How can we predict & change the course and outcome of anorexia nervosa?

Transcription

1 Download slides bit.do/annakeski How can we predict & change the course and outcome of anorexia nervosa? Anna Keski-Rahkonen Associate Professor University of Helsinki, Finland

2 How can we change the course and outcome of anorexia nervosa? #1 By understanding the etiology of anorexia #2 By understanding the magnitude of the problem What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease #3 By in understanding this patient if I do not intervene? is natural course? #4 By understanding whether treatment can change the natural course of anorexia nervosa #5 By understanding prognostic factors #6 By understanding each other

3 How can we change the course and outcome of anorexia nervosa? #1 By showing that the problem exists and that it is real (local prevalence studies, personal stories, media) #2 By thoroughly understanding the etiological mechanisms of anorexia nervosa -> tailoring precision interventions #3 By having a detailed understanding of the natural course of anorexia nervosa ( What happens if I DO NOT INTERVENE? #4 By understanding factors that can change the natural course of anorexia nervosa. These include Treatment choices ( Will this treatment help? ) Patient-related prognostic factors ( Who will benefit?

4 How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene?? #1 By Understanding the Etiology of Anorexia

5 Why do people get anorexia nervosa? Various psychological theories Various biological theories Genetic, neurobiologial, animal research BOTTOM LINE:

6 Genes load the gun, the environment pulls the trigger Anorexia: 2-3% complete

7 Triggering factors: sociocultural factors + whatever slings & arrows life sends your way Gossip Girl

8 Personal, possibly inherited, biological vulnerability???

9 How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene?? #2 By Understanding the Magnitude of the Problem

10 A bunch of high school students. Who will get anorexia nervosa?

11 Prevalence of Anorexia Nervosa in Finland Anorexia nervosa, 3.6% 0.3%? Mustelin et al 2016 PMID , Raevuori et al 2009 PMID

12 How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene?? #3 By Understanding the Natural Course of the Problem

13 Natural course: The common cold Will the child get better if we don t intervene?

14 Natural course: Anorexia nervosa Will the child get better if we don t intervene?

15 Prevalence of Anorexia Nervosa in Finland Anorexia nervosa, 3.6% 0.3%? Mustelin et al 2016 PMID , Raevuori et al 2009 PMID

16 Who is still ill at age 30? Mustelin et al 2016 PMID , Raevuori et al 2009 PMID

17 Life after anorexia nervosa: How are women in their 30s doing? Weight restoration University degree Employment Marriage/cohabitation Pregnancy? Mustelin et al, Int Journal of Eating Disorders 2015

18 Recovery from Anorexia Nervosa in Finland 72%

19 0 recovered 100% Finnish women with Anorexia in the 1990s Half have received treatment, half have not. Can we predict who will get better? time (years) Data based on analyses in the Finnish Twin Cohorts (Keski-Rahkonen et al 2007, Keski-Rahkonen et al 2009)

20 What does this mean? Possible interpretations Treatment was not available widely Available treatment was not long enough Available treatment was not frequent enough Available treatment was not effective enough Available treatment was not based on correct etiological models

21 Finnish women with Anorexia. Can we predict who will get better based on Comorbidity? By 5 years: 74% recovered No depression p= DSM-IV depression By 5 years: 52% recovered

22 Risk of Death from Anorexia Nervosa AN, no comorbidity: 2.8 x AN, depression: 4.7 x AN, personality: 5 x AN, alcohol: 12 x (Kask et al 2016, PMID )

23 Anorexia & the risk of death 6 x the mortality of the general population Leading causes of death: suicide, starvation-related causes, infections Indirect evidence from Swedish registries that specialized eating disorder treatment reduces mortality Lindblad et al Am J Psychiatry 2006 Arcelus et al Arch Gen Psychiatry 2011

24 How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene?? #4 By Understanding the Treatment Altenatives

25 How to Save Lives: Detection & Diagnosis of Eating Disorders Lataa talteen itsellesi: bit.do/edinfo BMJ

26 Choice of Treatment

27 Basic Clinical Management Psychodynamic Approaches Oatmeal 1 kg Psychodynamic

28 Cognitive Behavioral Therapy Family Therapy

29 Evidence-based Treatment of Anorexia Nervosa Adults: No sufficient evidence of any psychotherapeutic approach Adolescents: Family therapy may be superior Inpatient treatment and outpatent treatment Antidepressants not useful for treating anorexia

30 Full bowl and empty bowl:

31

32 Cookbooks for Beginner Cooks

33 Cookbooks for Advanced Cooks

34 Can we predict who responds to treatment?

35 How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene?? #4 By Understanding Individual Prognostic Factors

36 Hi, I m Katja. I have some issues with food Hi, I m Anna. I am trying to help Ellie..

37 I hate the way I look. I don t deserve food. I have no time for friends. Running feels good. Drinking feels even better. I ve eaten nothing today. II m not telling her about cutting. I don t want to be here. Uh oh..

38 PMID:

39 Predictors of Eating Disorder Treatment Outcome Favorable prognosis: Fewer symptoms Shorter duration Higher BMI Low comorbidity High self esteem Interpersonal skills Greater motivation At risk of dropping out: Weight suppression Bingeing and purging Depressive symptoms Impulsivity Comorbidity Low motivation

40 Final BMI Ideal World: Precise Models, Accurate Predictions r=0.95 Intake BMI Simulation: rlanders.net

41 Final BMI Real World: Weak Signals, Fuzzy Predictions Intake BMI Simulation: rlanders.net

42 Try to achieve symptom reduction early on Focus on motivation Identify individuals with *severe symptoms * binge/purge behaviors *driven exercise *depression *personality problems * longstanding symptoms

43 Which Patients Need Us Most? Patients with severe symptoms, comorbid disorders, personality problems, poor interpersonal skills, suicidal behaviors, substance use

44 How can YOU change the course and outcome of anorexia nervosa? Practical suggestions Help those who are somatically in danger to get stabilized to reduce mortality What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene?? Start building networks of experts on anorexia nervosa Train professionals (multiple methods = good) Conduct research on locally relevant questions (for example, track local prevalence of eating disorders or treatment outcomes) Educate the public

45 Thank you!