Therapies for anorexia nervosa to be evaluated

School of Medicine therapists and eating disorders specialists are joining investigators at a few sites around North America to evaluate anorexia nervosa treatments. Only 25 percent of anorexia patients recover completely, and the goal of this study is to improve those odds.

Funded by the National Institute of Mental Health, the study will look at therapeutic approaches that involve families and test whether antidepressant medication can enhance the results. The researchers will compare two types of family therapy. Participants will come to 16 one-hour family therapy sessions over a nine-month period. In addition, half of the patients with anorexia nervosa will receive the drug fluoxetine (Prozac). The rest will take a placebo.

“We’re examining whether one type of family therapy is superior to another, and whether or not there is an added benefit from medication, both in terms of initial improvements and long-term health,” said Denise E. Wilfley, Ph.D., professor of psychiatry, of medicine and of pediatrics in the School of Medicine, of psychology in Arts & Sciences and principal investigator at the WUSTL study site. “Anorexia nervosa is the eating disorder that we’ve been aware of the longest, but very few large-scale studies have been conducted, so it’s virtually impossible to provide good evidence-based recommendations for care.”

Anorexia nervosa is associated with serious medical complications, including cardiovascular, dermatological and gastrointestinal problems and osteoporosis.

“Many teenagers with anorexia nervosa also do poorly in school because starvation interferes with their cognitive function as well as multiple other systems in the body,” Wilfley said. “This disorder affects both physical and psychological health, and it has among the highest suicide rates of any psychiatric illness. In fact, while anorexia nervosa is rare, it has the highest death rate of any mental disorder.”

The investigators will recruit 240 anorexia patients and their families at six sites in North America, making this the largest NIH-funded treatment study of the disorder. Some 40 patient families will receive treatment at the School of Medicine.

The families will be divided into four groups: Behavioral Family Therapy (BFT), an intervention that focuses on changing the patient’s eating behavior; BFT and the antidepressant drug fluoxetine; Systems Family Therapy (SFT), an intervention that explores family issues that may influence the development of the eating disorder; and SFT plus fluoxetine for the patient.

The researchers are seeking families with a male or female child between 12-18 who has anorexia nervosa.

Families who qualify will be randomly assigned to one of the four study groups. Dorothy Van Buren, Ph.D., research assistant professor of psychiatry, will be involved in BFT therapy. She said among the unique aspects of the treatment is the session at which the counselor observes a family meal.

“We observe how effective they are at being able to encourage their child to eat an adequate amount,” Van Buren said. “That gives us information about how best to coach the family, what their strengths are and some areas where they might need to improve.”

Van Buren describes BFT as encouraging and structuring the family situation so that eating is expected. Often, she said, parents are so fearful of anorexia nervosa that they stop expecting their child to eat normally, and as the child becomes sicker, the expectations get lower as the family accommodates the eating disorder.

“The behavioral therapy is designed to help families find ways to break that cycle,” she said.

Families randomly selected for the SFT treatment also will come in for family therapy sessions with a different philosophical approach, according to Robinson Welch, Ph.D., assistant professor of psychiatry.

“We assume families have a ‘set point’ where they function best, and we intervene via a series of questions and reflections to help them make changes in the ways they operate,” Welch said. “Whereas the behavioral approach provides something like a map for the family, the systems approach is like holding up a mirror. The therapist helps the family reflect on how they are different and how the family dynamic may have changed as a result of anorexia nervosa. Going through that process, we hope they will be able to self-correct.”

Both behavioral and systems family therapy have been demonstrated to be effective treatments for anorexia nervosa, but there has been little research about which approach works best. There also is some evidence that antidepressant drugs like fluoxetine may help this patient population.

“Fluoxetine could help anorexia nervosa patients deal more effectively with the anxiety and the depressive features of the disorder,” Wilfley said. “Controlling those symptoms could make therapy more effective. That’s important because when patients do recover, there still is a 40 percent relapse rate.”

Divorced and nontraditional families are welcome to participate, and all family members living in a household are expected to participate in behavioral or systems family therapy sessions. Screenings, family treatment, medication and medical monitoring are provided at no cost.

For more information or to volunteer, call project coordinator Nichole Cecil at 286-0076.