Early Intervention & Innovative Treatment for Adolescents with Eating Disorders

1. Early Intervention & Innovative Treatment for Adolescents with Eating Disorders Steven F. Crawford, M.D. Center for Eating Disorders at Sheppard Pratt

2. Educational 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)

3. Importance of Appearance • 1973 Survey: • 29% Men • 32% Women • 1993 Survey: • 63% Men • 68% Women

4. Drive 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

5. Drive For Thinness • 42% of 1st-3rd grade girls want to be thinner • 81% of 10 yr olds are afraid of being fat

6. Dieting • 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

7. Dieting • 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

8. 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

9. Eating Disorders • Anorexia Nervosa • Bulimia Nervosa • Binge Eating Disorder

10. 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.

11. 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

12. Anorexia Nervosa: Subtyping Binge-Eating Purging Type Restricting Type

13. AN - 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

14. AN: 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

15. AN - 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

16. AN - 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)

17. AN - 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

18. AN - 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

19. AN - Outcomes • Third most common chronic illness among adolescents • 12 times more likely to die than other women same age without anorexia nervosa

20. History 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

21. Bulimia 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

22. Bulimia Nervosa: Subtyping Non-purging Purging

23. BN- 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

24. BN - 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

25. BN - 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

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

27. BN - 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

28. 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

29. Binge 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

30. Classification EDNOS Binge-eating disorder Anorexia nervosa Bulimia nervosa

31. 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”

32. The “Anorexogenic” Family • 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”

33. 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

34. The “Psychosomatic” Family • 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

35. The “Psychosomatic” Family • 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

36. 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

37. 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

38. Risk Factor Research:Cross-Sectional Studies • Findings are inconsistent • Growing support that families are heterogeneous group with respect to socio-demographic characteristics, family relationships, etc.

39. 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

40. The Maudsley Approach Family Based Treatment (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

41. The Maudsley Approach Family Based Treatment (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

42. Principles of Family Based Treatment (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

43. Principles of Family Based Treatment (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

44. 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

45. Family Based Treatment:Role of the Therapist • 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

46. Family Based Treatment:Three Phases • Phase 1: Weight Restoration • Phase 2: Returning Control Over Eating to the Adolescent • Phase 3: Establishing Healthy Adolescent Identity

47. Weight 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

48. Weight 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

49. 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

50. Establishing 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