Anorexia Nervosa in Adolescence and Maudsley Family-Based Treatment

Anorexia nervosa is a serious psychiatric disorder that generally occurs in adolescence, with a median age at onset of 17 years (Steiner et al., 2003; Wentz, Gillberg, Anckarsa, Gillberg, & Rastam, 2009). Prevalence of anorexia is estimated at 0.3%, with rates increasing, particularly in females between the ages of 15 and 24 years, over the last century (Hock, 2006). Anorexia is more common in girls by 10 to one, increasing to one male for every 20 females by young adulthood (Kohn & Golden, 2001). For the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM; www.dsm5.org/ProposedRevisions/Pages/EatingDisorders.aspx), changes have been proposed for anorexia diagnostic criteria. These potential changes will be focused more clearly on the behaviors that lead to weight loss, making these criteria more clinically relevant. Currently, however, diagnostic criteria for anorexia include (a) a refusal to maintain body weight at or above a minimally normal weight for age and height; (b) an intense fear of gaining weight or becoming fat, even though the individual is underweight; (c) a disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight; and (d) amenorrhea in postmenarcheal females for three consecutive menstrual cycles. Furthermore, there are two subtypes of anorexia. Restricting subtype occurs when the person has not regularly engaged in binge-eating or purging behavior during the period of anorexia. Binge-eating or purging type occurs when the person has regularly engaged in binge-eating or purging behavior during the episode of anorexia (DSM [4th ed., text rev.]; American Psychiatric Association, 2000). If weight loss is not reversed, major medical complications such as bradycardia, peripheral edema, and osteoporosis may develop (Mitchell & Crow, 2006). The causes of anorexia are considered multi factorial with the most common risk factors being genetic predisposition, specific personality traits such as perfectionism, and early dieting behaviors (Steiner et al., 2003). Adolescence, especially for females, is an illness-specific risk period because of the changes that take place in a young person's body during puberty, leading to an increase in body dissatisfaction that may increase dieting behaviors (Steiner et al., 2003). Although much of the research purports that anorexia is a chronic illness (average duration of illness, 5-7 years; Beumont & Touyz, 2003), some research has indicated that many young people do achieve full recovery from the illness. Strober, Freeman, and Morrell (1997) conducted a naturalistic, longitudinal study of 95 adolescents with anorexia and found that although illness duration was protracted (ranging from 57 to 79 months), most patients were weight recovered and females were menstruating regularly by the end of the 15-20 year follow up, with 76% of the cohort meeting the criteria for full recovery. They also found that relapse after recovery was relatively uncommon. It is sobering to note that the outcome is not always positive, with anorexia having the highest mortality rate of any psychiatric illness; approximately 10%-20% of individuals with the disorder die within 20 years of onset (Katzman, 2005). It is estimated that about one half of the deaths are due to suicide and one half are due to secondary physical complications of anorexia, particularly cardiac failure (Herzog et al., 2000). Given the severity and complexity of anorexia, effective treatment is essential to prevent a protracted illness and to reduce potential morbidity and mortality. Anorexia has a profound impact on the lives of individuals with the disorder and their families (Robin, Siegel, & Moye, 1995; Wallin & Kronvall, 2002). Over the last 25 years, empirical evidence has been accumulated suggesting that family-based interventions are effective outpatient treatments for children and adolescents with early onset anorexia. …