Eating Disorders: An Overview Julie Lesser, MD Medical Director Beth Brandenburg, MD Associate Medical Director Center for the Treatment of Eating Disorders Children s Hospitals and Clinics of Minnesota Abbott Northwestern Hospital Outline Keys Study Etiology Classification Medical complications Refeeding Syndrome Treatment 2 2013 Center for the Treatment of Eating Disorders (CTED) We are an evidence-based, specialty program focusing on outpatient treatment using two main models: FBT (Family Based Therapy) CBT-E (Cognitive Behavioral Therapy-Enhanced) Our model includes Ongoing staff education and training Supervision with treatment developers (Lock and Fairburn) Measures of outcomes, tracking of key interventions We see outpatients of all ages Outpatient clinic - 910 Medical Building in Minneapolis Our inpatient units: Children s Hospital - up to age 21 (based on developmental level) Abbott Northwestern Hospital - adults 3 2013 1
Historical Review Accounts of fasting Catholic Saints in 14 th century Anorexia nervosa introduced by Sir William Gull in 1874 Gerald Russell named Bulimia nervosa in 1979 4 2013 Minnesota Starvation Study Ancel Keys, et al Recruited 36 conscientious objectors in 1944 During 24 week starvation period, diet adjusted to achieve loss of 25% of body weight Followed by rehabilitation phase 5 2013 Physical Effects of Starvation Weakness Cold sensitivity Decrease in: temperature pulse respiration Edema Hair loss Decreased sexual interest Poor concentration Fatigue Sleep problems 6 2013 2
Behavioral Effects of Starvation Preoccupation with food Social withdrawal Depression, emotional distress Eating rituals Food cravings Vicarious pleasure in watching others eat Increased fluid consumption Compulsive gum chewing Hoarding, obsessiveness 7 2013 What causes eating disorders? Cultural influences Gender Genetic factors Psychosocial factors **Families do not cause eating disorders 8 2013 Psychosocial risk factors Perfectionism Low self esteem Anxiety and mood disorders Negative life events 9 2013 3
DSM 5: Feeding and Eating Disorders Persistent disturbance of eating or eating related behaviors resulting in altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning Diagnostic criteria provided for Anorexia Nervosa Bulimia Nervosa Binge-Eating Disorder Avoidant/Restrictive Food Intake Disorder (ARFID) Pica Rumination Disorder Unspecified or Other Specified Eating Disorder 10 2013 Anorexia Nervosa Significantly low body weight Mild: BMI >17 Moderate: BMI 16 16.99 Severe: BMI 15 15.99 Extreme: BMI <15 Fear of fatness or persistent behavior that interferes with weight gain Body image disturbance or persistent lack of recognition of the seriousness of the current low body weight Restricting type or binge-eating/purging type 11 2013 Anorexia Nervosa cont. Peak age of onset 14 18 Lifetime prevalence 0.9% for women in U.S. High rates of mood and anxiety disorders Highest mortality rate of any psychiatric disease 5-10% 10 year mortality rate Mortality rate increases 5.6% per decade that an individual remains ill 12 2013 4
Bulimia Nervosa Recurrent binge eating Recurrent purging (vomiting, misuse of laxatives, diuretics or other medications, fasting or excessive exercise) Episodes of binge eating/purging on average at least 1 time per week for 3 months Over-evaluation of shape and weight Not anorexia nervosa 13 2013 Bulimia Nervosa cont. Peak age of onset 16 to 22 2 to 3 % of young women Elevated rates of depression, bipolar disorder, anxiety disorders, substance use disorders, and personality disorders 14 2013 Binge-Eating Disorder Recurrent episodes of bring eating Episodes are associated with 3 (or more) of: Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of feeling embarrassed about how much is consumed Feeling disgusted, depressed or very guilty after a binge Marked distress regarding binge eating is present Occurs, on average, at least 1 time/week for 3 months Not bulimia or anorexia 15 2013 5
Avoidant/Restrictive Food Intake Disorder (ARFID) Eating or feeding disturbance disallowing appropriate nutritional and/or energy needs associated with one (or more) of: Significant weight loss Significant nutritional deficiency Dependence on enteral feeding or oral supplements Marked interference with psychosocial functioning Not better explained by lack of available food or associated culturally sanctioned practice Not anorexia or bulimia and there is no evidence of a disturbance in one s body image Not attributable to a concurrent medical condition or mental disorder 16 2013 Avoidant/Restrictive Food Intake Disorder (ARFID) Differentiating the feeding disturbance (examples): Apparent lack of interest in eating or food Avoidance based on the sensory characteristics of food Concern about aversive consequences of eating GI problems/pain Vomiting Choking 17 2013 Unspecified Feeding or Eating Disorders (307.50) Clinically significant distress or impairment in, social, occupational, or other important areas of functioning predominate but do not meet full criteria for any of the disorders Used when the clinician chooses not to specify the reason criteria are not met Includes presentations in which there is insufficient information (e.g., in emergency room settings) 18 2013 6
Other Specified Feeding or Eating Disorder (307.59) Atypical AN (all criteria for AN are met, except despite the significant weight lose the individuals weight is within or above the normal range) Subclinical BN or BED (all criteria for BN are met, not meeting frequency criteria) Purging Disorder (recurrent purging to influence weight or shape, and may include misuse of laxatives and other medications in the absence of binge-eating) Night Eating Syndrome (recurrent episodes of night eating causing distress and impairment and not better explained by other disorders or medication affects) 19 2013 Medical Complications of Eating Disorders Low blood pressure/pulse, risk of arrhythmias Osteoporosis, fractures Brain volume loss Delayed growth and development Delayed gastric emptying, gastroparesis Muscle wasting Lanugo on body, loss of hair from scalp Decreased body temperature, hypothermia 20 2013 Osteoporosis 21 2013 7
Brain Volume Loss 22 2013 Medical Complications of Eating Disorders Hypoglycemia Elevated LFT s Low phosphorous Leukopenia, anemia Mitral valve prolapse Secondary amenorrhea Dehydration Electrolyte abnormalities (potassium) Erosion of dental enamel Esophageal tears, rupture 23 2013 Refeeding Syndrome Complication of feeding severely malnourished patients Low phosphorous Seizures Heart failure Arrhythmias 24 2013 8
Preventing Refeeding Syndrome Close monitoring of electrolytes (particularly phosphorous), cardiac status Start with 1500 kcal diet, gradually increase to 3,000 4,000 Weight regain no more than 2 to 3 pounds per week Avoid use of total parenteral nutrition 25 2013 Inpatient Treatment Necessary for patients with very low weight or medical instability APA guidelines Multidisciplinary approach 26 2013 Child and Adolescent Inpatient Admission Criteria Weight <75% of est. healthy body weight Rapid weight loss even if weight is not less than 75% below the normal weight Refusal to eat Heart rate <50 bpm Blood pressure <80/50 Orthostatic hypotension (with an increase in pulse of 20>bpm or a drop in BP of >10 20 mm Hg/min from supine to standing) Hypokalemia, hypophosphatemia or hypomagnesemia Dehydration Hypothermia Symptomatic hypoglycemia Uncontrolled vomiting or hematemesis Cardiac arrhythmia Syncope Lack of improvement or worsening despite outpatient treatment Suicide intent, plan or high level of risk 27 2013 9
Adult Inpatient Admission Criteria Weight <75% of estimated healthy body weight (usually BMI <16) Heart rate <40 bpm Symptomatic orthostatic hypotension Blood pressure <90/60 Potassium <3 meq/l Electrolyte imbalance (including hypophosphatemia) Dehydration Hypothermia Symptomatic hypoglycemia Uncontrolled vomiting or hematemesis Cardiac arrhythmia Lack of improvement or worsening despite outpatient treatment Suicide intent and suicide plan or other factors suggesting a high level of suicide risk (which may indicate need for psychiatric hospitalization, but if medically compromised should be admitted to medical unit on 1 to 1 patient monitoring) 28 2013 Treatment of Eating Disorders Psychotherapy Family based therapy Multi-family therapy Cognitive behavioral therapy Interpersonal therapy Cognitive remediation therapy (adjunctive treatment) Medications Inpatient treatment Residential treatment, levels of care 29 2013 Family Based Therapy 30 2013 10
Family Based Therapy cont. Developed at Maudsley Hospital in London Key interventions Agnostic about etiology, medical model Collaborative weighing Parental and sibling alliances Family meal Phases of treatment Separation of illness from the child Goal to have child eating independently and maintaining an ideal, expected BMI at the 50 th percentile Parents play an active role in helping to restore the child s weight, then transition the control over eating back to the child and encourage normal adolescent development 31 2013 Family Based Therapy cont. Over half of adolescent AN patients are recovered at the end of FBT, with further improvement at later follow up. In older studies, 75 90% are fully weight recovered at 5 year follow-up Currently the first line treatment for Anorexia nervosa in children and adolescents 32 2013 Cognitive Behavioral Therapy Enhanced (CBT-E) for Eating Disorders 33 2013 11
Key Interventions of CBT-E Collaborative weighing Regular eating Self monitoring Making a cognitive formulation Problem solving and emotion regulation strategies Addressing maintaining factors including interpersonal problems, core low self esteem and clinical perfectionism More involvement of parents in the adolescent protocol 34 2013 CBT-E 20 to 40 weeks of individual therapy Applicable to all types of eating disorders 2/3 of patients with BMI >17.5 recovered at end of treatment, sustained at 1 year follow-up Emerging data for patients with AN Adults and adolescents with 50% recovery at 1 year f/u Studied in adolescents as young as age 13 35 2013 Interpersonal Therapy Evidence based therapy for Depression in adults and adolescents Effective for Bulimia nervosa Manual exists for Anorexia nervosa Key interventions Interpersonal inventory Problem solving Motivational strategies Formulation Interpersonal World Mood 36 2013 Nutritional Status 12
Medications for Bulimia Nervosa Fluoxetine 60 mg/day FDA approved Effective in reducing binge eating and purging Topiramate Odansetron 37 2013 Medications for Anorexia Nervosa SSRI s for comorbid depression or anxiety disorders Olanzapine may be effective in decreasing obsessionality No medications have been shown to improve weight regain 38 2013 What is the role of partial hospital and residential treatment? Practice guidelines 2/3 relapse rate Consideration of comorbid conditions Need for tracking and publishing outcomes 39 2013 13
Sample Weight Graph: 14yo Female 19.5 Cognitive Behavioral Therapy-Enhanced 18.5 17.5 Inpatient 16.5 15.5 Family-Based Therapy 14.5 4/4 5/14 6/23 8/2 9/11 10/2111/30 1/9 2/18 3/30 5/9 6/18 7/28 9/6 40 2013 BMI Graph: 21yo 20 19 18 17 16 15 14 4/1 5/1 6/1 7/1 8/1 9/1 10/111/112/1 1/1 2/1 3/1 4/1 5/1 6/1 7/1 8/1 41 2013 BMI Graph: 21yo 20 19 18 17 16 15 11/1 1/1 3/1 5/1 7/1 9/1 11/1 1/1 3/1 42 2013 14
Outpatient Clinic Team Psychiatrists Julie Lesser, MD Beth Brandenburg, MD Jill Gorius, MD Therapists Joan Valente, PhD Collaborative Care: Melissa Adler, LICSW Patient follows with Georgia Banks, LICSW primary care/referring Tina Welke, LICSW provider Cindy Gieseke, LICSW Lindsey Utzinger, PsyD Dietician Libby Johnson, RD Administrative Traci Horejsi, Clinic Coordinator Pamela Coleman, LPN, Lynnae Sniker, MA 43 2013 Inpatient Teams at Children s and Abbott Only hospital-based programs in MN offering immediate access to medical stabilization and specialists Inpatient teams: Hospitalists Social Work Physical Therapy Psychiatrists Psychologists Child Life Nurses Integrative Medicine Dieticians Penny George Institute Staff training based on Janet Treasure s New Maudsley Method Separate units for children and adults 44 2013 Contact information Outpatient clinic P: 612 813 7179 F: 612 813 7190 For child and adolescent referrals Children s Physician Access: 612 343 2121 Adult referrals OneCall 612 863 1000 45 2013 15
Thank you! 16