IMPLICATIONS OF THE DSM-5 REVISIONS ON THE DIAGNOSIS AND TREATMENT OF EATING DISORDERS

Transcription

1 IMPLICATIONS OF THE DSM-5 REVISIONS ON THE DIAGNOSIS AND TREATMENT OF EATING DISORDERS PRESENTED BY KARYN L. SCHER, PH.D. 6/18/14 PENNSYLVANIA PSYCHOLOGICAL ASSOCIATION ANNUAL CONVENTION

2 ABSTRACT Eating Disorders, more prevalent in diverse ethnic and socioeconomic groups, are renamed "Feeding & Eating Disorders," in the DSMV. The working group updated criteria for Anorexia, Bulimia, & Eating Disorder NOS. In addition, Binge Eating Disorder has been incorporated into that category following decades of a presence in the Appendix only. We will look at the new criteria and discuss implications for diagnosis, treatment, and insurance coverage OUTLINE I. Hors D oeuvres: Brief History of the DSM A. Objectives in 1952, 1968, 1980, 1994, B. Implications of labeling mental disorders C. Initial labeling of anorexia, bulimia. D. History of Binge Eating Disorder incorporated into Appendix II. Appetizer: Objectives of the DSM-5 A. Why 5 not V? B. Psychiatric working groups, evidence-based, and eventual compatibility with ICD-10. C. Elimination of multi-axial system (including no AXIS II, but increased dimensionality. D. Elimination of not otherwise specified (NOS).

3 ABSTRACT [continued] Eating Disorders, more prevalent in diverse ethnic and socioeconomic groups, are renamed "Feeding & Eating Disorders," in the DSMV. The working group updated criteria for Anorexia, Bulimia, & Eating Disorder NOS. In addition, Binge Eating Disorder has been incorporated into that category following decades of a presence in the Appendix only. We will look at the new criteria and discuss implications for diagnosis, treatment, and insurance coverage OUTLINE III. The Meat of the Matter: FEEDING AND EATING DISORDERS A. Renaming the Category B. The new criteria and their rationale. C. The basis for Binge Eating Disorder as a separate category; comorbidity issues, the obesity variable. IV. Side Dishes: Other Feeding/Eating Disorders recategorized A. Avoidant/Restrictive Food Intake Disorder B. Pica, Rumination Disorder V. Dessert: Future Implications for treatment, medication influences, insurance perspectives. A. Psychologists roles in diagnosis and treatment. B. Case discussions.

4 HORS D OEUVRES: BRIEF HISTORY OF THE DSM Objectives in 1952, 1968, 1980, 1994, 2000 Implications of labeling mental disorders Initial labeling of Anorexia (1952)& Bulimia (1980) History of Binge Eating Disorder incorporated into Appendix.

5 DSM THROUGH THE AGES: DOES THE POPULATION GET MORE ILL?

6 DSM THROUGH THE AGES: DOES THE POPULATION GET MORE ILL?

7 DSM IV CRITERIA FOR ANOREXIA NERVOSA DSM-5 changes A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. 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.

8 DSM IV CRITERIA FOR ANOREXIA NERVOSA DSM-5 changes [continued] D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration). Specify type: --Restricting type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in bingeeating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) --Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in bingeeating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

9 DSM IV CRITERIA FOR BULIMIA NERVOSA DSM-5 changes A. Recurrent episodes of binge eating. An episode of binge is characterized by both of the following: 1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances 2)a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such a self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

10 DSM IV CRITERIA FOR BULIMIA NERVOSA DSM-5 changes [continued] D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. Specify type: --Purging type: during the current episode of Bulimia Nervosa, the person has regularly engaged in selfinduced vomiting or the misuse of laxatives, diuretics, or enemas. --Non-purging type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

11 EATING DISORDER NOT OTHERWISE SPECIFIED in DSM IV; eliminated from DSM-5 The EDNOS category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. Examples include: 1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses. 2.All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual s current weight is in the normal range. 3. All of the criteria for Bulimia are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less twice a week or for a duration of less than 3 months. 4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies). 5. Repeatedly chewing and spitting out but not swallowing, large amounts of food. 6. Binge-eating disorder (see research criteria)

12 RESEARCH CRITERIA FOR BINGE-EATING DISORDER A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1) eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. 2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. The binge-eating episodes are associated with three (or more) of the following: 1) eating much more rapidly than normal 2) eating until feeling uncomfortably full 3) eating large amounts of food when not feeling physically hungry 4) eating alone because of being embarrassed by how much one is eating 5) feeling disgusted with oneself, depressed, or very guilty after overeating

13 RESEARCH CRITERIA FOR BINGE-EATING DISORDER (continued) C. Marked distress regarding binge eating is present D. The binge eating occurs, on average, at least 2 days a week for 6 months E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g. purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa

14 APPETIZER: OBJECTIVES OF THE DSM-5 Why 5 not V? Psychiatric working groups, evidence=based and eventual compatibility with ICD-10. Elimination of multi-axial system, but increased dimensionality (i.e., addressing severity to track clinical improvement). What happened to Axis II? Elimination of not otherwise specified (NOS)

15 THE MEAT OF THE MATTER: FEEDING & EATING DISORDERS Renaming the category. The new criteria and their rationale. The basis for Binge Eating Disorder as a separate category; co-morbidity issues; comparisons to non-bed obese and normative cultural periodic overeating.

16 RATIONALE FOR B.E.D. AS A NEW DIAGNOSTIC CATEGORY BED tends to run in families BED is not a simple familial variation of obesity. BED shows a relatively distinct demographic profile with a greater likelihood of male cases, older age, and a later age of onset, compared to other E.D. BED is also differentiated from obesity in terms of greater concerns about shape and weight, more personality disturbance, and a higher likelihood of psychiatric comorbidity in the form of mood disorders and anxiety disorders. BED is associated with lower quality of life than obesity. BED may be differentiated from other eating disorders in terms of its lower level of diagnostic stability and greater likelihood of remission.

17 RATIONALE FOR B.E.D. AS A NEW DIAGNOSTIC CATEGORY [continued] In clinical course, BED also shows a greater likelihood of medical morbidities (e.g., selfreported weight gain and metabolic syndrome indicators) than is typically seen in other eating disorders, or in obesity. In studies of treatment response, there is evidence that individuals with BED have a more positive response to specialty treatments than to generic behavioral weight loss treatments in terms of reduction of eating disorder psychopathology. Antidepressant medication is useful in the treatment of BED, but is not generally useful in the treatment of obesity.

18 SUMMARY OF CHANGES Binge Eating Disorder Binge eating disorder is defined as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with binge eating disorder may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months. This change is intended to increase awareness of the substantial differences between binge eating disorder and the common phenomenon of overeating. While overeating is a challenge for many Americans, recurrent binge eating is much less common, far more severe, and is associated with significant physical and psychological problems. Anorexia Nervosa Anorexia nervosa, which primarily affects adolescent girls and young women, is characterized by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat. The criteria have several minor but important changes: Criterion A focuses on behaviors, like restricting calorie intake, and no longer includes the word refusal in terms of weight maintenance since that implies intention on the part of the patient and can be difficult to assess. The DSM-IV Criterion D requiring amenorrhea, or the absence of at least three menstrual cycles, will be deleted. This criterion cannot be applied to males, pre-menarcheal females, females taking oral contraceptives and postmenopausal females. In some cases, individuals exhibit all other symptoms and signs of anorexia nervosa but still report some menstrual activity.

19 SUMMARY OF CHANGES [continued] Bulimia Nervosa Bulimia nervosa is characterized by frequent episodes of binge eating followed by inappropriate behaviors such as self-induced vomiting to avoid weight gain. DSM-5 criteria reduce the frequency of binge eating and compensatory behaviors that people with bulimia nervosa must exhibit, to once a week from twice weekly as specified in DSM-IV.

20 SIDE DISHES: OTHER FEEDING/EATING DISORDERS Previous listing among Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence. Criteria for Avoidant/Restrictive Food Intake Disorder Pica Rumination Disorder

21 DESSERT: FUTURE IMPLICATIONS FOR TREATMENT, MEDICATION INFLUENCES, INSURANCE PERSPECTIVES. Psychologists roles in diagnosis and treatment Switching from Axes I/II/III to single disorder list; V codes for context; change from GAF to symptom severity coding and WHO-DAS. Change from NOS to categories that define clinical characteristics. Case Discussions

22 CASE VIGNETTES FOR DSM 5 CHANGES A) Steven, a 17 yo wrestler, presented for therapy after concern was expressed by family and friends that his weight was decreasing post-season. A referral to his pediatrician revealed that, while he had maintained 90% of his preseason weight during the season in order to compete, an illness 2 months post-season that lead to an office visit with a routine weigh-in revealing that he had lost nearly 10% more of his original weight. On intake with the psychologist, Steven admitted that he was extremely concerned about regaining his pre-season weight, which he believed made him look gross, and that he continued to use self-induced vomiting at least weekly and a couple of hours of cardio daily in the gym to control his weight, as he had done before wrestling meets. Compare the DSM IV diagnosis of EDNOS to DSM-5 Anorexia Nervosa, binge eating/purging subtype. B) Theresa, a 26 year old graduate student, presented for therapy stating that she knew she had some kind of eating problem, but didn t fit into any categories when she researched the diagnoses online. She reported that her weight was well within the normal range, though she was acutely aware of her daily caloric intake and generally tried to stay within calories, with an adequate variety of nutritious food groups. However, every Sunday night, her Italian grandmother fed the entire family with a bounty of homemade pastas, breads, followed by tira misu and cannoli. Theresa felt obligated to participate in the ritual and was always teased about her meager intake, until she surrendered and overate. Her binge left her so upset and guilty, but she continued eating the care package of leftovers until it was gone, followed by the inevitable purge at her own home. Compare the DSM IV and DSM-5 frequencies of binging/purging to determine the pros/cons of diagnosing Theresa with Bulimia Nervosa. C) After nearly 6 months of therapy for under-functioning in his sales job, Brian, an overweight, 32 yo father of 3, revealed that, although he had a normal sized breakfast and dinner at home with his family, alone on the road for work, he often had the equivalent of 3 full meals and 2 large desserts for lunch during the week. Suffering episodes of gout and of excruciating back pain, both attributable to his weight, he admitted that he ate until he felt stuffed, and was furious with and ashamed of himself for being out of control. Brian said he did his Google research, and determined that he did not have an eating disorder since only thin women had them, but knew that he had some type of food problem. How might treatment with Brian change with the appearance of Binge Eating Disorder in the DSM-5 as a diagnosis in the Feeding and Eating Disorder category?

23 BIBLIOGRAPHY Attia E & Roberto CA, Should Amenorrhea be a Diagnostic Criterion for Anorexia Nervosa? International Journal of Eating Disorders, 2009; 42: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, D.C., American Psychiatric Association, American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, D.C., American Psychiatric Association, Marcus MD & Wildes JE, Obesity: Is it a mental disorder? International Journal of Eating Disorders, 2009; 42: Walsh BT & Sysko R, Broad Categories for the Diagnosis of Eating Disorder (BCD-ED): An alternative system for classification. International Journal of Eating Disorders, 2009; 42: Wilfley DE, Bishop ME, Wilson GT, Agras WS. Classification of eating disorders: toward DSM-V. International Journal of Eating Disorders, 2007, Nov.40: Supplement: S Review. Wilson GT & Sysko R. Frequency of binge eating episodes in bulimia nervosa and binge eating disorder: Diagnostic considerations. International Journal of Eating Disorders, 2009; 42: Wolfe BE, Wood Baker C, Smith AT, & Kelly-Weeder S. Validity and utility of the current definition of binge eating. International Journal of Eating Disorders, 2009; 42: Wonderlich SA, Gordon KH, Mitchell JE, Crosby RD, & Engel SG. Validity and clinical utility of binge eating disorder. International Journal of Eating Disorders, 2009; 42: