Katharine L. Loeb, PhD Fairleigh Dickinson University
Outline of Talk WHAT Concept and history of early intervention for psychiatric disorders Its application to eating disorders WHY Importance of early intervention in anorexia nervosa (AN) HOW Early Case Identification ○ Using multiple informant methods Early Treatment ○ An adaptation of FBT for prodromal AN
Support and Disclosures K23MH074506: Early Identification and Treatment of Anorexia Nervosa R21HD057394: Parent-Based Treatment for Pediatric Overweight NIFA/USDA 2011-67002-30086: Optimal Defaults and Parent Empowerment in the Prevention of Early Childhood Obesity: A Community Center-Based Pilot Study No other financial disclosures
Continuum of Prevention toTreatment Relapse Prevention Successfully Treated Individuals TreatmentEarly Identification Diagnosed IndividualsEarly TreatmentClinically Significant Indicated Preventionbut Not (Yet?) High-Risk IndividualsDiagnosticPresentations Selective Prevention At-Risk Individuals Universal Prevention General Population
History of Early Intervention inPsychiatry Originated in the study and treatment of psychosis Impending syndrome severe enough to warrant “risking” treating false positive cases Identifiable prodrome Emerging symptom profile is clinically significant in its own right Promising results ○ Reduction of extant symptoms ○ Prevention of conversion to full syndrome ○ Fewer hospitalizations Bipolar Disorder Autism
Early Intervention in AN:Do the Same Criteria Apply? Impending syndrome severe enough to warrant “risking” treating false positive cases? Identifiable prodrome? Emerging symptom profile is clinically significant in its own right? Promising results? ○ Reduction of extant symptoms ○ Prevention of conversion to full syndrome ○ Fewer hospitalizations
How to distinguish betweenindicated prevention vs. earlytreatment in eating disorders? When specific risk factors (vulnerability for progression to the full disorder) are exhibited, targeted prevention is appropriate Once symptoms diagnostically essential for the full disorder are exhibited, the prodrome is conceptualized and early treatment is indicated Stice et al., 2010
Early identification and treatment ofAN Positively skewed prevalence and onset distributions of AN across age Early identification and treatment efforts have therefore appropriately targeted children and adolescents Such efforts appear to have a positive prognostic impact on the course of illness The optimal point of their application remains unclear
Prevention of AN in high riskyouth New, AN-spectrum presentations are associated with significant clinical severity and medical risk, equivalent to levels seen in AN Such presentations may reflect a disorder in evolution (prodrome), rather than a stable subsyndromal state or transient phase Identifying and treating the AN prodrome could prevent conversion to AN, which is notoriously refractory to treatment
Identifying the AN SANProdrome within a Subsyndrome ~ SyndromeWorking Model of SeveritySubsyndromal AN Risk Subsyndrome = Subsyndrome = Prodrome Subsyndrome = Subsyndrome = Syndrome (Disorder in Subsyndrome Partial Remission (Early Caseness) Evolution) (Atypical AN) (Former AN) Age-Specific Limitations of Manifestations Current Of Full Diagnosis Assessment Stable/Chronic Transient Not Accounted Methods For in DSM-IV Le Grange & Loeb, 2007
Differentiation of prodromal vs.atypical AN: Pilot data Twenty-seven adolescents with SAN SAN defined as: Meeting 2 of the 4 DSM-IV diagnostic criteria for AN If Criterion A is not met, participants must have engaged in dietary restriction leading weight < 100% expected, in combination with 2-3 additional criteria Never met criteria for full AN Qualitatively subtyped sample as follows: High Risk for Conversion to AN (Prodromal AN) ○ Steady worsening of symptoms from point at which symptoms became clinically significant High Risk for Chronic SAN (Atypical AN) ○ Following a period of symptom progression, symptoms have stabilized for a period of 3+ months
Prodromal vs. Atypical cont.Variable Prodromal AN Atypical AN t (df=25) Sig (2-tailed) (n=13) (n=14) Mean (SD) Mean (SD)Age 14.54 (1.81) 14.57 (1.83) -.045 .963Duration of 4.31 (2.78) 25.21 (18.37) -4.06 .000Illness (months)%IBW 88.75 (7.31) 82.48 (6.81) 2.31 .030EDE Restraint 3.34 (1.74) 1.56 (1.52) 2.84 .009EDE Shape 3.16 (1.72) 1.55 (1.64) 2.50 .020ConcernEDE Weight 2.84 (1.82) 1.64 (1.52) 1.86 .075ConcernEDE Eating 2.19 (1.72) 0.92 (1.21) 2.24 .035ConcernSum (max=16) 14.00 (6.61) 7.93 (6.89) 2.33 .028EDE Dx Items
Prodromal vs. Atypical cont. Differences between subtypes suggest that those patients who appear to be at higher risk for developing AN by virtue of a linear and often steep symptom progression in fact exhibit more AN-like psychopathology than their more chronic and stable SAN counterparts Unclear whether intervention strategies need to be tailored accordingly
Early Intervention is Predicatedon Case Identification… …which in turn is challenged by: The ego-syntonic nature of eating disorders, resulting in denial and minimization Developmentally insensitive diagnostic criteria Normal adolescent development, which can obfuscate awareness of an emerging eating disorder because of shared features ○ preoccupation with appearance ○ individuation from parental support systems ○ expression of strong attitudes ○ mood lability Eating disorders can present with the strong will and affect of typical adolescence, resulting in alienation from family members and increased space for the disorder to intensify.
Patient vs. Parents as InformantsPatients ParentsDeny ReportMinimize observable, behavioraOften lack insight l indicators of psychological featuresFear implications of their of the illness symptom Consider information endorsement reported by reliable third parties, such as the housekeeper or the child’s siblings, friends, or teachers Report “clues” to behavioral symptoms, even et al., 2011 Loeb secretive ones
Parents as informants in caseidentification: Examples (Loeb et al, 2011)Patients ParentsI’m not bingeing. I find bags of junk food hidden in her room.I’m not vomiting. She runs to the bathroom right after meals, and our housekeeper finds vomit residue on the toilet.I’m getting my period regularly. I haven’t bought sanitary products for her in 6 months.I’m an athlete. I’m not exercising Her coach says she trains to lose weight. beyond what her teammates do.I’m fine with my body. She wears only baggy clothes.I’m fine with my weight. She weighs herself several times a day.I’m not scared of gaining weight. She won’t eat more than 500 kcal per day.
Eating Disorder Examination(EDE): Direct patient reportexampleFEAR OF WEIGHT GAIN (Diagnostic item, Shape Concern subscale)*Over the past four weeks have you been afraid that you might gain weight?[With participants who have recently gained weight the question may rephrased as "..... have you been afraid that you might gain more weight".]How afraid have you been?[Rate the number of days on which a definite fear (common usage) has been present. Exclude reactions to actual weight gain.]0 - No definite fear of weight gain1 - Definite fear of weight gain on 1 to 5 days2 - Definite fear of weight gain on less than half the days (6 to 12 days)3 - Definite fear of weight gain on half the days (13 to 15 days)4 - Definite fear of weight gain on more than half the days (16 to 22 days)5 - Definite fear of weight gain almost every day (23 to 27 days)6 - Definite fear of weight gain every day [ ][With participants whose weight might make them eligible for the diagnosis of anorexia nervosa, ask about each of the preceding two months. Rate 9 if not asked.] month 2 [ ] month 3 [ ] Cooper & Fairburn, 1987; Fairburn & Cooper, 1993; Fairburn, Cooper, & O’Connor, 2008
EDE – Parent Version(Loeb, 2005)FEAR OF WEIGHT GAIN (Diagnostic item, Shape Concern subscale)*Over the past four weeks has your child expressed a fear of gaining weight or becoming fat?....If yes:What exactly has s/he said to indicate this?....Re-rate this item taking into account behavioural evidence of fear of weight gain. For children who are underweight or whom parents or doctors are concerned have lost too much weight: Have you tried to encourage your child to eat more in order to gain weight? How has s/he responded? Has s/he rejected advice or prescriptions (from you, doctors, or other professionals) to increase his/her weight? In addition to taking notes, mark whether or not there was a negative response to efforts to increase the child’s food consumption or weight by circling yes or no: [Yes/No]Has s/he refused attempts (by you, doctors, or other professionals) to increase his/her weight? [Yes/No]If yes:…by passive resistance (e.g., by simply refusing to eat)? [Yes/No]…and/or by active resistance such as…? [Yes/No] …yelling? [Yes/No] …throwing a tantrum? [Yes/No] …throwing food or dishes? [Yes/No] …running away? [Yes/No] …threatening to hurt him/herself if made to eat? [Yes/No] …other (specify)?.....
Parents as informants in case identification: DataKappas for Parent-Child Agreement on the EDE and P-EDE DSM-IV DiagnosticCriteria for AN____________________________________________________________________DSM-IV Criterion A Criterion B Criterion C Criterion DCriteria forAN____________________________________________________________________Cohen’sKappa .307* .210 .368** .795**____________________________________________________________________*p < .05 **p < .01 E.g., for Fear of Weight Gain, parents (+ behavioral indicators) can increase diagnostic symptom identification by up to 50% Loeb et al., 2009
FBT for SAN:Modifications to the Foundation Approach I Dual focus of risk reduction (prophylaxis of AN) and the resolution of extant symptoms (treatment) The risks of conversion to AN are emphasized, while noting that science cannot yet predict which cases are truly prodromal vs. misdiagnosed vs. atypical vs. transient The clinical severity of SAN is emphasized in its own right, addressing the general and the specific: The functional impairment associated with the overall presentation The dangers of each individual symptom Attention to a wider range of developmental stages to encompass childhood cases. While AN typically onsets in mid-late adolescence, prodromal AN by definition precedes this.
Modifications to the Foundation Approach II Modifications to the language of the treatment to emphasize risk, e.g., Your daughter is at the precipice of a deadly disorder The eating disorder is like an octopus whose tentacles have just taken hold and are squeezing harder and harder over time Modifications to the family picnic meal (session two) instructions to address the variability in SAN presentation: In deciding what to bring for your daughter to eat, consider her degree of weight loss and how you want to help her eat normal, healthy amounts of food again. Please include at least one food she used to like but has stopped eating. Quality of food eaten (e.g., a forbidden food) may be as important as quantity (“one more bite”)
Modifications to the Foundation ApproachIII A greater emphasis on the regulation of eating patterns and the incorporation of a full range of foods in the child or adolescent’s diet, especially for adolescents who have lost significant weight but do not yet meet the weight cutoff for AN Psychoeducation regarding the role of excessive dietary restraint in the development and maintenance of eating disorders, and the ineffectiveness of extreme restriction and eating disorder behaviors in achieving and maintaining a healthy weight range Emphasis on deriving a positive self-concept from domains other than body image
Modifications to the Foundation ApproachIV The prescription of regular family meals at home While research on the negative correlation between family meals and eating disorders does not tease apart self-selection from effect, common sense dictates that family meals at least provide the following: ○ An opportunity to observe and correct unhealthy eating habits in offspring ○ An opportunity for parents to model healthy, non-restrictive eating habits ○ A forum in which to identify and discuss stressors that may precipitate or exacerbate the onset of an eating disorder
Modifications to the Foundation ApproachV It is important that parents do not explicitly exhibit behaviors and attitudes consistent with an eating disorder The difference between AN and other presentations (above-normative levels of discontent regarding shape/weight, fad dieting) is sufficiently stark that the illness offers a clear target. With SAN, the boundaries between the eating disorder and non-disordered but unhealthy behaviors and attitudes may be more diffuse from the family’s perspective, and especially from the child’s perspective Given data on genetic risk for AN, for some cases, treatment must attempt reshape a genetically influenced environment
HypothesizedMechanismsof Treatment Loeb et al., 2012
FBT RCT for prevention of AN inhigh-risk adolescents Sample: 60 children and adolescents with emerging (prodromal) or atypical AN Two study interventions: FBT modified for prevention Individual supportive psychotherapy Using a partially randomized preference design Testing PEDE as an informant-based assessment tool to complement direct evaluation Two primary questions: Is FBT effective for reduction of extant symptoms and prophylaxis of AN? Are these cases in fact child/adolescent manifestations of full AN? Supported by 1 K23 MH074506-01
Preliminary FBT onlyfindings N=45 %IBW Mean (SD) age: 100 13.3 (2.1) 83.3% female 95 89.2% Caucasian 85% from intact 90 families 89% stabilized or 85 improved 11% converted to 80 AN Baseline EOT
Case Study: “Bella” Seventeen year old monozygotic twin Twin sister unafflicted Two-parent household Identified and referred by general therapist, who was treating the patient for anxiety and perfectionism Four month history of weight loss, from 102% IBW to 89.5% IBW Categorically denied a fear of weight gain, but admitted to regarding her body as fat, her thighs as “huge” and her hips as “wide” Missed two periods Loeb et al., 2009
Parents are essential in the Diagnosis Prevention Treatment of child and adolescent eating disorders Early Identification Informants of direct symptom expression and behavioral indicators Early Treatment Agents of change with FBT principles and techniques