James Lock, MD.
Professor of psychiatry and pediatrics at Stanford University School of Medicine
Dr. Lock has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: Why did you specialize in eating disorders?
Dr. Lock: On our child psychiatry inpatient unit, among the kids with eating disorders, I saw that half or more were medically ill as a result of malnutrition or other behavioral problems associated with eating disorders that led to problems with electrolytes or blood pressures. I saw these wonderful young people—mostly girls, but boys too—who were amazing kids in many ways, but terribly lost in the confused thinking and values and behaviors that we know as eating disorders. At that time, we were completely taking care of things on an inpatient level, because we didn’t have an outpatient program.
CCPR: How common are anorexia and bulimia in young people?
Dr. Lock: Anorexia nervosa (AN) is actually a comparatively rare one—a little under 1% of adolescent females—but then you add bulimia, which is 2%–3%, and then you add binge eating, which is another 3%–4%, and you get to numbers and percentages that are rather high at 7%–8%, maybe even higher if you begin to count dysfunctional eating that leads to obesity that isn’t necessarily binge eating but close.
CCPR: What is typical age of onset?
Dr. Lock: For AN it’s about age 14. Bulimia has a slightly later onset. The behaviors might start at 16, but by 18, 19 you get full-fledged bulimia.
CCPR: Are the motivators different in young people than adults that develop anorexia and bulimia?
Dr. Lock: Not really. The motivators—being good, being perfect, being in control and serene—are the kinds of things that underlie the kind of psychological make-up of people with AN. We talk about AN being ego-syntonic, meaning patients actually like their illness because they get something good from it. There is hardly any variation in AN across cultures and ages: People with AN have the same types of personality characteristics. They are perfectionistic; they’re driven; they’re anxious people. AN patients aren’t working on their appearance; they diet not for others but for themselves. They are not really motivated by attracting a lot of people to them physically. In fact, most kids with AN are pretty socially and sexually avoidant. That’s not what’s pulling them into the process.
CCPR: So there is a definite personality type to keep in mind for anorexia. Are there different behavioral tendencies for kids who develop bulimia?
Dr. Lock: Yes. Bulimia is ego-dystonic. People are ashamed of their behaviors; they’re ashamed of their binging; they’re ashamed of their purging generally. And so there’s a very different kind of mindset. Bulimic patients typically do care a lot about wanting to be attractive to other people and diet to try and do that. They do want to engage the attention of others and are frustrated by their attempts to create a body that will attract people. Now, some of them drift all the way into AN, and some anorexics evolve into becoming bulimics over time. But, in their true forms, one way to put it is that anorexic patients have a sort of pride in accomplishment, and bulimics have a shame of failing to diet sufficiently. Although these illnesses come from different psychological places, clinicians should be aware of the same types of behavioral signs.
CCPR: And what are some behavioral clues for eating disorders?
Dr. Lock: Pay attention to any kid in your office who is starting to diet and clearly doesn’t need to be, or who starts losing significant amounts of weight—that should be a cautionary flag. If by history or presentation you have a young person who is high-performing, competitive, and perfectionist, be worried that this could be a place where they could start applying that same kind of thinking. Also, kids who are over-exercising, meaning that they are exercising more than they need to be either for their sport or for their health, and with a design of losing weight, that’s a warning sign.
CCPR: That’s good to know. Where do parents fit into this? Are they usually in sync as to what’s going on?
Dr. Lock: Yes, most of the time they will have noticed a weight loss, especially with the younger ages. I’d say what usually happens is that the caregivers will be concerned and either contact the pediatrician for a specific appointment or bring up the topic during a well or sick visit. So, usually these kids are seen at some point when things are starting.
CCPR: So it’s the pediatrician who usually detects the problem and acts on it?
Dr. Lock: Well, it’s interesting that you say that, because most psychology training programs don’t provide adequate experience and training for the detection and treatment of eating disorders. That in itself is astonishing, because it’s so common. And, if the psychiatrists and psychologists aren’t learning about it, you can be sure that the pediatricians aren’t learning either. The pediatrician often says, “Come back in 3 months.” But, 3 months later is too late. The thing they don’t understand is that, once these kids get these behaviors, they may start off sort of slowly over a 5- or 6-month period, when they reach a crescendo, which usually is about when the parents are really aware that there’s a problem. A weight loss of 10 to 15, even 20 pounds over a 2- to 3-month period is common (very rapid, in other words). So, between the time they see the pediatrician and the 3-month return visit, they’re often already in the hospital.
CCPR: That’s very concerning. So for some of these patients, you don’t end up seeing them until things may have become dire?
Dr. Lock: Right. We still get referrals where parents say, “Well, we went to the pediatrician. She lost 10 or 12 pounds. She was dieting extensively and over-exercising, and we were told, ‘This is a phase, she’ll outgrow it.’ Well, she didn’t outgrow it, and now she’s in the hospital with a heart rate of 37.”
CCPR: So, going back to that initial clinic visit. What needs to happen?
Dr. Lock: The patient needs to receive good, sound advice: You need to eat more, you need to exercise less, the emotional and physical effects of proper nutrition, etc. And the pediatrician or other clinician should say, “We’re going to schedule an earlier visit to make sure that the advice you just got has led to a change.” There will be some kids for whom it is a phase; when corrected, they go back to normal eating and that’s fine and their weights normalize. The problem is, most often, that isn’t what happens.
CCPR: Let’s shift and talk about treatment. How did you create your current outpatient intervention program?
Dr. Lock: When I first began working with kids with AN, it was in an inpatient setting, where the kids often stayed for 3 to 4 months. They were admitted and discharged mostly weight restored and eating pretty much independently. They would go home, but many of them didn’t do well. So, it was very confusing and not very rewarding to have kids return to the hospital in just as bad shape or worse a few months after we’d been treating them. What we discovered was that since inpatient wasn’t working all that well, let’s try a better outpatient approach. And we discovered this stunning—truly shocking fact: We didn’t know anything about how to treat outpatient AN. There were no evidence-based treatments, which is why we developed the family-based treatment (FBT) approach.
CCPR: And how does family-based treatment work?
Dr. Lock: The goal of FBT is to teach parents how to help their children with AN develop healthy eating and weight habits. In the first phase (sessions 1–8), the focus is on the eating disorder and includes a family meal. We make sure the parents realize they are not responsible for causing the disorder and we compliment them on the positive aspects of their parenting. Families consult with a therapist and figure out how best to re-feed their child with AN. In phase 2 (sessions 9–14), once weight restoration is nearing completion, parents are taught how to give control of eating back to the adolescent. The third phase (sessions 15–18) starts once the patient has achieved a normal weight and does not display any more anorexic symptoms. The theme in this phase is to help the adolescent establish and maintain a positive long-term relationship with their parents.
CCPR: Is family-based treatment widely offered?
Dr. Lock: Unfortunately, it depends on where patients live and what resources the family can access. They may hear that “the best evidence-based treatment is family-based therapy,” but if they live in rural Montana and there is not a single trained person available to teach that treatment, then that’s a problem. One way we’re trying to address that challenge is to train professionals using technology. We are developing an online version of training that we’re piloting and actually testing in a randomized global clinical trial right now. We hope that the results will tell us whether this strategy will be useful for dissemination.
CCPR: And what about online training for families as opposed to professionals? Is that feasible?
Dr. Lock: Yes, in fact we just completed a pilot study that taught guided self-help to parents. They essentially received the same or very similar training online that we would give to professionals, along with a weekly 30-minute therapist-guided discussion. Although you can’t meet with the whole family as in traditional family therapy, it looks like the kids whose families participated in the study did relatively well. It wasn’t a randomized clinical trial, but it gives a sense that guided self-help versions of family therapy might indeed be feasible for some patients.
CCPR: Have you had any success applying technology like phone apps and such?
Dr. Lock: We have a project right now that uses phone apps for binge eating and bulimia; it promotes self-monitoring, which is really the key piece of behavioral therapy for these conditions. Using that app alone, about 30% of patients improved their eating-related psychopathology. That’s encouraging, and we are refining the app so that it’s even more attractive to users.
CCPR: That’s good to hear. Thank you for your time, Dr. Lock.