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Despite the availability of a large number of treatment studies for adult Bulimia Nervosa (BN), none has specifically included or investigated adolescents with BN. This is consistent with the overall paucity of clinical intervention research for adolescents with eating disorders. Nonetheless, more is known about the treatment of adolescent Anorexia Nervosa (AN). In addition to several reports on the inpatient management, the first controlled treatment studies involving the families of adolescent AN patients were conducted in the mid 1980s at the Maudsley Hospital in London. This treatment, also known as the "Maudsley Approach," has been shaped by a series of controlled trials in which family therapy has been compared with individual supportive therapy. In these trials, family therapy has shown a positive response for adolescent AN patients with a short history of illness. These studies have shown that involving the parents and siblings in treatment of AN helps to reverse the course of the eating disorder and enhance the adolescent's ability to negotiate physical and psychological development uninterrupted by starvation. Since then, a group in Detroit has published a family treatment study of adolescent AN, the Maudsley treatment has been manualized, and a large treatment study with adolescent AN is nearing completion at Stanford University. The Detroit group found that, after 16 months of treatment, family therapy resulted in greater body-mass index changes and return of menstruation, while both treatments demonstrated similar results in other measures (eating attitudes, body-shape concerns, and eating-related family conflicts).
The application of a family-based treatment for adolescents with BN seems a natural progression from our current work with adolescent AN. Because of considerable overlap in symptomatology between these two eating disorders, treatments proven effective for adolescent AN might also be beneficial in adolescents with BN. However, families with AN offspring may be different from those with a bulimic offspring, and these differences may have implications for the involvement of family members in therapy. For instance, women with BN report more troubled childhood experiences than women with AN. Moreover, AN patients are described as obsessional, introverted, emotionally reserved, socially insecure, self-denying, deferential, overly compliant, self-abasing, limited in autonomy, rigid and stereotyped in thinking.
Conversely, BN patients are described as having problems identifying and articulating internal states, their moods are highly variable and are accompanied by feelings of agitation and impulsive behaviors, they doubt themselves, have high expectations of themselves while also being harsh and self-critical, they are sensitive to rejection and seek the approval of others, while members of a subgroup have more substantial intrapsychic difficulties associated with boundary lapses similar to patients with borderline personality disorder. These personality differences suggest that adjustments involving parents to family-based therapy are needed to take these characteristics into account.
Our own studies have shown that there may be a greater likelihood of conflict or criticism in families with bulimic adolescents compared to their anorexic counterparts, but that it would be premature to talk about a "typical anorexic family" versus a "typical bulimic family". Notwithstanding, the secrecy of the bulimic behaviors as opposed to the more obvious fragility of a starving anorexic teenager, as well as the general difficulty in engaging adolescents in therapy, implies that family intervention has an important place in both of these disorders. From a developmental perspective, it is possible to argue that adolescent BN and AN patients share similar challenges, e.g., the negotiation of individuation, separation, sexuality, etc. Therefore, it is clinically feasible that adolescent bulimic patients still living with their families of origin may benefit from family therapy, especially if the treatment accommodates differences between AN and BN in adolescents.
Consistent with our own clinical observations, family-based treatment shows promise for BN in adolescents. We have treated more than 15 adolescents with AN (binge/purge subtype) in the context of a randomized clinical trial using the Maudsley family-based treatment. In this model the family is seen together and the parents are specifically put in charge of refeeding their child. In the case of AN (binge/purge subtype), the parents are also asked to take charge of preventing these behaviors. In these sessions, the patient is seen alone for the first 10-15 minutes where she is weighed and discussions of her perspective on her parents' efforts at refeeding take place. This information is used to help facilitate communication and effective treatment strategies in the whole family session that follows. For our adolescent patients with AN (binge/purge subtype), this treatment approach has been effective. Patients and families experience the treatment as a comfortable balance of individual support and family treatment. These findings are comparable to Eisler and colleagues' study that found AN (binge/purge subtype) did as well as AN (restrictor subtype) using family-based treatment. However, compared to AN (binge/ purge subtype) adolescents, BN patients present as more independent, more likely to have romantic relationships, more conscious of struggle and conflict with their parents, and more likely to have experimented with alcohol and drugs use. These observations are consistent with the literature regarding the differences between adult patients with AN and those with BN. Thus, although family-based treatment of AN (binge/purge subtype) seems to be effective, the combination of a more independent and rebellious group and the need to provide focused help with problems with shape and weight concerns support the need to revise family-based treatment for adolescents with BN.
The only systematic evidence we have that a psychological treatment may be effective with an adolescent BN population comes from a preliminary report from the Maudsley group. Their investigation of family therapy for adolescent BN was encouraging. The finding in a small cohort of eight patients suggests that family therapy is helpful for this population. The authors concluded that inclusion of educational principles of the disorder and involvement of the parents in helping to stop the binge/purge cycle seem to be successful. Most patients responded positively and showed significant changes in bulimic symptoms from the start of treatment to one-year follow-up. Although optimistic, these results should still be viewed with caution; this study described a small group of patients, follow-up was brief, and no control group was included.
Nevertheless, as with all adolescents, there are strong theoretical and clinical arguments for involving the family in treatment of adolescents with bulimia nervosa. In family therapy, information about the condition can be shared with the parents and the adolescent, and issues around meals and the impact of the eating disorder on family relationships can be addressed. The intrinsic denial of the alarming nature of bulimic symptoms renders many adolescents incapable of appreciating the seriousness of the illness. This necessitates that the parents make sure that the adolescent receives adequate treatment. If the bulimic adolescent is defined in the same manner that the anorexic teenager is conceptualized i.e., "out of control" and "unable to take care of herself," then the parents of the BN adolescent should be coached to work as a team in developing ways to restore healthy eating in their offspring. In addition, apart from any relevant family issues, heightened feelings of shame, guilt, and blame in the parents can reinforce the symptomatic behavior in the adolescent.
In summary, family therapy for adolescent BN has considerable potential. The extant data raise a clinically important and theoretically interesting possibility that adolescent BN can be successfully treated by having the patient's parents assume responsibility to restore healthy eating habits in their offspring through family therapy, a question that is currently under investigation at The University of Chicago. In the remainder of this article, we will describe the development of manual-based family treatment for adolescent BN, and demonstrate how this treatment may work in practice by presenting one case that has successfully completed treatment.
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