UNDERSTANDING AND COPING WITH BINGE EATING DISORDER: THE PATIENT S PERSPECTIVE

Transcription

1 UNDERSTANDING AND COPING WITH BINGE EATING DISORDER: THE PATIENT S PERSPECTIVE Susan L. McElroy, MD Anna I. Guerdjikova, PhD, LISW, CCRC Lindner Center of HOPE and University of Cincinnati Medical Center, Cincinnati, Ohio This activity is supported by an independent educational grant from Shire.

2 Financial Disclosures Dr McElroy is a consultant for Bracket, F. Hoffmann-La Roche, MedAvante, Naurex, Novo Nordisk, Shire, and Sunovion and has received grant/research support from Alkermes, Cephalon, Forest, Marriott Foundation, Naurex, Orexigen Therapeutics, Shire, and Takeda. Dr Guerdjikova has no personal affiliations or financial relationships with any commercial interest to disclose relative to this presentation.

3 Objectives After watching this video, you should be able to: Recognize warning signs and clues to a possible binge eating disorder (BED) in your patients Educate patients about pharmacologic and nonpharmacologic strategies to manage BED Assess patients with BED for comorbid disorders such as mood and anxiety disorders

4 Prevalence and Features of BED

5 BED is the Most Common Eating Disorder in the United States 2.6% of US adults have BED at some point in their lifetime 60% of people with BED are female 40% of people with BED are male Data from the National Eating Disorders Association. infographic-binge-eating-disorder. Kessler RC et al. Biol Psych. 2013;73(9):

6 What is BED? BED is a disorder characterized by recurrent episodes of consumption of large amounts of food, associated with loss of control (binge eating episodes) without compensatory measures (purging). Features of BED: Heritable: shared genetic factors with obesity and mood disorders Increased intake in binge and non-binge meals Increased gastric capacity/distention Neuroimaging abnormalities Abnormalities in neurotransmitter function Dysregulation in reward system Disinhibition, decreased impulse control APA. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

7 Heritability of BED Unique environment 42% 45% Additive genetic 13% Shared environment Data from Mitchell KS et al. Psychol Med. 2010;40(11):

8 BED is Associated With Overeating (night eating, grazing, loss of control) and weight gain Obesity, including severe obesity (BMI 40) and possibly metabolic syndrome Mood, anxiety, substance use, and impulse control disorders (eg, ADHD) Reduced quality of life and impairment in role functioning (comparable to bulimia nervosa) Agh T et al. Eat Weight Disord. Published online ahead of print Jan 9, Hudson JI et al. Am J Clin Nutr. 2010;91(6): Kessler RC et al. Biol Psych. 2013;73(9): Preti A et al. J Psychiatric Res. 2009;43(14):

9 BED: Medical Comorbidities >40% of obese patients with BED have metabolic syndrome 1,2 Elevated triglycerides Abdominal obesity Hypertension Low HDL Type 2 diabetes 2x more frequent in men than women Headaches and chronic pain 3 Fibromyalgia 4 Irritable bowel syndrome 4 1. Hudson JI et al. Am J Clin Nutr. 2010;91(6): Barnes RD et al. Primary Care Companion CNS Disord. 2011;13(2):ii. 3. Kessler RC et al. Biol Psych. 2013;73(9): Javaras KN et al. J Clin Psych. 2008;69(2):

10 BED: Psychiatric Comorbidities National Comorbidity Survey Replication 1 80% of people with BED meet criteria for at least 1 of the core DSM-IV disorders ~50% meet criteria for 3 Mood disorders 1,2 Major depressive disorder, especially atypical depression 3 Bipolar disorders Anxiety disorders 1,2 Panic disorder, OCD, PTSD Substance use disorders 1 Impulse control disorders 1 ADHD, oppositional defiant disorder, conduct disorder Suicidality 4 1. Hudson JL et al. Biol Psychiatry. 2007;61(3): Kessler RC et al. Biol Psych. 2013;73(9): Lasserre AM et al. JAMA Psychiatry. 2014;71(8): Swanson SA et al. Arch Gen Psychiatry. 2011;68(7):714.

11 Diagnosis of BED

12 DSM-5 Criteria for the Diagnosis of BED General Presentation: Recurrent episodes of binge eating occurring at least once a week for 3 consecutive months* Eating a larger amount of food than normal during a short time frame (any 2-hour period) A sense of lack of control over eating during the binge episode (cannot stop eating or control type or amount of food) *Change from DSM-IV criteria APA. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

13 DSM-5 Criteria for the Diagnosis of BED Binge eating episodes are associated with 3 of the following: Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not physically hungry Eating alone out of embarrassment over quantity eaten Feeling disgusted, depressed, ashamed, or guilty after overeating APA. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

14 DSM-5 Criteria for the Diagnosis of BED Additional characteristics: Marked distress regarding binge eating is present Binge eating is not associated with regular inappropriate compensatory behavior, such as purging or excessive exercise Binge eating does not occur exclusively during the course of bulimia nervosa or anorexia nervosa APA. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

15 Typical BED Presentation in a Primary Care Setting BED and depression are often comorbid Patients often ask for help for depression and weight gain rather than binge eating BED symptoms often increase during stressful situations, such as divorce

16 Treatment of BED

17 Most People With BED Remain Untreated A minority of patients with BED have received treatment in the past 12 months or during their lifetime Patients, % Month Treatment Lifetime Treatment Hudson JI et al. Biol Psychiatry. 2007;61(3):

18 Standard of Care for BED Has Not Been Defined CBT (CBT-E) is considered gold standard in BED treatment Psychoeducation is imperative for good treatment Treatment needs to address shame, poor self-image, self-disgust, and other negative emotions and psychological issues Treatment for BED must be highly individualized Wilson GT et al. Am Psychol. 2007;62(3): McElroy SL et al. Ther Clin Risk Manag. 2012;8:

19 Goals and Treatments for BED and Its Comorbid Illnesses Target Pathology Treatment Goals Treatments Eating psychopathology Comorbid psychopathology Excess adiposity Reduce: binge eating episodes, obsessive/compulsive features of BED Reduce: anxiety and depressive symptoms Prevent further weight gain or begin weight loss CBT IPT DBT Pharmacotherapy Pharmacotherapy CBT IPT Behavioral weight management Pharmacotherapy Bariatric surgery CBT = cognitive behavioral therapy, DBT = dialectical behavioral therapy, IPT = interpersonal therapy

20 Treatment Goals and Outcomes No consensus on treatment outcomes in BED: Response is often defined as a 50% to 75% or greater reduction in binge eating behavior Remission is often defined as cessation of binge eating for 28 days Currently, the field focuses on treating BED symptoms and not the weight issue, which is a debatable problem because many patients seek help for weight loss and not specifically for BED Treatment goals: Reduce the frequency of eating binges Improve the patient s emotional well-being Lose weight when necessary Define goals with patients and ensure they understand the complexity of the problem Lock J et al. Int J Eat Disord. 2013;46(8): Wilson GT et al. Am Psychol. 2007;62(3): Grilo CM et al. J Consult Clin Psychol. 2011;79(5):

21 Treatment Options for BED Psychoeducation, self-help strategies Empirically based psychological treatments Behavioral weight loss treatment Obesity surgery Pharmacotherapy Combination therapy McElroy SL et al. Ther Clin Risk Manag. 2012;8: Williams PM et al. Am Fam Physician. 2008;77(2):

22 Psychoeducation Educate patients about BED BED is a treatable medical condition BED is NOT a sign of weakness or a character flaw Offer self-help treatment options Self-help organizations (BEDA) Self-help books (eg, Overcoming Binge Eating by C. G. Fairburn, Crave: Why You Binge Eat and How to Stop by C. M. Bulik) Explain that most people get better and many recover Emphasize that patients must put a high priority on taking care of themselves Williams PM et al. Am Fam Physician. 2008;77(2):

23 Psychological Treatments Cognitive behavioral therapy (CBT), including guided self-help (CBTgsh) and CBT-E (CBT for Eating Disorders) Interpersonal therapy (IPT) Behavioral weight loss (BWL) CBT and IPT are more effective for binge eating than for weight loss CBTgsh and IPT are both more effective than BWL for binge eating McElroy SL et al. Ther Clin Risk Manag. 2012;8: Iacovino JM et al. Curr Psychiatry Rep. 2012;14(4): Wilfley DE et al. Arch Gen Psychiatry. 2002;59(8): Wilson GT et al. Arch Gen Psychiatry. 2010;67(1):

24 CBT-E The leading evidence-based treatment for all 3 types of eating disorders 1 Suitable for a wide range of patients, including for some complex patients Highly acceptable to patients Requires trained staff and significant time commitment from patients and can be difficult to implement in patients with pronounced comorbidities Detailed treatment guide: Fairburn CG. Cognitive Behaviour Therapy and Eating Disorders. Guilford Press, New York, 2008 Up to 80% abstinence rates have been reported 2 1. Williams PM et al. Am Fam Physician. 2008;77(2): Iacovino JM et al. Curr Psychiatry Rep. 2012;14(4):

25 Essential Features of CBT-E for BED Requires a 6-month time commitment with initial bi-weekly visits to clinic Create a personalized diagram of the processes that maintain the eating disorder Establish real-time self-monitoring Introduce collaborative weighing Establish regulated eating and engage family in treatment if necessary Address barriers to change, such as dietary restrictions and over-evaluation of shape and weight Williams PM et al. Am Fam Physician. 2008;77(2):

26 Treating BED Properly diagnose and treat the mood disorder (depression) first Assess eating symptoms regularly and collect data to support BED diagnosis (prior excessive dieting, weight history, history of long-lasting compromised relationship with food) Once depression is under control, focus on BED treatment (augment antidepressant with self-help/psychotherapy/ pharmacotherapy) If BED is in consistent long-term remission and patient is educated on nutrition and lifestyle choices, weight eventually self regulates

27 Bariatric Surgery and BED BED is not a contraindication for bariatric surgery Surgery produces weight loss, metabolic improvements, and reduced binge eating Research is inconsistent; patients with BED either do as well as or more poorly than those without BED Surgery may have higher rates of post-operative complications, less weight loss, and more weight regain Clinicians need to address binge eating in pre- and post-operative care, including loss of control eating McElroy SL et al. Ther Clin Risk Manag. 2012;8: Colles SL et al. Obesity (Silver Spring). 2008;16(3): Kofman MD et al. Obesity (Silver Spring). 2010;18(10): Livhits M et al. Obes Surg. 2012;22(1):70 89.

28 Pharmacotherapy of BED Antidepressants (SSRIs, TCAs, bupropion) Modest effect on binge eating and depressive symptoms; no clinically significant effects on weight (opposite for bupropion?) Sibutramine Effective for binge eating, weight loss, and depressive symptoms; removed from market in 2010 Topiramate Effective for binge eating, obsessivecompulsive symptoms, and weight loss; side effects problematic Orlistat Modestly effective for weight loss and possibly binge eating; side effects problematic Lisdexamfetamine Studies show it to be superior to placebo in decreasing number of binge eating days per week Only FDA-approved medication for moderate-to-severe BED McElroy SL et al. Ther Clin Risk Manag. 2012;8: McElroy SL et al. New Research Poster NR8-54, May 6, 2014, APA.

29 Meta-Analysis of Antidepressants in BED (7 Studies) Outcome Measure Finding Remission rate Antidepressants (40.5%) > PBO (22%); P =.003 Mean binge eating frequency Antidepressants = PBO; P =.06 BMI Antidepressants = PBO Depressive symptoms Antidepressants > PBO; P =.03 Adherence/treatment discontinuation Antidepressants (27.5%) = PBO (22%) Stefano SC et al. Eat Behav. 2008;9(2):

30 Response of BED to Antiepileptics Drugs superior to placebo: Phenytoin Topiramate Zonisamide Drugs not superior to placebo: Lamotrigine (failed trial) McElroy SL et al. CNS Drugs. 2009;23(2): McElroy SL et al. Ther Clin Risk Manag. 2012;8:

31 Other Drugs by Targeted BED Pathology Reduction in impulsivity/regulation of reward system function (including hedonic feeding behavior) Atomoxetine, lisdexamfetamine, methylphenidate Reduction of cravings (alcohol, drugs, food) Acamprosate Opioid antagonists (eg, naltrexone, intranasal naloxone, and ALKS 33) Baclofen (GABA analogue) Reduction of appetite and consumption Psychostimulants, zonisamide Treatment of comorbidities Duloxetine, bupropion (in combination with naltrexone) McElroy SL et al. Ther Clin Risk Manag. 2012;8:

32 Pharmacotherapy of BED: Future Research Stimulants/ADHD drugs/dopamine agonists Novel Antidepressants: SNRIs (venlafaxine, milnacipran) Novel Anti-Obesity Agents: Selective 5-HT receptor agonists (lorcaserin) Topiramate & phentermine Buproprion & naltrexone Buproprion & zonisamide Liraglutide Novel Antiepileptics Anti-Craving Agents: Novel Anti-Opioid Compounds McElroy SL et al. Ther Clin Risk Manag. 2012;8:

33 Challenges of BED Treatment BED is under-recognized and underdiagnosed Providers and patients need education on BED and on avoiding stigma related to weight and mental illnesses Weight issues often precede BED diagnosis BED treatment requires commitment and resources Specialized psychotherapies are generally not effective for weight/obesity Bariatric surgery data is inconsistent Currently used medications are not effective for everyone and have unwanted side effects

34 Conclusion BED is a diagnosable but often untreated eating disorder Patients usually seek treatment for weight loss rather than BED BED is often comorbid with medical or psychiatric conditions such as metabolic syndrome and mood disorders Treatment options include psychoeducation, psychotherapy, bariatric surgery, pharmacotherapy, and combination strategies Treatment must be highly individualized Thank you!

35 End Credits Brought to you by the CME Institute of Physicians Postgraduate Press, Inc. Video production services were provided by Running Pony Productions 2015 Physicians Postgraduate Press, Inc.