Understanding Anorexia Nervosa in Adolescent Females - Treatment, Risks, and Myths

1. Eating Disorders21 November 2013 KrissySchwerin, MD Child and Adolescent Psychiatrist Canterbury District Health Board South Island Eating Disorders Service Child Adolescent & Family Rural Service

2. Anorexia Nervosa (AN) Bulemia Nervosa (BN) BingeEating disorder (BED) Unspecified Feeding or Eating Disorder (UFED) Other Eating/Feeding problems Diagnosis Epidemiology Medical risks Etiology Treatment Prognosis Overview

3. Misconceptions Myth: White, upper-middle class females in metropolitan areas of the western world Eating disorders are increasing in prevalence in males, younger children, older adults, and other ethnic groups. Our field needs to do a better job screening and treating…

4. Case Vignette #1 - Carla Carla is a 13 year-old female who presented to the ER with a grand-mal seizure from hyponatremia. She had been binging on water in order to fend off hunger. Carla had always been a happy child and great student, but had recently become obsessed with her schoolwork and isolated from her friends and close-knit family. Carla began losing weight after her PMDtold her she was overweight. This coincided with a family trip to parents’ country of origin where Carla didn’t like the food. She lost >40 poundsand stopped getting her period

5. Anorexia Nervosa (AN) - DSM V • Persistent restriction of energy intake leading low weight (lower than minimally expected for age/sex) • Intense fear of gaining weight or becoming fat, or behaviour that interferes with weight gain • Disturbance in body image, undue influence of shape/weight on self-evaluation, lack of recognition of seriousness of low body weight • Restricting sub-type • Binge-eating/purging sub-type **DSM-IV: 1. “refusal” to maintain weight 2. <85 percentile weight 3. amnorrhea was required

7. Anorexia Nervosa: chief complaint… • Family or school is concerned about eating habits or personality change • Physical symptoms • Other psychological concerns – depression, anxiety, obsessive • “unintentional” weight loss • Amenorrhea • Patient: “I’m fine!”

8. Anorexia Nervosa:Risk Factors, Precipitating Factors, & Traits • Perfectionism • Early Puberty • Failed attempts to lose weight • Antecedent illness with weight loss • Athletics • Beginning a diet • Family history of eating disorder • Life/family stressors

9. Anorexia Nervosa: Epidemiology • Lifetime prevalence 0.5-1% • Females:Males 10:1 • Usually arises during adolescence or young adulthood • Increased risk in 1st degree biological relatives with AN • 1/3 will develop bulimia nervosa • Long-term mortality 10-20%

10. Physical Risks • Death (suicide, starvation, sudden cardiac death) • Hypometabolic state (bradycardia, hypotension, hypothermia) • Orthostasis • Dehydration • Arrhythmia, heart failure, liver failure • Bone marrow suppression • Malnourishment • Bone loss • Lanugo • Peripheral edema • Stunted growth • Delayed sexual maturity • Hair loss, brittle hair • Cognitive impairment • Water intoxication • Re-feeding syndrome

11. Neurological Effects • Cerebral Atrophy • Associated with weight loss but not necessarily with lowest BMI • May improve but do not necessarily return to normal Katzman D et al, Journal of Pediatrics 1996

12. Anorexia Nervosa: Medical Workup • Vitals(w/ temperature) • ECG (look for long QTc) • Lytes, CBC, LFTs, ESR, TFTs, CK • β-HCG, LH, FSH, prolactin, estradiol if indicated • Bone density (don’t be fooled by normal bloods!!!)

13. Etiology From Silber et.al.

14. Anorexia Nervosa: Treatment • Determine level of care • Inpatient medical stabilization • Inpatient eating disorders service • Outpatient treatment • 1st: weight restoration • 2nd: psychological • 3rd: maintenance (long-term) • Multidisciplinary Team Approach! (psychiatrist, PCP, nurse, psychologist, family therapist, social worker, occupational therapist, dietician)

15. Considering Medical Admission • <75% ideal body weight • Hypothermia T<35.5 C • Bradycardia HR<50 (peds) or HR <40 (adults) • Orthostasis-drop in sbp >10, increase in HR>35 • Dehydration • Potassium < 2.5 or other electrolyte abnormality • Acute medical complication • Delirium • Re-feeding syndrome • Severe depression/suicidality– psychiatric admit

16. Anorexia Nervosa: Treatment • No evidence-based psychotherapy for Anorexia Nervosa in adults! • No evidence-based pharmacologic treatments in any age!

17. Psychological Treatments:Adolescents with AN • Family Based Treatment (FBT) (aka “Maudsley Approach”) • no-blame approach, family did not cause anorexia • family is the best resource to help her/him get better • Empower parents to get the young person to eat in order to save his/her life: “intense scene” • Align siblings with the patient for support • “Externalize” the anorexia • Family Meal (Session #2) • Focus on weight restoration first • then explore the family dynamics and psychological issues that may get in the way of maintaining weight

18. Psychological Treatments:Adults with AN None are “evidence-based” We use… Motivational Interviewing Cognitive Behavioural Therapy (CBT) Supportive Psychotherapy Metacognitive Therapy Couples or Family Therapy, or family involvement Psychodynamic Therapy Interpersonal Therapy (IPT) Group Therapy

19. Anorexia Nervosa: Medications • No approved medication treatments for Anorexia Nervosa • Fluoxetine(or other SSRI) for co-morbid depression or anxiety • Growing evidence for low-dose atypical antipsychotics (Olanzapine) for obsessive ruminations and possibly weight gain (still off-label)

20. Re-feeding Syndrome • Metabolic abnormalities as a result of reinstating nutrition to patients who are malnourished • Potentially fatal • Low phosphate • Edema • Tachycardia • Hypoglycemia (hyperinsulinemic response) • Treatment • admit • replace phosphate • higher protein: carbohydrate ratio

21. Anorexia Nervosa: Prognosis • 1/3 recover • 1/3 continue with milder course • 1/3 chronic severe • Young age of onset, short time since onset of illness: very good prognosis • >7 years of illness, very unlikely recovery (but not zero!!!)

22. Case Vignette #2: Katie Katie is a 20 year-old University student who had been in therapy for anxiety, self-harm, and a prior trauma that occurred in early adolescence. One session Katie revealed to her therapist that she had an embarrassing secret that she wanted to disclose. She had been bingeing and purging multiple time per week throughout the course of treatment. For years she had gone to great lengths to hide this from roomates/family, going to extents of hiding bags of vomit in the outside rubbish. She finally decided to tell her therapist and ask for help, because after years of being under 130 pounds, her weight has now increased to 134 poundsand she thinks her body is “disgusting”. Current BMI is 22.

23. Bulemia Nervosa (BN)– DSM V • Recurrent episodes of binge eating (eating larger amounts of food than others would eat in a discrete- 2 hour- period of time, with a sense of lack of control) • recurrent episodes of compensatory behavior (vomiting, laxatives, diuretics, excessive exercise) • Both occur at least 1x/week for 3 months • Self-evaluation is unduly influenced by body shape or weight • Does not occur exclusively during episodes of Anorexia Nervosa **DSM-IV: compensatory episodes had to be 2x/week

24. Bulemia Nervosa: Risk Factors, Precipitating Factors, & Traits Often normal weight or overweight (easy to forget to screen for eating disorders!) Shame and guilt History of sexual abuse not uncommon Impulsivity, risk-taking behaviours Depression/anxiety, emotional dysregulation, self-harm Less denial compared to AN, but may go to great lengths to keep symptoms secret

25. Bulemia Nervosa: Epidemiology • Lifetime Prevalence • 1.5% women • 0.5% men • Prevalence of binge-purge behaviors: • 13% girls • 7% boys • Slightly older average age of onset compared to Anorexia Nervosa • Purging extremely rare in children

26. Bulemia: Etiology genetic Family dynamics • Multifactorial!!! Individual Temperament (ie. impulsive) Societal,cultural Media factors biological

27. Medical Risks • Electrolyte abnormalities (hypokalemia, ketosis) • Dental – loss of enamel, chipped teeth, cavities • Parotid hypertrophy • Conjunctival hemorrhages • Calluses on dorsal side of hand (Russell’s sign) • Esophagitis, Mallory-weiss tears, Barrett esophagus • hematemesis • Latxative-dependent: cathartic colon, melena, rectal prolapse • Elevated CK or other injuries (over-exercising) • Poor nutrition (if severe purging) • Edema upon cessation of purging

28. Bulemia Nervosa: Treatment • Again, multidisciplinary team!!! • Adults: • Best evidence: Cognitive Behavioural Therapy (CBT) + Antidepressant (SSRI) • Adolescents • Evidence for adolescents is sparse; we extrapolate from the evidence for adult treatment • CBT + SSRI • or Family-Based Treatment (FBT) modified for BN (good evidence, but not as good as for AN)

29. Bulemia Nervosa: CBT or DBT • Best evidence is for CBT or DBT (good outcomes, but outcomes are short-term) • Cognitive Behavioral Therapy (CBT) • Thought Challenging: “I will gain weight if I eat normal amounts of food.” • Break the cycle of: “dieting” -> feel hungry/deprived -> binge -> guilt -> purge • Dialectical Behavioral Therapy (DBT) Chain analysis, mindfulness, emotion-regulation skills thought feeling behavior Felt angry Called friend, She was too Busy to talk Felt lonely Binge Fight with mom

30. Bulemia: Other Therapies • Family Therapy and/or family involvement • Interpersonal therapy (IPT) (short-term treatment focused on life transitions) • Psychodynamic Psychotherapy (good for long-term results in people with chronic depressive and personality symptoms) • Psychotherapy for comorbidities

31. Bulemia Nervosa: Medications • High-dose Fluoxetine (SSRI) – very good evidence! • Sertraline (SSRI) – some good evidence • Topiramate (mood stabalizer, promotes weight loss) – some good evidence, but use with caution especially if low-weight • Remember: Buproprion (other antidepressant) is contraindicated! (risk of seizures if history of purging)

32. Bulemia: Prognosis • 33% remit every year • But another 33% relapse into full criteria • Adolescent-onset better prognosis than adult-onset • Death-rate = 1%

33. Case Vignette #3 - Laura Laura is a 47 year-old divorced female in treatment for depression. She has suffered from morbid obesity ever since she stopped using cocaine 13 years ago. When Laura’s teenage son (who is involved in an inner-city gang) does not come home on time, or when she feels empty and lonely about not having a romantic relationship, she eats excessive amounts of food, despite her mindset and efforts throughout the rest of the day to watch her diet. Laura visits multiple different fast-food restaurants in succession and in neighborhoods far from home, so that this behavior will not get noticed by others. Laura one of 7 siblings. She is always identified as the “strong” one in the family who will take care of others who are ailing.

34. Binge Eating Disorder (BED) – DSM V • Recurrent episodes of binge eating • Eating definitely more than most people would eat in discrete 2-hour period of time • Sense of lack of control during the episode • Three or more of the following: • Eating much more rapidly than normal • Eating until uncomfortably full • Eating large amounts when not physically hungry • Eating alone because embarrassed by how much eating • Feeling disgusted, depressed, or guilty afterwards • Marked distress regarding binge eating • On average at least once a week for 3 months • No compensatory behaviours such as in bulemia nervosa **DSM IV: Binge-eating disorder was only in the appendix, frequency of binge episodes was >2x/week

35. Binge Eating Disorder vs. Obesity Binge Eating Disorder: may be overweight, but not required for diagnosis Binge Eating Disorder: more subjective distress about episodes of over-eating compared to obese non-BED

36. Binge Eating Disorder:Epidemiology • Most common eating disorder • Lifetime prevalence: • 3.5% women • 2% men

37. Binge Eating Disorder: Etiology genetic Family dynamics • Multifactorial!!! Individual Temperament (ie. impulsive) Societal,cultural Media factors biological

38. Binge Eating Disorder:Treatment (Medication) • SSRI • high dose reduces binge behavior short-term • but doesn’t help weight loss • Topiramate, Zonisamide (anticonvulsants, mild mood stabalizer) • Helps binge reduction • Helps weight loss • Caution for adverse effects, high discontinuation rates

39. Binge Eating Disorder:Treatment (Therapy) • Therapies either prioritize… • Weight loss • Binge-reduction • Neither (ie. relationships, depression etc) • Group psychotherapy • There is little evidence that obese individuals who binge should receive different therapy than obese individuals who do not binge

40. Binge Eating Disorder:Psychosocial Support • Family may need help with co-dependency • Attachment approach, particularly with youth • Weight loss programs • 12-step self-help groups (addressing the problem as an addiction) • Food Addicts in Recovery Anonymous

41. Case Vignette #4: Alisa Alisa is an 8 year-old girl who was admitted to the hospital for malnutrition. She had stopped eating due to a subjective sense of stomach pain every time she ate. Nasogastric feedings were initiated, and Alisa underwent a complete GI workup which was negative for a medical cause for her pain. Her parents had difficulty accepting that there may be a psychological component to her illness. Parents were divorced, with a high level of post-divorce conflict. Alisa’s older brother had low-functioning Autistic Spectrum Disorder with behavior/aggression problems, and the family were always impressed with Alisa’s resilience. Alisa denied body image distortion or desire for weight loss.

42. Other Eating/Feeding DisordersDSM V Pica- eating non-nutritive substances Rumination Disorder- chewing/spitting, re-chewing, regurgitating Avoidant/Restrictive Food Intake Disorder- failure to meet energy/nutritive needs, dependence on enteral feeding or supplements

43. Unspecified Feeding or Eating Disorder (UFED) Formerly Eating Disorder NOS (EDNOS) • Clinically significant distress/impairment but do not meet criteria for other eating disorders • May be used when not enough clinical information (ie. emergency room settings) • Atypical presentations ** Overall changes in eating disorders are meant to limit the use of this “unspecified” category, which was too large in DSM-IV. (ED-NOS was more common than AN or BN, and actually represented a very “sick” group.)

44. Other Feeding Problems in Infancy/Childhood (non-DSM) Selective Eating Food Phobias Pervasive Food Refusal Food Avoidance Emotional Disorder

45. Eating Disorders: Take Home Points • Great need for provider-awareness (both in mental health and non-mental health) • Very medically risky!!! Need intense psychological AND medical management! • Multifactorial etiology • Multidisciplinary treatment approach • Involve the family in treatment whenever you can • Young patient with new AN cannot afford to wait for FBT • Prevalent in teens, but much less research to guide us in their treatment • Little evidence for medications in EDs: this is why psychiatrists need to be more than med-managers!

46. References • Hay et.al. “Psychological Treatments for Bulemia Nervosa and Bingeing” The Cochrane Library 2010 • Lock, J., “Evaluation of Family Treatment Models for Eating Disorders” Current Opinion in Psychiatry 2011 • Lock & LeGrangeTreatment Manual for Anorexia Nervosa, Second Edition2013 • Rosen et.al. “Identification and Management of Eating Disorders in Children and Adolescents” Pediatrics 2010 • Treasure et.al. “Eating Disorders” Lancet 2010 • Vockset.al. “Meta-Analysis of the Effectiveness of Psychological and Pharmacological Treatments for Binge Eating Disorder” International Journal for Eating Disorders 2010 • www.dsm5.org Feeding and Eating Disorders Fact Sheet, American Psychiatric Association 2013

47. Any questions? krissy.schwerin@cdhb.health.nz krissy@schwerno.com