FAMILY EDUCATION SERIES

Transcription

1 FAMILY EDUCATION SERIES

2 FAMILY EDUCATION SERIES OUTLINE o Eating Disorders Overview o What Has to Be Addressed and Why: An Overview o Levels and the Continuum of Care o Nutrition Overview o Medical Overview o Psychiatry Overview o Traits, Temperament and Vulnerability o The Role of the Family in Treatment and Recovery o Communication and Connection o What Do We Do When? Managing Behaviors o What Do We Do When? Managing Emotions

3 Medications used in the Treatment of Eating Disorders

4 OVERVIEW o Introduction o Psychiatric symptoms and psychiatric disorders often seen in patients with eating disorders o Anxiety o Depression o Cognitive flexibility / set-shifting o Ruminating thoughts o Substance abuse o Mood lability

5 OVERVIEW o Myths regarding psychotropic medications o Psychotropic medications in the treatment of eating disorders o Anorexia Nervosa (AN) oalterations in neurotransmitters due to malnutrition ouse of atypical antipsychotic medications in the treatment of AN Rationale for use / mechanism of action Target symptoms Examples

6 OVERVIEW o Bulimia Nervosa (BN) & Binge Eating Disorder (BED) o Medications used to treat BN and BED ossri s Target symptoms Examples oantiepileptic drugs / mood stabilizers Target symptoms Examples

7 OVERVIEW o Bulimia Nervosa (BN) & Binge Eating Disorder (BED) o Medications used to treat BN and BED (continued) oother atypical antidepressants Target symptoms Examples ostimulants Target symptoms Examples

8 OVERVIEW o Medications used to treat insomnia otarget symptoms oexamples

9 Introduction

10 EATING DISORDERS o Complex illnesses o Combination of medical and psychological issues o Patients not always happy about being in treatment o Patients often have difficulty trusting treatment providers o Inherent to the disorder o Psychiatric comorbid illnesses Depression Anxiety Obsessive-compulsive disorder Bipolar disorder Substance abuse o Medical comorbid illnesses Diabetes IBS GERD / dyspepsia / PUD Gluten enteropathy Polycystic ovary syndrome

11 CHALLENGES OF EATING DISORDERS o Detection o Denial and resistance o Ego syntonic symptoms o Eating disorder symptoms feel normal and don t feel foreign to patients o Medical dangers, including mortality risk o Untreated Anorexia Nervosa has mortality rate of 20% o Legal and financial barriers to treatment o Frequent relapse after hospitalization o Complex interplay of medical and psychiatric symptoms o Inherent tendency of healthcare providers and insurance carriers to classify symptoms as purely medical or psychiatric symptoms

12 Psychiatric Symptoms and Disorders often seen in Patients with Eating Disorders

13 EATING DISORDERS AND PSYCHIATRIC COMORBIDITY o Comorbidity of eating disorders o Anxiety (23-75%) o Mood disorders ( %) o Suicidal ideation (31-57%) o Suicidal attempts (3.1-17%) o Substance abuse (alcohol: %) o Personality disorders (increased severity of symptoms with BPD, and increased risk of AN in OCD PD) Buhren et al Eur Eat Disorder Review 2014; Swinbourne et al. Aust NZ J Psych. Feb 2012; Kaye et.al. Americal J Psych. Dec 2004 Root et al. Int. J Eat Disorders Jan 2010; Reas et al. Int. J Eat Disorders 2013; Rowe et al. Aust NZ J Psych. 2008

14 Psychiatric Symptoms in Anorexia Nervosa

15 DIFFICULTY WITH COGNITIVE FLEXIBILITY / SET-SHIFTING o Cognitive flexibility or set-shifting o Neurocognitive concept refers to ability to switch between tasks and behaviors with flexibility o The mental ability to change behavior in relation to changing rules and demands o Several studies found adults with Anorexia Nervosa have set-shifting deficits in that they tend to perseverate on previously applicable rules o Such findings are consistent with clinical observation that these patients tend to be cognitively rigid and persistent

16 RUMINATING THOUGHTS o APA criteria for level of care o Residential treatment: patient preoccupied with intrusive, repetitive thoughts four to six hours a day o Rumination is one of several forms of repetitive thinking o Rumination o Mode of responding to distress that involves repetitively and passively focusing on symptoms of distress and possible causes and consequences of symptoms o Research suggests rumination is a particularly detrimental form of repetitive thinking, as it has been found to predict anxiety, binge eating, binge drinking, self-injury and especially depression

17 RUMINATING THOUGHTS o Psychopathology happens when there is an inability to control or shut off ruminations o Studies indicate ruminations of all types are generally associated with increased sustained amygdala activity o When controlling for amygdala activity, distinct activity patterns in hippocampus were also associated with specific dimensions of rumination

18 AMYGDALA AND HIPPOCAMPUS

19 Psychiatric Symptoms in Bulimia Nervosa and Binge Eating Disorder

20 MOOD LABILITY o Mood swings o Bipolar I o Bipolar II o Borderline Personality Disorder o Post substance use o Irritability o Depression o Bipolar o Borderline Personality Disorder o Post substance use

21 Myths Regarding Psychotropic Medications

22 MYTHS REGARDING MEDICATION o It will change who I am, I will be a zombie o I will have to take it forever o Uncle Henry took it and that is when he really became crazy o Once I take it and stop, the depression will come back because I have taken something now. My body will be different and I will need to take it forever o Psychiatric meds make you fat

23 MYTHS REGARDING MEDICATION o My daughter is really smart and determined, she can do it on her own our family does not need to do things the easy way we come from a long line of success and have strong genes we don t need medications o She is too young for medication it is bad for her brain o Eating disorders are not real illnesses that need medication, we both know all she has to do is eat o Antipsychotics! She s not crazy, that is way too strong for her and doesn t it have side effects?

24 WHAT ARE THE FACTS? o Psychotropic medications typically work on one of the three monoamine neurotransmitter systems that help regulate mood o Dopamine o Norepinephrine o Serotonin o Psychiatric disorders and, to a large degree, response to medications are often highly genetic o High probability medications that work for your family members will also work for you (why we take a comprehensive family history) o We can also use genesight testing (genetic testing that identifies genetic changes in liver enzymes which play a role in drug metabolism; gives a profile of medications you will likely respond to)

25 WHAT ARE THE FACTS? o Psychotropic medications are meant to correct the imbalance that has occurred in the neurotransmitter system and should not in any way change your personality or not make you feel like yourself o Once you are on the correct medication and dosage you should feel like yourself again o If you stop taking a medication you will not get depressed just because you went off of the medication and your body went into withdrawal o Taking medication is a choice. Clinicians can provide the facts and clinical expertise, but choosing to take medication is up to the patient and parents (just as in the case of taking medication for diabetes)

26 WHAT ARE THE FACTS? o Once you start a medication, it is recommended to continue that medication for six months to one year. After that time period, an evaluation can be completed to see if further treatment is indicated o Will I need the medication again? o Statistics in depression (adults) o50% recurrence rate after first depressive episode o70% second o90% third

27 Psychotropic Medications in Treatment of Anorexia Nervosa

28 ANOREXIA NERVOSA (AN) o Target symptoms for medication o Improve cognitive flexibility/set-shifting o Decrease eating disorder ruminations o Decrease the pathological focus on weight and food o Decrease obsessive-compulsive symptoms o Reduce agitation o Note: paradoxically in AN, atypical antipsychotics are not particularly useful in weight restoration (the doses we use are too low to promote weight gain)

29 ATYPICAL ANTIPSYCHOTICS o Aripiprazole (abilify) o Mechanism of action o Aripiprazole is a partial agonist at D2 receptors o Lowering dopaminergic neurotransmission in the mesolimbic pathway (decreases ruminations / delusions) o Enhancing dopaminergic activity in the mesocortical pathway (improves cognitive symptoms) o Lower risk of extrapyramidal symptoms (EPS) and hyperprolactinemia than other antipsychotics o Target symptoms o Ruminating thoughts, cognitive flexibility, depression

30 Psychotropic Medications in Treatment of Bulimia Nervosa and Binge Eating Disorder

31 SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRIS) o Mechanism of action o Blocks re-uptake of serotonin at presynaptic neuron, thus allowing more 5HT to remain in synaptic cleft o Target symptoms o Bingeing o Depression (can also use in anorexia after patients are close to 90% ideal body weight) o Anxiety o Ruminations o At higher doses SSRIs work on obsessions and ruminations o Example: Fluoxetine (prozac), 80 mg daily o Examples: Fluoxetine (prozac), Sertraline (zoloft), Escitalopram (lexapro)

32 MECHANISM OF SSRIS

33 SEROTONERGIC SIDE EFFECTS o Common side effects oinsomnia oheadache ogi upset oanxiety or agitation osexual dysfunction opotential to increase suicidality(?)

34 SSRIS AND BLACK BOX WARNING In October 2004, the Food and Drug Administration (FDA) issued a black-box warning on antidepressants indicating they were associated with increased risk of suicidal thinking, feeling and behavior in young people o Twenty-four trials, containing 4,400 children and adolescents o Nine antidepressants included o No completed suicides in trials o More youth on a medication spontaneously reported suicidality vs. youth on placebo (4/100 vs. 2/100) o Included suicidal thoughts and behaviors, but none of these studies had any completed suicides o Experts questioned FDA analysis because studies they used were not properly designed to measure suicidality

35 SSRIS AND BLACK BOX WARNING o A more recent trial has shown a decrease in the amount of SSRI use has led to an increase in suicide rates in children and adolescents o FDA mindful of the need to balance small risk associated with antidepressant treatment against its proven benefits o Changed black-box warning in 2007 stating depression itself was associated with increased risk of suicide o Bottom line: if you are prescribed an antidepressant and in any way feel worse, you should stop taking the medication and call your doctor immediately because this is not an normal response

36 SEROTONERGIC SIDE EFFECTS o Serotonin syndrome o Greatest risk of serotonin syndrome occurs if taking two or more drugs and / or supplements together that influence serotonin o Potential cases: SSRIs, SNRIs, MAOI, Buspar, Trazodone, Triptans, Demerol, Tramadol, Dextromethophran, Reglan, Zofran, St. John s Wort, illicit drugs (LSD, MDMA, cocaine) o Condition more likely to occur when you first start a medicine or increase the dose

37 ANTIEPILEPTIC AGENTS (AED) o Mechanism of action: blockade of sodium channels o Acts pre- and post-synaptically o Pre-synaptically it inhibits release of excitatory neurotransmitters (glutamate and aspartate) o Post-synaptically it diminishes excitability of neurons o Calming effect on neurons o Target symptoms o Mood swings seen with mood disorders, substance use disorders and borderline personality disorders o Decrease bingeing (i.e. Topiramate (topamax)) o Examples: Lamotrigine (lamictal), Topiramate (topamax)

38 ANTIEPILEPTIC AGENTS CLINICAL PEARLS o Lamotrigine (lamictal) is useful mood agent in patients o Used for chronically depressed and / or patients with dysregulated mood o Used for patients with Borderline Personality Disorder o Used for patients with Bipolar II o Tolerated well with little side effects o Topiramate (topamax) is helpful agent when patient has binge eating and is not doing intuitive eating model o Stay below 200mg daily to minimize cognitive effects (i.e. word finding difficulties)

39 OTHER ANTIDEPRESSANTS: BUPROPION o Mechanism of action: norepinephrine and dopamine reuptake inhibitor (NDRI); increases dopamine neurotransmission in both nucleus accumbens and the prefrontal cortex o Target symptoms: binge eating, depression, smoking cessation, ADHD o Not appropriate for patients with bulimia due to purging o Example: Bupropion (wellbutrin), Bupropion XL (wellbutrin XL)

40 STIMULANTS o Lisdexamfetamine (vyvanse) o Mechanism of action olisdexamfetamine is prodrug of dextroamphetamine oamphetamines block reuptake of norepinephrine and dopamine in presynaptic neuron and increase amount of active neurotransmitters in synaptic cleft odrug has less abuse potential because it is not activated until it reaches the gut o Target symptoms: ADHD, binge eating o Example: Lisdexamfetamine (vyvanse)

41 STIMULANTS o Use with caution o Helpful with Binge Eating Disorder and Bulimia Nervosa due to appetite suppression and decreased tendency to binge olisdexamfetaime (vyvanse) is preferred because it has less abuse potential

42 INSOMNIA: SLEEP CHAIN o Start with melatonin and / or valerian root o Trazodone o Doxepin o Temazepam o Ambien, lunesta o Seroquel

43 CLINICAL PRINCIPLES o Start at low dose, but go as high as needed (children metabolize medications faster than adults) o Use least amount of medication possible o Unless patient is in crisis, abstain from doing medication changes at initial visit o Psychoeducation upfront is priority (patient and family) oinform adolescents of what they will find when they google the medication on the internet

44 Conclusion

45 EATING DISORDERS AND MEDICATION o Eating disorders are complicated o With advances in neurobiology, we are understanding more about underlying psychopathology and neurotransmitter abnormalities present in eating disorders o Using this information, we use psychotropic agents to better target abnormalities and aid in treatment of these notoriously hard to treat disorders

46 CONTACT INFORMATION Clementine Psychiatry o Chief of Psychiatry: Dr. Lauren Ozbolt, MD o lozbolt@clementineprograms.com o Clementine Miami: Dr. Marilyn Peraza, MD o mperaza@clementineprograms.com o Clementine Portland: Dr. Alfredo Velez, MD o avelez@montenido.com o Clementine Briarcliff: Dr. Darlene Osipuk, MD o dosipuk@montenido.com

47 WE HELP EACH ADOLESCENT REPLACE THE EATING DISORDER WITH HEALTHY SKILLS AND A DEEP UNDERSTANDING OF HOW TO LIVE A LIFE THAT REFLECTS THEIR INDIVIDUALITY.