cuzzolaro seed very short - sisdca09/05/2016 massimo cuzzolaro 2 bulimia nervosa other specified...

Bologna, 9 maggio 2016

s e v e r e a n d e n d u r i n g e a t i n g d i s o r d e r s

09/05/2016 massimo cuzzolaro 1


B u l i m i aN e r v o s a

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c r o s s - d i a g n o s t i c e a t i n g p a t t e r n s

BMI

BED

BNAN

OS•FED

• r e s t r i c t i v e e a t i n g

• b i n g e e a t i n g

• b i n g e d r i n k i n g

• f o o d c r a v i n g

• n i g h t e a t i n g

• e m o t i o n a l e a t i n g

• …


stili alimentari ( eating patterns )

� restrizione ( restraint )

� avversione selettiva ( selective food aversion )

� piluccamento ( grazing, nibbling, snacking, grignotage )

� mangiare schizzinoso ( picky fussy eating )

� mangiare e sputare ( chewing and spitting )

� mangiare per sedare emozioni ( emotional eating )

� mangiare dopo cena e/o di notte ( night eating )

� iperfagia ai pasti o ad alcuni pasti ( overeating )

� iperfagia compulsiva ( compulsive overeating )

� bramosia selettiva ( selective food craving, sweet eating )

� abbuffata compulsiva ( binge eating )

� ruminazione ( merycism )

� mangiare materiali non commestibili (pica )

� ...


d i e t a r y r e s t r a in t=

the i n t en t i on t o r e s t r i c t

f ood i n t ake i n o rde r t o con t r o l

b ody we i gh t(He rman & Mack

1975 )

d e f i n i n g

f e a tu r e

r i s k

f a c t o r

p e r p e tu a t i n g

f a c t o r

EDs

p e r p e tu a t i n g f a c t o r

( we i g h t c y c l i n g )

obes i ty


r e s t r a in t

d e f i n i n g

f e a t u r e

r i s k

f a c t o r

p e r p e t u a t i n g

f a c t o r

EDs

p e r p e t u a t i n g

f a c t o r

( we i g h t c y c l i n g )

obes i ty

t h e r a p e u t i c

f a c t o r

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r i s k

f a c t o r

• Restrictive eating can mean eating an amount

of food that most o t h e r s w o u l d t h i n k i s t o o l i t t l e . For example,

eating an apple for dinner or fasting all day could be considered restrictive eating.

• Restrictive eating can mean eating far l e s s t h a n o t h e r s in a similar situation. For

example, eating a diet frozen meal at Thanksgiving dinner with family could be considered restrictive eating.

• Restrictive eating can mean eating l e s s t h a n i s a p p r o p r i a t e f o r y o u r b o d y s i z e o r h u n g e r l e v e l . For example, if you are very hungry or

are underweight and you eat only a small salad for dinner, this could be considered restrictive eating.


H a v e t h e r e b e e n a n y t i m e s

w i t h i n t h e p a s t m o n t h

wh e n y o u h a v e e a t e n i n t h i s m a n n e r

b e c a u s e

y o u we r e c o n c e r n e d

a b o u t y o u r b o d y s h a p e a n d / o r we i g h t ?


B u l i m i aN e r v o s a

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D S M - 5 f e e d i n g a n d e a t i n g d i s o r d e r s( A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , 2 0 1 3 )

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D S M - 5 d i a g n o s t i c c r i t e r i a f o r a n o r e x i a n e r v o s aD S M - 5 d i a g n o s t i c c r i t e r i a f o r a n o r e x i a n e r v o s a


DSM-5 Feeding and eating disorders

Major changes: Anorexia Nervosa

In DSM-5, the criteria for anorexia no l onge r spec i f y ameno r rhea , or the absence of at least three menstrual cycles.

The past requirement was problematic because it excluded men or girls who hadn't started

menstruating and women whose periods continued.

(In some cases of anorexia, individuals exhibit all other relevant symptoms and signs but still

report some menstrual activity)

In addition, in terms of weight maintenance, the word "r e fu sa l " was removed since

• it implied intention on the part of a patient

• was difficult for clinicians to evaluate.

Anorexia NervosaDSM-IV-TR and DSM -5 diagnostic criteria




Anorexia Nervosa • criterion 1

Pe r s i s t en t r e s t r i c t i on

of energy intake

relative to requirements,

leading to

s i gn i f i c an t l y

l ow body we i gh t

in the context of age, sex, developmental trajectory, and physical health.

• l e s s th an m i n i m a l l y n o r m a l

• l e s s th an th a t m i n i m a l l y e x p e c t e d (for children and adolescents)

res t r i c t i on/we igh t



Anorexia Nervosa • specify if in remission

i n p a r t i a l r e m i s s i o n i n f u l l r e m i s s i o nAfter full criteria

for anorexia nervosawere previously met,

Criterion A (l o w b o d y w e i g h t )has not been met

for a sustained period,but

either B or Cis still being met

After full criteriafor anorexia nervosawere previously met,

n o n e o f t h e c r i t e r i ahave been met

for a sustained period of time.



Anorexia Nervosa • severity levels

sever i t y leve l BMIm i l d ≥ 17

m o d e r a t e 16 – 16.99

s e v e r e 15 – 15.99

e x t r e m e < 15

T h e l e v e l o f s e v e r i t y

m a y b e i n c r e a s e d

t o r e f l e c t t h e d e g r e e o f

• o the r symptoms• d i s ab i l i t y


DSM-5 Feeding and eating disorders • definition( Amer i can Psych ia t r i c Assoc ia t i on , 2013 )

i s b od y imag e d is tu rb anc e r eq u i r ed f o r d iag nos i s?

• pica no

• rumination disorder no

• avoidant/restrictive food intake disorder no

• anorexia nervosa yes

• bulimia nervosa yes

• binge-eating disorder no


DSM-5 Feeding and eating disorders and body image( Amer i can Psych ia t r i c Assoc ia t i on , 2013 )

b od y imag e d is tu rb an c e is usual l y p r esen t in

• anorex i a ne rvosa

• bu l im ia ne rvosa

• b inge - ea t ing d i so rde r

• a typ i ca l ano rex i a ne rvosa

• a typ i ca l bu l im ia ne rvosa ( purg ing d i so rde r )


i s o n l y a n o r e x i a n e r v o s a a s e v e r e a n d d a n g e r o u se a t i n g d i s o r d e r ? i s o n l y a n o r e x i a n e r v o s a a s e v e r e a n d d a n g e r o u se a t i n g d i s o r d e r ?

AN The standardized mortality ratio

was 11.6 (95% CI = 5.5-21.3)

for all causes of mortality

and

56.9 (95% CI = 15.3-145.7)

for suicide.

• S M R 12 ( a l l c a u s e s )

• S M R 57 ( s u i c i d e )


BNThe standardized mortality ratio

was 1.3 (95% CI = 0.0-7.2)

• S M R 1 ( a l l c a u s e s )

The standardized mortality ratio

was 4.37 (95% CI=2.4-7.3)

for lifetime anorexia nervosa.

AN SMR 4.37


The standardized mortality ratio

was 2.33 (95% CI=0.3-8.4)

for bulimia nervosa

with no history of anorexia nervosa

BN SMR 2.33

Multivariate predictors of mortality

included:

• long duration of illness

• alcohol and other substance abuse

• low body mass index

• poor social adjustment.


These findings highlight

the need for

early identification

and

intervention

258 BN (DSM-IV)

consecutive inpatients

were included (1988-2004).

Vital status was established from the

French national register.

Mean follow-up duration was

10.5 years.


• C M R 3 . 9 %

a l l c a u s e s

• S M R 5 . 5 2 ( C I 9 5 % 2 . 6 4 - 1 0 - 1 5 )

s u i c i d e

• S M R 3 0 . 9 ( C I 9 5 % 5 . 7 - 6 8 . 7 )

225 consecutively admitted patients

from 1999 to December 2005

- median follow-up of about 9 years -

Vital status was ascertained

with a

National Death Index search

in 219 out of 225.


At follow-up,information about the deceased

was obtained by interviewing• a spouse or relative• or a doctor responsible for post-

treatment.

11 deathswere recorded

• CMR 5 %• SMR 3.90 (95% CI 2.05-7.21)

atypical anorexia nervosa not underweight ✦✦✦✦ definit ion( W h i t e l a w M e t a l , 2 0 1 4 ; S a w y e r S M e t a l , 2 0 1 6 )

Adolescents

with atypical anorexia nervosa

have lost significant weight

but

are not underweight

✦

They are presenting to

pediatric eating disorder services

at an increasing rate


Atypical AN considerably affects

physical and psychological functioning,

despite adolescents presenting

within or above

the normal weight range

✦

The morbidity

of adolescents with atypical AN

does not appear less severe

than that

of adolescents with full-threshold AN

atypical AN not underweight vs. typical AN ✦✦✦✦

increasing rate of inpatients( W h i t e l a w M e t a l , 2 0 1 4 )


2005 2009 2010

atypical AN

______

typical AN

8% 47% 43%

atypical AN vs. typical AN ✦✦✦✦ physical features - a( S a w y e r S M e t a l , 2 0 1 6 )


atypical AN typical AN p

age 15.5 15.4 ns

female gender 88% 88% ns

current BMI 21.4 16.0 < .001

currently overweight or obese 17% 0% < .001

highest premorbid BMI 27.7 20.1 < .001

overweight or obese in the past 71% 12% < .001

loss of weight kg 17.6 11.0 < .001

age at menarche 11.9 12.4 .05

amenorrhea 32% 61% .003

atypical AN vs. typical AN ✦✦✦✦ physical features - b( S a w y e r S M e t a l , 2 0 1 6 )


atypical AN typical AN p

bradycardia(< 50 bpm)

24% 33% ns

orthostatic instability(> 20 bpm, > 10 mm Hg)

43% 38% ns

hypothermia(< 35.5oC)

10% 13% ns

admitted to hospital at presentation

41% 52% ns

age at menarche 11.9 12.4 .05

amenorrhea 32% 61% .003

atypical AN vs. typical AN ✦✦✦✦ psychological features( S a w y e r S M e t a l , 2 0 1 6 )


atypical AN vs. typical AN ✦✦✦✦ EDE( S a w y e r S M e t a l , 2 0 1 6 )


The weight

adolescents with atypical AN

are currently at

is still higher

than the weight they

would secretly like to be.

✦

Being

overweight or obese before

they developed the ED

could fuel a "fear of fatness”

and perpetuate the disorder itself.



Anorexia Nervosa • severity levels

sever i t y leve l BMIm i l d ≥ 17

m o d e r a t e 16 – 16.99

s e v e r e 15 – 15.99

e x t r e m e < 15

T h e l e v e l o f s e v e r i t y

m a y b e i n c r e a s e d

t o r e f l e c t t h e d e g r e e o f

• o the r symptoms• d i s ab i l i t y


r e c e n t g u i d e l i n e s f o r t r e a t m e n t o f E D sr e c e n t g u i d e l i n e s f o r t r e a t m e n t o f E D s

E D g u i d e l i n e s & r e s o u r c e s • A u s t r a l i a & N e w Z e a l a n d


E D g u i d e l i n e s & r e s o u r c e s • A u s t r a l i a & N e w Z e a l a n d , 2 0 1 4



a n o r e x i a n e r v o s a -d u r a t i o n o f i l l n e s s a n d o u t c o m ea n o r e x i a n e r v o s a -d u r a t i o n o f i l l n e s s a n d o u t c o m e


Duration of i l lness and outcome • a

Dally (1969) wrote that

recovery was not possible

after seven years of

illness …

… Ratnasuriya et al (1991)

suggested that after 12

years of illness patients

with AN are unilkely to have

improved .


Duration of i l lness and outcome • b

Full recovery may take 5-7

years even among those

who fully recover from AN

and …

Strober et al, 1997

… very long-term outcome

studies have demonstrated

that at least partial

recoveries are still possible

after 15-20 years of

illness

Theander, 1985

Ratnasuriya, 1991

Chronic Eating Disorders Strober M, 2004 – Kaplan AS, 2009

A permanence of the disease state in spite of repeated exposures to state-of-the-art therapy

Strober M.

Managing the chronic, treatment-resistant patient with anorexia nervosa.

Int J Eat Disord. 2004; 36: 245-255.

There is no

widely accepted definition of treatment resistance

in this population

and criteria

for

the duration of illness

numbers of failed treatments

do not exist.

Kaplan AS, 2009


Chronic Eating DisordersKaplan AS, Psychiatric Times . Vol. 26 No. 8, 2009

As with many chronic

illnesses, the goals and

expectations in patients

with a treatment-resistant

eating disorder shift from a

focus on full recovery to …

reduction in mortality

symptom alleviation

improving the quality of life

improving the medical stability



Chronic courses vary along a number of dimensions …(Yager, J 2007) a

serious medical

complications

fewer m

edical com

plications


Chronic courses vary along a number of dimensions …(Yager, J 2007) b

good productive life

totally disabled


Chronic courses vary along a number of dimensions …(Yager, J 2007) c

stability

instability


Chronic courses vary along a number of dimensions …(Yager, J 2007) d

treatment

reluctance

under-treatment

optimal treatm

ent non

-response


Clinicians …(Yager, J 2007) a

therapeutic neglect

therapeutic zeal


Clinicians …(Yager, J 2007) b

therapeutic nihilism

unrealistically high expectancies

MAIN RISKS (burn-out syndrome)

• narcissistic challenge

• frustration

• anger

• impotence

• disengagement

MAIN RISKS (burn-out syndrome)

• narcissistic challenge

• frustration

• anger

• impotence

• disengagement

REMEDIES

• adequate training

• frequent supervision

• research


Modest therapeutic goals in a stepwise fashion

- Safety (life-saving nasogastric and parenteral feeding, involuntary treatment)

- Reducing hospitalizations

- Reducing psychopathological features (e.g. self-harming behaviors)

- Motivational interviewing (Miller WR et al, 2003)

- Psychosocial rehabilitation (Sullivan MJ et al, 2005)

- Family counseling or treatment

- Medications (SSRI, atypical and typical antipsychotic)

Modest therapeutic goals in a stepwise fashion

- Safety (life-saving nasogastric and parenteral feeding, involuntary treatment)

- Reducing hospitalizations

- Reducing psychopathological features (e.g. self-harming behaviors)

- Motivational interviewing (Miller WR et al, 2003)

- Psychosocial rehabilitation (Sullivan MJ et al, 2005)

- Family counseling or treatment

- Medications (SSRI, atypical and typical antipsychotic)

don’t beat a dead horse(Yager, J 2007)


Guidelines parallel those for other patients with

chronic unremitting illnesses that may lead to prem ature death

� do not harm (primum non nocere)

� ideally, base decisions on clinical effectiveness r ather than on finances

� avoid communicating undue optimism or self-protecti ve nihilism

� realize that ongoing contact with a caring, involve d clinician conveys

meaning and hope

� keep the long view

Guidelines parallel those for other patients with

chronic unremitting illnesses that may lead to prem ature death

� do not harm (primum non nocere)

� ideally, base decisions on clinical effectiveness r ather than on finances

� avoid communicating undue optimism or self-protecti ve nihilism

� realize that ongoing contact with a caring, involve d clinician conveys

meaning and hope

� keep the long view

Compassionate clinical decision makingfor intractable patients …

(Yager, J 2007)


The only benefit one can expect from aggressive and sometimes

incresingly assaultive treatments is to prolong lif e, but certainly

not to keep its quality from deteriorating.

As with patients with terminal cancer or AIDS, it i s often the

treating staff and the family who are unable to acc ept the

rational nature of the patient’s desires to die.

The only benefit one can expect from aggressive and sometimes

incresingly assaultive treatments is to prolong lif e, but certainly

not to keep its quality from deteriorating.

As with patients with terminal cancer or AIDS, it i s often the

treating staff and the family who are unable to acc ept the

rational nature of the patient’s desires to die.

Chronically-suicidal patient andwalking-on-the-edge patients

(Yager, J 2007)

SE-AN ✦✦✦✦ a review(Hay et a l , 2012)

Hay PJ, Touyz S, Sud R (2012)

Treatment for severe and enduring anorexia nervosa: a review.

Aust N Z J Psychiatry

46 (12):1136-1144. doi:10.1177/0004867412450469

• treatment trials need to move beyond targeting core eating disorder pathology (primarily weight restoration)

• trials should examine efficacy and effectiveness in minimising harm and reducing personal and social costs of chronic illness

• there is also a need to develop better definitions of chronicity, with or without treatment 'resistance' specifiers.


SE-AN ✦✦✦✦ RCT(Touyz et a l , 2013)

Touyz S, Le Grange D, Lacey H, Hay P, Smith R, Maguire S, Bamford B, Pike KM, Crosby RD (2013)

Treating severe and enduring anorexia nervosa: a randomized controlled trial.

Psychol Med

43 (12):2501-2511. doi:10.1017/S0033291713000949

• 63 patients with at least a 7-year illness history

• during 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM (specialist supportive clinical management), both modified for SE-AN

• patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved

• for the first time symptom reduction was not designated as a primary outcome measure

• the main outcome measures were quality of life, mood disorder symptoms and social adjustment.


SE-AN ✦✦✦✦ Editorial(Touyz et a l , 2015)

Touyz S, Hay P (2015)

Severe and enduring anorexia nervosa (SE-AN): in search of a new paradigm.

J Eat Disord

3 (26): 1-3

doi:10.1186/s40337-015-0065-z

• most patients with SE-AN are unlikely to fully recover. Some do but they are in the minority. It is therefore extremely important not to focus solely upon symptom reduction, but to also take into account a more holistic model of care

• the ethical debate has already begun as to whether interventions such as deep brain stimulation is in fact offering hope to the hopeless or merely exploiting the vulnerable


Park R, Tan J.Giving hope to the hopeless or exploitation of the vulnerable? The ethics of deep brain stimulation

research for severe anorexia nervosa.

In: Proceedings of the International Conference on Eating Disorders, Boston.

23rd–25th April, 2015.

http://www.aedweb.org/ICED2014/downloads/Final_Program1.pdf. Accessed 18 June 2015.

severe and enduring eating disorders (SEED)(Hay P & Touyz, 2015)

Hay P, Touyz S.

Treatment of patients with severe and enduring eating disorders.

Curr Opin Psychiatry

28:473–477

2015

For the treatment of SEED,

some new s t ra teg ies

are picked up

from

other fields in psychiatry,

especially from findings

in the field of

sch izophren ia .


SEED ✦✦✦✦ recovery model (Hay P & Touyz, 2015)

it might be useful

for especially

anorexia nervosa

to apply the

recovery mode l

as understood

for

sch izophren ia .

The recovery model

emphas izes

funct iona l i ty

with meaning and purpose in life

and

de -emphas izes

symptom remiss ion


a staging model for eating disorders(Treasure J et a l , 2015)

Treasure J, Stein D, Maguire S.

Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence.

Early Interv Psychiatry

9:173–184

2015

it might be useful

for especially

anorexia nervosa

to apply

s tag ing mode l s

from other medical fields such as

onco logy


SEED ✦✦✦✦ staging models(Treasure J et al, 2014; Hay P & Touyz, 2015)

• pre - syndroma l 'h i gh - r i sk ' s t age

• ear l y s ymptoms

• fu l l s yndromes

• se ve re endur ing i l l ne ss w i th

• markedly impaired quality of life

• neurocognitive deficits

• entrenchment of altered reward habit learning


cognitive remediation therapy(Danner UN et a l , 2015)

Danner UN, Dingemans AE, Steinglass J.

Cognitive remediation therapy for

eating disorders.

Curr Opin Psychiatry

28:468–472

2015

cognitive remediation therapy (CRT)

is a

behav ioura l -based

training intervention

that aims to improve

cogn i t ive p rocesses

with the goal of

durable improvement in

funct iona l outcomes .


cognitive remediation therapy for SEED(Danner UN et a l , 2015)

Recent studies of

CRT in schizophreniadescribe improvement in

• symptoms

• cognitive functioning

• psychosocial functioning

• changes in neural activity

the first RCT studies

cognitive remediation therapy in eating disorders

show

• less symptoms

• more cognitive flexibility

• improvement in quality of life

• good acceptability

• low attrition rates


cuzzolaro seed very short - sisdca09/05/2016 massimo cuzzolaro 2 bulimia nervosa other specified...

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