James Lock
Stanford University, Psychiatry and Behavioral Science, Faculty Member
Research Interests: Psychology and Fidelity
Anorexia nervosa is characterised by a low body mass index (BMI), fear of gaining weight, denial of current low weight and its impact on health, and amenorrhoea. Estimated prevalence is highest in teenage girls, and up to 0.7% of this age... more
Anorexia nervosa is characterised by a low body mass index (BMI), fear of gaining weight, denial of current low weight and its impact on health, and amenorrhoea. Estimated prevalence is highest in teenage girls, and up to 0.7% of this age group may be affected. While most people with anorexia nervosa recover completely or partially, about 5% die of the condition, and 20% develop a chronic eating disorder. Young women with anorexia nervosa are at increased risk of bone fractures later in life. METHODS AND OUTCOMES: We conducted a systematic review which aimed to answer the following clinical questions: What are the effects of treatments for anorexia nervosa? What are the effects of interventions to prevent or treat complications of anorexia nervosa? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included...
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Research Interests: Psychology, Family Therapy, Psychopathology, Treatment Outcome, Adolescent, and 15 moreMedicine, Anorexia Nervosa, Humans, Child, Business and Management, Female, Feasibility Studies, Male, Attrition, Parents, Randomized Controlled Trial, Expectancy Theory, Body Weight, Weight Gain, and Behaviour Therapy
Research Interests: Psychology, Eating Disorders, Psychopathology, Adolescent, Medicine, and 15 moreAnorexia Nervosa, Humans, Female, Male, Psychological Intervention, Clinical Sciences, Cross Section, Longitudinal Study, Eating Disorder, Adolescent Psychiatry, Case Control Study, Bulimia, Protective Factor, cultural characteristics, and High risk
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Although mobile technologies for eating disorders (EDs) are burgeoning, there is limited data about the clinical characteristics of individuals using specialized smartphone applications (apps) without accompanying traditional forms of... more
Although mobile technologies for eating disorders (EDs) are burgeoning, there is limited data about the clinical characteristics of individuals using specialized smartphone applications (apps) without accompanying traditional forms of treatment. This study evaluated whether the users of an ED app cluster in clinically meaningful groups. Participants were 1,280 app users (91.3% female; mean age 27) who reported not being in a weekly treatment for their ED. A hierarchical cluster analysis distinguished five groups of participants, all approximating DSM-5 ED categories. One cluster comprised of non-female, ethnically diverse users with Bulimia Nervosa features. Findings suggest that app users resemble known patient classifications.
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Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are increasingly prevalent among children and adolescents. Whereas AN has a peak age of onset in early to mid-adolescence, BN typically presents during or after late... more
Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are increasingly prevalent among children and adolescents. Whereas AN has a peak age of onset in early to mid-adolescence, BN typically presents during or after late adolescence. There is a spectrum of eating disorders that can be categorised by the criteria in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders into AN, BN and 'eating disorder not otherwise specified (ED-NOS)'. The key clinical signs of AN are those of protein calorie malnutrition. In BN, signs of purging are also important. Despite marked physical changes, metabolic decompensation occurs late and when present is an indication for hospital admission. During refeeding, electrolyte disturbances, in particular hypophosphataemia, should be serially monitored. For females with AN, restoration of gonadotropins, oestradiol and resumption of menses is a cardinal indicator of nutritional recovery. Treatment should address the medical, nutritional and psychological needs of children and adolescents with eating disorders. No single professional can be proficient in all spheres. Children and adolescents with eating disorders are best managed by a 'team approach'. Treatment may occur in a variety of inpatient, daypatient or outpatient settings. The aims of medical treatment are to promote bodyweight gain and nutritional recovery. Psychiatric goals address the psychosocial precipitants, treat comorbid mood symptoms and assist the patient to develop alternative coping skills. The crude mortality of AN has decreased to around 6%. For children and adolescents, the morbidity from malnutrition is increased because of the biological changes that are interrupted.
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BackgroundAnorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies... more
BackgroundAnorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest that longer initial hospitalizations that normalize weight produce better outcomes and fewer admissions than shorter hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of hospitalization for weight restoration (WR) to medical stabilization (MS) in adolescent AN.MethodWe performed a randomized controlled trial (RCT) with 82 adolescents, aged 12–18 years, with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for gender, age and height, both followed by 20 sessions of out-patient, manualized family-based treatment (FBT).ResultsThe pr...
Research Interests: Psychology, Pediatrics, Evidence Based Medicine, Eating Disorders, Australia, and 15 morePsychopathology, Treatment Outcome, Adolescent, Medicine, Anorexia Nervosa, Psychological Medicine, Humans, Child, Hospitalization, Female, Male, Length of Stay, Randomized Controlled Trial, Body Weight, and Neurosciences
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Research Interests: Psychology, Eating Disorders, Adolescent, Medicine, Bulimia Nervosa, and 12 morePsychosomatic Medicine, Cognitive Flexibility, Neurocognitive, Humans, Child, Female, Wisconsin Card Sorting Test, Cognition disorders, Case Control Studies, Neuropsychological Tests, Psychology and Cognitive Sciences, and Medical and Health Sciences
Abstract The paper describes a manualized specific form on individually based developmentally oriented therapy for Anorexia Nervosa (AN) in adolescents. Adolescent focused psychotherapy for AN is derived from a self-psychology model and... more
Abstract The paper describes a manualized specific form on individually based developmentally oriented therapy for Anorexia Nervosa (AN) in adolescents. Adolescent focused psychotherapy for AN is derived from a self-psychology model and is designed to address key deficits in ...
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Research Interests: Psychology, Psychiatry, Eating Disorders, Psychopathology, Adolescent, and 14 moreMedicine, Bulimia Nervosa, Humans, Child, Female, Male, Psychosocial, Clinical Sciences, Outpatients, Randomized Controlled Trial, Selection Bias, Ambulatory Care, Randomized Controlled Trials as Topic, and Patient selection
Research Interests: Psychology, Clinical Psychology, Psychiatry, Eating Disorders, Child Development, and 15 moreAdolescent Development, Adolescent, Medicine, Anorexia Nervosa, Bulimia Nervosa, Children, Child Behavior, Malnutrition, Humans, Child, Classification, Adolescents, Clinical Sciences, Children and Adolescents, and Adolescent Behavior
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OBJECTIVE: Although eating disorders are common psychiatric disorders that usually onset during adolescence, few evidence-based treatments for this age group have been identified. A critical review of treatments used for Anorexia Nervosa... more
OBJECTIVE: Although eating disorders are common psychiatric disorders that usually onset during adolescence, few evidence-based treatments for this age group have been identified. A critical review of treatments used for Anorexia Nervosa (AN) and Bulimia Nervosa (BN) and related conditions (EDNOS) is provided that summarizes the rationale for the treatments, evidence of effectiveness available, and outcomes. METHOD: Critical review of published randomized clinical trials (RCTs). RESULTS: There are only seven published RCTs of psychotherapy for AN in adolescents with a total of 480 subjects. There are only two published RCTs for outpatient psychotherapy for adolescent BN with a total of 165 subjects. There are no published RCTs examining medications for adolescent AN or BN. For adolescent AN, Family-Based Treatment (FBT) is the treatment with the most evidence supporting its use. Three RCTs suggest that FBT is superior to individual therapy at the end of treatment; however, at follow...
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Even though anorexia nervosa (AN) was first recognized more than 125 years ago, this disorder still bewilders patients and their families and perplexes clinicians and researchers. Our understanding of the medical features of AN has... more
Even though anorexia nervosa (AN) was first recognized more than 125 years ago, this disorder still bewilders patients and their families and perplexes clinicians and researchers. Our understanding of the medical features of AN has advanced, increasing our success at weight restoration in specialist inpatient settings. Inpatient and day hospital treatments are generally effective in weight restoration, however, they are disruptive to the adolescentʼs family, social and educational life, and relapse is common. Moreover, weight restoration alone is not sufficient for recovery. The Maudsley family-based outpatient treatment for AN is a promising alternative model to costly inpatient or day hospital programs. This model, which strives to bring about weight restoration and restore the adolescentʼs developmental trajectory, is explored in this article. Research into treatment of anorexia in adolescents Few controlled clinical trials have been conducted to explore efficacious outpatient tr...
BACKGROUND Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak.... more
BACKGROUND Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak. OBJECTIVE The primary objective of this study was to evaluate the efficacy of an indicated, parent-based, Web-based preventive program Eltern als Therapeuten (E@T) in reducing risk factors and symptoms of AN. METHODS Girls aged between 11 and 17 years were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre- and postintervention (6 weeks later) and at 6- and 12-month follow-up (FU). RESULTS A total of 12,377 screening questionnaires were handed out in 86 German schools, and 3941 including consent returned. Overall, 477 (447/3941, 12.10%) girls were identified as at risk for AN and 256 of those could be contacted. In all, 66 familie...
Much has been written about the importance of humanities to the practice of health care in the last several decades, but for many, the rationale, need, and importance of the humanities remain poorly understood and appreciated [1]. By... more
Much has been written about the importance of humanities to the practice of health care in the last several decades, but for many, the rationale, need, and importance of the humanities remain poorly understood and appreciated [1]. By definition, health care always occurs in the human context. The health care provider-patient relationship is at the heart of almost all health care practices [2]. Developments in science, technology, and the economics of health care, while essential to the health care and the delivery of care, also pose significant challenges to the nature, quality, and maintenance of this relationship [3]. Evidence suggests that clinical outcomes, satisfaction (for both patients and health care providers), and costs are negatively affected when the human side of health care is neglected, marginalized, or otherwise disregarded. In addition, health care is a powerful cultural force that wields significant effects on knowledge and values and promotes actions in broader society that are often underappreciated and poorly understood [4]. Academic medical centers and medical schools are often associated and sometimes located in close proximity to an active university campus with scholars in humanities, social sciences, and the arts at the doorstep thus giving rise to an opportunity to promote interdisciplinary work at the interface of health care and these places. Historians, anthropologists, philosophers, and literary scholars are often active in attempting to shed light on health care in the broader human context. However, their insights and wisdom too seldom find their way to the medical campus.
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Treatments for avoidant/restrictive food intake disorder (ARFID) lack strong empirical support. There is a critical need to conduct adequately powered studies to identify effective treatments for ARFID. As a first step, the primary aim of... more
Treatments for avoidant/restrictive food intake disorder (ARFID) lack strong empirical support. There is a critical need to conduct adequately powered studies to identify effective treatments for ARFID. As a first step, the primary aim of this study was to assess the feasibility of conducting a randomized clinical trial (RCT) comparing Family-based Treatment for ARFID (FBT-ARFID) to usual care (UC). The primary outcomes were recruitment, attrition, suitability, and expectancy rates. The secondary aim was to assess changes in percent estimated body weight, eating related psychopathology, and parental self-efficacy from baseline to end of treatment/UC period in both groups. Recruitment rates were 1.87 per month; 28 children with ARFID and their families were randomized and attrition rate was 21%. Therapeutic suitability and expectancy rating suggested that FBT-ARFID was acceptable to families. Effect size (ES) differences on measures of weight and clinical severity were moderate to large, favoring FBT-ARFID over UC. Parental self-efficacy improvement also demonstrated a large ES favoring FBT-ARFID, which was correlated with improvements in ARFID symptoms. There is a research gap between our knowledge base on how to treat children with ARFID and clinical need. The data presented suggest that an RCT comparing FBT-ARFID and UC is feasible to conduct.
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OBJECTIVE This article uses three brief case reports to illustrate how family-based treatment (FBT) can be used to treat pre-adolescents with avoidant/restrictive food intake disorder (ARFID). METHOD We present case material illustrating... more
OBJECTIVE This article uses three brief case reports to illustrate how family-based treatment (FBT) can be used to treat pre-adolescents with avoidant/restrictive food intake disorder (ARFID). METHOD We present case material illustrating how FBT can be used in three different clinical presentations of ARFID: (1) low appetite and lack of interest; (2) sensory sensitive eaters; and (3) fear of aversive consequences eaters-all without shape or weight concerns. RESULTS This case material illustrates that the main principles of FBT-agnosticism as to the cause of the illness, externalization, emphasizing the seriousness of ARFID, parental empowerment, behavioral consultation, and practical behavioral focus-are applicable for a range of ARFID clinical presentations. Common challenges in this patient group include (1) promoting urgency; (2) challenging long term behavioral accommodation; (3) lack of parental alignment, parental fatigue, (4) and co-morbid psychiatric problems in the patients. Strategies to address these problems are described. CONCLUSION FBT can be adapted for children with ARFID using the main principles of the approach.
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PURPOSE OF REVIEW Family interventions for eating disorders are often recommended for the treatment of children and adolescents. Treatment studies and a range of treatment guidelines now recommend family-based treatment (FBT) for... more
PURPOSE OF REVIEW Family interventions for eating disorders are often recommended for the treatment of children and adolescents. Treatment studies and a range of treatment guidelines now recommend family-based treatment (FBT) for adolescents with anorexia nervosa (AN) and bulimia nervosa. The current report focused on studies that have been conducted over the past 2 years, most of them aimed at augmenting or improving outcomes using a range of new family approaches or adding other forms of therapy to standard FBT. RECENT FINDINGS There is increasing confusion of what type of family therapy is supported by the evidence, including FBT, FT-AN, MFT-AN, and parent-focused therapy. Seventy-five percentages of the adolescents with anorexia nervosa studies in randomized clinical trials used manualized FBT. None of the other family therapy approaches have more than 16% of the total adolescents with anorexia nervosa studied. Thus, FBT is the only form of family therapy with a substantive evidence base. Augmentation by varying the format of family therapy may be clinically useful, but differences in outcome from standard FBT are minor. SUMMARY The evidence base supporting the use of family therapy for adolescent anorexia nervosa is for manualized FBT. Augmentations of FBT using different formats (e.g., parents only, family groups, addition of individual therapy) have not demonstrated substantially improved outcomes over standard FBT for anorexia nervosa.
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Anorexia nervosa (AN) usually develops during adolescence when considerable structural and functional brain changes are taking place. Neurocognitive inefficiencies have been consistently found in adults with enduring AN and were suggested... more
Anorexia nervosa (AN) usually develops during adolescence when considerable structural and functional brain changes are taking place. Neurocognitive inefficiencies have been consistently found in adults with enduring AN and were suggested to play a role in maintaining the disorder. However, such findings are inconsistent in children and adolescents with AN. The current study conducted a comprehensive assessment of attention networks in adolescents with AN who were not severely underweight during the study using an approach that permits disentangling independent components of attention. Twenty partially weight-restored adolescents with AN (AN-WR) and 24 healthy adolescents performed the Attention Network Test which assesses the efficiency of three main attention networks-executive control, orienting, and alerting. The results revealed abnormal function in the executive control network among adolescents with AN-WR. Specifically, adolescents with AN-WR demonstrated superior ability to ...
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Adolescents with anorexia nervosa who have obsessive-compulsive (OC) features respond poorly to family-based treatment (FBT). This study evaluated the feasibility of combining FBT with either cognitive remediation therapy (CRT) or art... more
Adolescents with anorexia nervosa who have obsessive-compulsive (OC) features respond poorly to family-based treatment (FBT). This study evaluated the feasibility of combining FBT with either cognitive remediation therapy (CRT) or art therapy (AT) to improve treatment response in this at-risk group. Thirty adolescents with anorexia nervosa and OC features were randomized to 15 sessions of FBT + CRT or AT. Recruitment rate was 1 per month, and treatment attrition was 16.6% with no differences between groups. Suitability, expectancy and therapeutic relationships were acceptable for both combinations. Correlations between changes in OC traits and changes in cognitive inefficiencies were found for both combinations. Moderate changes in cognitive inefficiencies were found in both groups but were larger in the FBT + AT combination. This study suggests that an RCT for poor responders to FBT because of OC traits combining FBT with either CRT or AT is feasible to conduct. Copyright © 2017 Jo...
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Cognitive remediation therapy represents a new approach to the treatment of anorexia nervosa (AN) emerging from research, suggesting that adults with chronic AN have specific neurocognitive inefficiencies. Specifically, adults with AN... more
Cognitive remediation therapy represents a new approach to the treatment of anorexia nervosa (AN) emerging from research, suggesting that adults with chronic AN have specific neurocognitive inefficiencies. Specifically, adults with AN demonstrate an overly detailed cognitive processing bias (Roberts, Tchanturia, & Treasure, 2013) and difficulties shifting set quickly and efficiently (Roberts, Tchanturia, Stahl, Southgate, & Treasure, 2007). These characteristics manifest as rigid, rule-bound, and detail-focused cognitions, beliefs, and behaviors. Versions of these problems appear to persist after weight restoration (Tchanturia et al., 2004) and are observable in patient's healthy sisters (Roberts et al., 2013). Thus, central coherence difficulties and set-shifting problems have been proposed as endophenotypes and maintaining factors of AN (Roberts et al., 2013). (PsycINFO Database Record
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Dissemination and implementation of evidence-based treatments are among the biggest challenges facing clinical psychiatry. Developing scalable evidence-based treatments is a major priority and fraught with challenges. This article... more
Dissemination and implementation of evidence-based treatments are among the biggest challenges facing clinical psychiatry. Developing scalable evidence-based treatments is a major priority and fraught with challenges. This article describes the development of 3 technology-based innovations. It discusses the use of massive open online courses (MOOCs) and mobile applications. Three projects are presented: (1) the modification of a MOOC methodology for psychotherapy training clinicians in manualized family-based therapy (FBT) for adolescents with anorexia nervosa; (2) a modified MOOC platform for the delivery of FBT; and (3) the development of mobile applications for treatment augmentation and delivery.
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Insights into how males experience eating disorder symptoms early in the course of illness are important to improve detection efforts and may also provide valuable information for treatment. In this qualitative study, 10 adolescent males... more
Insights into how males experience eating disorder symptoms early in the course of illness are important to improve detection efforts and may also provide valuable information for treatment. In this qualitative study, 10 adolescent males and 10 matched female patients completed standardized questionnaires and were interviewed. Results indicated that although there were many similarities between the genders, females were more likely to describe the involvement of family systems and males were more likely to describe involvement in sports as being catalysts for their disorders. Males in this study were more positive about being in treatment.
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The connection between maternal eating disorders and feeding and eating problems among their children has been substantially demonstrated. This pilot study focused on the interactions between mothers with eating disorders and their... more
The connection between maternal eating disorders and feeding and eating problems among their children has been substantially demonstrated. This pilot study focused on the interactions between mothers with eating disorders and their toddlers in non-feeding situations. Twenty-eight dyads of mothers with prenatal eating disorders and their toddlers were compared to a case-matched control group with no eating disorder. Maternal current eating and co-occurring psychopathology, children's symptoms and mother-child interactions were measured. Mothers with eating disorders were less sensitive to their children, tried to control their children's behaviors more, and were less happy during mother-child interactions. The children in the maternal eating disorder group were rated as less responsive to their mothers and their mothers also reported more behavioral problems than those in the control group. Findings imply that maternal eating disorders may be linked with a wide range of adverse maternal and child behaviors beyond those associated with eating.
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The children of mothers with eating disorders are at high risk of feeding and eating problems and broader developmental difficulties. The Parent-Based Prevention (PBP) of eating disorders targets risk factors and facilitates behavioral... more
The children of mothers with eating disorders are at high risk of feeding and eating problems and broader developmental difficulties. The Parent-Based Prevention (PBP) of eating disorders targets risk factors and facilitates behavioral change in parents to mitigate potentially negative outcomes of their children. This pre/post uncontrolled study evaluated the feasibility and preliminary outcomes of PBP. PBP was found to be a feasible intervention for mothers with eating disorders and their spouses, with satisfactory retention rates. A total of 16 intact families were assessed at three measurement points for parents' feeding practices, child outcomes, and maternal functioning. Both parents reported improved feeding practices as well as more positive perceptions of their children in comparison to baseline. These pilot findings suggest that PBP is linked with decreased risk of eating and mental problems among the offspring of mothers with eating disorders.
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There is a paucity of randomized clinical trials (RCTs) for adolescents with bulimia nervosa (BN). Prior studies suggest cognitive-behavioral therapy adapted for adolescents (CBT-A) and family-based treatment for adolescent bulimia... more
There is a paucity of randomized clinical trials (RCTs) for adolescents with bulimia nervosa (BN). Prior studies suggest cognitive-behavioral therapy adapted for adolescents (CBT-A) and family-based treatment for adolescent bulimia nervosa (FBT-BN) could be effective for this patient population. The objective of this study was to compare the relative efficacy of these 2 specific therapies, FBT-BN and CBT-A. In addition, a smaller participant group was randomized to a nonspecific treatment (supportive psychotherapy [SPT]), whose data were to be used if there were no differences between FBT-BN and CBT-A at end of treatment. This 2-site (Chicago and Stanford) randomized controlled trial included 130 participants (aged 12-18 years) meeting DSM-IV criteria for BN or partial BN (binge eating and purging once or more per week for 6 months). Outcomes were assessed at baseline, end of treatment, and 6 and 12 months posttreatment. Treatments involved 18 outpatient sessions over 6 months. The primary outcome was defined as abstinence from binge eating and purging for 4 weeks before assessment, using the Eating Disorder Examination. Participants in FBT-BN achieved higher abstinence rates than in CBT-A at end of treatment (39% versus 20%; p = .040, number needed to treat [NNT] = 5) and at 6-month follow-up (44% versus 25%; p = .030, NNT = 5). Abstinence rates between these 2 groups did not differ statistically at 12-month follow-up (49% versus 32%; p = .130, NNT = 6). In this study, FBT-BN was more effective in promoting abstinence from binge eating and purging than CBT-A in adolescent BN at end of treatment and 6-month follow-up. By 12-month follow-up, there were no statistically significant differences between the 2 treatments. -Study of Treatment for Adolescents With Bulimia Nervosa; http://clinicaltrials.gov/; NCT00879151.
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The current study examined the relation between parental expressed emotion (EE) and treatment outcome among adolescents participating in a treatment study for adolescent anorexia nervosa, as well as its impact on family functioning. One... more
The current study examined the relation between parental expressed emotion (EE) and treatment outcome among adolescents participating in a treatment study for adolescent anorexia nervosa, as well as its impact on family functioning. One hundred and twenty-one families were assigned to family-based treatment or adolescent-focused therapy. Paternal criticism predicted lesser improvement in eating disorder psychopathology at end of treatment. There was also a significant interaction between maternal hostility and treatment, indicating that adolescents whose mothers displayed hostility had greater increases in percent of expected body weight in adolescent-focused therapy than family-based treatment. In addition, maternal hostility predicted less improvement in general family functioning and family communication at the end of treatment. Findings suggest that maternal and paternal EE may differentially impact treatment outcome and should be directly attended to in clinical settings. Futur...