early intervention & innovative treatment for adolescents with eating disorders steven f....

Early Intervention & Innovative Treatment for Adolescents with Eating

Disorders

Early Intervention & Innovative Treatment for Adolescents with Eating

Disorders

Steven F. Crawford, M.D.Center for Eating Disorders

at Sheppard Pratt

Steven F. Crawford, M.D.Center for Eating Disorders

at Sheppard Pratt

Educational ObjectivesEducational Objectives

Define the syndromes

Recognize the Importance of Early Intervention

Review the History of Family Therapy in the Treatment of Eating Disorders

Family Based Treatment (The Maudsley Approach)

Define the syndromes

Recognize the Importance of Early Intervention

Review the History of Family Therapy in the Treatment of Eating Disorders

Family Based Treatment (The Maudsley Approach)

Importance of AppearanceImportance of Appearance

1973 Survey: 29% Men 32% Women




Drive For ThinnessDrive For Thinness

80% American women report dissatisfaction with their appearance

Gaesser survey: 50% of females between the ages of 18-25 would prefer to be run over by a truck then be fat; 66% would rather be mean or stupid

40% women and 20% men would trade 3-5 years of their life to achieve goal body weight

80% American women report dissatisfaction with their appearance

Gaesser survey: 50% of females between the ages of 18-25 would prefer to be run over by a truck then be fat; 66% would rather be mean or stupid

40% women and 20% men would trade 3-5 years of their life to achieve goal body weight

Drive For ThinnessDrive For Thinness

42% of 1st-3rd grade girls want to be thinner

81% of 10 yr olds are afraid of being fat

42% of 1st-3rd grade girls want to be thinner

81% of 10 yr olds are afraid of being fat

DietingDieting

91% of college-aged women diet 25% American men and 45%

American women are on a diet on any given day

$48 billion dollars spent each year on dieting products/programs

91% of college-aged women diet 25% American men and 45%

American women are on a diet on any given day

$48 billion dollars spent each year on dieting products/programs

DietingDieting Over 50% teen girls and 33% teen boys

use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, or taking laxatives

51% 9-10 yr old girls diet 82% 9-10 yr old girls report someone in

their family is on a diet Age of first diet

1970: 14 yrs old 1990: 8 yrs old

Over 50% teen girls and 33% teen boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, or taking laxatives

51% 9-10 yr old girls diet 82% 9-10 yr old girls report someone in

their family is on a diet Age of first diet

1970: 14 yrs old 1990: 8 yrs old

DietingDieting

95% of all dieters regain their lost weight in 1-5 years

35% of “normal” dieters progress to pathological dieting

Most common behavior preceding onset of an eating disorder is dieting

95% of all dieters regain their lost weight in 1-5 years

35% of “normal” dieters progress to pathological dieting

Most common behavior preceding onset of an eating disorder is dieting

Eating DisordersEating Disorders

Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

History of Anorexia Nervosa

History of Anorexia Nervosa

Richard Morton (1689): First recognized anorexia nervosa and described “nervous consumption.”

Gull and Leségue (late 19th century): Independently described what is now recognized as modern anorexia nervosa.

Richard Morton (1689): First recognized anorexia nervosa and described “nervous consumption.”

Gull and Leségue (late 19th century): Independently described what is now recognized as modern anorexia nervosa.

Anorexia Nervosa Refusal to maintain body weight at or

above a minimally normal weight for age and height

Intense fear of weight gain or becoming fat, even though underweight

Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight

Amenorrhea for 3 consecutive months

Anorexia Nervosa: Subtyping

Anorexia Nervosa: Subtyping

RestrictingRestrictingTypeType

Binge-Eating

Purging Type

Binge-Eating

Purging Type

AN - EpidemiologyAN - Epidemiology

Prevalence is estimated at 0.5 - 3.7% of populations at highest risk (adolescent females)

Female:male ratio 10:1 Significantly higher rates if sub-

threshold EDNOS cases are included Incidence in young women has

tripled in last 40 years

Prevalence is estimated at 0.5 - 3.7% of populations at highest risk (adolescent females)

Female:male ratio 10:1 Significantly higher rates if sub-

threshold EDNOS cases are included Incidence in young women has

tripled in last 40 years

AN: EpidemiologyAN: Epidemiology

40% of newly identified cases are in girls 15-19 yrs old

Increase in incidence of anorexia in women ages 15-19 in each decade since 1930

Childhood anorexia (<10 yrs old) is relatively rare but increasing

40% of newly identified cases are in girls 15-19 yrs old

Increase in incidence of anorexia in women ages 15-19 in each decade since 1930

Childhood anorexia (<10 yrs old) is relatively rare but increasing

AN - Medical ConsequencesAN - Medical

Consequences Metabolic down-regulation - bradycardia, orthostatic hypotension, hypothermia, syncope

Dehydration, cardiac changes, arrhythmia

Gastric disturbances, constipation Osteopenia/Osteoporosis Anemia, leukopenia, electrolyte

disturbances Growth retardation

Metabolic down-regulation - bradycardia, orthostatic hypotension, hypothermia, syncope

Dehydration, cardiac changes, arrhythmia

Gastric disturbances, constipation Osteopenia/Osteoporosis Anemia, leukopenia, electrolyte

disturbances Growth retardation

AN - Social ConsequencesAN - Social Consequences

Profound impact on interpersonal relationships and family

Decreased rates of marriage and fertility

Diminished achievement in school and occupation relative to potential

High dependence on health care system at extremely high cost (second only to schizophrenia)

Profound impact on interpersonal relationships and family

Decreased rates of marriage and fertility

Diminished achievement in school and occupation relative to potential

High dependence on health care system at extremely high cost (second only to schizophrenia)

AN - OutcomeAN - Outcome

About 60% improve with focused treatment About 20% remain morbidly and chronically ill Long term follow up studies suggest that

mortality is approx. 5-10% per decade of illness Average mortality of chronic cases is 8-13% Suicide accounts for about 1/2 mortality Highest mortality of any psychiatric illness

About 60% improve with focused treatment About 20% remain morbidly and chronically ill Long term follow up studies suggest that

mortality is approx. 5-10% per decade of illness Average mortality of chronic cases is 8-13% Suicide accounts for about 1/2 mortality Highest mortality of any psychiatric illness

AN - OutcomeAN - Outcome

About 50% develop bulimic symptoms Depression and anxiety disorders

develop in a majority of the morbidly ill Long term outcome has few reliable

predictors Short-term outcome is worse in persons

with laxative abuse, bingeing, and familial psychopathology

About 50% develop bulimic symptoms Depression and anxiety disorders

develop in a majority of the morbidly ill Long term outcome has few reliable

predictors Short-term outcome is worse in persons

with laxative abuse, bingeing, and familial psychopathology

AN - OutcomesAN - Outcomes

Third most common chronic illness among adolescents

12 times more likely to die than other women same age without anorexia nervosa

Third most common chronic illness among adolescents

12 times more likely to die than other women same age without anorexia nervosa

History of Bulimia NervosaHistory of Bulimia Nervosa

Description of bulimic symptoms in literature since 1873

Case of Ellen West (1944): first well documented account

Gerald Russell (1979): Landmark description of bulimia nervosa

Description of bulimic symptoms in literature since 1873

Case of Ellen West (1944): first well documented account

Gerald Russell (1979): Landmark description of bulimia nervosa

Bulimia NervosaBulimia Nervosa

Recurrent episodes of binge eating Regular compensatory measures to

prevent weight gain Occurrence at least twice per week for

three months Attitude about body shape

predominantly influences self evaluation

No evidence of anorexia nervosa

Recurrent episodes of binge eating Regular compensatory measures to

prevent weight gain Occurrence at least twice per week for

three months Attitude about body shape

predominantly influences self evaluation

No evidence of anorexia nervosa

Bulimia Nervosa: Subtyping

Bulimia Nervosa: Subtyping

PurgingPurging Non-purgingNon-purging

BN- EpidemiologyBN- Epidemiology

Lifetime prevalence is estimated at 1.1-4.2% of females

Up to 19% of college-aged women in America are bulimic

Female:male ratio 10:1 84% have a college education Incidence tripled between ‘88-’93

in 10-39 yr old women

Lifetime prevalence is estimated at 1.1-4.2% of females

Up to 19% of college-aged women in America are bulimic

Female:male ratio 10:1 84% have a college education Incidence tripled between ‘88-’93

in 10-39 yr old women

BN - EpidemiologyBN - Epidemiology

Age of onset between mid-adolescence and late 20’s

Girls that diet are 12 times more likely to start binge-eating than their peers that do not diet

Up to 3% adolescent boys and 10% adolescent girls purge one time per week

Age of onset between mid-adolescence and late 20’s

Girls that diet are 12 times more likely to start binge-eating than their peers that do not diet

Up to 3% adolescent boys and 10% adolescent girls purge one time per week

BN - EpidemiologyBN - Epidemiology

Children as young as 6 yrs old have been diagnosed with bulimia

Approximately 4.5% of ALL American high school students have vomited or used laxatives as a means to lose weight within the last 30 days

Children as young as 6 yrs old have been diagnosed with bulimia

Approximately 4.5% of ALL American high school students have vomited or used laxatives as a means to lose weight within the last 30 days

BN - Medical ComplicationsBN - Medical

Complications Electrolyte disturbances - hypokalemia Orthostatic hypotension Esophageal tear (Mallory-Weiss) Gastritis, gastric dilation, rupture Cardiac arrhythmias Menstrual irregularities Osteopenia Sudden death

Electrolyte disturbances - hypokalemia Orthostatic hypotension Esophageal tear (Mallory-Weiss) Gastritis, gastric dilation, rupture Cardiac arrhythmias Menstrual irregularities Osteopenia Sudden death

BN - OutcomeBN - Outcome

Treatment response is highly variable 50% “recover”, 30% demonstrate

improvement, 20% continue to meet full diagnostic criteria

10% meet criteria after 10 years Longer duration of the disorder at

presentation and history of substance use disorder predicted worse outcome

Treatment response is highly variable 50% “recover”, 30% demonstrate

improvement, 20% continue to meet full diagnostic criteria

10% meet criteria after 10 years Longer duration of the disorder at

presentation and history of substance use disorder predicted worse outcome

Binge-Eating DisorderDSM-IV-TR Research

Criteria

Binge-Eating DisorderDSM-IV-TR Research

Criteria Recurrent episodes of binge-eating Marked distress regarding binge-

eating Occurrence at least two days per

week for six months Not associated with the regular use

of inappropriate compensatory measures

Recurrent episodes of binge-eating Marked distress regarding binge-

eating Occurrence at least two days per

week for six months Not associated with the regular use

of inappropriate compensatory measures

Binge Eating DisorderBinge Eating Disorder

Lifetime prevalence rate is 1-5% One study showed 3% current

population meet criteria for BED Onset usually occurs during late

adolescence or in the early 20’s 40% are male

Lifetime prevalence rate is 1-5% One study showed 3% current

population meet criteria for BED Onset usually occurs during late

adolescence or in the early 20’s 40% are male

ClassificationClassification

Binge-eating Binge-eating disorderdisorder

EDNOSEDNOS

AnorexiaAnorexia nervosanervosa

Bulimia Bulimia nervosanervosa

The “Anorexogenic” Family


Lasegue portrayed a relatively neutral view of parents

Gull recommended limiting parental-child contact during treatment to prevent enabling behaviors of parents

Charcot considered parents to be “particularly pernicious”

Lasegue portrayed a relatively neutral view of parents

Gull recommended limiting parental-child contact during treatment to prevent enabling behaviors of parents

Charcot considered parents to be “particularly pernicious”



View that parents were a hindrance to treatment and that the family environment had contributory role in development of illness persisted in first half of 20th century

Recommendations for treatment usually included a “parentectomy”

View that parents were a hindrance to treatment and that the family environment had contributory role in development of illness persisted in first half of 20th century

Recommendations for treatment usually included a “parentectomy”

The “Psychosomatic” Family


In 1960’s, major shift to identifying family mechanisms which may contribute to development of AN and could be targeted by treatment

Bruch, Palazzoli and Minuchin were primary contributors

In 1960’s, major shift to identifying family mechanisms which may contribute to development of AN and could be targeted by treatment

Bruch, Palazzoli and Minuchin were primary contributors



Minuchin placed emphasis on pathological interactive familial processes in the pathogenesis of AN

Focused on rigidity, enmeshment, over-involvement and conflict avoidance

Child’s role in family was to serve as a go-between in cross-generational alliances

Minuchin placed emphasis on pathological interactive familial processes in the pathogenesis of AN

Focused on rigidity, enmeshment, over-involvement and conflict avoidance

Child’s role in family was to serve as a go-between in cross-generational alliances



A no blame on the parents model Advocated for family therapy to

“alter” the family structure Critical shift was the engaging of

the family in the treatment process

A no blame on the parents model Advocated for family therapy to

“alter” the family structure Critical shift was the engaging of

the family in the treatment process

AN Risk Factor Research: Cross-Sectional Studies

AN Risk Factor Research: Cross-Sectional Studies

Inappropriate parental pressures Early-life overprotection Greater incidence of separation,

arguments, criticism, high expectations, over-involvement, under-involvement, low affection

Inappropriate parental pressures Early-life overprotection Greater incidence of separation,

arguments, criticism, high expectations, over-involvement, under-involvement, low affection

BN Risk Factor Research: Cross-Sectional Studies

BN Risk Factor Research: Cross-Sectional Studies

Parental indifference Family discord Lack of parental care Greater adversity Significant greater change in family

structure (e.g. a parent leaving or a step-parent entering the family) the year before onset of the illness

Parental indifference Family discord Lack of parental care Greater adversity Significant greater change in family

structure (e.g. a parent leaving or a step-parent entering the family) the year before onset of the illness

Risk Factor Research:Cross-Sectional StudiesRisk Factor Research:

Cross-Sectional Studies Findings are inconsistent Growing support that families are

heterogeneous group with respect to socio-demographic characteristics, family relationships, etc.

Findings are inconsistent Growing support that families are

heterogeneous group with respect to socio-demographic characteristics, family relationships, etc.

Current Focus Current Focus

Current understanding is a shift away from evaluating the family as a cause of the eating disorder to evaluating family dynamics that may develop in the context of an eating disorder and may function as maintenance mechanisms

Current understanding is a shift away from evaluating the family as a cause of the eating disorder to evaluating family dynamics that may develop in the context of an eating disorder and may function as maintenance mechanisms

The Maudsley Approach Family Based Treatment

(FBT)


(FBT) Developed by a team of child and

adolescent psychiatrists at the Maudsley Hospital in London

Assist the parents in their efforts to help their adolescent in recovery from AN so that he/she can return to normal adolescent development

Developed by a team of child and adolescent psychiatrists at the Maudsley Hospital in London

Assist the parents in their efforts to help their adolescent in recovery from AN so that he/she can return to normal adolescent development


(FBT)


(FBT) 66% of adolescents are recovered

at the end of FBT 75-90% are fully weight recovered

at five year follow-up Young patients with AN require on

average no more than 20 treatment sessions over the course of 6 to 12 months, with 80% being weight restored with resumption of menses

66% of adolescents are recovered at the end of FBT

75-90% are fully weight recovered at five year follow-up

Young patients with AN require on average no more than 20 treatment sessions over the course of 6 to 12 months, with 80% being weight restored with resumption of menses

Principles of Family Based Treatment

(FBT)


(FBT) Parents are viewed as the most

useful resource in their child’s treatment

Parents play an active and vital role in the recovery process and in restoring their child’s weight

Parents are viewed as the most useful resource in their child’s treatment

Parents play an active and vital role in the recovery process and in restoring their child’s weight


(FBT)


(FBT) The adolescent is viewed as

incapacitated in terms of eating behaviors with an inability to maintain an optimal weight for age and height

Focus of FBT is on current eating disorder symptoms and not underlying issues

The adolescent is viewed as incapacitated in terms of eating behaviors with an inability to maintain an optimal weight for age and height

Focus of FBT is on current eating disorder symptoms and not underlying issues

Family Based Treatment:Role of the Therapist


Coach, a consultant to the parents Empowers the parents to develop

strategies to manage the anorexia and ways to help feed their child until weight restoration is achieved

Directs conversation towards parents building a strong alliance

Coach, a consultant to the parents Empowers the parents to develop

strategies to manage the anorexia and ways to help feed their child until weight restoration is achieved

Directs conversation towards parents building a strong alliance



Encourages sibling support and understanding

Teaches the family to externalize the illness, modeling a no-blame approach with recognition that the eating disorder behaviors are mostly outside the control of the adolescent

Encourages sibling support and understanding

Teaches the family to externalize the illness, modeling a no-blame approach with recognition that the eating disorder behaviors are mostly outside the control of the adolescent

Family Based Treatment:Three Phases

Family Based Treatment:Three Phases

Phase 1: Weight Restoration Phase 2: Returning Control Over

Eating to the Adolescent Phase 3: Establishing Healthy

Adolescent Identity

Phase 1: Weight Restoration Phase 2: Returning Control Over

Eating to the Adolescent Phase 3: Establishing Healthy

Adolescent Identity

Weight RestorationWeight Restoration

Parents are supported in their efforts to restore their adolescent’s weight

Parents are encouraged to present a united front

Parents monitor meals and snacks while restricting physical activity

Therapist conveys message that parents will succeed

Parents are supported in their efforts to restore their adolescent’s weight

Parents are encouraged to present a united front

Parents monitor meals and snacks while restricting physical activity

Therapist conveys message that parents will succeed

Weight RestorationWeight Restoration

Therapist conveys to adolescent message that while he/she has many fears about weight gain, these fears cannot deflect parents efforts toward weight restoration

Weight restoration takes precedence over almost any other issue until self-starvation has been reversed

Therapist conveys to adolescent message that while he/she has many fears about weight gain, these fears cannot deflect parents efforts toward weight restoration

Weight restoration takes precedence over almost any other issue until self-starvation has been reversed

Returning Control to the Adolescent

Returning Control to the Adolescent

Begins when adolescent has reached 90% of ideal body weight and is eating without much resistance

Process is gradual and age dependent

Begins when adolescent has reached 90% of ideal body weight and is eating without much resistance

Process is gradual and age dependent

Establishing Healthy Adolescent IdentityEstablishing Healthy Adolescent Identity

Begins when adolescent has achieved a healthy weight for age and height

Treatment focused on general issues of adolescent development and ways in which the eating disorder impacted this process

Goals are increased personal autonomy, relationships with peers, or getting ready to leave home for the first time

Begins when adolescent has achieved a healthy weight for age and height

Treatment focused on general issues of adolescent development and ways in which the eating disorder impacted this process

Goals are increased personal autonomy, relationships with peers, or getting ready to leave home for the first time

Establishing Healthy Adolescent IdentityEstablishing Healthy Adolescent Identity

Final stages of treatment focus on relapse prevention strategies

Identification and recognition of early warning signs for a developing relapse

Family responses to potential relapse outlined and an action plan developed

Final stages of treatment focus on relapse prevention strategies

Identification and recognition of early warning signs for a developing relapse

Family responses to potential relapse outlined and an action plan developed

early intervention & innovative treatment for adolescents with eating disorders steven f....

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