Diagnosing adult patients with feeding and eating disorders - challenges and pitfalls Professor Øyvind Rø, MD Psychologist Kristin Stedal, PhD Oslo Universitetssykehus oyvind.ro@ous-hf.no
After 20 years as a clinician and researcher: Diagnosing adult patients with eating disorders is difficult. In research diagnostic criteria can have big influence on results Which BMI threshold when including AN patients in studies, 17.5/18,5 or 20? In clinical practice not so important to be aware of all the diagnostic details but we have to report diagnoses and it should be as correct as possible.
The content of the workshop: Diagnostic challenges in DSM 5 Case discussion Demonstration of the online diagnostic tool Eating Disorder Assessment EDA 5
Mental illness diagnosis: Should we use diagnoses to categorize or label our patients? Communication with the patient, relatives and other health care professionals. Planning of health services and research. Categorical approach but in real life a dimensional experience
When is having a difficult time a mental disorder? DSM the disturbances cause clinically significant distress or impairment in social, occupational or other areas of functioning What is clinically significant distress or impairment? Relevant for eating disorders
Allen Frances Psychiatrist and former leader of DSM VI task force The new edition of the "bible of psychiatry," the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), will turn our current diagnostic inflation into hyperinflation by converting millions of "normal" people into "mental patients."
Eating disorder diagnoses DSM 5 ICD 10, new edition ICD-11 planned to be released in 2018 Important shortcoming in ICD-10, no binge eating disorder diagnose This workshop focuses on DSM 5 among adults Does not include Pica, Rumination disorder or Avoidant/ Restrictive Food Intake Disorder
Under - diagnosing People in need of treatment do not get access to treatment due to no diagnose Only persons with significant problems are offered treatment Over diagnosing Normally over focusing on weight, body and eating make people into patients Too many seek treatment, not enough available resources
Which diagnosis should my patient have? 25 year old woman: Focused on body and eating since she was a teenager, active with physical exercise At a party three years ago she was given tranquilizers and woke up the day after, did not remember what happened, she thinks she was sexually abused, increasing eating problems thereafter Present situation: Restrictive eating, a lot of eating rules Moderate physical exercise 1-2 times a week to loose weight, much more frequent physical exercise previously Stable BMI about 18,0 last 6 months Vomiting 1-2 times a week after food intake, very seldom binge eating episodes Fear of increasing weight
DSM-5, May 2013
DSM-5 Feeding and Eating Disorders Pica Rumination Disorder Avoidant/Restrictive Food Intake Disorder ARFID Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder BED Other Specified Feeding and Eating Disorder OSFED Unspecified Feeding or Eating Disorder USFED Child and adolescent Regional Seksjon Department Spiseforstyrrelser Eating Disorders
Other Specified Feeding and Eating Disorder (OSFED) Atypical Anorexia Nervosa Bulimia Nervosa (of low frequency and/or limited duration) Binge Eating Disorder (of low frequency and/or limited duration) Purging Disorder Night Eating Syndrome Unspecified Feeding and Eating Disorder (USFED) symptoms characteristic of feeding and eating disorder that cause significant distress. but do not meet the full criteria for any of the disorders in the feeding and eating disorder diagnostic class.
Diagnosing When to diagnose a patient? Start of treatment or end of treatment? How to give a patient a diagnose? Clinical evaluation and extra information Consensus meeting? Structured clinical interview SCID-5-CV (DSM 5) Mini International Neuropsychiatric Interview MINI 6 (DSM VI and ICD- 10) only AN and BN Eating Disorder Examination EDE version 17.0 (DSM 5) Eating Disorder Assessment EDA-5 (DSM 5)
SCID-5-CV I. Screening for other current disorders p. 91-93. I 10. In the past 3 months, have you had a time when you weighed much less than other people thought you ought to weigh? IF YES: Consider Anorexia Nervosa (DSM-5, p. 338; User s Guide, p. 122) I 11. In the past 3 months, have you had eating binges, that is, times when you couldn t resist eating a lot of food or stop eating once you started? IF YES: Consider Bulimia Nervosa (DSM-5, p. 345; User s Guide, p. 122) or Binge-Eating Disorder (DSM-5, p. 350; User s Guide, p. 123). I 12. In the past month, since (ONE MONTH AGO), have you been uninterested in food in general or have you kept forgetting to eat? If NO: In the past month, have you avoided eating a lot of food because of the way they look or the way they feel in your mouth? If NO: In the past month, have you avoided eating a lot of different foods because you are afraid you won t be able to swallow or that you will choke, gag, or throw up? IF YES TO ANY: Consider Avoidant/Restrictive Food Intake Disorder (DSM-5, p. 334; User s Guide, p. 123)
Symptom severity DSM diagnose Time Partial remission Full remission
Main challenges in clinical practice and research Does the patient/person give accurate information? Reluctance to give information Minimizing the symptoms Want or do not want treatment
Main challenges in clinical practice and research Does the patient/person have an eating disorder? Boundaries between well and sick Eating disturbances and eating disorder Recovering from an eating disorder Boundaries between OSFED/USFED and AN,BN and BED diagnoses Diagnostic shift over time
Diagnostic shift AN OSFED USFED BED BN
Transdiagnostic view Fairburn & Cooper 2011. Eating disorders, DSM 5 and clinical reality One eating disorder diagnose With or with out underweight Eating disorders BMI below 17,5 Diagnose shift Common psychopathology, over-evaluation of shape and weight CBT-E treatment good results for all eating disorder diagnoses
Challenges: Psychological symptoms, how much distressed? Time criteria Frequency criteria Weight/BMI threshold What is a binge?
Psychological symptoms: When is the distress above threshold? AN B C «Intense fear of gaining weight» EDE interview, item 32 score 4 «Disturbance in the way in which one s body weight or shape is experienced» «undue influence of body weight or shape on self-evaluation» EDE interview, item 31 score 4 «persistence lack of the seriousness of the current low body weight»
Psychological symptoms: When is the distress above threshold? BN Criteria D «Self-evaluation is unduly influenced by body shape and weight» EDE interview, item 31 score 4 BED Criteria C «Marked distress regarding binge eating is present»
Time period and diagnoses AN: no clearly defined lengths of symptoms BN: BED To separate between restricting type and binge-eating/purging type: behavior last 3 months Binge eating, duration of binge eating «within any 2-hour period» Binge eating and inappropriate compensatory behaviors for 3 months Binge eating, duration of binge eating «within any 2-hour period» Binge eating for 3 months
DSM 5 partial or full remission, AN, BN, BED Partial/full remission, criteria not met for a sustained period of time ED partial remission full remission
Partial or full remission? Patients with previously full criteria for BN Last 10 weeks no binge eating, vomiting after normal size meals about every second week Last 10 weeks no binge eating or compensatory behavior Last 4 months no binge eating or compensatory behavior
What is a «sustained period of time»? One month Three months Six months One year Two year
Is it partial remission or diagnostic shift to OSFED/USFED? AN Partial remission or Atypical AN (OSFED) BN Partial remission or BN of low frequency and/or limited duration (OSFED) BED Partial remission or BED of low frequency and/or limited duration (OSFED)
Challenges about time and OSFED Atypical anorexia nervosa: No time specification Purging disorder: No time specification 3 months (as for BN)? Night eating syndrome: No time specification 3 months (as for BN/BED)?
The challenges of frequency criteria AN: no frequency criteria BN: both binge eating and inappropriate compensatory behaviours on average at least once a week for 3 months BED: binge eating on average at least once a week for 3 months
What is «on average» once a week, binges? Fluctuation of symptoms: Total numbers of binges last 3 months 16, on average 16/12 = 1,3 Week 1 4: 1 binge pr. week Week 5: 6 binges Week 6: 4 binges Week 7-10: 0 binge pr. week no binges for 4 weeks! Week 11-12: 1 binges pr. week Total number 16 EDE interview: not more than 2 weeks without binge eating/compensatory behavior as a BN/BED criteria
What is «on average» once a week, compensatory behavior? Fluctuation of symptoms: Inappropriate compensatory behavior Vomiting Fasting for how long time? Excessive exercise difficult to define Misuse of laxatives Misuse of diuretics number of pills? Misuse of thyroid hormones Patients with diabetes reducing insulin doses Misuse of enema +++
Challenges of frequency criteria and OSFED BN of low frequency and/or limited duration: What should be the minimum of binges or inappropriate compensatory behaviors last 3 month? BED of low frequency and/or limited duration: What should be the minimum of binges last 3 month? Purging disorder: What should be the minimum of purging behavior? Once a week last 3 months (as for BN)? Night eating syndrome: What should be the minimum of night eating episodes? Once a week last 3 months (as for BN/BED)?
AN and weight thresould DSM III 25% less than expected body weight DSM III R and DSM IV 15% less than expected body weight DSM 5 Significantly low weight Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected. An adult with a BMI between 17.0 and 18.5, or even above 18.5, might be considered to have a significantly low weight if clinical history or other physiological information supports this judgment ICD-10 BMI 17,5
How exact is the weight? Normal weight fluctuations 1-2 kg pr day Menstruations cycles Dehydration or intake of liquids Use of laxatives and diuretics Rebound effect after withdrawal of laxatives and diuretics Clothes Time of day Different scales
BMI thresholds WHO: <18,5 Underweight 18,5-24,9 Normal weight 25,0-29,9 Overweight >30 Obesity Eating disorders <17,5 Significantly underweight 17,6-18,9 Underweight 19.0-19,9 Low weight 20,0-24,9 Healthy weight 25,0-29,9 Overweight >30 Obesity
Calculation of BMI Measurement error height: 2 cm error in height ca. 0,5 BMI difference Weight Height BMI 40 160 15,6 40 162 15,2 60 160 23,4 60 162 24,9 80 160 31,3 80 162 30,5 0,4 0,5 0,8
Binge eating DSM-5 Binge eating is chatacterized by: 1. Eating, in a discrete periode of time (e.g., within any 2-hour period), an amout of food that is definitly larger than what most individuals would eat in a similiar period of time 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).
What is «definitly larger than what most individuals would eat»? My experience as a clinician and researcher most difficult Wilson 1992: «no widely accepted cut-off for determining what constitutes a large binge» Normal meal about 470 kcal (Davis, Freeman,& Garner, 1988) Self-identified binge-eating episodes in BN patients on average 1173-2799 kcal (Wolfe et al. 2009) Some research studies have used 1000 kcal as threshold (Kaye et al. 2004, Keel et al. 2007)
What is the threshold for an unusually large amount of food?
What is the threshold for an unusually large amount of food?
What is the threshold for an unusually large amount of food?
Establishing thresholds for unusually large binge eating episodes International Journal of Eating Disorders Volume 45, Issue 2, pages 222-226, 25 APR 2011 DOI: 10.1002/eat.20930 http://onlinelibrary.wiley.com/doi/10.1002/eat.20930/full#fig1
Conclusion: Males reported higher threshold amounts that females 1,9 small hamburgers versus 1.3 small hamburgers Overweight and ED sample higher threshold Definition of unusual large binge eating episodes depending on gender, BMI and ED status
Conclusion: Both gender and food type should when determining whether the amount of food consumed meets the criteria for DSM-5 bingeeating episode. A threshold of 1000 kcal could be a rule of thumb Fast food portions have increased, 1/3 exceed 1000 kcal (Dumanovsky et al 2009) Arikian et al. / Forney et al. 1,5 chocolate bars / 2 chocolate bars 1,5 small hamburger / 1.5 (women), 2.5 (men) hamburgers
EDE interview classification: ICD-11 BN probably include both objective and subjective bulimic episodes «Loss of control» may be the core component of binge eating (Mond et al. 2010)
EDE interview:
Vignett Boy, 25 years In despair over weight gain and body dissatisfaction Gradual increase in weight over the last year and currently has a BMI of 28 Nibbles on an almost daily basis but does not report loss of control Some days hardly eating at all Uses large amounts of laxatives every day
Vignett: Girl, 17 years Exercises a lot and has lost around 5 kilograms over the last six months Has a BMI of about 18 Constantly pre-occupied with what to eat and her body shape Experiences the body as being too big Lately, the menstruation has been irregular
Vignett Woman, 35 years, seeking help for eating problems Problems concerning eating for many years Snacks a lot throughout the day, unstructured eating pattern For some years: two-three times a week she eats large quantities which makes her stomach hurt but not the last 2-3 months Unable to vomit and does not use laxatives or diuretics Has gradually become obese and has a current BMI of 34
Vignett 28 year old woman Many years of eating problems Apparent body dissatisfaction which makes her unable to go swimming in public baths Preoccupied with eating healthily, has a limited diet and multiple eating rules. Some days (about once pr. month) she loses control and eats «forbidden» foods in moderate amounts before vomiting Runs, trains almost daily for 1-2 hours with a focus on weight and body shape BMI of about 19, irregular menstruation
Eating disorder assessment for DSM-5 EDA-5 Developed at Columbia Center for Eating disorders Translated to Norwegian HTTP://WWW.EDA5.ORG/
Eating disorder assessment for DSM-5 EDA-5: Provides a comprehensive assessment of all current DSM-5 feeding and eating disorder criteria for adults Requires minimal interviewer training Reduces participants burden 10-20 minutes Does not transmit the information over the Internet Possible to save the final report on the device being used Psychometric studies have demonstrated high rates of diagnostic agreement with Eating Disorder Examination and clinical interview. Excellent test-retest reliability. (Sysko et al. 2015)