Dr. David Herzog presents a slideshow regarding adolescents and their struggle with eating disorders. Do they ever get better and move past their eating disorders?
3. Prevalence in Youth
Anorexia nervosa and bulimia nervosa are rare in
children and adolescents (<4%)
Eating disorder symptoms may be more common
Typical eating disorders far more common in
females than males
Criteria for diagnoses are same in youth, but
symptom profiles may differ
4. Symptom Presentation in Youth
Denial of symptoms high
Difficulty expressing/understanding motivation
for low weight/restriction/bingeing/purging
Desire to be “healthy” often
May begin as
Diet
Physical illness (e.g., flu)
Fear of choking/stomach or GI pain
5. Sociocultural Factors
Media images
Celebrities (Selena Gomez, Taylor Swift, Miley Cyrus)
TV (Pretty Little Liars, Gossip Girl, Disney channel)
Cultural pressures to be slim
Anti-obesity programs, messages
Technology
Pro-eating disorder websites
Facebook, Twitter, Tumblr
Teasing and harassment
13. Clinical ToolsClinical Tools
Be informed but allow patient to educate youBe informed but allow patient to educate you
Allow the control to reside with patient as muchAllow the control to reside with patient as much
as possibleas possible
Be active, respectful, courteous, puzzledBe active, respectful, courteous, puzzled
Take some chancesTake some chances
14. Clinical ToolsClinical Tools
(continued)(continued)
Anticipate:Anticipate:
MistrustMistrust
IntellectualizationIntellectualization
DenialDenial
LyingLying
Be aware that many ED symptoms may beBe aware that many ED symptoms may be
benignbenign
Be aware that some body imageBe aware that some body image
disturbance may persistdisturbance may persist
15. Addressing Denial andAddressing Denial and
Low MotivationLow Motivation
Small statureSmall stature
Confusion aboutConfusion about
why others perceivewhy others perceive
them as being toothem as being too
thinthin
LonelinessLoneliness
Family tensionFamily tension
Boredom in routinesBoredom in routines
Lack of pleasureLack of pleasure
Domination of life byDomination of life by
thoughts about bodythoughts about body
OsteoporosisOsteoporosis
Brain MRIBrain MRI
Look for “windows in” to building alliance:Look for “windows in” to building alliance:
16. Family-Based Treatment (FBT)
FBT for children and adolescent AN patients
with a short duration of illness is promising
Most patients respond favorably after relatively
few outpatient treatment sessions
FBT as effective in brief form as in longer form;
in conjoint form as in separated form
The beneficial effects of FBT are sustained at 4-
5 year follow-up
17. Key Tenets of FBT
Agnostic view AN etiology
Parents not to blame, no guilt (not no anxiety!)
Therapist does not pathologize or look for etiology
Initial focus on symptoms (Pragmatic)
Efforts on understanding devpt. of sxs and problem-solving on
how to change them
Parents are responsible for weight restoration
(Empowerment)
Family is a resource with skills and investment to help ill child
Non-authoritarian therapeutic stance (Joining)
Therapist is expert consultant
Separation of child and illness (Respect for adolescent)
Externalization of illness
18. Three Phases of Treatment
Phase I (Sessions 1-10):
Parents restore their child’s weight
Phase II (Sessions 11-16):
Transfer control back to adolescent
Phase III (Sessions 17-20):
Adolescent development issues
Termination
19. Session Two (Family meal)
Goals:
Assess family structure as it may affect ability of
parents to refeed patient
Provide opportunity for parents to successfully feed
patient
Assess family process during eating
Interventions:
Family meal
One more bite
Coaching parents to work together
Aligning patient with siblings for support
Challenges:
No meal!, parents not united
20. Comparing FBT with Systemic FT
for Adolescent AN
Duration of Rx 9 months
Remission rates for FBT 33% at end of Rx & 41% at 12-
month follow-up
Corresponding rates for SyFT 25% & 39%
Both Rx equally effective in terms of weight gain
Family-based therapy led to faster weight
gain early in Rx, fewer days in hospital, & lower Rx
costs per patient at end of Rx
Agras, WS et al., JAMA Psychiatry, 2014
21. Cognitive Behavioral Therapy
Psychoeducation and self-monitoring
Building a personalized formulation
Establishing regular eating
Preventing relapse
22. Psychoeducation on Starvation
Many ED symptoms:
Are a consequence of
insufficient intake
May resolve with weight
restoration/eating
normalization
Examples:
Preoccupation with food
Food rituals
Binge eating
Affective dysregulation
24. Talking Openly about Pros/Cons of ED
Recognizing pros = builds rapport
Typically, pros are short-term, cons are long-term
Discuss or list in individual therapy
As a group, put ED “on trial”
Pros Cons
Being thin Preoccupied with food and
weight
Feeling in control Social isolation
Feeling special or superior Health problems
Escape from negative affect Forced treatment
Eat and still stay slim Sometimes feel “out of control”
25. Form is More Important than Content
Prescribe regular meal pattern
3 meals + 2 snacks
Let patient choose foods
Even if they choose “diet” foods at first
Form is more important than content early on
Soothing post-meal activities are helpful
To distract attention from post-prandial fullness (AN)
To prevent post-meal purging (BN)
27. Preventing Relapse
Disabuse patients of model that one is always “in
recovery”
This is not what the data show
Full recovery is possible!
Realistically anticipate that urges to engage in ED
behaviors may return during stressful life transitions
Identify upcoming stressors
Make plan for dealing with each
Resume self-monitoring exercises
Return to therapy
28. Pharmacotherapy for AN
No significant clinical effects with:
Amitriptyline (Biederman et al., 1985)
Risperidone (Hagman et al., 2011)
Olanzapine (Kafantaris et al., 2011)
29. Pharmacotherapy for BN
SSRIs for adult bulimia nervosa:
Fluoxetine most studied, safe and effective
Sertraline effective
Fluvoxamine effective
No controlled studies with paroxetine
For adolescent bulimia nervosa:
Only one open trial with fluoxetine (Kotler et al 2003)
ED symptoms improved after 8 wks of treatment
Medication generally well-tolerated
31. Course & OutcomeCourse & Outcome
“What am I going to
be like in 1, 2, 5, or 10 years,
whether I have treatment or I don’t?”
32. Longitudinal Study of Anorexia
and Bulimia Nervosa
Initiated in 1987
Longitudinal project mapping the course and
outcome of eating disorders
246 treatment-seeking adolescent & adult women
with AN or BN followed for 25 years and
interviewed semi–annually
Prospective study with naturalistic design
36. Mortality
16 women (14 AN, 2 BN) out of 246 died.
Mortality is significantly elevated for AN:
SMR=4.37
AN suicide rate 57X higher than expected for
women of similar age
37. “To say that I recovered during that time
applies primarily to the clinical side of
things. And to say that the more
complicated, internal struggles
vanished along with the preoccupation
– the daily battle with things like
closeness, vulnerability, and anger –
would be a lie.
Am I rigid and ritualistic about
food these days? No. But am I rigid
about other things? Exercise? Work?
My daily routines? Absolutely.
Anorexia is no longer what I am,
but it is – and I believe I can say this
with acceptance, rather than regret –
a part of who I am.”
- Knapp, C.
The Phoenix
1/24/92