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Working with Eating Disorder Patients Elise Curry Psy.D. Program Manager UCSD IOP Terry Schwartz MD Medical Director UCSD Eating Disorders Program Asst Clinical Professor UCSD Structure of 3 day training Day 1: Intro to ED assessment and treatment Day 2 and 3: More specifics “how to”, therapy modalities, special populations Anorexia Nervosa Most homogenous psychiatric disorder 90-95% female Onset teenage years – puberty Monotonous puzzling symptoms Poor response to treatment Highest mortality rate 50% to 80% contribution of genes DSM IV Criteria for Anorexia Nervosa Preoccupation with body shape, weight/size <85% ideal BW Fear of becoming fat despite low weight Loss of 3 consecutive periods in women Types: restricting,binge/purge,purge DSM IV criteria for Bulimia Nervosa Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as selfinduced vomiting or misuse of laxatives, diurética, enemas, or other medications (purging); fasting; or excessive exercise The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months Self-evaluation is unduly influenced by body shape and weight Diagnostic challenges in EDs (ED NOS) BN vs. AN: binge/purge type Sandy is 5 ft tall and weighs is 80 lbs. She has regular periods and no body distortion. She is 16 yrs old. Sally purges normal meals, but does not binge. Tom thinks he needs to gain weight. He uses exercise to purge. He binges 2 times per week and then goes running. Shelly chews and spits her food several times a day Possible Signs of an Eating Disorder Preoccupation with food/weight Dramatic weight loss or gain Chronic dieting Feels cold all the time Dental problems History of ballet, wrestling, or modeling Disgusted by red meat or desserts Has difficulty eating with people Cuts out food groups Becomes vegetarian/vegan as a teen Uses bathroom after meals Wears baggy clothes or layers Cooks for other excessively Excessive exercise Scope of The Problem Prevalence increasing AN: .5-2% BN: 3-4% AN BN More common westernized cultures 10% of eating disordered individuals in treatment are male 5%-20% of AN patients die (disorder or suicide) Primary Causes of Death in Patients with Eating Disorders 1. Starvation 2. Cardiac arrhythmia/failure from hypokalemia of ipecac abuse 3. Suicide 4. Gastric Dilation AN, Restricting Subgroup AN, Bulimia Subgroup ++ + + ++ ++ + ++ ++ + + Bulimia Nervosa Scope of the problem: continued One of the highest death rates from any mental health condition (AN) Increasing incidence in elementary age children (8-11 year old) The incidence of bulimia in 10-39 year old women TRIPLED between 1988 and 1993. There has been a rise in incidence of anorexia in young women 15-19 in each decade since 1930. Ethnic Diversity in EDs Minnesota Adolescent Health Study found that dieting was associated with weight dissatisfaction, perceived overweight, and low body pride in all ethnic groups (Story et al, 1997). Among the leanest 25% of 6th and 7th grade girls, Hispanics and Asians reported significantly more body dissatisfaction than did white girls. Robinson et al (1996) Cultural Issues More common in Westernized Societies Historically self starvation reported prior to 19th century (religious/spiritual “reasons”) Cultural importance placed on “thinness” Less common in cultures where roundness is sign of fertility, health, prosperity Hong kong, India : AN w/o fear of fat. “Many individuals in our culture, for a number of reasons, are concerned with their weight and diet. Yet less than half of one percent of all women develop anorexia nervosa, which indicates to us that societal pressure alone isn’t enough to cause someone to develop this disease,” said Kaye. Media Stats The average young adolescent watches 3 to 4 hours of TV per day (Levine, 1997). A study of 4,294 network television commercials revealed that 1 our of every 3.8 commercials send some sort of “attractiveness message,” telling viewers what is or is not attractive (as cited in Myers et al, 1992). These researchers estimate that the average adolescent sees over 5,260 “attractiveness messages” per year. Another study of mass media magazines discovered that women’s magazines had 10.5 times more advertisements and articles promoting weight loss than men’s magazines did (as cited in Guillen & Barr, 1994). Drive for thinness and dieting Girls who diet frequently are 12 times as likely to binge as girls who don’t diet (Neumark-Sztainer,2005). Most fashion models are thinner than 98% of American women (Smolak, 1996). The average American woman is 5’4” tall and weighs 140 lbs. The average model is 5’11” and weighs 117 lbs. 35% of “normal dieters” progress to pathological dieting. Of those, 20-25% progress to partial or full syndrome eating disorders (Shisslak & Crago, 1995). 95% of all dieters will regain their lost weight in 1 to 5 years (Grodstein, et al., 1996). Americans spend over $40 billion on dieting and diet related products each year (Smolak, 1996). Body Image How you see yourself when you look in the mirror or when you picture yourself in your mind. What you believe about your own appearance (including your memories, assumptions, and generalizations). How you feel about your body, including your height, shape, and weight. How you sense and control your body as you more. How you feel in your body, not just about your body. NEDA website Negative body image A distorted perception of your shape – you perceive parts of your body unlike how they really are. You are convinced that only other people are attractive and that your body size or shape is a sign of personal failure. You feel ashamed, self-conscious, and anxious about your body. You feel uncomfortable and awkward in your body. NEDA website Positive body image A clear, true perception of your shape – you see various parts of your body as they really are. You celebrate and appreciate your natural body shape and you understand that a person’s physical appearance says very little about their character and value as a person. You feel proud and accepting of your unique body and refuse to spend an unreasonable amount of time worrying about food, weight, and calories. You feel comfortable and confident in your body. NEDA website Childhood Symptoms OC Personality Traits: Percentage of Individuals With Traits 100 AN (n=26) % of Patients 80 60 65 72 AN-BN (n=18) 77 BN (n=28) 80 62 61 50 50 40 25 20 0 Perfectionistic Inflexible Anderluh MB, et al. Am J Psychiatry. 2003;160(2):242-247. Rule Bound Psychological Correlates of Anorexia Nervosa Poor self concept Obsessive compulsive and avoidant personality style Perfectionistic, obsessive, harm avoidant traits Family dynamics: enmeshment, anxiety, over-achievers Troubles with major life transitions an attempt to regress, avoid development Difficulty managing and expressing anger Cognitive distortions Ego-syntonic nature of disease Psychological Correlates of Bulimia Nervosa Poor self concept Chaotic developmental history, parental deficit ambiguous communication styles Affective regulation problems Cognitive distortions Ego-dystonic nature of disease Impulsivity, substance abuse, self harm, sexual acting out, shop lifting Distorted Beliefs There are “good” foods and “bad” foods. If I am fat, no one will love me. If I eat too much, I need to get rid of it by purging. If I eat this piece of cheesecake, I will be able to see it on my body tomorrow. You can never be too rich or too thin. Thinness equals happiness. Using laxatives gets rid of all the food. Purging gets rid of all the food. My worth is my weight. It is more important to be thin than anything else. Everyone hates fat people. Men like women who are skinny. Recovery Beliefs My worth is not my weight. My body is an instrument, not an ornament. When I treat my body well, by eating 3 balanced meals per day and exercising moderately, my body will find its own set-point weight. People come in all kinds of shapes and sizes. I don’t have to try to mold my body into a standard set by the media or fashion industry. I need some fat in my diet in order to have soft skin, shiny hair, and be able to become pregnant some day. I can enjoy having a more curvy body, instead of striving for thinness. I am unique and special due to my inner qualities. Perfectionism only leads to disappointment, not happiness. Goal of Psychological Treatment Help pt to adjust to their personality traits/temperament Reduce anxiety through use of positive coping skills Reduce “eating disorder voice” and develop a “recovery voice.” Increase focus on inner qualities to define self, rather than physical traits like thinness. Important initial assessment/screening issues/tools in EDS See Screening Handout Screening Questions How many diets have you been on in the past year? Do you think you should be dieting? Are you dissatisfied with your body size? Does your weight affect the way you think about yourself? Introduction to Treatment NEEDS met by the eating disorder: Safety/Survival: reduction of anxiety Love/Belonging: best friend Freedom: no one can take the e.d. away Power/control/importance: feeling superior, weight loss as an accomplishment Fun/relaxation/release: endorphins released by purging Case Study: Tom A Major Truth: Feelings Follow Thoughts & Actions Thoughts Actions Needs Want Choices Feelings Physiology Group Therapy Structured on-site meal Milieu therapy/ use of group CBT/DBT Process group Nutritional counseling Body image group Art Therapy Relaxation, meditation Power of the Group Reduce isolation Enhance accountability Shame reduction Encourage each other Forward momentum of the group Establish healthy group norms How group leader uses group to enhance individual growth Individual Therapy Affect regulation and tolerance Impulsivity Externalization of self worth Feelings of ineffectiveness, inadequacy Rejection sensitivity DBT PMD and dietitian Family Therapy Required with Adolescents Maudsley Family Therapy Systemic Family Therapy Couples UCSD Eating Disorder IOP (Individual and Family Therapy by appointment) Mon. Tues. Adult and Teen Process Groups Wed. Thurs. Adult Art Therapy Dialectical Behavioral Therapy Meditation Snack Goal Setting Group Dinner Meal and Nutrition Education Treatment Team for all Staff Cognitive Behavioral Therapy Adult Mindfulness Based Stress Reduction Or Teen Art Therapy Goal Setting Dinner Meal Process Meal Goal Setting Fri. Common Management Issues Denial, resistance Lack of insight and motivation for treatment Failure to learn from experience Adolescent – anxious parents, conflicts Adults – family burn out Ambivalence: pt wants to recover, but does not want to gain any weight Expected Issues Patients and Families Obsessive anxiety – much reassurance and discussing details of care Perfectionism – not good enough Stress and conflicts over eating, weight, control, meal plan etc. Over-exercise Undermining treatment: i.e. taking the pt running Countertransference Issues Feeling angry at the patient for not recovering Thinking this is “willful” behavior Blaming the parents Feeling incompetent Giving up hope for the patient Not taking the disorder seriously Coping with Countertransference Issues Practice patient acceptance: The average recovery rate is 7 years. Have compassion for the suffering of the patient. See their behavior as part of the disorder, not personal toward you. Practice good self-care. Overview of biological underpinnings of EDS Genetic Correlates in Anorexia Nervosa Family and twin studies Serotonin receptor gene Variation in Dopamine 2 receptor gene Chrom 1 and 10 Family history of OCD, OCPD, AN Genetic Correlates of Bulimia Nervosa Twin studies 5ht2A receptor alteration Family history of affective, anxiety, substance abuse d/o Neuroendocrine Correlates of Anorexia Nervosa Serotonin (5HT2A receptor) Dopamine Endogenous opiate response to starvation Hypothalamus dysfunction (satiety, amenorrhea) Neuroendocrine correlates of Bulimia Nervosa Serotonin (5HT1A receptor) Endogenous opiate response to binge purge Neuropsychiatric correlates of Eating Disorders Iowa gambling task: AN vs CW: Differences seen on fMRI AN: Neuropsych testing: difficulties with set shifting, flexibility AN: Detail focus, to the point of missing global (Janet Treasure) AN vs BN Use in clinical practice Cognitive Flexibility Anorexia Nervosa Perceptual rigidity Cognitive rigidity AN Weight recovery No changes AN Full recovery Partial improvement in cognitive flexibility tasks Bulimia Nervosa Slowness in cognitive shifting tasks Fluctuations in Perceptual task Psychiatric co morbidity PSYCHIATRIC COMORBIDITY: Anorexia Nervosa affective disorders anxiety disorders psychotic disorders personality disorders Substance abuse PSYCHIATRIC COMORBIDITY: Bulimia Nervosa affective disorders anxiety disorders ICDs personality disorders Substance abuse Psychiatric symptoms in AN and BN Premorbid onset “Best little girl in the world” Majority have childhood anxiety disorder that precedes onset AN, BN Childhood negative self-evaluation, perfectionism, rule bound, inflexible, obsessive personality Persistent symptoms after recovery Obsessions - body image, weight, food Obsessions - perfectionism, symmetry, exactness Anxiety, harm avoidance Behaviors are exaggerated by malnutrition Differences Between AN and BN Novelty seeking BN > AN, BN extremes of over- and under-control Anxiety Disorders (AD) Lifetime and Premorbid Rates Study ED n Lifetime AD AD before ED Deep 95 AN 24 68% 58% Bulik 97 AN 68 60% 54% Bulik 97 BN 116 57% 54% Godart 00 AN 29 83% 62% Godart 00 BN 34 71% 62% AN,BN 672 64% 61% 23% OCD 13% social phobia Kaye 04 Lifetime OCD Diagnosis in AN, BN Diagnosis AN AN BN BN Range 10 – 62% 10 – 66% 0 – 43 % Percent with Diagnosis Review of Literature Godart 2002 Price Foundation Genetic Collaborative Study Total 1416 subjects DSM IV, SCID I, Y-BOCS MS/PhD Clinical Interview N. America, England, Germany 60 50 40 30 20 10 0 AN (n 619) AN BN (n 515) BN (n 282) General population rate OCD: 1-3% of adults; 2-4% of children (Grados 97, Riddle 98; Serpell 02) Obsessive-Compulsive Personality Disorder (OCPD) Diagnoses in ED from Clinical Interviewer Assessment Cassin S, von Ranson K: Personality and eating disorders: a decade in review Clin Psychol Rev 2005;25(7):895-916 Subjects Range of OCPD RAN 2 – 30% BN 2 – 19% Important Medical issues in treatment of EDs Physical Complications of Anorexia Nervosa Organ System Symptoms Lab Test Results 1. Whole body Weakness, lassitude Low weight/body mass index, low body fat percentage 2. CNS Apathy, poor concentration CT: ventricular enlargement; MRI: decreased gray and white matter 3. CV Pre-syncope, palps, dyspnea, weakness, cold extremities, chest pain ECG: sinus bradycardia, other arrhythmia, QTc prolongation; cardiac echo (consider): MVP, silent pericardial effusion Physical Complications of Anorexia Nervosa; Cont. Organ System Symptoms Lab Test Results 4. Muscular Weakness, muscle aches Muscle enzyme abnormalities in severe malnutrition 5. Reproductive Prepubertal psychosexually Hypoestrogenemia; prepubertal patterns of LH, FSH 6. Endocrine, metabolic Fatigue, cold intolerance, diuresis, vomiting Elevated cortisol; euthyroid sick; dehydration; electrolyte abnormalities; low phos on refeeding; hypoglyc.(rare) Physical Complications of Anorexia Nervosa; Cont. Organ System Symptoms Lab Test Results 7. GI Vomiting, abdom. pain, bloating, constipation Delayed gastric emptying; occas. abnl LFTs 8. Renal Pitting edema Elevated BUN; renal failure 9. Skeletal Bone pain w/ exercise X-ray/bone scan w/ stress fx; DEXA w/ osteopenia or osteoporosis Physical Complications of Bulimia Nervosa Organ system Symptoms Lab Test Results 1. Metabolic Weakness; irritability Dehydration; serum electrolytes: ↓K+, ↓Cl alkalosis w/ vomiting; ↓Mg, ↓K+, ↓Phos w/ laxative abuse 2. GI Abdom. pain; constipation; bloating; reflux Physical Complications of Bulimia Nervosa; cont. Organ system Symptoms Lab Test Results 3. Oropharyngeal Dental decay; swollen cheeks X-rays confirm erosion of dental enamel; elevated serum amylase 4.CV and muscular (in ipecac abusers) Palpitations; weakness Cardiomyopathy and arrhythmias; peripheral myopathy Amenorrhea and Osteopenia Most serious complication of prolonged amenorrhea is osteopenia, or reduced bone mass Degree of osteopenia depends on age of onset and duration of amenorrhea Adolescence is critical time for bone mass acquisition Approx 60% of peak bone mass is accrued during adolescence Little net gain in bone mass after 2 yrs post-menarche Peak bone mass achieved by end of Osteopenia and Osteoporosis Osteopenia refers to decreased quantity of normally mineralized bone Osteoporosis is clinical syndrome consisting of decreased bone mass, disruption in normal bone architecture with decreased bone strength, pathological fractures, pain and disability Osteoporosis defined as greater than 2.5 SD below the mean for young adult women Osteopenia 1-2.5 SD below young adult ref Bone Density and Fractures Each SD decrease in bone density doubles the fracture risk DEXA is most widely used method for measuring bone density May be compared with age-matched children and adolescents (Z scores) Prevalence of Bone Loss in AN (N=130) % Women with AN and Bone Loss at Any Site 100 90 80 70 60 50 40 30 20 10 0 Osteopenia (Grinspoon et al, Ann Int Med, 2000) Osteoporosis Mechanisms of Bone Loss in AN Undernutrition: – Low lean body mass – Reduced calcium and Vitamin D intake – IGF-I deficiency Hormonal: – – – – Estrogen deficiency Resistance to growth hormone (GH) Elevated cortisol (stress hormone) Deficiency of other hormones • Testosterone • Dehydroepiandrosterone (DHEA) Bone Loss Treatment Strategies No therapies proven effective for bone loss in women with AN. Estrogen: Decision on estrogen individualized, but no convincing data that estrogen alone increases bone density in AN population. Potential therapies under study: – IGF-I – DHEA – Testosterone – Bisphosphonates Osteoporosis Treatment Weight gain Calcium supplementation improves bone mass (1500-2000mg/day) Vitamin D Moderate weight-bearing exercise increases bone mass When medically stable, wt bearing exercises 3-4 times per week Is there a benefit to treatment of Amenorrhea Drugs – Appearance of normal menses AN – abnormalities driven by malnutrition Drugs are NOT substitute for nutrition – Illusion that problem is “solved” ? Ineffective or harmful – Menses – regulated by complex neuroendocrine circuits Medical evaluation for Anorexia Nervosa Assess for co morbidity Screening labs: electrolytes, Ca++, Mg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UA Bone density (DEXA) EKG REFEEDING COMPLICATIONS Normal food – – – – Peripheral edema Bloating or discomfort Reflux Rare gastric dilitation Nasogastric feeding – Seldom indicated – Nasal, esophageal erosion Central hyperalimentation – Rarely indicated – Pneumothorax, infection, metabolic disturbances Nutritional Restoration and Weight Gain in AN Starvation and weight loss – ego syntonic Increased dysphoria before and during meals Food and weight obsessions and rituals – Stereotypic food choices, ritualized eating, calorie counting – Delusionary quality – Nothing else is more important Requirements for weight gain in anorexia nervosa excess calories (over maintenance) to gain 1 kg Study calories Russell and Mezey. 1962 7525 + 585 Walker et al 1979 6401 + 1627 Dempsey et al 9768 + 4212 Forbes et al 1984 5340 + 1850 Kaye et al 1988 8301 + 2272 Eating behavior in AN – After weight restoration Hypermetabolic restoration after weight – RAN need 50 to 60 kcal/kg/day – BAN need 40 to 50 kcal/kg/day – 50 kg women = 2000 to 3000 kcal/day Probably normalizes in long term Probable contribution to high rate of relapse Medical evaluation for Bulimia Nervosa Assess for comorbidity Screening labs: electrolytes, Ca++, Mg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UA EKG Dental Pharmacology for AN SSRIs Atypical antipsychotic medications Meds tried and failed for appetite enhancement GI meds to aid physical symptoms Pharmacology for BN Serotonin re-uptake inhibitors AEDs (topiramate, ?zonisamide) Antipsychotics Mood stabilizers reglan, H2 blockers Methods of Treatment A. Regular Weight restoration • • • B. 2 to 3 lbs/wk inpatient 1 to 2 lbs/wk day-hospital 1 lb/wk outpatient Nutritional Teaching • • • Provide patient support Prevention from vitamin and mineral deficiency Prevention of osteoporosis Aim for high Ca++ intake Vitamin D to aid in Ca++ absorption; vegetarians may need supplements Eat iron-containing foods, especially important for vegetarians Integrated treatment programs Multidisciplinary treatment team Program manager Psychiatrist Therapists with ED training Registered Dietitian Internist/Pediatrician AN: Hospital vs Outpatient Treatment From American Psychiatric Association Guidelines for the Treatment of Eating Disorders Weight Medical complications Suicidal, comorbid psych d.o. Motivation, insight, cooperation Excessive exercise, purging, etc Stress, family dynamics Outpatient Inpatient >85% < 75% none Not present HR, BP, K etc severe yes no minimal severe minimal severe Referral to Higher level of care Pt is failing lower level. Pt’s weight loss is continuing in spite of treatment Pt is unable to stop bingeing/purging. Pt’s physical symptoms warrant greater supervision (fainting, dehydration, heart palpitations) Pt is resisting current level of care Specific LOC Considerations OP: high motivation, >85% IBW IOP: moderate motivation, >80%IBW PHP: >75% RTC: clinical issues IP: <75% IBW, psych co morbid severe (SI) UCSD Intensive Family Therapy program Legal controversy Outcome Data for EDs Data mixed results due to design of studies AN 10 yr: 50% rec, 20-30% improved but still symptomatic, 1020% chronic, up to 10% mortality BN 10yr: 50%-70% rec, 30% some improvement, 20% chronic Outcomes for EDS Some studies show ave of 7 years to rec Less than 1 year of treatment has poorer prognosis Chronicity, OCPD, purging in AN associated with worse outcome