Treatment Quad Cities Eating Disorders Consortium

Transcription

1 Treatment Quad Cities Eating Disorders Consortium James E. Mitchell, MD UND School of Medicine and Health Sciences Neuropsychiatric Research Institute

2 ANOREXIA NERVOSA BULIMIA NERVOSA BINGE EATING DISORDER

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4 Pike et al Good Intermediate Poor CBT Nutr. Counseling

5 CBT for AN Recognize the egosyntonic nature of thinness and self-control Recognize the desperation that drives symptom choice. Don t attach surplus meaning to resistance. Acknowledge the difficulty of change.

6 Anorexia Nervosa Psychotropic Drug Therapy Adjunctive

7 Anorexia Nervosa More recently SSRIS Atypical Neuroleptics

8 SSRIs in Low Weight AN Low tryptophan levels ( L-Tryp( Tryp./LNAA) Inadequate serotonin response? Tryptophan supplementation not help

9 Haloperidol Dopamine D1 Dopamine D2 Serotonin 5-HT2 1-adrenergic Muscarinic

10 Olanzapine Dopamine D1 Dopamine D2 Serotonin 5-HT2 1-adrenergic Muscarinic

11 Atypical Antipsychotics Target --- Delusions Target --- OCD symptoms Target --- Mood Target --- Weight

12 CBT for BN self-monitoring nutrition/meal planning cues/consequences cognitive restructuring relapse prevention 16 session - 20 weeks

13 Societal Pressure for Thinness Weight and Shape Concerns Dieting Binge-Eating Purging

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15 CBT-E Extension and refinement of prior CBT Addresses also Mood intolerance Clinical perfectionism Core low self-esteem Interpersonal difficulties Adopted to all eating disorders

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17 Clinician Manual Integrative Cognitive-Affective Therapy for the Treatment of Bulimia Nervosa Wonderlich, S.A., Peterson, C., Mitchell, J.E., Crow, S.J., Smith, T.L., & Klein, M. Unpublished Manuscript (2008) Supported by NIH Grant R34 MH077571

18 ICAT Description 21 sessions Clinician Manual and Patient Workbook PDA/Paper Wallet Coping Skills

19 Theoretical Underpinnings of ICAT CBT for BN Motivational Interviewing Emotion Focused Interventions Intensive Opening Phase Self Monitoring Disrupt Dieting Recognizing Ambivalence Positive Function of Disorder Binge/Purge as escape from negative emotion Diet as avoiding negative emotion

20 Theoretical Underpinnings of ICAT (Cont d) Self Discrepancy Theory Structural Analysis of Social Behavior Relapse Prevention Actual, Ideal, Ought, Feared Selves Relationship Problems and Interpersonal Patterns Self directed Style Lapse Training Skill Maintenance

21 Antidepressant Treatment of Bulimia Nervosa % Reduction in Binge Frequency IMI AMI DMI IMI Bupropion Phenelzine Trazadone IMI 60 mg Fluoxetine 20 mg DMI Fluoxetine Brofaromine IMI

22 Bulimia Nervosa SSRI s TCAs Drug Fluoxetine Fluoxetine Fluvoxamine Imipramine Desipramine Amitriptyline MAO s Other Findings BE/P Prevent Relapse No evidence BE/P BE/P /- BE/P Phenelzine Meclobemide BE/P BE/P Isocarboxazide BE/P Bupropion Trazadone Mianserin BE/P BE/P No evidence Evidence O Contraindiction O

23 CBT Non-responders

24 CBT F/U Only Remission Rapid Intervention 20 Sessions BN 16 Weeks IPT Symptomatic Fluox. Desip.

25 McKnight BN Study 50% 50% 40% 40% 48% 32% 30% 30% 24% 20% 20% 10% 10% 0% 0% Remit Drop IPT 19% Remit Drop Meds

26 Bulimia Nervosa Psychotropic drug therapy well established Primary Intervention CBT Begin Drug Therapy if lack of early response Begin Drug Therapy if depressed

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28 Drugs vs. Psychotherapy Mitchell, et al Agras, et al Leitenberg, et al Goldbloom, et al Walsh, et al Jacobi, et al Imipramine CBT Group Desipramine CBT Ind. Desipramine CBT Ind. Fluoxetine CBT Ind. Desip. / Fluox. CBT Ind. Supp. Ind. CBT Ind. Fluoxetine

29 Reduction in Frequency of Binge Eating CBT Active CBT PBO SPT Active SPT PBO Meds

30 Signal Detection Analysis After 6 sessions Purging < 70% Non-responders

31 Multicenter Effectiveness Trial Bulimia Nervosa Self-Help CBT /- Meds MEDS CBT

32 Remit Assisted Self-help Add Fluox Remit Symptomatic Add CBT Symptomatic CBT Improved or Remit Add Fluox Symptomatic

33 Percent Remitted-ITT CBT 70 CBT MED 60 SH SH MED SH CBT 30 SH MED CBT

34 Self-help in BN Year Author Random N Supervised Abstinent 1993 Schmidt, et al % 1994 Cooper, et al % 1996 Cooper, et al % 1996 Treasure, et al % 1997 Mitchell, et al % 1997 Dalle Garve % 2000 Bailer, et al % 2001 Thiels, et al % 2001 Benasiak, Benasiak, et al % 2002 Palmer, et al. 121 (Also BED) Phone/person 25% 2003 Carter, et al % (improved) 2003 Durand & King 34 Results = Specialist Care 2003 Ghaderi & Scott 31 (Also BED, EDNOS) // Bailer, et al % 2004 Pritchard, et al % 33% BE with no differences

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37 New Models/Technologies for Service Delivery Self-help Supervised self-help Telemedicine Phone-based Internet-based Computer-adjunct Computer-based

38 Telemedicine Study CBT via Telemedicine vs. CBT on Site Recruit North Dakota, Minnesota.

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40 Group 3.5 Mean GLOBAL EDE SCORE TV-CBT FTF-CBT BASELINE END OF TREATMENT 3 MONTH FU Assessment 1 YEAR FU

41 Palm Pilot Ecological Momentary Assessment (EMA) Therapy modules

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43 Treatment of BED Psychotherapy Evidence BE Wt CBT* //- IPT* //- DBT* //- Desipramine* Desipramine* Fluoxamine* Fluoxamine* Fluvoxamine* Citralopram* Citralopram* Sertraline* Sibutramine* Topiramate* Venlafaxine () () () Zonisamide* () () () Pharmacotherapy Escitalopram* * Randomized trials

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45 Patient: Age: Dx: Ht/Wt: Hx: AN #1 Denise 20 AN, Binge/Purge Subtype 5 7, 110 lbs. Resistant to Outpatient Gained in Partial from 98 lbs. Still depressed, anxious, but cooperative with psychotherapy

46 AN #1 Treatment: CBT 2x/week Fluoxetine-- 20mg/day 2 weeks Then 40 mg/day Outcome: Anxiety/Depression Obsessionality Weight

47 AN #2 Patient: Age: Dx: Ht/Wt: Hx: Lisa 15 AN, Restricting Subtype 5 2, 74 lbs. Onset age 14 Failure Outpatient (Lost 92 74). Hospitalized; very resistant Depressed Obsessed with body image

48 AN #2 (cont.) Treatment: Behavioral Conting. for Wt. Gain Individual Supportive Therapy Olanzapine 2.5 mg. to 5 mg. Day 7 to 7.5 mg. Day 14 Outcome: Anxiety/Depression Obsessionality Weight

49 AN #3 Patient: Age: Dx: Ht/Wt: Hx: Erin 30 AN, Binge/Purge Subtype 5 6, 88 lbs. Onset age 17

50 AN #3 (cont.) Hx (cont.): Numerous hospitalizations (>10) Committed for treatment twice Refuses to gain Family has given up Numerous antidepressant trials

51 AN #3 (cont.) Treatment: Supportive Psychotherapy Trials of Antidepressants Trials of Atypical Antipsychotics Hospitalize when unstable

52 BN #1 Patient: Age: Dx: Ht/Wt: Hx: Rachel 23 BN, Purging Subtype 5 6, 130 lbs. Active BN for 6 years BE/P 2x/day MDD, HAMD = 19 No prior Rx

53 BN #1 (cont.) Treatment: CBT (Group or Ind.) 20 mg Fluoxetine vs 60 mg

54 BN #2 Patient: Age: Dx: Ht/Wt: Hx: Sharon 24 BN, Purging Subtype 5 9, 160 lbs. Active BN for 4 years No response to prior psychotherapy Mild depression, HAMD = 11

55 BN #2 (cont.) Treatment: CBT If little improvement by week 4, add fluoxetine.

56 BN #3 Patient: Wendy Age: 28 Dx: BN, Purging Subtype Ht/Wt: 5 6, 180 lbs. Hx: Overweight since age 14 No response to CBT, psychodynamic Little, transitory response to Fluoxetine, Citalopram Depression

57 BN #3 (cont.) Treatment: Consider partial hospital for period of abstinence Consider sibutramine or topiramate Consider new psychotherapy trial

58 BED #1 Patient: Emily Age: 42 Dx: BED Ht/Wt: 5 5, 190 lbs. Hx: Multiple attempts at weight loss Behavioral/hypnosis/VLCD Depression

59 BED #1 (cont.) Treatment: Group CBT for BED (if available) Consider Sibutramine SSRI Topiramate Issues: Insurance/Cost

60 BED #2 Patient: Sally Age: 38 Dx: BED Ht/Wt: 5 7, 270 lbs. Hx: Multiple attempts at weight loss Fen-Phen/Behavioral Not depressed

61 BED #2 (cont.) Treatment: Group CBT for BED (if available) Consider SSRI Sibutramine Topiramate Consider Bariatric Surgery Issues: Insurance/Cost