At the end of this session, learners will understand: I serve as a section editor for UpToDate.com.

Transcription

1 Amy B. Middleman, MD, MSEd, MPH Professor of Pediatrics, Chief - Section of Adolescent Medicine University of Oklahoma Health Sciences Center Oklahoma City, OK I serve as a section editor for UpToDate.com. At the end of this session, learners will understand: the DSM 5 diagnostic criteria of the major eating disorders current treatment strategies for eating disorders how to determine if a patient has an eating disorder 1

2 Restriction of energy intake relative to requirements, leading to a significantly low body weight (less than minimally normal or expected) in the context of age, sex, developmental trajectory, and physical health Intense fear of gaining weight or becoming fat, or behavior that interferes with weight gain, even though less than minimally expected Disturbance in the way in which one s body weight or shape is experienced, undue influence of weight/shape on self-evaluation, or lack of recognition of the seriousness of low body weight DSM V 2

3 Subtypes: Restricting type Binge-eating/purging type Specify: Partial Remission Full remission Severity: Mild BMI > 17 kg/m 2 Moderate BMI kg/m 2 Severe BMI kg/m 2 Extreme BMI < 15 kg/m 2 Recurrent episodes of binge eating (amount;control) Recurrent inappropriate compensatory behavior to prevent weight gain Both binge eating/purging behaviors occur, on average, at least ONCE a week for 3 months Self-evaluation is unduly influenced by body shape/weight The disturbance does not occur exclusively during episodes of anorexia nervosa Specify: Partial Remission Full remission Severity: Mild An average of 1-3 episodes/week Moderate An average of 4-7 episodes/week Severe An average of 8-13 episodes/week Extreme An average of 14 or more episodes/week 3

4 Recurrent episodes of binge-eating (~1x/wk;3 mo) Binges must have 3 of 5 criteria: Eating more rapidly than normal Eating until uncomfortably full Eating large amounts when not hungry Eating alone because of embarrassment Feeling disgusted, depressed or guilty afterward Marked distress recurrent binge eating is present No inappropriate compensatory behavior; no diagnosis of AN or BN Specify: Partial remission Full remission Severity: Mild An average of 1-3 binge episodes/week Moderate An average of 4-7 binge episodes/week Severe An average of 8-13 binge episodes/week Extreme An average of 14 or more binge episodes/week Eating/feeding disturbance (e.g. lack of interest in food, avoidance based on sensory characteristics of food, concern for aversive consequences to eating) manifested as failure to meet appropriate nutritional needs Not better explained by lack of food, cultural practice Does not occur in context of AN or BN no evidence of body image disturbance Not attributable to another medical/mental health condition 4

5 Disordered eating behaviors that do not meet the more strict criteria of a specific eating disorder. Based on DSM IV Criteria Adult Females *AN.9% BN 1.5% BED 3.5% Adult Males *AN -.3% BN -.5% BED 2.0% *Estimates likely doubled for DSM 5 AN diagnosis Hudson JI. Biol Psychiatry. 61:348-58, Puberty represents change that challenges rigidity, exacerbates serotonin dysregulation Reduced dietary intake modulates serotonin and alleviates dysphoric mood Malnutrition and weight loss, however, exaggerates dysphoric mood Functional MRIs implicate interaction of pathways regulating appetite and emotion Genetics - twin studies suggest 50-80% genetic contribution to liability similar to bipolar Kaye W. Physiology and Behavior. 2008;94:

6 Attempting control at time of change Separation and individuation Identity formation: disorder defines self Family/social dysfunction or stressors Pressure to achieve Conducted by Ancel Keys from healthy, male volunteers University of Minnesota subjects lived in dorms Experiment Control period 12 weeks Starvation period 24 weeks 1570 calories on avg Rehabilitation period 12 weeks Psychological effects of starvation Depression Irritability Preoccupation with food Social introversion Decreased libido Decreased attention and problem solving (cognitive slowing) Physical effects of starvation Post-starvation hyperphagia Abundant calories required for recovery With recovery, preferential fat to the abdominal region/triceps 6

7 PATIENT PRESENTATION Susan is an 18 year old female with a history of obesity as a child here now for cold intolerance and a low heart rate noted by her pediatrician. Patient was overweight as a child. Her highest weight was 260 pounds by age 12 years. Her lowest weight was 130 pounds last month. Over the past several years, Susan has lost weight by becoming a vegetarian and exercising. Susan recently started college. She counts calories and eats approximately 2700 calories per day. She exercises daily at her gym for two hours and runs 4 miles per day. Recently, she was asked not to return to her gym. She denies laxatives, diet pills, diuretics, Ipecac, vomiting. Her last menstrual period was 9 months prior to the visit. 7

8 Susan had a fear of becoming obese again. She was experiencing increased weakness, cold intolerance, constipation, occasional chest pain, hair loss. She denied muscle cramps, growth delay, syncope. Susan was stretching during the interview. When asked, she indicated she thinks about food or weight 90% of her waking hours. Hair loss Abdominal pain Constipation Weakness and fainting Coarse, yellow skin Short stature and/or delayed puberty Muscle cramps Chest pain Moodiness and irritability Low self-esteem Perfectionism Social withdrawal and intolerance of others Overly sensitive to criticism Extreme concern about appearance Change in food choices; vegetarianism 8

9 Do you think you are too thin, too heavy, or just right? Have you had difficulty maintaining your weight recently? Have you ever felt you had to vomit or diet to keep your weight stable? Recent dietary changes? Have you ever used laxatives, diuretics, diet pills or Ipecac? Do you drink a lot of caffeine? Do you smoke cigarettes? How often/for how long do you exercise? (remember to ask about night-time exercise) When was your last menstrual period? Have your periods been irregular? Are you cold when others in the room seem comfortable? Have you had any bone fractures? Patient appears jittery and nervous HR 33 beats per minute BP 90/60 Temperature 96.7 degrees F Lying/Standing 33 bpm/42 bpm; 90/50 lying and 90/55 standing UA no abnormalities Urine pregnancy test - negative 9

10 Renal effect/fluids and electrolytes Cardiovascular Gastrointestinal Endocrine Reproductive Hematologic Skeletal* Dermatologic Neurologic* * potentially irreversible effects Golden NH. JAH, 2015;56:370. Multiple studies have revealed no improvement in bone with use of combination hormone pills High estrogen dose in OCPs suppresses IGF-1, a bone trophic hormone Use of patch (100 µg 17β-estradiol patch twice weekly with cyclic progesterone) or physiologic doses of estrogen (for those with BA<15 years) preserve bone Misra M et al. JBMR 2011;26:

11 Additional Advantages to Estrogen Replacement Performance on the WJ-III according to menstrual function. a P <.05 compared with control subjects; b P<.01 compared with control subjects; c P <.05 compared with irregular or absent menses AN. Chui HT. Pediatrics. 2008;122:e426-e437. Eating Disorder Inflammatory bowel disease Achalasia Celiac disease Primary endocrine disorder Diabetes mellitus Addison s disease Depression or other psychiatric disease Malignancy including CNS tumor Pregnancy 11

12 An interdisciplinary team approach is ideal Medical care by providers trained in eating disorders Nutritional support Psychological treatment with age appropriate family support Teamwork and alliance with family prevents the patient s disorder from dictating treatment Treatment takes many months to years Focus on health not weight When patient stable, more autonomy and choice can be therapeutic and developmentally appropriate Treatment approach from all team members including family must be consistently supportive versus punitive/shaming 12

13 Severe malnutrition less than 75% median body mass index for age and sex Dehydration or electrolyte imbalance Cardiac arrhythmias; EKG abnormalities Physiologic instability severe bradycardia hypotension (<90/45 mm Hg) hypothermia (<96 F) severe orthostatic changes Arrested growth and development Failure of outpatient treatment (three visits) Acute food refusal Uncontrolled binge eating and purging Acute complications of malnutrition (syncope, seizures, pancreatitis, etc.) Acute psychiatric emergencies Very little data pertaining to adolescents Fluoxetine most commonly studied: No effect on eating behaviors or weight maintenance for AN; use for antecedent depression/anxiety/ocd + or after weight restoration Decreases vomiting/binge-eating behaviors for BN 60 mg per day produced greater effects than 20 mg per day, especially among those with depression* American Psychiatric Association: medications are not recommended as sole or primary treatment for eating disorders +Couturier J et al. J Can Acad Child Adolesc Psychiatry. 2007;16: *Goldstein DJ et al. Int J Eat Disord. 1999;25:

14 Third Wave CBT Challenges rigid, distorted thoughts about food and body image; does not investigate the why Psychoeducation that challenges ED thinking comes from all team members Ego-syntonic nature of AN can make CBT difficult CBT is the treatment of choice for BN With progress, focus moves beyond food and weight Dialectical behavior therapy teaches skills to replace maladaptive coping (Federici A. Int J Eating Disorders. 2013) Acceptance and commitment therapy (ACT) focus on mindfulness work, experiential avoidance Interpersonal therapy investigates how relationships may be causing/maintaining ED (Fairburn C, APA Press. 1993) Psychodynamic therapy creates insight into later effects of earlier experiences/relationships Supportive psychotherapy seeks resolution of underlying issues More data are needed; only 2 RCT with adolescent EDs Family-based therapy (FBT) is increasingly popular ( Maudsley Method ) for AN Maudsley Model = Intense family involvement Phase 1 weight gain through refeeding with high family involvement (rewards system) Phase 2 transfer control back to patient Phase 3 individual therapy for the patient Most FBT is not truly Maudsley; Maudsley has no interdisciplinary team Varchol L et al. Curr Opin Pediatr. 2009;21:

15 Most effective for younger patients with shorter duration of illness Variations in method yield similar results; parental involvement may be key element Smith A, Cook-Cottone C. J Clin Psychol Med Settings 2011;18: OU Disordered Eating Program In-hospital treatment Individual and family (CBT structural, communicationbased) therapy Daily medical visits; dietitian daily, then as needed Physical therapy; child life Daily interdisciplinary team consultation Discharge to timely outpatient follow-up Same medical doctor Same individual therapist Same family therapist Weekly interdisciplinary team meeting 15

16 OUTPATIENT TREATMENT The patient is expected to: Gain weight (as appropriate) Eat three balanced meals per day Decrease frequency of disordered behaviors including: vomiting, hyperexercise, diet pill or laxative use, diuretic use, restriction Work toward therapy goals including improved communication and coping strategies Weigh after voiding (look at SG), in a gown only, no hair accessories or jewelry Remaining vital signs after lying for 3 minutes; again after standing for 5 minutes Screen for 24 diet history, exercise history, eating behavior history (binge/purge), related symptoms (dizziness, fatigue, chest pain, palpitations) Assess mood Patients followed as needed 16

17 INPATIENT TREATMENT (primarily for malnutrition) The patient is expected to: Achieve 85% MEBW/MEBMI Maintain stable vital signs with a resting heart rate of at least 50 beats per minute Eat three unobserved meals per day and continue to make progress Desist from disordered eating behaviors Establish and begin work on individual and family therapy goals to support patient as an outpatient Video monitoring/bathroom restrictions initially and as needed Bedrest as needed Point system (nutritional intake) Behavioral plan (includes use of cells, computers, off-the-floor privileges) Individual therapy at least 3x per week Family therapy at least 1x per week Physical therapy daily Child life daily Chaplain services on request 17

18 No IVs unless specified Weights in gown only, no hair accessories or jewelry, post-void and pre-breakfast Specific gravity checked qam Provide nutrition orally; meals and post-meal time observed Avoid NG or parenteral feeding when possible (psychological/medical complications) Reintroduction of carbohydrate releases insulin Phosphorus, potassium, magnesium shift to intracellular space; fluid imbalance Neutra-Phos-K; labs qod for 8 days Multivitamin provides any needed thiamine New data safe to refeed more quickly than in the past 18

19 Start out low and move slowly! Start with approximately kcal/kg ( cal/day) Increase calories by approximately 200 calories every 1-2 days Goal = 2-3 pound gain/wk in the hospital; 1 pound gain/wk as an outpatient 35 subjects; mean age 16.2 yrs Controlled environment Calories increased from 1205 to 2668 per refeeding guidelines 83% of subjects initially lost weight (Minnesota) Higher calories assigned at presentation associated with: Faster weight gain Shorter length of stay Garber et al. JAH 2012;50: year retrospective review 46 admissions Mean age 15.7 yr; %MBW 72.9% 61% of admissions started on 1900 kcal/d 28% started on 2200 kcal/day Intake increased to 2700 kcal/d by day 5; up 300 cal/d thereafter as needed No patient developed moderate or severe hypophosphatemia (HP); 38% mild HP Whitelaw M et al. JAH 2010;46:

20 Benefits of moving more quickly are not clear Biologically (e.g., fat distribution) Psychologically (e.g., increased stress of rapid change, decreased patient autonomy versus improved cognition) Refeeding quickly requires greater monitoring; some suggest lower carbs/continuous NG to obviate insulin shifts and decrease risk Requires study incorporating psychological consequences 212 patients hospitalized with AN in Europe Variables on logistic regression independently associated with BMI>17.5 at follow-up (~8 yr) were: Pre-morbid BMI OR=1.31, p=0.02 BMI at first discharge OR=1.39, p=0.04 Age at admission OR=0.70, p=0.02 Keep patients until 85% MBW Repeat hospitalization rates 13% at TCH (Houston) Repeat hospitalization rates in literature 45% (European data; patient stays shorter) Unpublished data for TCH; Steinhausen et al. Int J Eat Disord 2008;41: Steinhausen et al. Int J Eat Disord 2009;42: Fourteen adolescent medicine academic disordered eating programs 1 year follow-up of 700 patients 54% AN 34% atypical AN 12% ARFID Higher intake %MBMI predicted weight recovery (no psychological parameters studied) Atypical AN>AN>ARFID odds of weight recovery No treatment strategy significantly associated with higher odds of weight recovery (FBT approached significance) Forman S et al. JAH 2014; 55:750 20

21 Meta-analysis (not adolescent-specific) mortality is 0.56% per year 10-fold increase in mortality compared to agematched controls; 6-fold increase overall (approx 2- fold for BN/BED) Cause of death: Complications of the AN 54% Suicide 27% Prognosis is good; specific data sparse; approximately 70% recovery rate. Sullivan PF. Am J Psychiatry. 1995;153:1073. Smink F. Curr Psych Rep. 2012; 14:406. Eating disorders are primarily psychological diseases with relatively high mortality rates An interdisciplinary team approach is ideal Medical complications require inpatient stay with follow-up outpatient care Data are sparse regarding optimal inpatient and outpatient protocols for care; data collection is ongoing The goal is to determine best practices to help patients achieve emotional and physical health as quickly as possible 21

22 Golden NH, Katzman D, et al. Position paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adol Health 2015; 56:121. Misra M, Katzman D, et al. Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. JBMR 2011; 26: Kaye W. Neurobiology of anorexia and bulimia nervosa. Physiology and Behavior 2008; 94: Attia E, Walsh BT. Behavioral management for anorexia nervosa. NEJM 2009; 360: Kohn MR, Madden S, Clarke SD. Refeeding in anorexia nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr Opin Pediatr 2011;23: Smith A, Cook-Cottone C. A review of family therapy as an effective intervention for anorexia nervosa in adolescents. J Clin Psychol Med Settings 2011;18: Strober M, Johnson C. The need for complex ideas in anorexia nervosa Int J Eat Disord 2012;45: