Table Of ContentTreating Bulimia in Adolescents
Treating Bulimia
in Adolescents
A Family-Based Approach
DANIEL LE GRANGE
JAMES LOCK
THE GUILFORD PRESS
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LibraryofCongressCataloging-in-PublicationData
LeGrange,Daniel.
Treatingbulimiainadolescents:afamily-basedapproach/byDanielleGrange
andJamesLock.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN-13:978-1-59385-414-0(hardcover:alk.paper)
ISBN-10:1-59385-414-5(hardcover:alk.paper)
1. Eatingdisordersinadolescence. 2. Bulimia—Patients—Family
relationships. 3. Familypsychotherapy. 4. Parentandteenager. I. Lock,
James. II. Title.
[DNLM: 1. BulimiaNervosa—therapy. 2. Adolescent. 3. FamilyTherapy—
methods. WM175L433t2007]
RJ506.E18T7442007
616.85′2600835—dc22
2006031305
For my late sister, Lizette—DLG
For my family, without whose love and support
this work would not have been possible—JL
About the Authors
Daniel le Grange and James Lock have been treating adolescents with
eating disorders for a combined total of 30 years. They have devoted their
careers to supporting parents and children with eating disorders in the
treatment of these challenging illnesses. They have especially devoted
considerabletimeoverthepast5-plusyearstolearningmoreaboutbulimia
nervosa in adolescents and how best to support families in their efforts to
cope with the complexities and unknowns of this disorder. They are
the coauthors, along with W. Stewart Agras and Christopher Dare, of
the only evidence-based treatment manual for anorexia nervosa, Treat-
ment Manual for Anorexia Nervosa: A Family-Based Approach (Guilford,
2001), and also wrote a book for parents, Help Your Teenager Beat an
Eating Disorder (Guilford, 2005).
Daniel le Grange, PhD, is Associate Professor in the Department of
Psychiatry,SectionforChildandAdolescentPsychiatry,andDirectorofthe
Eating Disorders Program at the University of Chicago. He received his
doctoraleducationattheInstituteofPsychiatry,UniversityofLondon,and
trained at the Maudsley Hospital in London, where he was a mem-
ber of the team that developed family-based treatment (the “Maudsley
approach”) for anorexia nervosa. Dr. Le Grange completed postdoctoral
work at the Maudsley Hospital and the University of London as well as a
fellowship at Stanford University School of Medicine. It is at Stanford that
he first introduced the Maudsley approach to his colleagues in the United
States.Heistheauthororcoauthorofnumerousresearchandclinicalarti-
cles, books, book chapters, and abstracts. Most of his scholarly work is
in the area of family-based treatment for adolescent eating disorders,
vi
About the Authors vii
includingthefirststudyoftwooutpatientfamily-basedtreatmentsforado-
lescents with anorexia nervosa. Dr. Le Grange was elected Fellow of the
AcademyforEatingDisordersin2002andhasheldseveralleadershipposi-
tionsattheAcademy.HeisapastrecipientofaNationalInstituteofMen-
talHealth(NIMH)CareerDevelopmentAwarddesignedtoinvestigatethe
relative efficacy of family-based treatment for adolescents with bulimia
nervosa; the principal investigator at the Chicago site for a 5-year NIMH
multisite study to investigate the efficacy of two psychosocial treatments
for adolescents with anorexia nervosa; and an investigator on a 4-year
NIMH multisite study of ecological momentary assessment of anorexia
nervosa. Dr. Le Grange has lectured extensively in the United States, Can-
ada, Europe, Australia, and South Africa.
James Lock, MD, PhD, is Professor of Child Psychiatry and Pediatrics
intheDivisionofChildandAdolescentPsychiatryandChildDevelopment,
Department of Psychiatry and Behavioral Sciences, Stanford University
School of Medicine, where he has taught since 1993. He is the director of
the Eating Disorders Program in the Division of Child Psychiatry and psy-
chiatric director of an inpatient eating disorder program for children and
adolescents at Lucile Salter Packard Children’s Hospital at Stanford. Dr.
Lock trained in general psychiatry at UCLA Medical Center and in child
psychiatryattheUniversityofCalifornia,Davis,MedicalCenter.Hismajor
research and clinical interests are in psychotherapy research, especially in
childrenandadolescents,andspecificallyforthosewitheatingdisorders.In
addition, he is interested in the psychosexual development of children and
adolescents and related risks for psychopathology. Dr. Lock has published
over 150 articles, abstracts, and book chapters. He serves on the editorial
boards of many scientific journals focused on psychotherapy and eating
disorders related to child and adolescent mental health. He is a Fellow of
the Academy for Eating Disorders and a member of the Eating Disorders
Research Society. Dr. Lock is a past recipient of an NIMH Early Career
DevelopmentAward;acurrentrecipientofanNIMHMid-CareerDevelop-
ment award focused on developing and studying treatment of adolescent
eating disorders; and the principal investigator at the Stanford site for an
NIMH grant comparing developmentally tailored individual treatment to
family-based treatment in adolescent anorexia nervosa. He has lectured
widely in the United States, Europe, and Australia.
Acknowledgments
We would like to acknowledge the contributions of a number of our
clinical colleagues in the development of this manual. We are grateful for
the guidance provided to us by Bennett Leventhal (Chicago), Timothy
Walsh (Columbia), Stewart Agras (Stanford), Michael Strober (UCLA),
Hans Steiner (Stanford), Joel Yager (University of New Mexico), and
Helena Kraemer (Stanford). The important work of our colleagues at the
University of Chicago Hospitals has been fundamental in the initial
development, piloting, and eventual empirical testing of this manual.
Among these are Roslyn Binford, Maureen Dymek, Khytam Dawood,
MarlaEngelberg,ReneeHoste,andChrisThurstone.Especially,wewould
like to thank the families who participated in the manualization process
and who so generously allowed us to use their transcripts in this book. In
addition, Dr. Le Grange was supported by a Career Development Award
from the NIMH (K23 MH01923), and Dr. Lock was supported by a Mid-
Career Award from the NIMH (K24 MH074467). Finally, and as always,
we wish to thank our families for their support in our efforts with this
project.
viii
Preface
Wewrotethisbookforclinicianswhoworkwithadolescentswithbulimia
nervosa.Thismanualisanadaptationofourworkonadolescentanorexia
nervosa(Lock,LeGrange,Agras,&Dare,2001),anapproachthatderives
from a family-based treatment (FBT) used first in controlled trials at the
Maudsley Hospital in London, then manualized and subjected to larger
controlledanduncontrolledtrialsatStanfordUniversityandtheUniversity
of Chicago.
Until now, our understanding of the treatment of adolescents with
bulimia nervosa has been limited by the total absence of evidence-based
treatment guidelines for this disorder in this age group. The present man-
ual is designed to begin to address this gap in our knowledge and to pro-
vide clinical guidance about how to provide FBT for bulimia nervosa.
Morespecifically,itdirectlyresultsfromexperiencesinadaptingandprac-
ticing FBT with adolescents with bulimia nervosa in the first controlled
trialintheUnitedStates,recentlycompletedattheUniversityofChicago.
Theoverallstrategiesaresimilartothoseoutlinedinourearlierbook,
Treatment Manual for Anorexia Nervosa: A Family-Based Approach.
However, the differences in the symptoms of bulimia nervosa and in the
personalities and families of adolescents with bulimia nervosa make the
processandparticularsofFBTdistinctfromthatprovidedtopatientswith
anorexia nervosa. Hence, this manual offers a new application of FBT for
a related but distinctly clinical population. The form of family treatment
describedhereutilizesparentsasaresourcetoassisttheadolescentwithher
recovery from bulimia nervosa. A key departure from FBT for adolescent
anorexia nervosa is the fact that the adolescent with bulimia nervosa is
ix
x Preface
enlisted to collaborate with her parents in their combined effort at her
recovery. By contrast, in FBT for adolescent anorexia nervosa, the parents
are asked to take control of weight restoration efforts and not to expect
collaboration from their child until weight is restored and eating is
normalized. For adolescents with bulimia nervosa, a more collaborative
approach is possible in part because of the ego-dystonic nature of bulimic
symptoms in most adolescents, a decided difference between these adoles-
cents and their peers with anorexia nervosa, for whom symptoms are
experiencedasegosyntonic. Inaddition,helpingthefamilytodiminishthe
shame that accompanies adolescent bulimia is often an avenue for engen-
deringincreasedcollaborationbetweentheadolescentandfamilymembers
in FBT.
As was the case with our manual for adolescents with anorexia
nervosa,ourprimaryhopeindevelopingthistreatmentmanualforbulimia
nervosa is to make FBT available in manualized format, so that more
adolescents with this disorder can be given the opportunity to experience
earlysymptomaticrelief,recoverfromtheirillness,andresumeadolescence
unencumbered by an eating disorder.
We have worked as clinicians and researchers in academic medical
settings for the past decade or so. Although we have worked in different
partsoftheworld,ourmutualinterestinthetreatmentofadolescentswith
eatingdisordershasbroughtustogetherinourthinkingabouthowbestto
undertake what we do on a daily basis in our respective practices. This
mutuality has led to a rich and productive collaboration that is now
approaching the decade mark. We started this collaboration in 1998 and
jointly wrote our first book, Treatment Manual for Anorexia Nervosa
(Lock et al., 2001), followed by a book for parents about eating disorders,
Help Your Teenager Beat an Eating Disorder (Lock & Le Grange, 2005),
and now this treatment manual for adolescent bulimia nervosa.
Description:An indispensable clinical resource, this groundbreaking book is the first treatment manual to focus specifically on adolescent bulimia nervosa. The authors draw on their proven approach to treating anorexia nervosa in the family context and adapt it to the unique needs of this related yet distinct c
