Severe and Enduring Eating Disorder or SEED

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Dr Jacobus Hamelijnck (Consultant Psychiatrist) presented a talk on (Severe and Enduring Eating Disorder or SEED) and what can be done to help patients with chronic symptoms.

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Severe and Enduring Eating Disorder or SEED

  1. 1. Severe and Enduring Eating Disorder - SEED Dr Jaap Hamelijnck Consultant Psychiatrist Anne Clement Support Worker
  2. 2. Introduction What is SEED How common is it Some examples from our service Complications Hypothesis Discussion
  3. 3. Definition 1. Chronic eating disorder, consisting on AN, restricting or binging/purging type, EDNOS 2. Being consistently ill for more than 10 years (7years) 3. Undergoing at least one unsuccessful evidence- based treatment 4. having severe impairment across a number of life domains 5. having a strong motivation to hold onto AN, and thus a reluctance to continue active treatment.
  4. 4. Prevalence • “perhaps 40 per million population” • Our team has 5 (out of caseload of 20)
  5. 5. Case 1, Late fifties with AN all her adult life, lives with her husband, no children due to AN and not been able to work for last 15 years Multiple admissions, not able to maintain her weight in community over longer period of time, BMI 13 Multiple psychotherapy attempts, different modalities Current care plan; short term, planned admissions for limited weight restoration
  6. 6. Case 2, Currently inpatient at general hospital, BMI 13 20 year history of AN, chronic relapsing course Discharged herself last year from specialist in- patient unit because worried she puts on too much weight Living at home with parents Recurrent severe depression
  7. 7. Case 3, Age 32, 10 year history of AN with binging purging type, currently at home BMI about 15 Severe osteoporosis Recurrent admissions to general hospital following collapse due to dehydration and electrolyte disturbances Several years of therapy, including CAT and NLP Bipolar affective disorder
  8. 8. Case 4, >10 year history of AN with severe OCD Several admissions, most recent under section 3 after severe malnutrition in community 2 children supportive family Sugar rich diet Exercise and restriction to control weight
  9. 9. Hypothesis; why do people not get better? Biological/genetic • Predisposition to a particular cognitive style or personality characteristics (narcissism) • Many mental disorders are chronic/episodic (i.e. OCD) • Co-morbidities make it more likely that the eating disorder becomes chronic (personality disorders, depression/bipolar, OCD) • Reward / addictive behaviours (repeated cycles of starvation / binging may impact on reward system)
  10. 10. Hypothesis; why do people not get better? Psychological/social • Trauma and attachment disorders (trust) • Primary/secondary gain (conflict theory, dependence) • Family (role of illness in family conflicts) • Financial/economical • Fear of becoming an adult (intimacy, responsibility) • Inability for change (ASD)
  11. 11. Narcissism Over confidence Heightened sense of entitlement, Special Inflated self-importance Dysempathy for others Hypersensitivity to criticism Proneness to deflation of self esteem Protect a vulnerable ego Create a deceptive allure of self-assurance, self-sufficiency or grandiosity Envious of others or think others are envious of him/her
  12. 12. Impact on engagement Nothing is good enough Elevating people followed by rubbishing them Not taking risks, maintaining status quo (protecting self, avoiding failure) Perfectionist Need of mastery (I will do it only if I am the best or perfect) Over controlling obsessive stance Attention seeking Unable to tolerate negative cognitions Avoiding loss or separation (I will leave you before you leave me) Narcissistic hurt (feeling let down by the slightest criticism) Eating disorder patients increased trait narcissism A controlled study of trait narcissism in anorexia and bulimia nervosa. Steiger et al. International journal of eating disorders; 1997.
  13. 13. Final Conclusion (Janet Treasure lecture on ASD and AN 2011) AN & ASD share weak coherence and this may be a risk factor possibly associated with OCPD traits. Starvation increases rigidity & OCPD traits. Starvation decreases social cognition. Starvation decreases emotional regulation. Starvation shifts reward from people onto food alone. People with acute AN resemble ASD People with ASD are at risk of eating disorders
  14. 14. Abnormal Reward processing in anorexia nervosa Patients with AN have an impaired ability to experience pleasure or reward (anhedonia) Patients’ engagement in illness behaviour is proposed to alleviate and anhedonic or dysphonic mood state Taste-reward tasks; split into “liking” and “wanting” Wanting is “incentive salience” quality of a stimulus that makes it a desirable and attractive goal, transforming it from a mere sensory experience into something that commands attention, induces approach, and causes it to be sought out. "liking" is a pleasure immediately gained from consumption AN patients prefer sweet stimuli, HC preference for high fat stimuli AN patients “like” a food but do not “want it”, do not enjoy pleasurably stimuli in the same way as HC (partial reward)
  15. 15. Abnormal Reward processing in AN Aversion toward high fat or sweet foods in consistent with a fear of weight gain Any process of behavioural reinforcement is an example of conditioning (linked with dopamine) AN is an illness characterised by behaviours that have become reinforced in a manner that has become pathological. Development of reward linked behaviours (involving conditioning and reinforcement) for example patients find emaciated body images and self-starvation reinforcing and rewarding. patients engage in starvation to relieve anhedonia and thus develop dependence on this mechanism. (reward dysfunction, become “addicted” to starvation) Eating rituals reduce anxiety/fear (negative reinforcement or reduced bad feelings, like OCD) Reward processing in anorexia nervosa; Neuropsychologia, 50(2012), 567-575
  16. 16. Treatment aims Focus on keeping people in services Improved quality of life Harm minimisation Avoidance of further failure experiences Increasing motivation levels Manage neuro-cognitive complications improving self-view and lifestyle that has been dominated by illness Improve physical well being treating severe and enduring anorexia nervosa: a randomized controlled trial. Touyz et al, Psychological Medicine (2013), 43, 2501-2511
  17. 17. RCT Touyz et al. Severe and enduring anorexia nervosa >7years 30 individual treatment sessions provided over 8 months in outpatient setting 2 treatment arms; CBT-AN and SSCM CBT-AN protocol by Pike (2003), focus on the cognitive and behavioural disturbances linked to the core features on AN and more global including motivational and schema work, weight gain and recovery were not treatment priorities SSCM (specialist supportive clinical management) includes education, care and support, fostering therapeutic relationship that promotes adherence to treatment. Praise, reassurance and advice. Weight gain not a priority, patients encouraged to improve their quality of life and physical well being. treating severe and enduring anorexia nervosa: a randomized controlled trial. Touyz et al, Psychological Medicine (2013), 43, 2501-2511
  18. 18. Results of RCT No difference in increase of BMI (minimal) Improvement in health related quality of life, depression and social adjustment larger for SSCM ED symptoms and readiness for change larger for CBT-AN Both treatment groups demonstrated significant improvements treating severe and enduring anorexia nervosa: a randomized controlled trial. Touyz et al, Psychological Medicine (2013), 43, 2501-2511
  19. 19. Future directions • Minimal weight restoration • Least harmful principle (binging/purging less harmful than starvation) • Engagement most important (whole team engagement) • Managing co-morbidity • Family/carer support • Encourage enjoyment, relieve boredom • “Coaching”
  20. 20. “Coaching” in eating disorders Help you achieve specific goals Help individual reach their fullest potential in life Coaching seeks to address the daily challenges of living with ED A coach helps people with ED carry out the practical activities of daily life in an organized, goal-oriented, and timely fashion Through a close partnership, an ED coach helps the client learn practical skills and initiate change in his or her daily life A coach may help an adult with ED: • Maintain focus to achieve identified goals • Translate abstract goals into concrete actions • Build motivation and learn to use rewards effectively
  21. 21. Coaching in ED (continued) Through regular interactions, coaches learn how the symptoms of ED play out in the daily lives of their clients and then provide encouragement, recommendations, feedback, and practical techniques to address specific challenges Coaches ask questions to help the client come up with strategies and act on them. Examples of such questions are: • What can you do about it? • How can you motivate yourself to take action towards this goal? • When must this action be completed? • What steps have you taken already, and when will you take the remaining steps? Coaching is not “therapy” but dealing with problems in everyday living

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