Milkshakes Are Medicine For Anorexic Teens In Family-based Outpatient Therapy

Getting your teenager to drink a chocolate milkshake isn't something most parents need to worry about. But this is just the approach used in one treatment for anorexia nervosa. Known as Behavioral Family Therapy, or the Maudsley Approach, parents are called up on to supervise the eating habits of their anorexic child, feeding them high-calorie meals like milkshakes and macaroni and cheese until they regain a healthy weight.

For the first time, the Maudsley Approach is being compared with a more established treatment known as Family Systems Therapy as part of an ongoing National Institutes of Health (NIH)-funded treatment study at NewYork-Presbyterian Hospital/Westchester Division and five other centers nationally. Both are outpatient therapies for adolescents, aged 12 to 18.

"Anorexia is a life-threatening condition. Treating it early is very important since it is during the teenage years that this disorder usually takes hold," says Dr. Katherine Halmi, founder of the Eating Disorders Program at NewYork-Presbyterian Hospital/Westchester Division and professor of psychiatry at Weill Cornell Medical College. "Traditionally, patients with anorexia have been treated in a hospital setting or through one-on-one outpatient therapy. While inpatient treatment is still appropriate in acute cases, we have increasingly seen the value of family-oriented outpatient therapy for adolescents."

The current study is designed to compare two different therapeutic approaches that involve the family — one is a behavioral therapy initially focused on weight gain, and the other examines various underlying issues in the family dynamic.

In the Maudsley Approach, named after the hospital in London where it was developed in the 1980s, the anorexic teenager attends therapy sessions together with their parents and siblings. Parents work with the Maudsley therapist to develop ways in which they can monitor their child's intake, choosing the amounts and types of foods necessary for them to regain to a healthy weight. Siblings are encouraged to act as a support system for their sister or brother. Once patients achieve a healthy weight, they graduate toward taking more responsibility for their intake. At this point, family and developmental issues relevant to the patient maintaining a healthy weight are addressed.

In Family Systems Therapy, families also attend regular therapy sessions, but discussions do not necessarily focus on eating. Instead, family members are free to broadly explore and challenge any problematic communication patterns or stressors within the family unit.

"In Maudsley, food is medicine that restores the body and mind. When the body is starving, the mind also weakens, becoming more susceptible to anorexia's rigid, often obsessive logic. Supervised feeding helps to break this vicious cycle. With the anorexia in charge, the adolescent really cannot regain the weight on his or her own. Nutritional rehabilitation gives the brain the nutrition it needs to re-establish healthy eating habits," says Dr. Dara Bellace, a clinical psychologist at NewYork-Presbyterian Hospital/Westchester Division and an instructor of psychology in psychiatry at Weill Cornell Medical College.

"This approach does not blame parents, but rather calls on their ability to nurse their child back to health. It requires a strong commitment to be with them for every meal — something that can mean rearranging schedules and taking a tag-team approach to sharing the responsibility," adds Dr. Bellace. "The adolescent must also dedicate themselves to the therapy, understanding that, until they regain the weight, their parents will be feeding them much as they did when they were younger, deciding what and how much they eat and making sure they finish."

Previous research has shown the Maudsley Approach successfully prevented hospitalization and helped adolescents recover their normal weights, with at least 75 percent of patients maintaining their recovery after five years.

A total of 240 adolescents aged 12 to 18 are being recruited for the study at six centers: NewYork-Presbyterian/Westchester; Stanford University in Palo Alto, Calif.; Sheppard Pratt in Baltimore, Md.; University of California at San Diego; University of Toronto; and Washington University in St. Louis. Those eligible must be medically stable individuals ages 12 to 18 with a body weight between 75 percent and 87 percent of its healthy range. Families are randomized to receive either the Maudsley Approach or Family Systems Therapy. In each family treatment, they attend 16 one-hour sessions over the course of nine months. Sessions are held weekly for the first seven to eight weeks, bimonthly for the next six sessions, and monthly for the remaining sessions.

Anorexia nervosa is an eating disorder characterized by extreme low body weight and body image distortion with an obsessive fear of gaining weight. The condition largely affects adolescent females, who make up more than 40 percent of all cases. As much as 3 percent of American girls and women are anorexic. Contributing causes may include genetics, personality type, hormones, stress and societal pressures.

Anorexia carries the highest mortality rate of any psychiatric condition. Previous research by Dr. Halmi found that 7 percent of affected women died within 10 years. In a Swedish study that followed patients for 30 years, 18 percent to 20 percent of the women died. Even when anorexia is not fatal, it can cause long-term complications, including damage to the heart and bones.

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