The Significance in the Etiology of Eating Disorders - Term Paper Example

EVIDENCE OF FAMILY THERAPY TREATMENT OF ANOREXIA NERVOSA INTRODUCTION Anorexia nervosa is considered a very serious, often chronic psychiatric disorder that is considered the most deadly of mental illnesses (Harris & Barraclough, 1998) and is the third most common persistent illness among female adolescents. Characterised by severely disturbed eating behaviour, anorexia is one of the two distinct eating disorders recognised by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as psychological disorders (American Psychiatric Association, 2000). Eating disorders are psychologically and physically devastating and give rise to or are associated with preexisting psychological difficulties. For instance, depression (American Psychiatric Association, 2000; Lowe, et al 2001) and anxiety disorders (American Psychiatric Association; 2000), particularly obsessive compulsive disorder (Halmi et al., 2003), are among the comorbid conditions found in people with eating disorders. In adolescent-onset anorexia, depression appears to be triggered by the eating disorder, and the individual is put at risk for experiencing future depressive episodes (Ivarsson et al, 2000). Although anorexia affects persons of all ages, adolescence appears to be the developmental period of particular significance in the etiology of eating disorders; hence, identification and clinical intervention during this stage are crucial. This paper aims to synthesise and critically analyse the existing research on the treatment of anorexia nervosa in adolescence from the perspective of evidence based practice, more particularly family therapy systems approach. UNDERSTANDING EVIDENCE BASED PRACTICE The term “evidence-based” is prevalent within the health care setting today. If there is any doubt, a quick glance at the current medical and allied health research literature would remove it. Medical doctors, physical therapists, occupational therapists, speech-language pathologists, music therapists, and many others, have begun to describe their treatment interventions as evidence-based. As with most established theories and concepts, the thoughts and beliefs behind evidence-based medicine have been traced by some to practices of ancient cultures throughout history (Sackett et al, 1996). However, most authors on the subject will credit Archie Cochrane, Scottish epidemiologist, with developing the modern concept behind evidence-based medicine, which was made popular through his landmark text Effectiveness and Efficiency: Random Reflections on Health Services (White, 1997). The most widely known and commonly quoted definition of evidence-based medicine was published in the British Medical Journal in 1996, by David L. Sackett et al. This definition, although altered and “improved upon” by numerous subsequent authors remains the standard for providing a clear explanation of evidence-based medicine. It states: Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (p. 71). Greenhalgh (2006) summarises the relationship among all evidence-based elements (medicine, research and practice) nicely in the following quote: “If you follow an evidence-based approach to clinical decision making, all sorts of issues relating to your patients … will prompt you to ask questions about scientific evidence, seek answers to those questions in a systematic way and alter your practice accordingly” (p. 1). Care providers in a variety of disciplines have acknowledged the desire to improve patient care through an approach toward evidence-based research and practice and have followed through by implementing the necessary elements within the facility (Rosenfeld et al., 2000). In addition, leaders of more specialised disciplines within the healthcare arena have acknowledged the need and desire for more evidence-based focused research and practice. The highest quality evidence available should be consulted when determining treatment decisions; however, other types of research contribute information to the treatment process as well. Perhaps the most common misunderstanding of evidence-based medicine and related excuse for not agreeing with its tenets is the concept that the only evidence upon which clinical decisions should be based is that which results from large randomised control trials (RCT) or meta-analyses of RCTs. In reality, supporters of evidence-based medicine, and now evidence-based practice, generally agree that evidence for different aspects of treatment comes from a variety of sources. For example, cross-sectional studies provide the necessary evidence for determining the accuracy of diagnostic instruments and follow-up studies are helpful in estimating a prognostic for a particular treatment (Sackett, et al., 1996). “And if no randomised trial has been carried out for our patient’s predicament, we must follow the trail to the next best external evidence and work from there” (Sackett, et al., 1996, p. 72). EVIDENCE BASED PRACTICE FOR ANOREXIA NEVROSA According to the APA Presidential Task Force on Evidence-Based Practice (2006), evidence-based practice in the field of psychology is defined as, “...the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273). In the evaluation of interventions, treatment efficacy (i.e. whether a particular treatment works) and clinical utility (i.e. the degree to which an intervention can be implemented in terms of feasibility, applicability, and usefulness) are important considerations (APA Presidential Task Force on Evidence-Based Practice, 2006). Treatment efficacy is established through empirical research, systematised clinical observation, clinical opinion, observation, and consensus among experts in the field (APA, 2002). Unfortunately, because there is a limited research base for many treatment approaches for this population, clinicians must then rely upon clinical judgment (Palmer, 2004). As evidence-based practice has been established by the APA to be the benchmark of care, it is the duty of psychologists to utilise treatment approaches to anorectic adolescents that have a sufficient evidence base. The degree to which specific treatment approaches have evidence base was determined primarily through the consideration of the amount and type (i.e. experimental, quasi-experimental, causal comparative, correlational research, case study, or qualitative methods) of research available for the use in the anorectic adolescent population. Such determinations were made with consideration of clinical utility (APA Presidential Task Force on Evidence-Based Practice, 2006) and treatment efficacy, as described by the APA (2002). Empirical research, including randomised controlled trials and quasi-experimental research, is at the most sophisticated level (APA, 2002) and yields the strongest evidence base for a particular approach to treatment. Due to the rising cost of inpatient hospital stays, the pressure from managed care companies to treat such individuals in general medical hospitals (Wiseman et al., 2001), and the lack of clearly established, evidence-based guidelines, treatment decisions regarding hospitalisations are often difficult for clinicians (Vandereycken, 2003). Nevertheless, inpatient hospitalisation is often necessary and the most appropriate treatment setting for some anorectic adolescents. Inpatient hospitalisation is most appropriate for anorectic adolescents who are severely emaciated and have significant medical complications (Winston & Webster, 2003), are suicidal (Crisp, 2002), whose treatment cannot be addressed in less structured outpatient programs (Crisp, 2002), and/or have very severe comorbid psychopathology or distorted pathology (Crisp, 2002; Winston & Webster, 2003). Each treatment setting may take a variety of approaches. Most often, inpatient, residential, and partial hospitalisation treatment settings take a multidisciplinary approach (Hay, 2004; Yager et al., 2006). As such, individuals typically receive treatment from psychiatrists, physicians, psychologists or other mental health practitioners, and nutritionists or dieticians (Yager et al, 2006). Further, the psychotherapeutic approach taken by each treatment setting often varies, and may include family, group, and/or individual therapy. FAMILY THERAPY: EVIDENCE FOR TREATMENT EFFECTIVENESS Due to the fact that family environment is often a contributing factor to the development and maintenance of anorexia nervosa (Murray, 2003), it is imperative that, particularly in the treatment of children and adolescents, the family be involved in therapy as part of the overall treatment package. The inclusion of a family in the treatment assists the parents in managing the adolescent and provides insight into typical adolescent developmental issues (Lyon et al., 2005). In family therapy approaches, the consideration of family interaction patterns, family structure, and family life cycle stage are important (Dare & Eisler, 1997). Typically, through family therapy, unresolved issues within the family are uncovered and addressed, with particular emphasis on how those issues manifest in the current system (Murray, 2003). Particular patterns and issues within the family that contribute to the eating disorder are often identified by the family therapist and addressed within the family. Kotler et al. (2003) express the importance of noting the distinction between family therapy and family-based treatment. In family therapy, the entire family is viewed as having a role in the identified patient’s problem - such as anorexia nervosa - and, thus, interventions target the family system. Alternatively, a family-based treatment approach does not consider the family to be part of the problem and actually aims to remove blame and empower family members to support the ailing family member (Kotler et al., 2003). Relatively few studies have been conducted that investigate the components of family therapy that are specifically effective in the treatment of anorexia nervosa. Examinations of behavioural family therapy and structural family therapy appear to be most prevalent; however, the use of constructive family therapy is a seemingly promising approach that beckons future research regarding its efficacy in the treatment of anorexia (Levitt, 2001). The Maudsley model is a systemic approach that considers genetic, sociocultural, and family influences in the development and maintenance of the eating disorder (Dare & Eisler, 1997). In the Maudsley approach, the eating disorder is externalised from the patient, which helps families avoid blaming the anorectic individual for having the disorder, a technique borrowed from the narrative therapy approach (Krautter & Lock, 2004). The effectiveness of the Maudsley approach has been reported by le Grange (1999), Krautter and Lock (2004), and Eisler (1996). Sim et al. (2004) presented two cases that demonstrated the success of the Maudsley model following failed attempts with more traditional care. In both cases, Sim et al. (2004) did not investigate the anorectic symptoms post treatment regarding a preoccupation with food and weight/shape disturbance, as the outcome focus was solely on weight gain. This limits the conclusions that can be drawn regarding the efficacy of the treatment. However considering these cases along with the research on the use of the Maudsley model, it is still evident that such an approach is ideal for anorectic adolescents. Moreover, results from empirical research, including randomised experimental studies and clinical case studies, indicate the efficacy of the Maudsley approach with anorectic adolescents. Additionally, recent literature describing clinical opinion, observation, and consensus among experts in the field of family therapy likewise support the efficacy of the Maudsley method. Most notably, the findings of Eisler et al. (1997) most clearly show the superiority of family therapy, particularly the Maudsley approach, over individual therapy in the treatment of anorectic adolescents. Elements that involve aspects of the Maudsley approach, such as parental involvement in refeeding and the integration of individual therapy as needed, has been shown to be highly effective in the treatment of adolescents with anorexia nervosa (Lock, 2002). Multi-family group therapy has recently emerged as an effective approach to the treatment of adolescents with anorexia nervosa. The use of the Maudsley method in a multi-family group setting was inspired by the inability of the traditional Maudsley family therapy approach to help all patients reach recovery (Rhodes et al, 2005). Prior to admittance to the multi-family group, patients and their families are seen initially for a medical and psychiatric assessment of the patient and an evaluation of the severity of the eating disorder (Dare & Eisler, 2000). In the Maudsley approach to multi-family therapy for anorexic adolescents, at most, six families are seen for eight hours per day over a four to five day period of treatment (Dare & Eisler, 2000). These eight-hour days are separated into groups where all families are treated together, as well as groups in which parents and their children meet separately. Additionally, a morning snack, mid-day meal, and an afternoon snack are built into the eight-hour day program (Dare & Eisler, 2000). Following this intensive four to five day period, families come together monthly or every 6 weeks for half of a day for up to a period of six months (Rhodes et al., 2005). In this approach, in addition to attending the multi-family group, families may also receive treatment from the traditional Maudsley family therapy approach, separated family therapy (i.e., where one therapist treats the patient and the parents separately), and/or individual therapy (i.e., with the patient and parents using different therapists) (Dare & Eisler, 2000). While there is little empirical evidence to support its effectiveness, results from empirical studies using the Maudsley approach in the multi-family group setting (Dare & Eisler, 2000), a clinical case study (Dare & Eisler, 2000) as well as clinical opinion (Dare & Eisler, 2000; Scholz et al., 2005) suggest that this approach is moderately evidence-based. In a preliminary report on the use of the Maudsley method in a multi-family setting, Dare and Eisler (2000) admit that because the sample size was too small and the diversity of patients was too large -diagnoses of individuals included anorexia or bulimia - conclusions as to the effectiveness of the approach cannot be made. However, they note that improvements in terms of eating disorder symptomatology were observed in all patients following the program’s end. The use of a similar multi-family group therapy approach, known as the Dresden model has been indicated through clinical opinion (Scholz & Asen, 2001) to be minimally evidence-based. The use of a multi-family group approach in an inpatient setting has also been described by Honig (2005) as an effective treatment approach. The behavioral family systems approach blends components of behavioral and family systems therapy in the treatment of anorexia nervosa (Powers & Santana, 2002). This approach includes an extensive assessment to evaluate the familys willingness and ability of adhering to the treatment (Powers & Santana, 2002). Patients and families are seen twice weekly until a sufficient amount of weight has been restored in the anorectic adolescent. Once weight has been restored, the family meets for therapy on a weekly basis. The parents are granted control of the adolescents eating in this approach (Lock, 2002; Powers & Santana, 2002). Cognitive therapy techniques are utilised to address issues both with the individual and the family (Robin & Siegel, 1999). For instance, cognitive restructuring techniques are utilised to address distorted thinking (Powers & Santana, 2002). Problematic family interactions are addressed through strategic/behavioral interventions. When the patient’s weight approaches what is normal for individuals of his/her age and height, control over the patient’s eating is given back to him or her. This treatment approach typically lasts one year (Powers & Santana, 2002). From the critical perspective, there is currently very little systematic research regarding the efficacy of family therapy in the treatment of anorexia nervosa (Lock & le Grange, 2005). The majority of randomised controlled trials that have been conducted in the area of treatment for anorexia nervosa have yielded insufficient power to determine clinical significance (Treasure & Kordy, 1998). Pertinent to the establishment of evidence-based practice, a consideration of the unique characteristics of each individual with anorexia nervosa “must be considered as important elements that may have relevance to and significant affects in making changes and gathering strength to put anorexia under control” (Levitt, 2001, p. 162). le Grange, Binford, and Loeb (2005) investigated the effectiveness of the Maudsley family therapy approach in restoring weight and the return of menses, using a sample of 45 anorectic children and adolescents ranging from 9 to 18 years in age. By the end of treatment, which averaged 17 sessions over a mean 9 months of treatment, all patients (n =36) who completed the treatment (6 had dropped out) had an increase in BMI. Specifically, patients mean BMI of 16.9 pre-treatment improved to 19.2 by the end of the treatment. Six of the patients in the study were male, which should be considered in light of the reported 16 patients who resumed menstruation by the end of treatment (le Grange et al, 2005). Morgan-Russell outcome categories were used to determine the overall response to treatment. A good outcome was achieved by 56% of the patients, while 33% had an intermediate outcome, and 11 % were determined to have a poor outcome. le Grange et al (2005) conclude that an approach that emphasises the parents’ active involvement in the treatment process leads to a favorable outcome for a majority of anorectic adolescents. The efficacy of behavioural family systems therapy was examined by Robin, Siegel, and Moye (1995), using a sample of 22 female adolescents (aged 12-19 years) randomly assigned to either weekly behavioural family systems therapy or supportive, solution-focused individual therapy, both of which were manualised treatment approaches, for a mean of 15.9 months. The researchers found that behavioural family systems therapy is an effective means of treatment for adolescents, as individuals in this treatment cohort maintained body mass indices, resumed menstruation, and displayed improved family interactions. Eisler et al. (1997) conducted a 5-year follow-up study to determine the efficacy of family therapy and individual supportive therapy in the treatment of anorexia nervosa. Eighty patients were assigned to either family therapy or individual supportive therapy, for which at 1 year, it was found that patients with both an early onset and short duration of illness, family therapy was most effective. On the other hand, individuals with a later onset had a better response to individual supportive therapy. At the 5-year follow-up, this continued to be the case, as individuals with early-onset and short illness duration treated with a family therapy approach, and those with a later onset treated with individual supportive therapy continued to show improvements (Eisler et al., 1997). Dare and Eisler (1997) acknowledge the utility of combining individual therapy and family therapy, as “There are tasks for family therapy and tasks for individual work” (p. 321). Further, they recognise how each approach mutually influences one another (Dare & Eisler, 1997). Herscovici and Bay (1996) report a favorable outcome resulting from a family-based approach to anorexia in Argentina. Most notably, the outcome results provide some indication of the acceptability of a family therapy approach to the treatment of diverse adolescent populations. During treatment, the adolescents (n=30) received medical care from a pediatrician and family therapy. The duration of treatment for the patients was not reported, which is unfortunate, as such information is critical when considering contributions to treatment outcome. At follow-up, 60% of the patients were determined to have a good outcome, 30% an intermediate outcome, and 10% were judged to have a poor outcome (Herscovici & Bay, 1996). The available research regarding the efficacy of family therapy in the treatment of adolescent anorexia nervosa establishes it as an important component of treatment. Fairburn (2005) argues that the support for family-based therapy needs to be carefully considered, and that research needs to be conducted to determine whether the effects of the treatment are related to family involvement or some other aspect of the treatment. Further, Fairburn suggests that the improvements noted in family-based therapy may simply be due to the good prognosis of adolescent anorexia, as compared to that for adults. The short- and long-term outcome effects of other treatment approaches in comparison to family-based therapy would be beneficial (Fairburn, 2005). Investigations of family therapy approaches for anorexia nervosa that do not contain the component of family-involvement in the refeeding process would be beneficial in shedding light upon whether improvements occur due to the parental control or to changes in family dynamics (Lock & le Grange, 2005). REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Report of the 2005 presidential task force on evidence-based practice. American Psychologist, (57(4), 271-285. Crisp, A. (2002). Treatment of anorexia nervosa: Is ‘where’ or ‘how’ the main issue? European Eating Disorders Review, 10(4), 233-240 Dare, C, & Eisler, I. (1997). Family therapy for anorexia nervosa. In D.M. Garner & P,E, Garfinkel (Eds.), Handbook of treatment for eating disorders (2n Ed., pp. 307-324). New York, NY: Guilford Press. Dare, C, & Eisler, I. (2000). A multi-family group day treatment programme for adolescent eating disorder. European Eating Disorders Review, 8, 8-14. Eisler, I. (1996). Combining individual and family therapy in adolescent anorexia nervosa: A family systems approach. In J. Werne (Ed.), Treating eating disorders (pp. 217-257). San Francisco, CA: Jossey-Bass. Eisler, I., Dare, C, Russell, G.F., Szmukler, G., le Grange, D., & Dodge, E. (1997). Family and individual therapy in anorexia nervosa. A 5-year follow-up. Archives of General Psychiatry, 54(H), 1025-1030. Fairburn, C.G. (2005). Evidence-based treatment of anorexia nervosa. International Journal of Eating Disorders, 37(Suppl.), S26-S30. Greenhalgh, T. (2006). How to read a paper: The basics of evidence-based medicine (3rd ed.). Oxford, UK: Blackwell Publishing Ltd. Halmi, K.., Sunday, S.R., Klump, K.L., Strober, M., Leckman, J.F., Fitcher, M. et al. (2003). Obsessions and compulsions in anorexia nervosa subtypes. International Journal of Eating Disorders, 33(3), 308-319. Harris, E.C., & Barraclough, B. (1998). Excess mortality of mental disorders. British Journal of Psychiatry, 173, 11-53. Hay, P. (2004). Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa. Australian and New Zealand Journal of Psychiatry, 38(9), 659-670. Herscovici, C.R., & Bay, L. (1996). Favorable outcome for anorexia nervosa patients treated in Argentina with a family approach. Eating Disorders, 4(\), 59-66. Honig, P. (2005). A multi-family group programme as part of an inpatient service for adolescents with a diagnosis of anorexia nervosa. Clinical Child Psychology and Psychiatry, 10(4), 465-475. Ivarsson, T., Rastam, M, Wentz, E., Gillberg, I.C., & Gillberg, C. (2000). Depressive disorders in teenage onset anorexia nervosa: A controlled longitudinal, partly community-based study. Comprehensive Psychiatry, 41(5), 398-403. Kotler, L.A., Bourdreau, G.S., & Devlin, M.J. (2003). Emerging psychotherapies for eating disorders. Journal of Psychiatric Practice, 9(6), 431-441. Krautter, T. & Lock, J. (2004). Treatment of adolescent anorexia nervosa utilizing manualized family-based treatment. Clinical Case Studies, 3(2), 107-123. le Grange, J. (1999). Family therapy for adolescent anorexia nervosa. International Journal of Clinical Psychology, 55, 727-739. le Grange, J., Binford, R., & Loeb, K.L. (2005). Manualized family-based treatment for anorexia nervosa: A case series. Journal of the American Academy of Child and Adolescent Psychiatry, 44( 1), 41 -46. Levitt, D.H. (2001). Anorexia nervosa: Treatment in the family context. The Family Journal: Counseling and Therapy for Couples and Families, 9(2), 159-163. Lock, J., & le Grange, D. (2005). Family-based treatment of eating disorders. International Journal of Eating Disorders, 57(Suppl.), S64-S67. Lyon, M.E., Silber, T.J., & Atkins, D. (2005). Process, promise, and pitfalls of collaborative treatment of anorexia nervosa in an adolescent patient. Clinical Case Studies, 4(2), 189-204. Lock, J. (2002). Treating adolescents with eating disorders in the family context: Empirical and theoretical considerations. Child and Adolescent Psychiatric Clinics of North America, 11, 331-342. Lowe, B., Zipfel, S., Bucholtz, C, Dupont, Y., Reas, D.L., & Herzog, W. (2001). Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychological Medicine, 31, 881-890. Murray, T. (2003). Wait not, want not: Factors contributing to the development of anorexia nervosa and bulimia nervosa. The Family Journal: Counseling and Therapy for Couples and Families, 11(3), 276-280. Palmer, B. (2004). The enemy of the good. European Eating Disorders Review, 12(5), 332. Powers, P.S., & Santana, C.A. (2002). Childhood and adolescent anorexia nervosa. Child and Adolescent Psychiatric Clinics of North America, 11, 219-235. Rhodes, P., Gosbee, M., Madden, S., & Brown, J. (2005). ‘Communities of concern’ in the family-based treatment of anorexia nervosa: Towards a consensus in the Maudsley model. European Eating Disorders Review, 13, 392-398 Robin, A.L., & Siegel, P.T. (1999). A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 35(12), 1482-1489 Robin, A.L., Siegel, P.T., & Moye, A. (1995). Family versus individual therapy for anorexia: Impact on family conflict. International Journal of Eating Disorders, 77(4), 313-322. Rosenfeld, P., Duthie, E., Bier, J., Bowar-Ferres, S., Fulmer, T., Iervolino, L.,McClure, M. L., McGivern, D., & Roncoli, M. (2000). Engaging staff nurses in evidence-based research to identify nursing practice problems and solutions [Electronic version]. Applied Nursing Research, 13(4), 197- 203. Sackett, D. L., Rosenberg, W., Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn’t [Electronic version]. British Medical Journal, 312 (7023), 71-72. Scholz, M., Rix, M., Scholz, K., Gantchev, K., & Thomke, V. (2005). Multiple family therapy for anorexia nervosa: Concepts, experiences, and results. Journal of Family Therapy, 27, 132-141. Scholz, M., & Asen, E. (2001). Multiple family therapy with eating disordered adolescents: Concepts and preliminary results. European Eating Disorders Review, 9, 33-42. Sim, L.A., Sadowski, CM., Whiteside, S.P., Wells, L.A. (2004). Family-based therapy for adolescents with anorexia nervosa. Mayo Clinic Proceedings, 79(10), 1305-1308. Treasure, J., & Kordy, H. (1998). Evidence based care of eating disorders: Beware the glitter of the randomised [sic] controlled trial. European Eating Disorders Review, 6(2), 85-95. White, K. L. (1997). Archie Cochrane’s legacy: An American perspective. In A. Maynard & I. Chalmers (Eds.), Non-random reflections on health services research (pp. 3-6). London: BMJ Publishing Group. Vandereycken, W. (2003). The place of inpatient care in the treatment of anorexia nervosa: Questions to be answered. International Journal of Eating Disorders, 34(41 409-422. Winston, A., & Webster, P. (2003). Inpatient treatment. In J. Treasure, U. Schmidt, & E. van Furth (Eds.), Handbook of eating disorders (2nd ed., pp.349-367). New York, NY: John Wiley & Sons. Wiseman, C.V., Sunday, S.R., Klapper, F., Harris, W.A., & Halmi, K.A. (2001). Changing patterns of hospitalization in eating disorder patients. International Journal of Eating Disorders, 30(2), 69-74. Yager, J., Devlin, M.J., Halmi, K.A., Herzog, D.B., Mitchell, J.E., Powers, P. et al. (2006). Part A: Treatment recommendations for patients with eating disorders. The American Journal of Psychiatry, 163 (Suppl.), 5-54. Read More