Outpatient treatment was begun after acute medical stabilization in a pediatric inpatient unit, where liaison was maintained through consultation with a child psychiatrist. After medical stabilization, the twins and their family signed informed consent to receive outpatient family therapy within a research study and were randomized to family-based therapy (described below). In addition, the twins were offered medical management services through the clinic. Medical necessity combined with consultation with the parents, determined the relative timing and choice of medications. At the outset, parents were open to medications but wanted to wait and see if behavioral interventions were effective. Although further observation in a baseline pre-medication state may have been scientifically desirable, Twin B suffered weight loss to 70% IBW within a week of post-hospital discharge with worsening caloric restriction but maintained medical stability. This prompted parental request for medication and the start of a trial of olanzapine. Twin A maintained or increased weight for several weeks prior to plateauing, but displayed increased anxiety, emotional dysregulation and OCD-like behaviors, which resulted in parental request to start medication.
Twin A was started on fluoxetine 10 mg taken by mouth every morning (week 8) and titrated up in 10 mg weekly increments to a final dose of 60 mg, which was maintained through week 36. She tolerated this regimen well without side effects. Twin B was started on olanzapine 2.5 mg taken by mouth at bedtime (week 2) and titrated further to 3.75 mg (week 6), which she tolerated well. The olanzapine dose was adjusted to 2.5 mg with the emergence of food cravings reported by twin B in the presence of steady weight gain (week 25). Olanzapine dose adjustment resulted in resolution of food cravings and was maintained through week 36. Monitoring of lipid profile and glucose levels did not reveal any abnormalities.
Both twins received family therapy for weight restoration in the same sessions over 9 months. This approach, identified as family-based treatment (FBT), was originally developed at the Maudsley Hospital in England and has shown significant promise for treating adolescents with AN. In FBT, the family is explicitly trained in regaining parental control over the adolescent patient’s eating behavior to achieve weight gain.29
Once weight and eating behavior are normalized, control is gradually returned to the adolescent while moving the focus to rebuilding relationships within the family and pursuing developmental milestones. Studies have shown short term and long-term efficacy for this therapeutic approach.30–33
Upon completing 9 months of outpatient treatment on separate medications while attending the same family therapy sessions, both twins had reduced eating disorder preoccupations or rituals, obsessions and compulsions. Throughout the course of treatment, Twin A was less communicative and forthcoming about her symptoms than Twin B, which was evident with collateral information from the parents. Interviewing Twin A was also complicated by her responses which mirrored those of Twin B, or at other times, she remained silent if interviewed separately. At the end of treatment assessment, per parents, both twins did not display obsessions, compulsions or rituals but Twin A continued to require prompting to maintain food intake and as opposed to Twin B who expressed hunger at meal times. Additionally, Twin A did not regain her normal eating pattern whereas Twin B did. After 9 months, Twin B was remarkably weight restored at 99.9% IBW, while Twin A had yet to weight restore at 84.4% IBW, meeting weight criteria for Anorexia Nervosa.