Five studies. That's the complete scientific literature about the effectiveness of different treatments for eating disorders for children and adolescents. The largest of these studies had 165 participants. No wonder patients, parents and professionals flail around when presented with the options.
Dr. Jim Lock presented these and other findings at a Feb. 27 workshop for the public at Lucile Packard Children's Hospital at Stanford.
The good news was that there were sixty people there - and they asked good questions. It's hard to get people to attend a discussion that includes the horrifying list of chronic and acute effects of eating disorders.
I learned a new one, parotid gland swelling, from Dr. Cynthia Kapphahn, who concluded her descriptions with this fact: "Parents and friends don't want to know this." Indeed, we would much rather have been home watching the Olympics.
We don't want to be blamed, a tradition that started with the first doctor to label a condition as anorexia nervosa.
Sir William Gull set the standard of blaming the parents, which just about always means the mother. Later researchers piled on "refrigerator mothers" and "double-binding mothers," Lock said. When Dr. Lock arrived at Stanford in 1993, parents were at best considering a nuisance in the treatment of eating disorders.
From the skimpy available evidence of five studies, Dr. Lock gleaned that family-based treatments are most effective and that cognitive behavioral therapy is "possibly useful." There was no evidence favoring antidepressants, save one small case series involving ten people that came out "possibly useful." Nutritional counseling was of limited usefulness. Psychiatric hospitalization showed "no specific benefit" in treating anorexia. There have been no studies about psychiatric hospitalization and bulimia, nor any documenting day programs and residential facilities.
In the question period, a man whose daughter has been hospitalized three times wondered how much he could push treatment on an unreceptive patient.
Parents must find the place between making threats and not doing anything at all - for fear of making things worse.
Dr. Kara Fitzpatrick attacked that dilemma. "If your child was drinking vodka before school to relieve anxiety, no question you'd intervene," she said. If your child is not eating, again, there should be no question.
Another question was about dual diagnoses, common with eating disorders. What do you treat first? A young adult has a psychotic break and is anorexic. Anorexia trumps even that, Dr. Lock said. It is life-threatening.
He concluded by quoting German philospher Arthur Schoepenhauer: "All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident."
As an aside, Sir Gull himself got a little confused.
On Friday, October 24, 1873, at a meeting of the Clinical Society of London, Sir William Gull achieved a coup de maitre by delivering two seminal reports. The first was called, "Anorexia Nervosa, (Apepsia Hysterica, Anorexia Hysterica)". The second was entitled, "On a Cretinoid State supervening in Adult Life in Women." The manuscript on anorexia was regarded by Gull's peers to be significant, but of lesser importance. The essay on hypothyroidism was generally regarded to be Gull's chef d'oeuvre. One hundred and twenty-four years later, the situation has reversed itself: the anorexia paper is heralded, while the other manuscript is all but forgotten.