Early Intervention

1
Early Intervention Innovative Treatment for
Adolescents with Eating Disorders

• Steven F. Crawford, M.D.
• Center for Eating Disorders
• at Sheppard Pratt

2
Educational Objectives

• Define the syndromes
• Recognize the Importance of Early Intervention
• Review the History of Family Therapy in the
  Treatment of Eating Disorders
• Family Based Treatment (The Maudsley Approach)

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Importance of Appearance

• 1973 Survey
• 29 Men
• 32 Women
• 1993 Survey
• 63 Men
• 68 Women

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Drive For Thinness

• 80 American women report dissatisfaction with
  their appearance
• Gaesser survey 50 of females between the ages
  of 18-25 would prefer to be run over by a truck
  then be fat 66 would rather be mean or stupid
• 40 women and 20 men would trade 3-5 years of
  their life to achieve goal body weight

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Drive For Thinness

• 42 of 1st-3rd grade girls want to be thinner
• 81 of 10 yr olds are afraid of being fat

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Dieting

• 91 of college-aged women diet
• 25 American men and 45 American women are on a
  diet on any given day
• 48 billion dollars spent each year on dieting
  products/programs

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Dieting

• Over 50 teen girls and 33 teen boys use
  unhealthy weight control behaviors such as
  skipping meals, fasting, smoking cigarettes,
  vomiting, or taking laxatives
• 51 9-10 yr old girls diet
• 82 9-10 yr old girls report someone in their
  family is on a diet
• Age of first diet
• 1970 14 yrs old
• 1990 8 yrs old

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Dieting

• 95 of all dieters regain their lost weight in
  1-5 years
• 35 of normal dieters progress to pathological
  dieting
• Most common behavior preceding onset of an eating
  disorder is dieting

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Eating Disorders

• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder

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History of Anorexia Nervosa

• Richard Morton (1689) First recognized anorexia
  nervosa and described nervous consumption.
• Gull and Leségue (late 19th century)
  Independently described what is now recognized as
  modern anorexia nervosa.

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Anorexia Nervosa

• Refusal to maintain body weight at or above a
  minimally normal weight for age and height
• Intense fear of weight gain or becoming fat, even
  though underweight
• Disturbance in the way in which ones body weight
  or shape is experienced, undue influence of body
  weight or shape on self-evaluation, or denial of
  the seriousness of the current low body weight
• Amenorrhea for 3 consecutive months

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Anorexia Nervosa Subtyping
Restricting Type

• Binge-Eating
• Purging
• Type

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AN - Epidemiology

• Prevalence is estimated at 0.5 - 3.7 of
  populations at highest risk (adolescent females)
• Femalemale ratio 101
• Significantly higher rates if sub-threshold EDNOS
  cases are included
• Incidence in young women has tripled in last 40
  years

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AN Epidemiology

• 40 of newly identified cases are in girls 15-19
  yrs old
• Increase in incidence of anorexia in women ages
  15-19 in each decade since 1930
• Childhood anorexia (lt10 yrs old) is relatively
  rare but increasing

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AN - Medical Consequences

• Metabolic down-regulation - bradycardia,
  orthostatic hypotension, hypothermia, syncope
• Dehydration, cardiac changes, arrhythmia
• Gastric disturbances, constipation
• Osteopenia/Osteoporosis
• Anemia, leukopenia, electrolyte disturbances
• Growth retardation

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AN - Social Consequences

• Profound impact on interpersonal relationships
  and family
• Decreased rates of marriage and fertility
• Diminished achievement in school and occupation
  relative to potential
• High dependence on health care system at
  extremely high cost (second only to schizophrenia)

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AN - Outcome

• About 60 improve with focused treatment
• About 20 remain morbidly and chronically ill
• Long term follow up studies suggest that
  mortality is approx. 5-10 per decade of illness
• Average mortality of chronic cases is 8-13
• Suicide accounts for about 1/2 mortality
• Highest mortality of any psychiatric illness

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AN - Outcome

• About 50 develop bulimic symptoms
• Depression and anxiety disorders develop in a
  majority of the morbidly ill
• Long term outcome has few reliable predictors
• Short-term outcome is worse in persons with
  laxative abuse, bingeing, and familial
  psychopathology

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AN - Outcomes

• Third most common chronic illness among
  adolescents
• 12 times more likely to die than other women same
  age without anorexia nervosa

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History of Bulimia Nervosa

• Description of bulimic symptoms in literature
  since 1873
• Case of Ellen West (1944) first well documented
  account
• Gerald Russell (1979) Landmark description of
  bulimia nervosa

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Bulimia Nervosa

• Recurrent episodes of binge eating
• Regular compensatory measures to prevent weight
  gain
• Occurrence at least twice per week for three
  months
• Attitude about body shape predominantly
  influences self evaluation
• No evidence of anorexia nervosa

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Bulimia Nervosa Subtyping
Non-purging
Purging
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BN- Epidemiology

• Lifetime prevalence is estimated at 1.1-4.2 of
  females
• Up to 19 of college-aged women in America are
  bulimic
• Femalemale ratio 101
• 84 have a college education
• Incidence tripled between 88-93 in 10-39 yr old
  women

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BN - Epidemiology

• Age of onset between mid-adolescence and late
  20s
• Girls that diet are 12 times more likely to start
  binge-eating than their peers that do not diet
• Up to 3 adolescent boys and 10 adolescent girls
  purge one time per week

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BN - Epidemiology

• Children as young as 6 yrs old have been
  diagnosed with bulimia
• Approximately 4.5 of ALL American high school
  students have vomited or used laxatives as a
  means to lose weight within the last 30 days

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BN - Medical Complications

• Electrolyte disturbances - hypokalemia
• Orthostatic hypotension
• Esophageal tear (Mallory-Weiss)
• Gastritis, gastric dilation, rupture
• Cardiac arrhythmias
• Menstrual irregularities
• Osteopenia
• Sudden death

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BN - Outcome

• Treatment response is highly variable
• 50 recover, 30 demonstrate improvement, 20
  continue to meet full diagnostic criteria
• 10 meet criteria after 10 years
• Longer duration of the disorder at presentation
  and history of substance use disorder predicted
  worse outcome

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Binge-Eating DisorderDSM-IV-TR Research Criteria

• Recurrent episodes of binge-eating
• Marked distress regarding binge-eating
• Occurrence at least two days per week for six
  months
• Not associated with the regular use of
  inappropriate compensatory measures

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Binge Eating Disorder

• Lifetime prevalence rate is 1-5
• One study showed 3 current population meet
  criteria for BED
• Onset usually occurs during late adolescence or
  in the early 20s
• 40 are male

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Classification
EDNOS
Binge-eating disorder
Anorexia nervosa
Bulimia nervosa
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The Anorexogenic Family

• Lasegue portrayed a relatively neutral view of
  parents
• Gull recommended limiting parental-child contact
  during treatment to prevent enabling behaviors of
  parents
• Charcot considered parents to be particularly
  pernicious

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The Anorexogenic Family

• View that parents were a hindrance to treatment
  and that the family environment had contributory
  role in development of illness persisted in first
  half of 20th century
• Recommendations for treatment usually included a
  parentectomy

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The Psychosomatic Family

• In 1960s, major shift to identifying family
  mechanisms which may contribute to development of
  AN and could be targeted by treatment
• Bruch, Palazzoli and Minuchin were primary
  contributors

34
The Psychosomatic Family

• Minuchin placed emphasis on pathological
  interactive familial processes in the
  pathogenesis of AN
• Focused on rigidity, enmeshment, over-involvement
  and conflict avoidance
• Childs role in family was to serve as a
  go-between in cross-generational alliances

35
The Psychosomatic Family

• A no blame on the parents model
• Advocated for family therapy to alter the
  family structure
• Critical shift was the engaging of the family in
  the treatment process

36
AN Risk Factor Research Cross-Sectional Studies

• Inappropriate parental pressures
• Early-life overprotection
• Greater incidence of separation, arguments,
  criticism, high expectations, over-involvement,
  under-involvement, low affection

37
BN Risk Factor Research Cross-Sectional Studies

• Parental indifference
• Family discord
• Lack of parental care
• Greater adversity
• Significant greater change in family structure
  (e.g. a parent leaving or a step-parent entering
  the family) the year before onset of the illness

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Risk Factor ResearchCross-Sectional Studies

• Findings are inconsistent
• Growing support that families are heterogeneous
  group with respect to socio-demographic
  characteristics, family relationships, etc.

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Current Focus

• Current understanding is a shift away from
  evaluating the family as a cause of the eating
  disorder to evaluating family dynamics that may
  develop in the context of an eating disorder and
  may function as maintenance mechanisms

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The Maudsley Approach Family Based Treatment
(FBT)

• Developed by a team of child and adolescent
  psychiatrists at the Maudsley Hospital in London
• Assist the parents in their efforts to help their
  adolescent in recovery from AN so that he/she can
  return to normal adolescent development

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The Maudsley Approach Family Based Treatment
(FBT)

• 66 of adolescents are recovered at the end of
  FBT
• 75-90 are fully weight recovered at five year
  follow-up
• Young patients with AN require on average no more
  than 20 treatment sessions over the course of 6
  to 12 months, with 80 being weight restored with
  resumption of menses

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Principles of Family Based Treatment (FBT)

• Parents are viewed as the most useful resource in
  their childs treatment
• Parents play an active and vital role in the
  recovery process and in restoring their childs
  weight

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Principles of Family Based Treatment (FBT)

• The adolescent is viewed as incapacitated in
  terms of eating behaviors with an inability to
  maintain an optimal weight for age and height
• Focus of FBT is on current eating disorder
  symptoms and not underlying issues

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Family Based TreatmentRole of the Therapist

• Coach, a consultant to the parents
• Empowers the parents to develop strategies to
  manage the anorexia and ways to help feed their
  child until weight restoration is achieved
• Directs conversation towards parents building a
  strong alliance

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Family Based TreatmentRole of the Therapist

• Encourages sibling support and understanding
• Teaches the family to externalize the illness,
  modeling a no-blame approach with recognition
  that the eating disorder behaviors are mostly
  outside the control of the adolescent

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Family Based TreatmentThree Phases

• Phase 1 Weight Restoration
• Phase 2 Returning Control Over Eating to the
  Adolescent
• Phase 3 Establishing Healthy Adolescent Identity

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Weight Restoration

• Parents are supported in their efforts to restore
  their adolescents weight
• Parents are encouraged to present a united front
• Parents monitor meals and snacks while
  restricting physical activity
• Therapist conveys message that parents will
  succeed

48
Weight Restoration

• Therapist conveys to adolescent message that
  while he/she has many fears about weight gain,
  these fears cannot deflect parents efforts toward
  weight restoration
• Weight restoration takes precedence over almost
  any other issue until self-starvation has been
  reversed

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Returning Control to the Adolescent

• Begins when adolescent has reached 90 of ideal
  body weight and is eating without much resistance
• Process is gradual and age dependent

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Establishing Healthy Adolescent Identity

• Begins when adolescent has achieved a healthy
  weight for age and height
• Treatment focused on general issues of adolescent
  development and ways in which the eating disorder
  impacted this process
• Goals are increased personal autonomy,
  relationships with peers, or getting ready to
  leave home for the first time

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Establishing Healthy Adolescent Identity

• Final stages of treatment focus on relapse
  prevention strategies
• Identification and recognition of early warning
  signs for a developing relapse
• Family responses to potential relapse outlined
  and an action plan developed