Eating Disorders
New Anorexia Treatments Stress Eating Instead of Psychotherapy

Aug. 22, 2002 — A wave of promising research is taking aim at anorexia nervosa, one of the most fatal and least understood mental illnesses.

Traditionally an affliction of teenage girls, anorexia has shown signs of migrating to preteens as well as twentysomethings, doctors say. But therapies have hardly changed in decades. Treatments have long stressed psychotherapy and blame-placing to gauge why a patient refuses to eat: Is it a fear of growing up? Has an overbearing parent been excessively critical? Family members aren't encouraged to participate -- after all, they may be partly to blame.

Now, several new studies are turning the previous thinking on its head. In many of them, searching for the cause isn't part of the plan. Instead, the emphasis is on eating -- the cure is the food, instead of the psychotherapy. "Food is seen as medicine, which indeed it is in severely malnourished people," says James Lock, a Stanford University child psychiatrist currently studying new treatments for anorexia.

While that may sound like common sense, it represents a sharp turnabout in the way doctors think about treating anorexia. Affecting as much as 16% of U.S. females ages 14 to 24, anorexia has one of the highest mortality rates among mental illnesses, due to the high suicide rate, as well as medical complications from starvation. The new approaches could work for other eating disorders, such as bulimia, in which patients follow overeating with vomiting, diuretics or laxatives. Eating disorders affect about eight million Americans.

Dr. Lock's program at Stanford represents one of the most striking departures from traditional therapies: Known as the Maudsley method, it puts the family directly in charge of making a patient eat. "It encourages the parents to treat the illness like any other illness," he says.

Other studies' approaches vary widely. Swedish researchers have developed a computer program that monitors patients' food intake and helps them learn to eat normally again. At the University of Michigan, therapists play down the patient's past relationships and work on helping the patient set personal goals such as learning to play an instrument. At the University of Pittsburgh, there is even genetic research under way that may shed light on who may be at risk of developing the disorder.

Several of the programs are still accepting new participants, including ones at Michigan, Columbia University, the University of Chicago and the University of Pittsburgh.

The therapies targeting adolescents run counter to current parenting styles in the U.S., where parents tend to treat children as autonomous beings whose independence should be encouraged. Many baby boomers pride themselves on being seen by their children as peers or pals.

But old-fashioned parenting is at the heart of the Maudsley program, named for the London hospital where it was developed: The parent is in charge. Parents of anorexics often avoid confronting the child over food, or they make compromises, which makes the problem worse. (For example, they agree it's OK if a child takes only a couple of bites.)

The Maudsley method, which is also being used at the University of Chicago and Columbia, tells parents not to back down. Resistance is normal; to break down that wall, the family offers the child incentives, such as linking finishing a meal with an activity the child enjoys. If that fails, they encourage sitting with the child until he or she eats, even if it takes hours; in extremely rare cases, a parent may choose to spoon-feed the child. In one study conducted during the 1990s at the Maudsley Hospital, 90% of the adolescent patients who underwent the family-based therapy were still fully recovered five years later.

"This program requires [the parents] to take charge of the feeding process as if their child was starving for some other medical reason," says Katharine Loeb, a research fellow in child psychiatry at Columbia University. "Other therapies assume that we have to reach a state of readiness and then the eating will happen."

A Swedish approach shares the emphasis on eating. The Center for Eating Disorders in Stockholm has developed a device called a Mandometer that tracks how much food a patient eats. A patient can compare the rate at which he or she eats with a normal rate. Clinical Director Cecilia Bergh says her clinic has achieved a 75% remission rate among its patients, using the Mandometer along with counseling, nutritional guidance and family therapy.

A Swedish family, the Johanssons, took their daughter, Rebecca, to the clinic after consulting with five other doctors. Eva Britt Johansson, Rebecca's mother, said Rebecca had lost eight pounds from her 86-pound frame while in a psychiatric hospital, and they were desperate.

Rebecca said the clinic's treatment was effective because her therapy focused on thinking about her future and her daily schedule was so highly regimented that it didn't give her much time to think about food. When she was in a psychiatric hospital, she used to sneak into the bathroom to do calisthenics. At Dr. Bergh's clinic, she was constantly supervised.

Rebecca credits the Mandometer with making eating less scary since it seemed like simply "a test to get through." She began gaining weight in the clinic and hasn't relapsed since she left.

Dr. Bergh is trying to introduce the Mandometer to the U.S. But some American physicians are skeptical. Katherine Halmi, a Cornell University psychiatrist who was approached to do a pilot study in the U.S., says many questions remain about how effective the Mandometer is. Dr. Halmi questions the Swedes' 75% remission rate, a figure that several other U.S. doctors cite as high, since more than two-thirds of anorexics relapse and it can take as long as seven years to be cured.

Dr. Bergh defends her methods and says she plans to do a clinical study in the U.S. next summer.

But many say there is no magic bullet. Dr. Lock, who has written a treatment manual for therapists, says, "No single treatment approach is going to work for everybody."

Source: The Wall Street Journal

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