Our 15 year old daughter has been battling anorexia for the past two years. We began using the Maudsley Approach about 12 months ago with the knowledge that it has the greatest recovery rate compared with other forms of treatment. Although we have finished FBT treatment, I am concerned because my daughter remains within a healthy weight range only by using a subconscious set of "control measures." Despite becoming more flexible throughout the course of her illness, she still struggles with issues of food choice, negative body image, anxiety surrounding additional weight gain, and perfectionism.
We have been advised that our daughter is "recovered" in that the anorexia thoughts are there but she is managing to restrain them enough to be able to regain the weight after she loses a bit. Is this an accurate description of recovery?
If underlying issues such as anxiety and perfectionism are not fully addressed as part of stage 3, how long is it considered reasonable to wait before seeking further psychological treatment (other than FBT)?
Angela Celio Doyle, PhD responds:
It sounds like your daughter has come a long way and there are still some legitimate areas of concern. Eating disordered thoughts (such as weight and shape concerns, and thoughts about restricting food) generally decrease over the course of FBT. In fact, these thoughts tend to return to a non-clinical level about 12 months after weight restoration. This can seem like a long time and, since weight restoration often occurs partway through FBT, these eating disordered concerns might not disappear until well after treatment has ended. This means your child might have some body image concerns or worries about food when you and your FBT therapist decide to end treatment. However, some adolescents – even when fully weight restored for more than a year – cling to efforts to restrict their eating or continue to have intensely negative body image. It’s important to determine why your adolescent is having difficulty with continued ED thoughts (and this task can be easier said than done!). Here are three possible scenarios, with different plans for follow-up.
Scenario #1 involves predictable challenges toward the end of FBT. For example, your adolescent is scared to move into making hard decisions about eating without help. Or your adolescent may be struggling with body image because she's still getting used to having a healthy looking body. This scenario can be addressed through Phases 2 and 3 of FBT, so be sure to discuss these possibilities with your therapist during treatment.
Scenario #2 is that your adolescent fears other aspects of making developmental steps forward (e.g., dating, leaving home) and holds on to restriction or other symptoms of the eating disorder to keep parents close at hand as a form of protection. Scenario #2 can also be addressed through FBT if the adolescent has insight into these developmental fears and/or these issues are openly identified and discussed in sessions.
In Scenario #3, your adolescent is experiencing another psychological challenge, such as an anxiety disorder, obsessive-compulsive disorder, social anxiety disorder, separation anxiety disorder, or post-traumatic stress disorder. Sometimes anxiety disorders have clearly caused trouble before the eating disorder developed; other times, anxiety disorders become more evident once weight restoration has occurred. Sometimes anxiety masquerades as the eating disorder. For instance, an adolescent might be fearful of eating two proteins in one meal for fear of disturbing her metabolism (which could be OCD), or eating in front of friends is very difficult due to fears of negative evaluation or feeling awkward (social anxiety).
Scenario #3 may require moving to a specific evidence-based treatment approach for the anxiety disorder (for instance, cognitive behavioral therapy and, more specifically for obsessive-compulsive disorder, exposure and response prevention treatment). A good rule of thumb for when to seek additional treatment for anxiety and perfectionism would be to determine if these issues are causing great distress or are interfering with daily living — for example, losing sleep because of spending many hours on school assignments that should not require so much time. If anxiety and perfectionism are problematic, talk with your therapist about individual psychotherapy for these specific issues. If they are present but tolerable, it might make sense to wait a number of months to see if the issues decrease over time, given what we know about the time it takes for eating disorder thoughts to decrease.