younger patient. In: Faiburn C, editor. Cognitive behavioral therapy and eating disorders. New York: Guilford; 2008. pp. 221–230.

[9] Pike K, Walsh BT, Vitousek K, Wilson GT, Bauer J. Cognitive-Behavioral Therapy in the Posthospitalization Treatment of Anorexia Nervosa. American Journal of Psychiatry. 2004;160:2046–2049.

[10] Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter J, Pike K, Devlin MJ, Woodside B, Roberto L, Rockert W. Fluoxetine after weight restoration in anorexia nervosa: a randomized clinical trial. JAMA. 2006;295:2605–2612.

[11] Treasure J. Getting beneath the phenotype of anorexia nervosa: the search for viable endophenotypes and genotypes. La revuew de psychiatrie. 2007;52:212–219.

[12] Roberts M, Tchanturia K, Stahl D, Southgate L, Treasure J. A systematic review and meta-analysis of set-shifting ability in eating disorders. Psychol Med. 2005;37:1075–1084.

[13] Fitzpatrick K, Lock J, Darcy A, Colburn D, Gudorf C. American Academy of Child and Adolescent Psychiatry. Honolulu, HI: pp Poster Session; 2009. Neuorcognitive processes in adolescent anorexia nervosa.

[14] Lopez C, Tchanturia K, Stahl D, Booth R, Holliday J, Treasure J. An examination of the concept of central coherence in women with anorexia nervosa. Int J Eat Disord. 2008a;41:143–152.

[15] Buhlman J. Cognitive retraining for organizational impairment in obsessive compulsive disorder. Psychiatry Research. 2006;144:109–116. anorexia.

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