Focusing on Family Dynamics in Treatment for AN

In what is believed to be the first study of its type, French and Canadian researchers found that the addition of family therapy sessions focusing on the dynamics of the family itself rather than upon eating symptoms improved treatment outcome in girls with severe anorexia nervosa
(AN)
(PLoS One 7(1):e28249.doi:10.1371/journal.pone/0028249).

The severe effects of AN are well known, and its mortality rate of 10% is the highest among psychiatric illnesses, yet research on treatment is scarce and the many multidisciplinary approaches have rarely been evaluated, according to Dr. Nathalie Godart and colleagues. Thus, the authors designed a study to compare two post-hospitalization outpatient treatment programs for adolescents with severe AN. Patients were randomized to treatment as usual or treatment as usual with additional sessions of family therapy. Sixty female AN adolescents 13 to 19 years of age were included in the randomized parallel controlled trial conducted from 2002 to 2004.

Teens in the treatment as usual group (n=30) had ambulatory care tailored to their individual mental and physical needs, including individual consultations, regular interviews involving the parents and, if required, individual psychotherapy sessions. Parents were advised to be supportive but to leave decisions about food to their teens. They were also asked not to directly discuss difficulties they observed with their daughter during or after the meal but to wait to bring up these issues at the time of consultation with the psychiatrist and their daughter.

The family therapy group (n=30) received treatment as usual, with the addition of a program of family therapy that focused not only on current issues but also on unresolved issues from the past as well as expectations of how these might impact the future. The sessions focused on the family dynamic as a whole and did not address eating behaviors directly (these behaviors were dealt with by the referring psychiatrist). The family therapy sessions included the patient, her parents and her siblings if they were older than 6 and living in the home. These 90-minute sessions were held every 3 or 4 weeks and ran for up to 18 months.

At the time of randomization, and then again 18 months later, a series of questionnaires and assessments were administered. In addition, the patient’s body mass index (BMI, kg/m²), menstrual status, use of contraceptives, and the number of hospitalizations during the course of follow-up were recorded. Patient outcome was reported as good when weight was greater than the 10th percentile BMI, with regular menstruation; intermediate outcome was weight greater than the 10th percentile BMI but with amenorrhea (defined as absence of menstruation for the past 3 months); and poor outcome was weight lower than the 10th percentile and/or presence of bulimic symptoms..

Additional therapy led to healthy advantages

The researchers found the two groups had certain characteristics in common: pre-study BMIs were much lower than the third percentile BMI, and post-study BMIs were above 17 kg/m^2. A fourth of the participants had been previously hospitalized for treatment of AN; there were comparable comorbid mood and anxiety disorders, and teens in both groups had received comparable psychiatric consultations. The participants in the adjunctive family therapy group attended an average of 11.8 family therapy sessions, and the total number of treatment sessions did not differ between the two treatment groups. And, as a whole, between the beginning of the study and 18 month follow-up, all participants had significant improvement for all parameters.

A higher proportion of teens fell into the good and intermediate outcome categories after treatment with adjunctive family therapy; as a group, these adolescents achieved a “good” or “intermediate” outcome 3.2 times as often as those from the treatment as usual group. The family therapy group also achieved a healthy weight about 3 times as often as those in the treatments as usual group. When each group was considered separately, only the family therapy group showed a significant evolution in higher BMIs and they had amenorrhea significantly less often.

The authors had hypothesized that adjunctive family therapy would reduce the number of relapses, but this did not occur. They noted that this result was similar to those of other follow-up studies of adolescent AN outpatients, where such percentages range from 25% to 30%.