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Toward A Greater Understanding of the Ways Family-Based Treatment Addresses the Full Range of Psychopathology of Adolescent Anorexia Nervosa

Toward A Greater Understanding of the Ways Family-Based Treatment Addresses the Full Range of... POLICY AND PRACTICE REVIEWS published: 24 January 2020 doi: 10.3389/fpsyt.2019.00968 Toward A Greater Understanding of the Ways Family-Based Treatment Addresses the Full Range of Psychopathology of Adolescent Anorexia Nervosa 1 2 James Lock and Dasha Nicholls Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States, Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, United Kingdom Family-based treatment (FBT) for anorexia nervosa (AN) is an empirically supported Edited by: treatment for this disorder. Derived from several different schools of family therapy, it is Martina De Zwaan, a highly focused approach that initially targets weight restoration under parental Hannover Medical School, Germany management at home. However, the view that manualized FBT is solely a behavioral Reviewed by: therapy directing parents to refeed their children AN with the single purpose of weight gain Ulrich Voderholzer, Schön Klinik Roseneck, Germany is a common but misleading over simplification of the therapy. Indeed, weight restoration Dagmar Pauli, is the main goal only in phase 1 of this 3-phase treatment. When practiced with fidelity and Psychiatric University Hospital Zurich, Switzerland skill, FBT's broadest aim is to promote adolescent development without AN thoughts and *Correspondence: behaviors interfering and disrupting these normal processes. Although weight restoration James Lock is a key starting point in FBT, the entire course of treatment takes into consideration the jimlock@stanford.edu ongoing impact of starvation, cognitions, emotions, and behaviors on adolescent development. These factors associated with maintaining low weight are viewed in FBT Specialty section: This article was submitted to as interfering with the adolescent being able to take up the tasks of adolescence and thus Psychosomatic Medicine, must be overcome before fully turning to those broader adolescent tasks. In addition, FBT a section of the journal Frontiers in Psychiatry recognizes that adolescence takes place in the context of family and community and Received: 30 September 2019 respects the importance of learning in a home environment both for weight gain as well as Accepted: 09 December 2019 related developmental tasks to have a lasting effect. Specifically, in this article we describe Published: 24 January 2020 how the current FBT manualized approach addresses temperament/personality traits, Citation: emotional processing, cognitive content and process, social communication and Lock J and Nicholls D (2020) Toward A Greater Understanding of the Ways connections, psychiatric comorbidity, and family factors. This report makes no claim to Family-Based Treatment Addresses superiority of FBT compared to other therapies in addressing these broader concerns nor the Full Range of Psychopathology of Adolescent Anorexia Nervosa. does it add interventions to augment the current manual to improve FBT. Front. Psychiatry 10:968. doi: 10.3389/fpsyt.2019.00968 Keywords: family-based treatment, anxiety, cognitions, social, family Frontiers in Psychiatry | www.frontiersin.org 1 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia how FBT helps with the other associated problems that are often INTRODUCTION present. Much of the early emphasis in FBT is about empowering The view that manualized family-based treatment (FBT) is solely a parents because AN is seen as life threatening while also limiting the behavioral therapy directing parents to refeed their children with adolescent's capacity for making sound decisions about eating, anorexia nervosa (AN) with the single goal of weight gain is a exercise, and weight gain (16). Thus, parents are needed to common but misleading over simplification of the therapy (1). temporarily manage these issues, but only until the adolescent Reports suggest that therapists implementing FBT are concerned herself is again able to make reality based decisions about her with the lack of specific interventions in the approach to address health. Many anxieties and obsessions are directly attributable to issues such as psychiatric comorbidity, perceived family weight loss and starvation and dissipate to a significant degree with dysfunction, and broader adolescent development and weight gain in the home environment. Parents are not viewed as a functioning (2–5). While there is deliberate focus on weight and necessary evil but rather the natural and best resource for helping eating normalization, FBT aims more broadly at promoting their children with their problems as they navigate them during adolescent development without AN thoughts and behaviors treatment. In this sense, the other problems that are common in AN interfering and disrupting these processes. Thus, in the such as social anxieties, mood lability, and family conflicts are seen structure, intervention, therapeutic style, and treatment phases, as part of the family work in FBT. Initially, these problems are FBT attends to the broad psychopathology of AN. However, in addressed mostly in the context of food and eating, but during FBT, weight restoration is a key starting point and is approached phases 2 and 3 when the adolescent is more involved in her usual from a developmental and learning perspective that recognizes the social, academic, and family life, support for taking up adolescent realities of adolescent abilities and the importance of their home process around peers and family are a clear focus—that is indeed the environment for weight gain to have a lasting effect. In this article reason for phases 2 and 3. While progress in phase 1 is highly we review how FBT promotes weight restoration and in this predictive of long term outcome (17), this does not imply that context, temperament/personality traits, emotional processing, phases 2 and 3 are not needed; instead, phase 1 is the foundation for cognitive content and process, social communication and the work of these phases. connections, psychiatric comorbidity, and family factors. It is also worth noting in this description of how FBT addresses There are only limited data that support the view that associated problems common in adolescent AN is the important manualized FBT leads to improvements in psychosocial role of the individual one to one time that occurs at the beginning functioning and related psychopathology. For example, longer of every FBT session. During this approximately 10-min time when term outcome studies found high levels of psychosocial the therapist meets alone with the adolescent, there is an important functioning 4 years posttreatment with FBT (6). With a mean age and ongoing opportunity to build rapport, evaluate cognitive and of about 19 years at time of follow-up, 73% of the participants were emotional states, identify specific concerns the adolescent may be no longer in any psychiatric treatment and 73% were in full time experiencing, and provide support. In phase 1 of FBT, these one to school or work. In addition the Youth Self Report scale (7)scores one meetings may be brief and consist mostly of taking the improved from 40.6 at baseline (BL) to 25.6 at 1 year posttreatment adolescent's weight and assessing her reactions to weight change andthe ChildBehaviorChecklist (7) scores improved by over 20%. and to the efforts her parents are undertaking to help her. Rapport In a separate study Agras (8) and colleagues found (unpublished is usually slow to build with adolescents with AN who, because of results) that for those treated with FBT the Beck Depression their investment in maintaining AN, initially perceive the therapist Inventory (BDI) (9) improved from 14.59 a BL to 7.1 at 1 year as obstructive. However, the skilled FBT therapist demonstrates follow-up. Furthermore, the Rosenberg Self-Esteem Scale (10) consistent warmth, interest, and concern for the adolescent, improved from.4.2 at BL to 2.1 at follow-up. In addition, the particularly in those facets of her identity and behavior that are Quality of Life and Satisfaction and Enjoyment Questionnaire independent of AN. Studies suggest that therapeutic alliance is (Short) (11) improved from 47.8 at BL to 53.2 at follow-up. There good in FBT, despite the often difficult beginnings (18, 19). This were also reductions in the Self-Esteem Questionnaire—Anxiety increased rapport built carefully over phase 1 typically improves in subscale score (4.5 at BL to 4.1 at follow-up) and the Childrens' phases 2 and 3 as trust develops that issues will be respectfully Yale-Brown Obsessive Compulsive Scale (12) (3.82 at BL to 3.64 at addressed with the family. Material gathered in these brief sessions follow-up). Interpretation of these findings is limited by the fact that are essential for addressing cognitive, emotional, social, and family these secondary outcomes were not tested for statistical significance processes more broadly as FBT proceeds. nor were the studies powered to examine them. In addition, there wasnoevidence thatthese changeswere greater in FBT than comparison treatments.[e.g., Adolescent Focused Therapy (13)and SPECIFIC STRATEGIES EMPLOYED IN Systemic Family Therapy (14)]. A recently published qualitative FBT TO ADDRESS THE BROAD study also support the view the FBT is helpful in overall adolescent development (15). Thus, these data are provided only for descriptive BEHAVIORAL AND PSYCHOPATHOLOGY purposes to illustrate that FBT appears to have positive effects on OF ADOLESCENT AN broader AN psychopathology. The treatment stance, family context, agnostic view of AN, Weight Restoration prioritization of AN over other psychiatric issues, as well as the Many of the behaviors associated with AN can be attributed to emphasis on adolescent development provide the overall context for the so called “starvation syndrome” characterized so well in the Frontiers in Psychiatry | www.frontiersin.org 2 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia classic Minnesota Semi-starvation studies (20). It has been FBT's approach to helping with this problem takes place in suggested that weight restoration should resolve much of the differing ways depending on the phase of treatment. In the related psychopathology of AN and for many years inpatient weight restoration phase (phase 1), most anxieties are focused settings saw this as a core treatment aim, only to find their on food and eating, and in FBT support for managing these patients relapsed on discharge. anxieties comes principally from parents as would be the case for One of the hallmarks of FBT is the early and highly focused most adolescent problems. In this phase, the adolescent gradually encouragement of parental management of their child's eating experiences decreased anxiety about weight gain by continuous while living with them in the home environment. Weight exposure to food, eating, and weight gain (weekly weighing) (32). restoration in this context differs from weight restoration in a This prepares her for experimenting and testing her own hospital or any other professionally managed environment. anxieties about eating and weight gain during phase 2. During Home is the environment where normal eating and weight phase 2, socialized eating—at school, with friends, in restaurants, management is generalizable. FBT takes seriously the principle at parties—is a main focus. Parents are asked to help facilitate that for learning to be optimized, it must take place in the and support the adolescent in these exposures, with the aim of environment where the learning is relevant. There is good increased mastery of social anxieties in these situations a main evidence that FBT's home learning environment is effective for treatment target. Helping the adolescent manage more general helping adolescents with AN to eat and gain weight more quickly social anxieties is a treatment goal in phase 3 of FBT. In this than other outpatient approaches, leading to both reduced phase, eating and weight restoration are not the focus, but hospital use and costs (8, 21, 22). instead, dating, sexuality, peer group participation, and In addition to emphasizing generalization of behavioral individuation from parents are targeted. If at the conclusion of learning, FBT also considers the developmental capacities of an FBT there continues to be significant social anxiety, then adolescent, usually around the age of 14–15 years, to make sound additional treatment for these problems should be considered. decisions and manage eating (23–25). It is not expected nor PerfectionismiscommoninANand interferes with typical for most adolescents at these ages to be in full control of psychosocial functioning and may need intervention in its own what they eat—they do not earn money to buy food, generally do right, as has been suggested by a modular addition to not regularly prepare food, nor do they eat special individualized transdiagnostic CBT (33). In the context of adolescents with meals; instead, parents have this responsibility in the context of AN, an anxious temperament is, as noted above sometimes family life. FBT's approach returns to the parents the authority expressed as social isolation and avoidance. Perfectionism for their adolescent's food intake, a responsibility that AN tries to differs from social anxiety, although both may be partly based take from them. FBT takes the position that this is not seen as a in an anxious temperament. Some of the ways perfectionism regression to an earlier developmental age but rather a result of expresses itself in AN is through rigid control over eating, AN, and uses externalization strategies to emphasize this point. mealtime rituals, strict rule following, obsessional checking of During phases 2 and 3, as AN symptoms abate, adolescent calories, weight, fat grams, etc., and weighing (34). Data suggest processeseitheronset (for youngerpatients) or are that the perfectionism in this sense is highly related to obsessive reestablished. This is of all the more importance when the compulsive personality features in AN (35).These, in turn, child is seriously malnourished and unable to participate interfere with treatment response in FBT by making the task of meaningfully in making these decisions because of the refeeding and weight restoration in phase 1 even more obsessional anxieties associated with an irrational fear of challenging (36). Of interest, perhaps, is the fact that inpatient weight gain (26). Nonetheless, it is important to note that it is treatment may reinforce these perfectionistic and obsessive during the first phase of FBT only that weight restoration is the tendencies, reducing response (37). FBT in phase 1 approaches almost exclusive overt focus. This phase lasts about 6–10 weeks perfectionism behaviorally, that is through parental strategies and is followed by 2–6 months of FBT aimed at age appropriate that disrupt the ability to reinforce perfectionistic and management of eating during phases 2 and 3. obsessional behaviors related to food and weight (e.g., calorie counting, ritualized eating, excessive weighing, and mirror Temperament and Personality Traits checking). These expressions of perfectionism as it relates specifically to AN are then the initial FBT target. In phase 2, A number of temperament or personality traits are associated with AN. The best characterized temperamental traits of perfectionism may contribute to social anxieties with peers by setting unrealistic standards for appearance and behavior either relevance to AN are perfectionism (27–29), harm avoidance (30), (low) novelty seeking and persistence, traits that for the adolescent herself, for her peers, or for both (38). During phase 2, although weight gain is still an aim, there is an explicit clinicians recognize can influence the course of illness, and treatment response. However, harm avoidance is significantly focus on addressing adolescent experiments with eating and socializing with others. During the individual meeting between lower, and reward dependence significantly higher in individuals therapist and adolescent that begins every FBT session, the whorecoverfromANthaninthose whoremainill (31), therapist has an opportunity to identify perfectionism and suggesting that what appear to be traits may in fact be features of the illness. From a developmental perspective, an anxious develop strategies with the adolescent to address these anxieties. These are then brought to the parents in the family temperament interferes with necessary adolescent social development with peers and associated socialization processes. session to address their impact and ways they can help overcome Frontiers in Psychiatry | www.frontiersin.org 3 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia them—especially with comparison with peers around eating, The parents are helped to learn not to react to these outbursts food, weight, and exercise. During phase 3, perfectionism when and instead to tolerate them rather than to respond in kind or by present can be addressed in FBT as a problem that interferes with giving in to food refusal. In this way, the adolescent is helped to the adolescent's relationships and general self-esteem (39, 40). If learn to manage and regulate her emotions through the repeated perfectionism continues to be at a concerning level at the end of modeling and support of parents, in the way tantrums in a much FBT, addition stand-alone treatment for this might be indicated younger child respond to similar forms of containment. outside the frame of FBT itself. Siblings can also play a role in helping to manage emotions in FBT by providing distractions and alternative supportive Emotional Processing activities such as playing games or watching videos. Strategies Emotional difficulties are often implicated in the development or for under emotional expression as well as depressed and maintenance of eating disorders and may be a risk factor for their withdrawn adolescents are similarly managed by parents with development (41). There are problems with experiencing sibling support in phase 1. In phases 2 and 3, as the adolescent is emotions, emotional sensitivity, and emotion regulation. eating more normally, emotional difficulties tend to be less about Alexithymia, the inability to identify and label emotions (42), reactions to food and weight gain, and instead are about social is present to a significant degree across studies in patients with and familial relationships. Anxieties about peer acceptance and AN (43). Depression and anxiety are well-described antecedents sadness about the impact of AN on relationships is part of the as well as comorbidities of AN, with the suggestion that focus of these phases. FBT sees the anxieties about self and others starvation blunts the experience of negative affect and is that “emerge” as weight and shape concerns recede as integral to therefore inherently rewarding through the avoidance of the disorder rather than separate and new. The therapist aversive feelings (34, 44). Unlike emotional sensitivity, identifies these issues and their specifics in the one to one emotional regulation is conceptualized as a skill that is learnt meeting held before the whole family session and helps the throughout life and most especially during adolescence as many adolescent to express these emotions with the family and new emotions are first experienced (45). The process of effective together they develop plans to address them. Thus, emotion regulation is predicated on recognition of emotions, management of these emotions is often treatment goals during utilization of cognitive or other strategies to manage emotions, the later phases of FBT. and the deployment of reflective function and emotional processing to enhance learning (46). Cognitive strategies Cognitive Content and Processes commonly used for emotion regulation include acceptance of The cognitions of greatest relevance in maintaining the emotions, cognitive reappraisal, problem-solving, rumination, psychopathology of AN are those related to the value of weight avoidance of emotions, and suppression. Functional cognitive and shape in self-evaluation (49). FBT does not include strategies for emotion regulation are impaired in those with interventions to directly challenge these maladaptive thoughts eating disorders, suggesting they are potential targets for and beliefs. In contrast, CBT for AN includes both motivational intervention (47). For example, women with eating disorders, and cognitive restructuring techniques. These approaches across ED subtypes, are inclined to suppress emotions and lack directly address these problems and while conceptually of the capacity to reappraise emotions. Rumination, repetitive interest, data supporting their effectiveness for AN, and thoughts about negative experiences and emotions, is adolescent AN in particular are limited (50, 51). In FBT, the implicated in mood and anxiety disorders and there is a approach to addressing distorted beliefs and cognitions about growing body of research on rumination in relation to eating food, weight and eating is initially approached behaviorally and disorders. In AN, rumination is particularly high around topics indirectly. Data suggest that in FBT, changes in these distorted such as negative emotions and body-related cognitions (48). thoughts occurs about 6–8 months after weight restoration (6, Development of cognitive and behavioral strategies for 52). The timing is important here because this “lag” is likely managing emotions, once recognized, is central to the related to prolonged reduction in the behaviors that maintain cognitive behavioral treatment (CBT) approach. In contrast, and reinforce these distorted cognitions. In other words, FBT the way that FBT enhances these skills is perhaps less intuitive. contends that only with sustained weight normalization and As a starting point, though, FBT posits that the parents and continued inhibition of under eating, dieting, and over exercise family are the usual, natural, and potentially most effective way do the cognitions lessen, presumably as a result of lack of reward to help adolescents with AN learn about their emotions and how for them over a prolonged period. to manage them. In the first phase of FBT, the adolescent with At the same time that FBT takes this longer view of cognitive AN displays a range of emotions—from a seeming unemotional change, there are a number of interventions in FBT that facilitate stance to one that is highly dramatic and dysregulated, especially cognitive change and practice. For example, in phase 1, the during mealtimes. Often the expression of these heightened adolescent is usually preoccupied with weight and shape emotions is new to both the patient and the family. The use of concerns, but because in each session her weight progress is externalization helps the family to understand that these discussed openly and frankly, she must learn to manage her emotions are related to the disorder of AN, especially because anxieties about weight gain because she is gradually, but they are expressed in contexts specifically involving demands for persistently presented with anxiety provoking data about eating and weight gain. Externalization helps to reduce blame weight to increase acceptance and toleration of them (32, 53). and judgment of the expression of these heightened emotions. By insisting on these exposures, even if they are sometimes Frontiers in Psychiatry | www.frontiersin.org 4 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia emotionally challenging, FBT blocks avoidance. The therapist in Social Communication and Connections the one on one time and the parents and family in session and at The emotional sensitivity of young people with AN appears to home can provide emotional support as the adolescent is have particular relevance and specificity in the area of social learning to manage her cognitions about fear of weight gain. In interaction (61). Sensitivity to social rejection, such as falling out sum, repeated exposure over the course of FBT leads to with friends, is at its peak in early adolescence, and is often cited diminished weight gain fears. In phase 2, the adolescent is as a trigger for onset of AN (62). Experimental studies suggest asked to participate actively with her parents in thinking that adults with AN are hypervigilant to social rejection and through dietary and activity changes. In other words, she is avoidant of social reward. Added to this social sensitivity is engaged in problem solving around challenging her beliefs and increasing evidence that, at least for a proportion of those with their behavioral impacts. Although not in any way formal AN, more pervasive social cognitive deficits may be a factor (63– cognitive restructuring as used in CBT, problem solving in 65). Recent evidence that impaired theory of mind is also found consultation with her parents lead to shifts in thinking in FBT. in unaffected third-degree relatives of patients with AN supports A number of studies now support the importance of the idea that these are trait rather than state characteristics (66, addressing thinking styles in the maintenance of AN through 67). Given the importance of social relationships in maintaining cognitive remediation therapy (CRT) (54). CRT targets psychological health and wellbeing for young people, treatments, metacognitive skills by helping patients recognize when their including FBT, should attend to reported difficulties in this area. thinking style may be impacting decision-making and When presenting for FBT, adolescents with AN have often subsequent actions. In the case of AN, the most consistently become socially isolated from families and friends. While there demonstrated cognitive inefficiencies are found in set-shifting may have been social anxieties and difficulties prior to the onset (changing track) and in central coherence (seeing the big picture of AN, these tend to be exacerbated by the illness. The in lieu of the detail) (55). These cognitive features are more preoccupations and activities required to maintain AN tend to marked in patients with AN who have high obsessive compulsive reinforce social isolation. AN becomes the social world for many traits, traits which are known to moderate the outcome from FBT adolescents who are ill. The impact of social isolation on mental (36). This is an area where the role of starvation on cognitive health, social and peer relationships, and overall adolescent function is also relevant. Fasting exacerbates set-shifting development are potentially life altering, setting the adolescent difficulties and impairs global processing, indicating weaker on a life time course of a lonely life revolving around weight and central coherence, in healthy controls (56). These findings (36) eating (65). FBT takes the perspective therefore that curing AN is suggest that for some patients these cognitive inefficiencies may a necessary first step to addressing these socialization processes be secondary to malnutrition while in others malnutrition may (68). Only by removing the behavioral and cognitive barrier that enhance existing tendencies. in AN leads to socially isolating the adolescent can progress be The evidence about cognitive processing problems in made. Parents and siblings are the first line of attack in helping adolescents with AN is still developing (57). It appears that a the adolescent reengage with others. In phase 1, this means good deal of cognitive rigidity improves with nutritional restoring healthy weight, meal time exposures with family, and rehabilitation, so FBT's initial focus on this is a strategy to over time at school. In phase 2, involvement with peers in an age address cognitive flexibility. In preliminary studies CRT has appropriate manner, specifically around food and eating are been added to FBT in adolescents with AN and increased stressed as a necessary step toward facilitating and developing obsessionality (a marker for cognitive inflexibility) found some peer relationships. For those who are in the early stages of improvement but the effects were small (58). In general, in adolescence, these may be novel experiments—eating on addition to weight gain, cognitive flexibility and big picture sleepovers, class birthdays, or parties. For older adolescents, thinking are encouraged in FBT during phases 2 and 3 as the this may mean eating on dates or in dining halls similar to adolescent is asked to take, and is able to take, a broader those that would be found in boarding schools or universities. perspective on her life and health than AN allowed and to While the direct focus is on behavioral learning and there is a participate in decision making about adolescent activities specific focus on food and eating, participation in socialized related not only to food, but to other social, educational, and eating actually is more than this because it promotes overall family processes. Again, this differs significantly from the social growth and normalization of peer relationships during cognitive exercise strategies employed by CRT and likely helps phase 3. For a small number of patients, social difficulties is more with the majority of children with AN with very mild and likely marked, a factor thought to be important for prognosis and state dependent cognitive processing difficulties (59). For those treatment response (69). It is important that these traits are with more severe and persistent cognitive processing challenges, identified and addressed. However, if developmental social a course of CRT can be added without disrupting FBT (58). It is learning processes are attended to alongside weight restoration, perhaps worth noting that the use of medications, particularly and reintegration with peers is achieved, the adolescent brain has atypical antipsychotics, is suggested to address cognitions in AN. potential to adapt and learn these skills in the majority of cases. While such medications may be sometimes useful for the acute Psychiatric Comorbidities management of severe anxiety in AN, there is little data to Comorbid psychiatric disorders are commonly diagnosed with support their effectiveness for improving cognitive content or AN, particularly depression, anxiety disorders, and obsessive process in AN itself (60). Frontiers in Psychiatry | www.frontiersin.org 5 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia compulsive disorder (53, 70–72). For many, these disorders their child with AN. Data suggest the FBT may take longer in though diagnosable are part of the clinical impact of AN on such cases (80). While there is evidence for the effectiveness of a the adolescent. Starvation leads to depression, fears about weight parent only format for FBT in addressing families with these gain and food increases anxiety, and obsessive thoughts about types of problems (81, 82), the usual whole family manual food, eating rituals, and exercise routines are often consistent provides many examples of how to work with the family as a with symptoms of OCD. In those cases, FBT's highly focused whole despite the presence of these issues. These include overtly approach to the treatment of AN leads to marked decreases in identifying criticism, hostility, and nonalignment as these disorders without focusing on them directly (6, 73). For the impediments to effective behavioral management of AN, most part, FBT recommends postponing other psychological modeling a noncritical stance and illustrating noncritical treatments for comorbidity until AN is resolved and a healthy comments through the extensive use of externalization and weight restored. This is recommended because of the life agnosticism to reduce blame and guilt. threatening nature of AN and the demands, both psychological and physical, on the adolescent and her family. This staged approach is feasible when the comorbidities are relatively mild or CONCLUDING COMMENT moderate. However, for patients with a clear history that predates AN, medications for comorbidities may well be In this article we have identified a number of significant, helpful in the context of FBT. commonly occurring problems in adolescent AN and described Another comorbid problem that is sometimes a concern is how the context, structure, and interventions of FBT can be used posttraumatic stress disorder (PTSD). Trauma or other adverse to successfully address many of them without introducing new events can trigger eating disorders if extreme enough, even in content or augmentative treatments that to date have not been those who might otherwise have healthy emotional responses, found systematically beneficial (83). Careful reading, accredited such that distress becomes overwhelming (74). A severe life event training, adequate supervision, and experience using manualized or difficulty, generally of an interpersonal nature, was identified FBT would likely decrease concerns about how FBT helps with prior to onset in 67% of a clinical sample of cases of AN (75). the full range of problems associated with adolescent AN. That Intrusive thoughts and related anxieties and fears related to these said, there is no data available that support that FBT is superior traumas can be an impediment to treatment, whatever the to other psychotherapies in addressing these broader issues nor approach.FBT takesthe position,however, FBT takesthe the impact of improvements in them on risk for relapse. Future position that traumas like other comorbidities should be studies are needed to compare the relative benefits of FBT to treated independently after AN is mostly resolved because of other approaches [e.g., CBT-E (50), Family Therapy-Anorexia the life-threatening and long term medical effects of ongoing Nervosa (84), Multi-Family Group Therapy (85), and Adolescent starvation. Attempting to address trauma at the same time as Focused Therapy (13)] on the broader psychopathology of AN. It weight restoration can lead to confusion about what the focus of may be particularly important to examine the relative effect of treatment should be. A case example of this is included in the FBT compared to Systemic Family Therapy for adolescents with FBT to illustrate how FBT prepares the adolescent to address comorbid obsessive compulsive disorder as this was identified trauma without the complications (medical and psychological) of post hoc as a moderator favoring Systemic Family Therapy and AN interfering and disrupting trauma work. should be confirmed (8). Furthermore, while FBT is effective for many, there is considerable room for improvement in outcomes Family Factors and strategies to improve or augment FBT developed and tested While any suggestion that specific family “types” or processes are (83). Careful study of the mechanisms mediating response to implicated in the causation of eating disorders remain unproven FBT, such as emotion regulation, trait characteristics, and social (76), the importance of family support and the responses of close competence as well as parent factors as outlined above, may give others are key to recovery seems to be more certain (77). clues to possible enhancements that would increase the Problems in families include parental and sibling anxiety, proportion of patients responding to the intervention. worry, blame, criticism, or hostility, resulting in communications and behaviors which have been hypothesized to influence outcome (78), and may moderate treatment (79). AUTHOR CONTRIBUTIONS The impact of these problems can be seen in common examples from clinical practice where the parental relationship, whether JL and DN conceptualized the paper and wrote the content. they are a couple or not, makes coparenting challenging. This can range from overt hostility in couples who are in the process of separating, to more subtle triangulation of young people in the parental relationship. Equally, the application of standard FBT ACKNOWLEDGMENTS can be impacted when a parent is grieving the loss of their The authors would like to acknowledge the clinicians and partner from death or separation, or is unable by virtue of other patients who treated or were treated using family-based demands (such as caring for others) or their own mental or treatment at Stanford University. physical health problems, to provide the necessary support to Frontiers in Psychiatry | www.frontiersin.org 6 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia 23. Kimmel D, Weiner I. Adolescence: A developmental transition. Lawrence REFERENCES Erlbaum Associates: Hillsdale, NJ (1985). 24. Marini A, Case R. The development of abstract reasoning about the physical and 1. Lock J, Le Grange D. 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Autism The remaining author declares that the research was conducted in the absence of spectrum disorder in individuals with anorexia nervosa and in their first- and any commercial or financial relationships that could be construed as a potential second-degree relatives: Danish nationwide register-based cohort-study. Br J conflict of interest. Psychiatry (2015) 206(5):401–7. doi: 10.1192/bjp.bp.114.153221 67. Tapajoz F, Soneira S, Catoira N, Aulicino A, Allegri RF. Impaired theory of mind in unaffected first-degree relatives of patients with anorexia nervosa. Eur Copyright © 2020 Lock and Nicholls. Thisisanopen-access article distributedunderthe Eat Disord Rev (2019). doi: 10.1002/rev2701 terms of the Creative Commons Attribution License (CC BY). The use, distribution or 68. Bukowski W, Lauren B, Rubin K eds. Handbook of Peer Interactions, reproduction in other forums is permitted, provided the original author(s) and the Relationships, and Groups. Guilford Press: New York (2019). copyright owner(s) are credited and that the original publication in this journal is cited, 69. Gilberg C, Gliberg C, Rastram M, Wentz E. Effects of autism spectrum in accordance with accepted academic practice. No use, distribution or reproduction is disorders on outcome in teenage-onset anorexia nervosa evaluated by the permitted which does not comply with these terms. Frontiers in Psychiatry | www.frontiersin.org 8 January 2020 | Volume 10 | Article 968 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Frontiers in Psychiatry Pubmed Central

Toward A Greater Understanding of the Ways Family-Based Treatment Addresses the Full Range of Psychopathology of Adolescent Anorexia Nervosa

Frontiers in Psychiatry , Volume 10 – Jan 24, 2020

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POLICY AND PRACTICE REVIEWS published: 24 January 2020 doi: 10.3389/fpsyt.2019.00968 Toward A Greater Understanding of the Ways Family-Based Treatment Addresses the Full Range of Psychopathology of Adolescent Anorexia Nervosa 1 2 James Lock and Dasha Nicholls Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States, Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, United Kingdom Family-based treatment (FBT) for anorexia nervosa (AN) is an empirically supported Edited by: treatment for this disorder. Derived from several different schools of family therapy, it is Martina De Zwaan, a highly focused approach that initially targets weight restoration under parental Hannover Medical School, Germany management at home. However, the view that manualized FBT is solely a behavioral Reviewed by: therapy directing parents to refeed their children AN with the single purpose of weight gain Ulrich Voderholzer, Schön Klinik Roseneck, Germany is a common but misleading over simplification of the therapy. Indeed, weight restoration Dagmar Pauli, is the main goal only in phase 1 of this 3-phase treatment. When practiced with fidelity and Psychiatric University Hospital Zurich, Switzerland skill, FBT's broadest aim is to promote adolescent development without AN thoughts and *Correspondence: behaviors interfering and disrupting these normal processes. Although weight restoration James Lock is a key starting point in FBT, the entire course of treatment takes into consideration the jimlock@stanford.edu ongoing impact of starvation, cognitions, emotions, and behaviors on adolescent development. These factors associated with maintaining low weight are viewed in FBT Specialty section: This article was submitted to as interfering with the adolescent being able to take up the tasks of adolescence and thus Psychosomatic Medicine, must be overcome before fully turning to those broader adolescent tasks. In addition, FBT a section of the journal Frontiers in Psychiatry recognizes that adolescence takes place in the context of family and community and Received: 30 September 2019 respects the importance of learning in a home environment both for weight gain as well as Accepted: 09 December 2019 related developmental tasks to have a lasting effect. Specifically, in this article we describe Published: 24 January 2020 how the current FBT manualized approach addresses temperament/personality traits, Citation: emotional processing, cognitive content and process, social communication and Lock J and Nicholls D (2020) Toward A Greater Understanding of the Ways connections, psychiatric comorbidity, and family factors. This report makes no claim to Family-Based Treatment Addresses superiority of FBT compared to other therapies in addressing these broader concerns nor the Full Range of Psychopathology of Adolescent Anorexia Nervosa. does it add interventions to augment the current manual to improve FBT. Front. Psychiatry 10:968. doi: 10.3389/fpsyt.2019.00968 Keywords: family-based treatment, anxiety, cognitions, social, family Frontiers in Psychiatry | www.frontiersin.org 1 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia how FBT helps with the other associated problems that are often INTRODUCTION present. Much of the early emphasis in FBT is about empowering The view that manualized family-based treatment (FBT) is solely a parents because AN is seen as life threatening while also limiting the behavioral therapy directing parents to refeed their children with adolescent's capacity for making sound decisions about eating, anorexia nervosa (AN) with the single goal of weight gain is a exercise, and weight gain (16). Thus, parents are needed to common but misleading over simplification of the therapy (1). temporarily manage these issues, but only until the adolescent Reports suggest that therapists implementing FBT are concerned herself is again able to make reality based decisions about her with the lack of specific interventions in the approach to address health. Many anxieties and obsessions are directly attributable to issues such as psychiatric comorbidity, perceived family weight loss and starvation and dissipate to a significant degree with dysfunction, and broader adolescent development and weight gain in the home environment. Parents are not viewed as a functioning (2–5). While there is deliberate focus on weight and necessary evil but rather the natural and best resource for helping eating normalization, FBT aims more broadly at promoting their children with their problems as they navigate them during adolescent development without AN thoughts and behaviors treatment. In this sense, the other problems that are common in AN interfering and disrupting these processes. Thus, in the such as social anxieties, mood lability, and family conflicts are seen structure, intervention, therapeutic style, and treatment phases, as part of the family work in FBT. Initially, these problems are FBT attends to the broad psychopathology of AN. However, in addressed mostly in the context of food and eating, but during FBT, weight restoration is a key starting point and is approached phases 2 and 3 when the adolescent is more involved in her usual from a developmental and learning perspective that recognizes the social, academic, and family life, support for taking up adolescent realities of adolescent abilities and the importance of their home process around peers and family are a clear focus—that is indeed the environment for weight gain to have a lasting effect. In this article reason for phases 2 and 3. While progress in phase 1 is highly we review how FBT promotes weight restoration and in this predictive of long term outcome (17), this does not imply that context, temperament/personality traits, emotional processing, phases 2 and 3 are not needed; instead, phase 1 is the foundation for cognitive content and process, social communication and the work of these phases. connections, psychiatric comorbidity, and family factors. It is also worth noting in this description of how FBT addresses There are only limited data that support the view that associated problems common in adolescent AN is the important manualized FBT leads to improvements in psychosocial role of the individual one to one time that occurs at the beginning functioning and related psychopathology. For example, longer of every FBT session. During this approximately 10-min time when term outcome studies found high levels of psychosocial the therapist meets alone with the adolescent, there is an important functioning 4 years posttreatment with FBT (6). With a mean age and ongoing opportunity to build rapport, evaluate cognitive and of about 19 years at time of follow-up, 73% of the participants were emotional states, identify specific concerns the adolescent may be no longer in any psychiatric treatment and 73% were in full time experiencing, and provide support. In phase 1 of FBT, these one to school or work. In addition the Youth Self Report scale (7)scores one meetings may be brief and consist mostly of taking the improved from 40.6 at baseline (BL) to 25.6 at 1 year posttreatment adolescent's weight and assessing her reactions to weight change andthe ChildBehaviorChecklist (7) scores improved by over 20%. and to the efforts her parents are undertaking to help her. Rapport In a separate study Agras (8) and colleagues found (unpublished is usually slow to build with adolescents with AN who, because of results) that for those treated with FBT the Beck Depression their investment in maintaining AN, initially perceive the therapist Inventory (BDI) (9) improved from 14.59 a BL to 7.1 at 1 year as obstructive. However, the skilled FBT therapist demonstrates follow-up. Furthermore, the Rosenberg Self-Esteem Scale (10) consistent warmth, interest, and concern for the adolescent, improved from.4.2 at BL to 2.1 at follow-up. In addition, the particularly in those facets of her identity and behavior that are Quality of Life and Satisfaction and Enjoyment Questionnaire independent of AN. Studies suggest that therapeutic alliance is (Short) (11) improved from 47.8 at BL to 53.2 at follow-up. There good in FBT, despite the often difficult beginnings (18, 19). This were also reductions in the Self-Esteem Questionnaire—Anxiety increased rapport built carefully over phase 1 typically improves in subscale score (4.5 at BL to 4.1 at follow-up) and the Childrens' phases 2 and 3 as trust develops that issues will be respectfully Yale-Brown Obsessive Compulsive Scale (12) (3.82 at BL to 3.64 at addressed with the family. Material gathered in these brief sessions follow-up). Interpretation of these findings is limited by the fact that are essential for addressing cognitive, emotional, social, and family these secondary outcomes were not tested for statistical significance processes more broadly as FBT proceeds. nor were the studies powered to examine them. In addition, there wasnoevidence thatthese changeswere greater in FBT than comparison treatments.[e.g., Adolescent Focused Therapy (13)and SPECIFIC STRATEGIES EMPLOYED IN Systemic Family Therapy (14)]. A recently published qualitative FBT TO ADDRESS THE BROAD study also support the view the FBT is helpful in overall adolescent development (15). Thus, these data are provided only for descriptive BEHAVIORAL AND PSYCHOPATHOLOGY purposes to illustrate that FBT appears to have positive effects on OF ADOLESCENT AN broader AN psychopathology. The treatment stance, family context, agnostic view of AN, Weight Restoration prioritization of AN over other psychiatric issues, as well as the Many of the behaviors associated with AN can be attributed to emphasis on adolescent development provide the overall context for the so called “starvation syndrome” characterized so well in the Frontiers in Psychiatry | www.frontiersin.org 2 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia classic Minnesota Semi-starvation studies (20). It has been FBT's approach to helping with this problem takes place in suggested that weight restoration should resolve much of the differing ways depending on the phase of treatment. In the related psychopathology of AN and for many years inpatient weight restoration phase (phase 1), most anxieties are focused settings saw this as a core treatment aim, only to find their on food and eating, and in FBT support for managing these patients relapsed on discharge. anxieties comes principally from parents as would be the case for One of the hallmarks of FBT is the early and highly focused most adolescent problems. In this phase, the adolescent gradually encouragement of parental management of their child's eating experiences decreased anxiety about weight gain by continuous while living with them in the home environment. Weight exposure to food, eating, and weight gain (weekly weighing) (32). restoration in this context differs from weight restoration in a This prepares her for experimenting and testing her own hospital or any other professionally managed environment. anxieties about eating and weight gain during phase 2. During Home is the environment where normal eating and weight phase 2, socialized eating—at school, with friends, in restaurants, management is generalizable. FBT takes seriously the principle at parties—is a main focus. Parents are asked to help facilitate that for learning to be optimized, it must take place in the and support the adolescent in these exposures, with the aim of environment where the learning is relevant. There is good increased mastery of social anxieties in these situations a main evidence that FBT's home learning environment is effective for treatment target. Helping the adolescent manage more general helping adolescents with AN to eat and gain weight more quickly social anxieties is a treatment goal in phase 3 of FBT. In this than other outpatient approaches, leading to both reduced phase, eating and weight restoration are not the focus, but hospital use and costs (8, 21, 22). instead, dating, sexuality, peer group participation, and In addition to emphasizing generalization of behavioral individuation from parents are targeted. If at the conclusion of learning, FBT also considers the developmental capacities of an FBT there continues to be significant social anxiety, then adolescent, usually around the age of 14–15 years, to make sound additional treatment for these problems should be considered. decisions and manage eating (23–25). It is not expected nor PerfectionismiscommoninANand interferes with typical for most adolescents at these ages to be in full control of psychosocial functioning and may need intervention in its own what they eat—they do not earn money to buy food, generally do right, as has been suggested by a modular addition to not regularly prepare food, nor do they eat special individualized transdiagnostic CBT (33). In the context of adolescents with meals; instead, parents have this responsibility in the context of AN, an anxious temperament is, as noted above sometimes family life. FBT's approach returns to the parents the authority expressed as social isolation and avoidance. Perfectionism for their adolescent's food intake, a responsibility that AN tries to differs from social anxiety, although both may be partly based take from them. FBT takes the position that this is not seen as a in an anxious temperament. Some of the ways perfectionism regression to an earlier developmental age but rather a result of expresses itself in AN is through rigid control over eating, AN, and uses externalization strategies to emphasize this point. mealtime rituals, strict rule following, obsessional checking of During phases 2 and 3, as AN symptoms abate, adolescent calories, weight, fat grams, etc., and weighing (34). Data suggest processeseitheronset (for youngerpatients) or are that the perfectionism in this sense is highly related to obsessive reestablished. This is of all the more importance when the compulsive personality features in AN (35).These, in turn, child is seriously malnourished and unable to participate interfere with treatment response in FBT by making the task of meaningfully in making these decisions because of the refeeding and weight restoration in phase 1 even more obsessional anxieties associated with an irrational fear of challenging (36). Of interest, perhaps, is the fact that inpatient weight gain (26). Nonetheless, it is important to note that it is treatment may reinforce these perfectionistic and obsessive during the first phase of FBT only that weight restoration is the tendencies, reducing response (37). FBT in phase 1 approaches almost exclusive overt focus. This phase lasts about 6–10 weeks perfectionism behaviorally, that is through parental strategies and is followed by 2–6 months of FBT aimed at age appropriate that disrupt the ability to reinforce perfectionistic and management of eating during phases 2 and 3. obsessional behaviors related to food and weight (e.g., calorie counting, ritualized eating, excessive weighing, and mirror Temperament and Personality Traits checking). These expressions of perfectionism as it relates specifically to AN are then the initial FBT target. In phase 2, A number of temperament or personality traits are associated with AN. The best characterized temperamental traits of perfectionism may contribute to social anxieties with peers by setting unrealistic standards for appearance and behavior either relevance to AN are perfectionism (27–29), harm avoidance (30), (low) novelty seeking and persistence, traits that for the adolescent herself, for her peers, or for both (38). During phase 2, although weight gain is still an aim, there is an explicit clinicians recognize can influence the course of illness, and treatment response. However, harm avoidance is significantly focus on addressing adolescent experiments with eating and socializing with others. During the individual meeting between lower, and reward dependence significantly higher in individuals therapist and adolescent that begins every FBT session, the whorecoverfromANthaninthose whoremainill (31), therapist has an opportunity to identify perfectionism and suggesting that what appear to be traits may in fact be features of the illness. From a developmental perspective, an anxious develop strategies with the adolescent to address these anxieties. These are then brought to the parents in the family temperament interferes with necessary adolescent social development with peers and associated socialization processes. session to address their impact and ways they can help overcome Frontiers in Psychiatry | www.frontiersin.org 3 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia them—especially with comparison with peers around eating, The parents are helped to learn not to react to these outbursts food, weight, and exercise. During phase 3, perfectionism when and instead to tolerate them rather than to respond in kind or by present can be addressed in FBT as a problem that interferes with giving in to food refusal. In this way, the adolescent is helped to the adolescent's relationships and general self-esteem (39, 40). If learn to manage and regulate her emotions through the repeated perfectionism continues to be at a concerning level at the end of modeling and support of parents, in the way tantrums in a much FBT, addition stand-alone treatment for this might be indicated younger child respond to similar forms of containment. outside the frame of FBT itself. Siblings can also play a role in helping to manage emotions in FBT by providing distractions and alternative supportive Emotional Processing activities such as playing games or watching videos. Strategies Emotional difficulties are often implicated in the development or for under emotional expression as well as depressed and maintenance of eating disorders and may be a risk factor for their withdrawn adolescents are similarly managed by parents with development (41). There are problems with experiencing sibling support in phase 1. In phases 2 and 3, as the adolescent is emotions, emotional sensitivity, and emotion regulation. eating more normally, emotional difficulties tend to be less about Alexithymia, the inability to identify and label emotions (42), reactions to food and weight gain, and instead are about social is present to a significant degree across studies in patients with and familial relationships. Anxieties about peer acceptance and AN (43). Depression and anxiety are well-described antecedents sadness about the impact of AN on relationships is part of the as well as comorbidities of AN, with the suggestion that focus of these phases. FBT sees the anxieties about self and others starvation blunts the experience of negative affect and is that “emerge” as weight and shape concerns recede as integral to therefore inherently rewarding through the avoidance of the disorder rather than separate and new. The therapist aversive feelings (34, 44). Unlike emotional sensitivity, identifies these issues and their specifics in the one to one emotional regulation is conceptualized as a skill that is learnt meeting held before the whole family session and helps the throughout life and most especially during adolescence as many adolescent to express these emotions with the family and new emotions are first experienced (45). The process of effective together they develop plans to address them. Thus, emotion regulation is predicated on recognition of emotions, management of these emotions is often treatment goals during utilization of cognitive or other strategies to manage emotions, the later phases of FBT. and the deployment of reflective function and emotional processing to enhance learning (46). Cognitive strategies Cognitive Content and Processes commonly used for emotion regulation include acceptance of The cognitions of greatest relevance in maintaining the emotions, cognitive reappraisal, problem-solving, rumination, psychopathology of AN are those related to the value of weight avoidance of emotions, and suppression. Functional cognitive and shape in self-evaluation (49). FBT does not include strategies for emotion regulation are impaired in those with interventions to directly challenge these maladaptive thoughts eating disorders, suggesting they are potential targets for and beliefs. In contrast, CBT for AN includes both motivational intervention (47). For example, women with eating disorders, and cognitive restructuring techniques. These approaches across ED subtypes, are inclined to suppress emotions and lack directly address these problems and while conceptually of the capacity to reappraise emotions. Rumination, repetitive interest, data supporting their effectiveness for AN, and thoughts about negative experiences and emotions, is adolescent AN in particular are limited (50, 51). In FBT, the implicated in mood and anxiety disorders and there is a approach to addressing distorted beliefs and cognitions about growing body of research on rumination in relation to eating food, weight and eating is initially approached behaviorally and disorders. In AN, rumination is particularly high around topics indirectly. Data suggest that in FBT, changes in these distorted such as negative emotions and body-related cognitions (48). thoughts occurs about 6–8 months after weight restoration (6, Development of cognitive and behavioral strategies for 52). The timing is important here because this “lag” is likely managing emotions, once recognized, is central to the related to prolonged reduction in the behaviors that maintain cognitive behavioral treatment (CBT) approach. In contrast, and reinforce these distorted cognitions. In other words, FBT the way that FBT enhances these skills is perhaps less intuitive. contends that only with sustained weight normalization and As a starting point, though, FBT posits that the parents and continued inhibition of under eating, dieting, and over exercise family are the usual, natural, and potentially most effective way do the cognitions lessen, presumably as a result of lack of reward to help adolescents with AN learn about their emotions and how for them over a prolonged period. to manage them. In the first phase of FBT, the adolescent with At the same time that FBT takes this longer view of cognitive AN displays a range of emotions—from a seeming unemotional change, there are a number of interventions in FBT that facilitate stance to one that is highly dramatic and dysregulated, especially cognitive change and practice. For example, in phase 1, the during mealtimes. Often the expression of these heightened adolescent is usually preoccupied with weight and shape emotions is new to both the patient and the family. The use of concerns, but because in each session her weight progress is externalization helps the family to understand that these discussed openly and frankly, she must learn to manage her emotions are related to the disorder of AN, especially because anxieties about weight gain because she is gradually, but they are expressed in contexts specifically involving demands for persistently presented with anxiety provoking data about eating and weight gain. Externalization helps to reduce blame weight to increase acceptance and toleration of them (32, 53). and judgment of the expression of these heightened emotions. By insisting on these exposures, even if they are sometimes Frontiers in Psychiatry | www.frontiersin.org 4 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia emotionally challenging, FBT blocks avoidance. The therapist in Social Communication and Connections the one on one time and the parents and family in session and at The emotional sensitivity of young people with AN appears to home can provide emotional support as the adolescent is have particular relevance and specificity in the area of social learning to manage her cognitions about fear of weight gain. In interaction (61). Sensitivity to social rejection, such as falling out sum, repeated exposure over the course of FBT leads to with friends, is at its peak in early adolescence, and is often cited diminished weight gain fears. In phase 2, the adolescent is as a trigger for onset of AN (62). Experimental studies suggest asked to participate actively with her parents in thinking that adults with AN are hypervigilant to social rejection and through dietary and activity changes. In other words, she is avoidant of social reward. Added to this social sensitivity is engaged in problem solving around challenging her beliefs and increasing evidence that, at least for a proportion of those with their behavioral impacts. Although not in any way formal AN, more pervasive social cognitive deficits may be a factor (63– cognitive restructuring as used in CBT, problem solving in 65). Recent evidence that impaired theory of mind is also found consultation with her parents lead to shifts in thinking in FBT. in unaffected third-degree relatives of patients with AN supports A number of studies now support the importance of the idea that these are trait rather than state characteristics (66, addressing thinking styles in the maintenance of AN through 67). Given the importance of social relationships in maintaining cognitive remediation therapy (CRT) (54). CRT targets psychological health and wellbeing for young people, treatments, metacognitive skills by helping patients recognize when their including FBT, should attend to reported difficulties in this area. thinking style may be impacting decision-making and When presenting for FBT, adolescents with AN have often subsequent actions. In the case of AN, the most consistently become socially isolated from families and friends. While there demonstrated cognitive inefficiencies are found in set-shifting may have been social anxieties and difficulties prior to the onset (changing track) and in central coherence (seeing the big picture of AN, these tend to be exacerbated by the illness. The in lieu of the detail) (55). These cognitive features are more preoccupations and activities required to maintain AN tend to marked in patients with AN who have high obsessive compulsive reinforce social isolation. AN becomes the social world for many traits, traits which are known to moderate the outcome from FBT adolescents who are ill. The impact of social isolation on mental (36). This is an area where the role of starvation on cognitive health, social and peer relationships, and overall adolescent function is also relevant. Fasting exacerbates set-shifting development are potentially life altering, setting the adolescent difficulties and impairs global processing, indicating weaker on a life time course of a lonely life revolving around weight and central coherence, in healthy controls (56). These findings (36) eating (65). FBT takes the perspective therefore that curing AN is suggest that for some patients these cognitive inefficiencies may a necessary first step to addressing these socialization processes be secondary to malnutrition while in others malnutrition may (68). Only by removing the behavioral and cognitive barrier that enhance existing tendencies. in AN leads to socially isolating the adolescent can progress be The evidence about cognitive processing problems in made. Parents and siblings are the first line of attack in helping adolescents with AN is still developing (57). It appears that a the adolescent reengage with others. In phase 1, this means good deal of cognitive rigidity improves with nutritional restoring healthy weight, meal time exposures with family, and rehabilitation, so FBT's initial focus on this is a strategy to over time at school. In phase 2, involvement with peers in an age address cognitive flexibility. In preliminary studies CRT has appropriate manner, specifically around food and eating are been added to FBT in adolescents with AN and increased stressed as a necessary step toward facilitating and developing obsessionality (a marker for cognitive inflexibility) found some peer relationships. For those who are in the early stages of improvement but the effects were small (58). In general, in adolescence, these may be novel experiments—eating on addition to weight gain, cognitive flexibility and big picture sleepovers, class birthdays, or parties. For older adolescents, thinking are encouraged in FBT during phases 2 and 3 as the this may mean eating on dates or in dining halls similar to adolescent is asked to take, and is able to take, a broader those that would be found in boarding schools or universities. perspective on her life and health than AN allowed and to While the direct focus is on behavioral learning and there is a participate in decision making about adolescent activities specific focus on food and eating, participation in socialized related not only to food, but to other social, educational, and eating actually is more than this because it promotes overall family processes. Again, this differs significantly from the social growth and normalization of peer relationships during cognitive exercise strategies employed by CRT and likely helps phase 3. For a small number of patients, social difficulties is more with the majority of children with AN with very mild and likely marked, a factor thought to be important for prognosis and state dependent cognitive processing difficulties (59). For those treatment response (69). It is important that these traits are with more severe and persistent cognitive processing challenges, identified and addressed. However, if developmental social a course of CRT can be added without disrupting FBT (58). It is learning processes are attended to alongside weight restoration, perhaps worth noting that the use of medications, particularly and reintegration with peers is achieved, the adolescent brain has atypical antipsychotics, is suggested to address cognitions in AN. potential to adapt and learn these skills in the majority of cases. While such medications may be sometimes useful for the acute Psychiatric Comorbidities management of severe anxiety in AN, there is little data to Comorbid psychiatric disorders are commonly diagnosed with support their effectiveness for improving cognitive content or AN, particularly depression, anxiety disorders, and obsessive process in AN itself (60). Frontiers in Psychiatry | www.frontiersin.org 5 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia compulsive disorder (53, 70–72). For many, these disorders their child with AN. Data suggest the FBT may take longer in though diagnosable are part of the clinical impact of AN on such cases (80). While there is evidence for the effectiveness of a the adolescent. Starvation leads to depression, fears about weight parent only format for FBT in addressing families with these gain and food increases anxiety, and obsessive thoughts about types of problems (81, 82), the usual whole family manual food, eating rituals, and exercise routines are often consistent provides many examples of how to work with the family as a with symptoms of OCD. In those cases, FBT's highly focused whole despite the presence of these issues. These include overtly approach to the treatment of AN leads to marked decreases in identifying criticism, hostility, and nonalignment as these disorders without focusing on them directly (6, 73). For the impediments to effective behavioral management of AN, most part, FBT recommends postponing other psychological modeling a noncritical stance and illustrating noncritical treatments for comorbidity until AN is resolved and a healthy comments through the extensive use of externalization and weight restored. This is recommended because of the life agnosticism to reduce blame and guilt. threatening nature of AN and the demands, both psychological and physical, on the adolescent and her family. This staged approach is feasible when the comorbidities are relatively mild or CONCLUDING COMMENT moderate. However, for patients with a clear history that predates AN, medications for comorbidities may well be In this article we have identified a number of significant, helpful in the context of FBT. commonly occurring problems in adolescent AN and described Another comorbid problem that is sometimes a concern is how the context, structure, and interventions of FBT can be used posttraumatic stress disorder (PTSD). Trauma or other adverse to successfully address many of them without introducing new events can trigger eating disorders if extreme enough, even in content or augmentative treatments that to date have not been those who might otherwise have healthy emotional responses, found systematically beneficial (83). Careful reading, accredited such that distress becomes overwhelming (74). A severe life event training, adequate supervision, and experience using manualized or difficulty, generally of an interpersonal nature, was identified FBT would likely decrease concerns about how FBT helps with prior to onset in 67% of a clinical sample of cases of AN (75). the full range of problems associated with adolescent AN. That Intrusive thoughts and related anxieties and fears related to these said, there is no data available that support that FBT is superior traumas can be an impediment to treatment, whatever the to other psychotherapies in addressing these broader issues nor approach.FBT takesthe position,however, FBT takesthe the impact of improvements in them on risk for relapse. Future position that traumas like other comorbidities should be studies are needed to compare the relative benefits of FBT to treated independently after AN is mostly resolved because of other approaches [e.g., CBT-E (50), Family Therapy-Anorexia the life-threatening and long term medical effects of ongoing Nervosa (84), Multi-Family Group Therapy (85), and Adolescent starvation. Attempting to address trauma at the same time as Focused Therapy (13)] on the broader psychopathology of AN. It weight restoration can lead to confusion about what the focus of may be particularly important to examine the relative effect of treatment should be. A case example of this is included in the FBT compared to Systemic Family Therapy for adolescents with FBT to illustrate how FBT prepares the adolescent to address comorbid obsessive compulsive disorder as this was identified trauma without the complications (medical and psychological) of post hoc as a moderator favoring Systemic Family Therapy and AN interfering and disrupting trauma work. should be confirmed (8). Furthermore, while FBT is effective for many, there is considerable room for improvement in outcomes Family Factors and strategies to improve or augment FBT developed and tested While any suggestion that specific family “types” or processes are (83). Careful study of the mechanisms mediating response to implicated in the causation of eating disorders remain unproven FBT, such as emotion regulation, trait characteristics, and social (76), the importance of family support and the responses of close competence as well as parent factors as outlined above, may give others are key to recovery seems to be more certain (77). clues to possible enhancements that would increase the Problems in families include parental and sibling anxiety, proportion of patients responding to the intervention. worry, blame, criticism, or hostility, resulting in communications and behaviors which have been hypothesized to influence outcome (78), and may moderate treatment (79). AUTHOR CONTRIBUTIONS The impact of these problems can be seen in common examples from clinical practice where the parental relationship, whether JL and DN conceptualized the paper and wrote the content. they are a couple or not, makes coparenting challenging. This can range from overt hostility in couples who are in the process of separating, to more subtle triangulation of young people in the parental relationship. Equally, the application of standard FBT ACKNOWLEDGMENTS can be impacted when a parent is grieving the loss of their The authors would like to acknowledge the clinicians and partner from death or separation, or is unable by virtue of other patients who treated or were treated using family-based demands (such as caring for others) or their own mental or treatment at Stanford University. physical health problems, to provide the necessary support to Frontiers in Psychiatry | www.frontiersin.org 6 January 2020 | Volume 10 | Article 968 Lock and Nicholls How FBT Address Pathology in Anorexia 23. Kimmel D, Weiner I. Adolescence: A developmental transition. Lawrence REFERENCES Erlbaum Associates: Hillsdale, NJ (1985). 24. Marini A, Case R. The development of abstract reasoning about the physical and 1. Lock J, Le Grange D. 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Autism The remaining author declares that the research was conducted in the absence of spectrum disorder in individuals with anorexia nervosa and in their first- and any commercial or financial relationships that could be construed as a potential second-degree relatives: Danish nationwide register-based cohort-study. Br J conflict of interest. Psychiatry (2015) 206(5):401–7. doi: 10.1192/bjp.bp.114.153221 67. Tapajoz F, Soneira S, Catoira N, Aulicino A, Allegri RF. Impaired theory of mind in unaffected first-degree relatives of patients with anorexia nervosa. Eur Copyright © 2020 Lock and Nicholls. Thisisanopen-access article distributedunderthe Eat Disord Rev (2019). doi: 10.1002/rev2701 terms of the Creative Commons Attribution License (CC BY). The use, distribution or 68. Bukowski W, Lauren B, Rubin K eds. Handbook of Peer Interactions, reproduction in other forums is permitted, provided the original author(s) and the Relationships, and Groups. Guilford Press: New York (2019). copyright owner(s) are credited and that the original publication in this journal is cited, 69. Gilberg C, Gliberg C, Rastram M, Wentz E. Effects of autism spectrum in accordance with accepted academic practice. No use, distribution or reproduction is disorders on outcome in teenage-onset anorexia nervosa evaluated by the permitted which does not comply with these terms. Frontiers in Psychiatry | www.frontiersin.org 8 January 2020 | Volume 10 | Article 968

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