Transdiagnostic Theory and Application of Family-Based Treatment for Youth With Eating Disorders

doi:10.1016/j.cbpra.2010.04.005

Cognitive and Behavioral Practice

Volume 19, Issue 1, February 2012, Pages 17-30

https://doi.org/10.1016/j.cbpra.2010.04.005 Get rights and content

Abstract

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Section snippets

Transdiagnostic Conceptualizations of Eating Disorders

The DSM-IV (American Psychiatric Association, 2000) eating disorders section includes three diagnoses: anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). The cardinal features of AN include refusal to maintain a normal body weight, disturbed experience of shape and weight (e.g., viewing oneself as fat despite emaciation), and an extreme fear of weight gain. BN is characterized by recurrent binge eating and purging in the context of a self-concept

Family-Based Treatment (FBT) for Eating Disorders: Clinical Description of the Foundation Approach

FBT is a brief (between 10 to 20 sessions) outpatient approach for the treatment of youth with eating disorders. Its specific interventions derive indirectly from a variety of schools of psychotherapy, including behavioral, family systems, and structural family therapy. While reflecting an amalgam of approaches in practice, FBT is explicitly atheoretical with regard to etiology of illness, and the family is treated not to uncover an underlying familial pathology expressing itself in the child's

A Transdiagnostic Model of FBT

As noted above, FBT posits no mechanism by which family or individual variables may have given rise to the eating disorder, nor are maintenance factors directly explored in the existing FBT literature. However, the key interventions and principles of FBT, and their effectiveness in the aggregate (no specific dismantling studies have been conducted to date) suggest the following transdiagnostic model of the approach. This model is designed to explain how the disorder can influence family-level

Empirical Research Supporting FBT as a Transdiagnostic Intervention for Youth With Eating Disorders

There are few systematic treatment studies of eating disorders in children and adolescents (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007). Only six randomized clinical trials with fewer than 400 adolescents studied in adolescent AN and two randomized clinical trials with fewer than 200 subjects studied in adolescent BN have been published (Eisler et al., 2000, Eisler et al., 2007, Eisler et al., 1997, Gowers et al., 2007, Le Grange et al., 1992, Le Grange et al., 2007, Lock et al., 2005,

Adaptations of FBT Across Developmental Stages and the Diagnostic Spectrum of Eating Disorders

As described above, FBT is based in several main therapeutic principles, each with a corresponding therapeutic technique, for intervening with child and adolescent eating disorders. The key tenets of FBT are adhered to and remain relatively uniform for FBT across ages and eating disorder diagnoses. However, the application of these principles and the interventions associated with them vary somewhat according to developmental stage and primary presenting symptoms. Such flexible adherence is

Therapeutic Alliance and Treatment Acceptability

A small number of studies have examined therapeutic alliance and acceptability of FBT for adolescents with AN (Krautter and Lock, 2004, Le Grange and Gelman, 1998, Pereira et al., 2006) and BN (Zaitsoff, Celio-Doyle, Hoste, & Le Grange, 2008). A primary goal in FBT is to empower parents to play a significant role in addressing their offspring's eating disorder, making this a highly demanding therapy. Early on in treatment the adolescent is not allowed to make independent decisions about eating

Case Study

This portion of the article will describe the implementation of FBT for a 13-year-old female, M, who presented with a 6-month history of an eating disorder. The family provided permission for deidentified case information to be used in this paper; in addition, aspects of descriptive and clinical data have been altered to protect their anonymity. This case will highlight the transdiagnostic implementation of FBT, as M presented with features of AN (refusal to maintain a healthy weight; highly

Conclusions

FBT is a promising outpatient treatment for AN, BN, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family-level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future

Author note

Work on this paper was supported in part by grants from the NIH (K23MH074506, PI: Loeb; R01MH079979, PI: Le Grange; K24MH074467, PI: Lock). The authors thank Terri Bacow for her comments on the manuscript and Lauren Alfano for her evaluation of the case reported in the paper. James Lock and Daniel le Grange receive royalties from Guilford Press for the sale of the published treatment manuals mentioned in this report.

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Protocol for a randomized clinical trial for Avoidant Restrictive Food Intake Disorder (ARFID) in low-weight youth
2023, Contemporary Clinical Trials
Citation Excerpt :
More importantly, this study seeks to address an important unmet need: the advancement of outpatient treatments for children with low-weight ARFID. As FBT is esteemed as the gold-standard treatment for both adolescent AN and BN, if this study reveals that FBT can successfully treat children with ARFID, FBT could be used as a transdiagnostic approach across eating disorders [46]. Strengths of the study include the utilization of videoconferencing platforms that allow for national recruitment and increased access to care.
Background
Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder recently added to the Diagnostic and Statistical Manual, 5th Edition (DSM-5) that involves nutritional, developmental, and/or psychosocial impairment, and often presents with a lack of interest in eating, sensory-related eating concerns, and/or fear of adverse consequences related to eating. There is limited evidence on treatments for ARFID, and in particular, treatments for children in the outpatient setting. Pilot data suggest that Family-Based Treatment (FBT) modified for ARFID is efficacious, and that improvements in parental self-efficacy may be the mechanism behind its success. This manuscript describes a study protocol seeking to confirm these preliminary findings through an adequately powered, randomized clinical trial (RCT).
This trial will randomize 100 children ages 6–12 years old who meet DSM-5 criteria for ARFID and their families to receive either 14 telehealth sessions of FBT-ARFID (n = 50) or a manualized Psychoeducational Motivation Therapy (PMT) treatment (n = 50), an individual therapy addressing the child's understanding of the problems ARFID is causing and promoting non-behavioral motivation and exploration of changing their eating patterns. Masked assessments will be conducted at baseline, one and two months within treatment, end-of-treatment, and six-month follow-up. Primary outcomes include change in body weight, parental self-efficacy, and parent feeding behaviors between baseline and end-of-treatment.
The results of this RCT will advance our understanding of effective treatments for low-weight ARFID in youth.
The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family based treatment for adolescents with anorexia nervosa
2021, Contemporary Clinical Trials
Adolescents with anorexia nervosa have set-shifting inefficiencies that can be exacerbated by starvation and that may interfere with outcomes of treatment interventions. Cognitive Remediation Therapy (CRT), an adjunctive treatment focused on improving set-shifting, can target inefficiencies and may augment treatment effectiveness. The best way to add CRT to the standard of care (Family Based Treatment, FBT) for adolescents with anorexia remains understudied.
This is a randomized controlled trial designed to determine if CRT is effective in increasing flexibility in adolescents with anorexia and/or their parents. Participants are adolescents 12–18 years old with anorexia and their parents. 54 family groups will be randomized into one of three groups: FBT only, FBT plus Parent-focused CRT, or FBT plus Adolescent-focused CRT. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study.
This is the first study of its kind to apply CRT to parents. All forms of CRT in the context of anorexia have targeted the individual with anorexia's thinking style. We propose that it may be impactful to target the parent of the adolescent with anorexia as parents carry the burden of treatment and re-nourishment of their child during FBT and may have similar thinking styles.
This study takes an experimental therapeutics approach to further our understanding of the mechanisms of treatment for adolescents with anorexia. It focuses on increasing cognitive flexibility in patients or their parents and determining the appropriate dose of CRT needed to achieve positive change.
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Pediatric obesity and eating disorders have adverse consequences on children's health and psychosocial functioning. Parents are involved in children's daily lives and their health, but the extent to which children's eating behaviors or weight impact parents' daily functioning is unknown.
The present study examined parent and child impairment because of child eating problems and weight in key life domains, including work/school, social life, and family life. Participants were parents (N = 861; 35.5% fathers) who completed an online cross-sectional survey, including perceived impairment because of their child's weight and eating behaviors.
Overall, 7.0% of parents reported clinically significant impairment because of child weight, and 6.9% reported clinically significant impairment because of child eating behaviors. Significantly more parents of children categorized as having obesity reported clinically significant parent and child impairment than other weight categories. Parents of children who regularly engaged in secretive eating reported greater child impairment than those without problematic eating. When child weight and problematic eating behaviors were analyzed jointly with parent sex, child sex, and parents' overinvestment in their child's weight, parents' overinvestment in child weight was associated significantly with parent and child impairment, and secretive eating maintained a significant association, but weight status was no longer associated significantly with impairment.
Understanding and considering individual and family impairment associated with obesity and problematic eating behaviors is critical for family-based prevention and treatment programs.
Feeding and eating disorders
2020, Handbook of Clinical Neurology
Citation Excerpt :
They play an active role in treatment, and their self-efficacy to make decisions regarding their child's treatment is empowered. FBT is, essentially, parent-facilitated exposure (Loeb et al., 2012). FBT has three phases and typically lasts 6–12 months.
Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence—a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.
Transdiagnostic vs. disorder-focused perspective in children and adolescents with eating disorders: Findings from a large multisite exploratory study
2018, European Psychiatry
The transdiagnostic model of eating disorders (ED) proposes common cognitive mechanisms in patients with ED psychopathology. Little is known about their role in the maintenance of ED in children and adolescents. This study aimed to determine whether the relationships between key factors (low self-esteem, weight and shape control, clinical perfectionism, interpersonal problems, distress and mood instability) and core maintaining mechanisms (binge-eating and restraint) would support a transdiagnostic theory in young patients.
A total of 419 patients (mean age 14.7 ± 2.14 years; age range: 7–18 years; males 13.8%) diagnosed with an ED were assessed in six Italian clinical centers in 2013. Multiple comparisons between ED diagnosis, correlation analysis and principal component analysis (PCA) were performed.
Of the entire collective, 51.5% of patients were diagnosed with Anorexia Nervosa (AN), 12.3% were diagnosed with Bulimia Nervosa (BN) and 36.2% with Eating Disorder Not Otherwise Specified (EDNOS). In PCA, the core ED mechanisms, dietary restraint and binge eating, acted as poles of attraction of the other variables. The AN group was particularly linked to restraint and the BN group was particularly related to “Bulimia”. Considering the diagnostic subtypes, there were no significant differences between the anorexic binge-purging group, bulimic purging group and bulimic non-purging group, which constituted a unique cluster related to affective, interpersonal problems and to perfectionism, indicating a very homogeneous subgroup. Restricting anorexic group (AN-R), related to shape concern and anxious-depressed mood, was not linked to the other subtypes. EDNOS appeared to be opposed to the AN-R group; the binge eating disorder group appeared to be independent from others.
Our results suggest the presence of both specific and transdiagnostic mechanisms in ED subtypes, whose knowledge is of relevance for clinical practice.
Eating Disorders
2018, Complex Disorders in Pediatric Psychiatry: A Clinician's Guide
This chapter details diagnostic criteria and epidemiology for the four eating disorders: anorexia nervosa (AN), bulimia nervosa, avoidant-restrictive food intake disorder (ARFID), and binge eating disorder (BED). We review common difficulties in diagnosis, including both psychologic and medical differentials. The chapter also provides an overview of empirically supported psychosocial treatment for each disorder separately. The majority of research has been on the treatment of pediatric AN. Family-based treatments (FBTs) are most effective; a broad description of treatment is provided. FBT appears to be effective for bulimia; there are no empirically based treatments for ARFID or BED. In addition to psychosocial treatments, we review the literature on the use of medication in pediatric eating disorders. The majority of research on the use of medication in the treatment of eating disorders has been focused on adult populations. Although we review typical medications used in the treatment of each eating disorder, there is not enough evidence to suggest that it is a first-line or stand-alone treatment in children. Throughout the chapter, we offer our clinical perspective on the abovementioned diagnostic criteria and treatments from both theory and experience.

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Transdiagnostic Theory and Application of Family-Based Treatment for Youth With Eating Disorders

Abstract

Section snippets

Transdiagnostic Conceptualizations of Eating Disorders

Family-Based Treatment (FBT) for Eating Disorders: Clinical Description of the Foundation Approach

A Transdiagnostic Model of FBT

Empirical Research Supporting FBT as a Transdiagnostic Intervention for Youth With Eating Disorders

Adaptations of FBT Across Developmental Stages and the Diagnostic Spectrum of Eating Disorders

Therapeutic Alliance and Treatment Acceptability

Case Study

Conclusions

Author note

Lancet

Behavior Research and Therapy

Behaviour Research and Therapy

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of Adolescent Health

Journal of the American Academy of Child and Adolescent Psychiatry

Diagnostic and statistical manual of mental disorders

Diagnostic and statistical manual of mental disorders

Diagnostic and statistical manual of mental disorders

Adolescents with bulimia nervosa and eating disorder not otherwise specified—purging only

International Journal of Eating Disorders

Anorexia nervosa treatment: A systematic review of randomized controlled trials

International Journal of Eating Disorders

Are single-parent families different from two-parent families in the treatment of adolescent bulimia nervosa using family-based treatment?

International Journal of Eating Disorders

Eating disorder not otherwise specified: Next steps

International Journal of Eating Disorders

Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: A multicenter study

International Journal of Eating Disorders

Family therapy for families containing an anorectic youngster

Anorexia nervosa in a long-term perspective: Results of the Heidelberg-Mannheim study

Psychosomatic Medicine

Diagnostic crossover in anorexia nervosa and bulimia nervosa: Implication for DSM-V

American Journal of Psychiatry

Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions

Journal of Child Psychology and Psychiatry and Allied Disciplines

Family and individual therapy in anorexia nervosa: A five-year follow-up

Archives of General Psychiatry

A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: A five-year follow-up

Journal of Child Psychology and Psychiatry

Cognitive behavior therapy and eating disorders

Transdiagnostic CBT for eating disorders

The eating disorder examination

Thinking afresh about the classification of eating disorders

International Journal of Eating Disorders

Transdiagnostic cognitive-behavior therapy for patients with eating disorders: A two-site trial with a 60-week follow up

American Journal of Psychiatry

Long-term stability of eating disorder diagnoses

International Journal of Eating Disorders

Twelve-year course and outcome predictors of anorexia nervosa

International Journal of Eating Disorders

Emotional processing of fear: Exposure to corrective information

Psychological Bulletin

Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial

British Journal of Psychiatry

A follow-up study of 33 subdiagnostic eating disordered women

International Journal of Eating Disorders

Is manualized family-based treatment for adolescent anorexia nervosa acceptable to patients? Patient satisfaction at end of treatment

Journal of Family Therapy