Renee Rienecke Hoste, PhD - University of Michigan Depression ...

Introduction to
Eating Disorders
Depression on College Campuses
February 26, 2013
Daniel E. Gih, M.D.
Clinical Assistant Professor, Section of Child & Adolescent Psychiatry
Medical Director, U-M Comprehensive Eating Disorders Program
1

Financial disclosures
• None
2

Eating Disorder Diagnoses
• Anorexia nervosa (AN)
• Bulimia nervosa (BN)
• Eating disorder Not Otherwise Specified (EDNOS)
• Not discussed in detail here
• Feeding disorder of infancy or early childhood
• Binge eating disorder
• Obesity
3

Disordered eating
through the ages
• Ancient Egypt - physicians recommended periodical purgation (enemas)
as a health practice
• Romans (~100 BC) – upper class (including Julius Caesar) vomited
between meals so they could eat more (unrelated to vomitoria)
• Renaissance (14 th -17 th century) – “Holy anorexics”
• 1689 - first medical description by Richard Morton (physician to the
court of England): fasting and emaciation without apparent medical
causation (“nervous consumption”)
• 1764 - Robert Whytt described bradycardia of anorexics
• 1873 - two neurologists, Ernest Charles Lasegue and Sir William Gull,
separately described “anorexia nervosa” (Gull’s term)
• 1979 - Gerald Russell described bulimia nervosa
4
References: Eur Neurol. 2004;52(4):191-2
Eur Neurol. 2006;55(1):53-6.

DSM IV-TR Criteria for
Anorexia Nervosa (AN)
A. Refusal to maintain body weight at or above a
minimally normal weight of age and height (weight loss
or failure to gain weight normally leading to < 85% of
expected weight)
B. Intense fear of gaining weight/being fat, even though
underweight
C. Disturbed body image/shape, undue influence of body
image on self-evaluation, or denial of seriousness of
current low body weight
D. In postmenarchal females, amenorrhea for 3+
cycles/months
Specify type:
• Restricting type
• Binge-eating purge type 5

DSM IV-TR Criteria for
Bulimia Nervosa (BN)
A. Recurrent episodes of binge eating.
1. Eating in a discrete period of time an amount larger than most
people would eat under time/circumstances
2. Sense of lack of control over eating during the episode
B. Recurrent compensatory behavior: purging,
laxatives, diuretics, enemas, fasting, exercise
C. Binge eating, twice a week (average) for 3 months.
D. Self-evaluation unduly influenced by body image
or shape
E. Disturbance does not occur exclusively during
episodes of anorexia nervosa
Specify type
• Purging type (usually by self-induced vomiting or laxative abuse)
• Nonpurging type (fasting, exercise)
6

Eating Disorder NOS (EDNOS)
1. For females, all of the criteria for Anorexia Nervosa are met except
that the individual has regular menses.
2. All of the criteria for Anorexia Nervosa are met except that, despite
significant weight loss, the individual’s current weight is in the normal
range.
3. All of the criteria for Bulimia Nervosa are met except that the binge
eating and inappropriate compensatory mechanisms occur at a
frequency of less than twice a week or for a duration of less than 3
months.
4. The regular use of inappropriate compensatory behavior by an
individual of normal body weight after eating small amounts of food
(e.g., self-induced vomiting after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large
amounts of food.
6. Binge-eating disorder (DSM IV-TR appendix)
7

Summary of Binge Eating Disorder (BED)
• Research (DSM IV-TR appendix)
• Criteria
A. Recurrent binge eating
B. Binge eating associated with 3+
1. Eating more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of being embarrassed by how much one is eating
5. Feeling disgusted, depressed, very guilty after overeating
C. Marked distress regarding binge eating
D. At least 2 days a week for 6 months
E. No compensatory behavior follows, not in course of
anorexia/bulimia
• Obesity is not required, but sometimes present
8

DSM-5 (May 2013)
9

DSM-V Feeding and Eating
Disorders (as of July 2012)
• Pica
• Rumination Disorder
• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
• Avoidant/Restrictive Food Intake Disorder
(Feeding Disorder of Infancy or Early Childhood)
• Feeding or Eating Disorder Not Elsewhere
Classified (DSM-IV ED NOS) 10

Recent numbers
• NCS-R 2007 report (community study)
• AN lifetime prevalence: 0.9% women, 0.3% men
• BN lifetime prevalence: 1.5% women, 0.5% men
• Adolescent ED
• EDNOS most common (57%) diagnosis (Eddy et al. 2008)
• Prevalences: 0.3% (AN), 0.9% (BN), 1.6% (BED) [Swanson 2011]
• Increases in U.S. hospitalizations for eating disorders,
1999–2000 to 2005–2006 (AHRQ, 2009)
• 18% increase in all ages
• 119% increase in children under age 12
11

Challenging our ED assumptions
Then
• Associated with affluent,
Caucasian females
• Illness confined to
western and
postindustrial societies
• 9:1 female to male ratio
(per DSM-IV)
Now
• Parental education,
household income, and
parental/ surrogate marital
status not significantly
associated with any
adolescent ED (Swanson, et
al., 2011)
• Non-Hispanic white
reported more AN;
Hispanics, highest
prevalence of BN
• Global distribution seen
• 3:1 F/M ratio (NCS-R 2007
report) 12

Likely multifactorial etiology
• Biological
• Genetic predispositions
• Pubertal hormones (trigger phenotypic expressions)
• Serotonin dysfunction (low 5-HIAA levels in CSF)
• Severe dieting
• Childhood anxiety disorders (precede eating disorders)
• Psychological
• Personality features (anxious, avoidant for AN)
• Conflicts with adolescent development?
• Social
• Competitive activities (e.g., gymnastics, running, wrestling,
dance, modeling)
• Sexual abuse
13
• Peer groups (i.e., sororities), exposure to media (Mazzeo, 2009)

Eating disorders begin in
adolescence
• Rare in younger children (< 5% occur
prepubertal)
• ~95% cases of AN occur before age 25 (Hoek and
Hoeken, 2003)
• National Comorbidity Survey Replication
Adolescent Supplement (NCS-A) data (2011):
median onset
• AN 12.3 years
• BN 12.4
• BED 12.6 14

Early warning signs
• Diet books
• Dieting behaviors
• Sudden decision to become a vegetarian
• Increased picky eating, especially eating only “healthy
foods”
• Always going to the bathroom immediately after eating
• Multiple showers in a day, especially following meals
• Skipping meals or large amounts of food missing
• Evidence of visiting pro-anorexia or eating disorder web
sites

College health
providers and staff are
likely in positions to
screen for eating
disorders.
What should we look out for? 16

The SCOFF questionnaire*
• Do you make yourself Sick because you feel
uncomfortably full?
• Do you worry you have lost Control over how much you
eat?
• Have you recently lost more than One stone (14 lbs) in a
3 month period?
• Do you believe yourself to be Fat when others say you
are too thin?
• Would you say that Food dominates your life?
*One point for every “yes”; a score of 2 indicates a likely case of
anorexia nervosa or bulimia (for adults)
17

Differential diagnoses
AN
• Diabetes mellitus
• Inflammatory bowel
disease (IBD)
• Thyroid disease
• Addison's
disease/adrenal
insufficiency
• Brain tumors
BN
• Depression
• Kleine-Levin
syndrome
• Gastric outlet
obstruction
• Hyperemesis
gravidarum
18

Illness course
AN
• Meta-analysis and 21 year
follow up (Steinhausen,
2002, Zipfel 2000)
• ~50% recovered (return of
menses, weight gain)
• 10-20% remained
chronically ill
• 15.6% AN-related death (in
21 year follow up)
• Little improvement in
success rates over last 5
decades
BN
• Steinhausen 2009
analysis
• 45% full recovery
• ~23% chronic protracted
course
• 27% on average improved
considerably
• 0.32% crude mortality rate
• Highest recovery rates
between 4 and 9 years
during follow-up 19

Eating disorders
affect nearly every
organ and may lead
to death.
20

Medical complications of AN
• Cardiovascular
• Decreased cardiac mass,
congestive heart failure
• EKG changes (low voltage,
increased QTc)
• Bradycardia, arrhythmia
• Hypotension
• Sudden cardiac death
• Mitral valve prolapse
• Gastrointestinal
• Gastroparesis
• Decreased motility
• Acute vascular compression of
the duodenum
• Endocrine
• Low T3, high reverse T3
• Increased corticotropin releasing
hormone (potent anorectic)
• Growth disturbance*
• Osteoporosis*
• Psychiatric
• Suicide
• Renal
• Stones
• Refeeding syndrome
• Partial diabetes insipidus
• Neurologic
• Lowered olfactory and gustatory
sensitivities
• Brain changes/atrophy*
(* May be permanent)
21

Medical complications of BN
• Cardiovascular
• Dizziness
• Hypotension
• fluid and electrolyte
imbalances
• Cardiomyopathy (ipecac use)
• Cardiac arrhythmias
(potassium depletion)
• Dental
• Caries
• Enamel loss
• Periodontal disease
• Gastrointestinal
• Parotidomegaly
• Sore throat
• Esophagitis
• Mallory-Weiss tears
• Esophageal rupture
(Boerhaave’s syndrome)
• Diminished gastroesophageal
sphincter tone (predisposes to
pulmonary aspiration)
• Reflex constipation (stimulant
laxatives)
• Cathartic colon (prolonged
laxative use) 22
Mehler PS. International Journal of Eating Disorders. 44(2):95-104, 2011 Mar.

Suicide
• 32x higher than expected (Br J Psychiatry.
1998 Jul;173:11-53)
• Meta-analysis: 1 in 5 deaths in AN (Arch Gen
Psychiatry. 2011;68(7):724-731)
23

Eating disorders are complex
• Psychiatric diagnoses
with substantial medical
morbidity and mortality
• Multifactorial etiology
including genetics and
environment
• Profound psychological
disturbance
• A coordinated
multidisciplinary team
offers best hope for
recovery
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http://www.abkontakt.se/?

Family-Based Treatment for Eating Disorders
Renee Rienecke Hoste, PhD
Clinical Assistant Professor of Psychiatry
Director of Clinical Services and Research, UM-CEDP
Depression on College Campuses
February 26, 2013

History and Background
“The patients should be fed at
regular intervals, and
surrounded by persons who
would have moral control
over them; relatives and
friends being generally the
worst attendants.”
Sir William Gull
(1816-1890)

Jean Martin Charcot
(1825-1893)
“It is necessary to
separate both
children and adults
from their father and
mother, whose
influence, as
experience teaches, is
particularly
pernicious.”

History of treatment for
eating disorders
Parental involvement deferred until eating disorder
behavior under control
Patients typically hospitalized
Separation was desirable, because the family will
interfere in the treatment of the eating disorder
(“parentectomy”)
Outpatient care emphasized adolescent’s need for
separation, individuation and autonomy
4

The Maudsley Hospital
Hospital

The Maudsley Approach
----------------------------------------------------------------------------------------------------------------
There is little doubt that the presence
of an ED has a major impact on family
life. With time, food, eating, and their
concomitant concerns begin to
saturate the family fabric.
Consequently, daily family routines as
well as coping and problem solving
behaviors are all affected.
Ivan Eisler, Principal
Architect of the
Maudsley Approach

The Maudsley Approach
Refined at University of Chicago and Stanford
University by Daniel Le Grange and James Lock
Theoretically agnostic
Parents are a resource with no blame directed toward
either the parents or the ill adolescent
Siblings play a supportive role and are protected from
the job assigned to the parents

Suitability and Context
Appropriate for children and adolescents, >75% IBW and
otherwise medically stable
Outpatient intervention designed to a) restore weight
and b) put adolescent development back on track
Brief hospitalization to resolve medical concerns
May not be suitable for families with severe parental
psychopathology or serious discord in relationship
between parents

Treatment Team
FBT is a team approach
Primary therapist: responsible for FBT and
coordinating care
Pediatrician/Adolescent Medicine Specialist:
responsible for the medical safety of patient
Child/Adolescent Psychiatrist: manages
meds/comorbid disorders
Consistency is key! Team members need to be on
the same page and giving the same messages to
each family member

What does treatment
look like?
Adolescent Anorexia Nervosa

Treatment Structure

Treatment Phases

Treatment Style
• Therapist balances an active stance (mobilizing
parental anxiety) with deference to the parents’
judgment (empowerment)

Fundamental Assumptions
------------------------------------------------------------------------------------------------------------------------
• Agnostic view of cause of illness
• Neither parents nor adolescent are to blame
• Non authoritarian therapeutic stance
• Joining with family
• Parents are responsible
• Empowerment
• Externalization
• Separation of child and illness
• Initial focus on symptoms
• Pragmatic

Initial Symptom Focus
--------------------------------------------------------------------------------------------------------------------
• Emphasis is first on behavioral change
• History-taking focuses on symptom development
• Delay of other issues until patient is less
behaviorally and psychologically involved with
ED
• No direct cognitive focus with adolescent

Effects of FBT Tenets
-----------------------------------------------------------------------------------------------------------------
Highly focused, staged treatment
Emphasis on behavioral recovery rather than
insight and understanding or cognitive change
This approach might indirectly improve family
functioning and cognitive change

Overview of Phase 1
------------------------------------------------------------------------------------------------------------------
• Focus is on helping parents take control of weight
restoration processes
• Lasts between 8-10 sessions, usually weekly
• Designed to help parents replicate at home what
would happen on an inpatient unit
• Principle aim is to help parents disrupt severe
dieting, exercise, and related dysfunctional
behaviors that are leading to or maintaining low
weight

Session One
----------------------------------------------------------------------------------------------------------
Goals:
Engage the family
Obtain a history of how AN affects family
Assess family functioning (coalitions, conflicts)
Reduce parental blame
Interventions include:
Separating illness from patient
Addressing parental anxiety
Charging parents with the task of weight restoration
Summary of session, instructions for family meal

Session Two: The Family Meal
---------------------------------------------------------------------------------------------------------------
Goals:
Coach parents regarding ways to interact with
the eating disorder and with their child
Provide opportunity for parents to succeed in
convincing patient to eat more than intended
Assess family process during eating

Remainder of Phase I
---------------------------------------------------------------------------------------------------
Goals:
Keep the family focused on the AN
Help the parents take charge of child’s eating
Mobilize sibling support for patient

Research Support for FBT
Controlled studies of adolescent AN
Russell et al (1987) / Eisler et al (1997)
Le Grange et al (1992) / Eisler et al (2000) / Eisler et al (2007)
Robin et al (1994) / Robin et al (1999)
Lock et al (2005) / Lock et al (2006)
Gowers et al (2007)
Lock et al (2010)
Godart et al (2012)

Lock et al., 2010
12 months of family-based treatment (FBT) or adolescentfocused
individual therapy (AFT)
Similarly effective in producing full remission at end of
treatment
FBT was significantly more effective in facilitating full
remission at 6 and 12 month follow up points
FBT should be the first line intervention for adolescents
with AN who are medically fit for outpatient treatment
Most patients respond favorably after relatively few
treatment sessions if illness is recognized early on
AFT could be a credible alternative for some patients

Manualized family-based treatment for AN
Manual (Lock, et al., 2001)
implemented in research
studies
23
Allows for testing in
controlled and uncontrolled
settings
Reference tool for therapists
Studies support parents are a
resource and it is feasible and
useful to incorporate them
into the treatment of an
adolescent
Parent handbook now available
(2005)

Treatment for Adults with AN
There is no clear first-line treatment for adults with AN
The NIMH outlines three important components in
treatment of adults:
Weight restoration
Reducing or eliminating the behaviors or thoughts related to
the eating disorder, along with relapse prevention
Treating the psychological issues related to the eating disorder

FBT for Young Adults
• Families continue to play a significant role in the
lives of their young adult children
• How does FBT-Y differ from FBT-AN?
• Approach is more collaborative
• Family of choice
• Developmental issues
• Time with patient

FBT-Y Case Series (Chen et al., 2010)
Four young adults (ages 18-21)
Duration of illness: 12-42 months
Treatment sessions: 11-20 over 6-12 months
Assessments conducted at baseline, end of treatment, and
6-month follow-up

BMI
FBT-Y Case Series
20.5
20
19.5
19
18.5
18
17.5
17
16.5
16
15.5
BL EOT 6mo
(Chen et al., 2010)

EDE Global Score
FBT-Y Case Series
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
BL EOT 6mo
(Chen et al., 2010)

BDI
FBT-Y Case Series
18
16
14
12
10
8
6
4
2
0
BL EOT 6mo
(Chen et al., 2010)

FBT for Young Adults
FBT-Y is still in development
FBT-Y may be promising
No first-line treatment for this population
Similarities between older adolescents and young adults
Research is needed to create and identify effective
treatments for adults with AN

31
U-M Comprehensive Eating Disorders Program
www.uofmhealth.org/eatingdisorders
734-232-7531

U-M Comprehensive Eating
Disorders Program
Ages 8-24 with primary AN or restrictive eating/weight loss
Currently two tracks available (8-17; 18-24)
Partial Hospitalization Program (6 hours/day, Monday-Friday):
Group and individual/family therapy along with two meals
and snack
Primary treatment philosophy is FBT
Adult caregiver required for children and adolescents
“Support person” strongly recommended for young adult patients
32

U-M CEDP
Multidisciplinary outpatient intake evaluation
Eligible patients will be entered into the PHP
Step down care to intensive outpatient program (IOP)
Coordinate care with outpatient mental health providers
in the community

FBT in a PHP
Parent participation is required daily
Parents choose meals, can bring food from home
Parent debriefing
All families go through Sessions 1 and 2 before joining
PHP
Parent skills group
Group therapies target associated psychopathology and
risk factors

Group Therapies
Dialectical Behavior Therapy
Cognitive Behavior Therapy (perfectionism and selfesteem)
Cognitive Remediation Therapy
Body Image
Psychoeducation
Process group
Relaxation
Self-expression

Next steps
Educational and provider outreach
Working with psychiatric inpatient unit
Developing evidence-based tracks for BN
Outpatient clinic
Developing research program
36

Research Program
At intake, patients complete two semi-structured diagnostic
interviews (MINI and EDE) by trained assessors
Before starting PHP, patients and parents complete a number
of self-report measures
Child Depression Inventory
Eating Disorder Examination Questionnaire
Clinical Impairment Assessment
Eating Disorder Inventory – 3
Family Environment Scale
Rosenberg Self-Esteem Scale
Symptom Checklist-90-R
Parent Vs. Anorexia Scale
Family Questionnaire
Working Alliance Inventory
Yale-Brown Obsessive Compulsive Scale

Research Program
Measures are completed at baseline, midtreatment, end of
treatment, and 3 month follow-up
Will assess:
Efficacy of treatment provided*
Possible mechanisms of change, including family and marital
relationships
Predictors of outcome
Adapting FBT for a PHP setting
Long-term goals:
Research funding to compare FBT-PHP to traditional outpatient FBT
Collaboration with other research teams to develop treatments to
assist parents in refeeding at home
Adapt treatment as needed
Develop additional parent interventions

Eating Disorder Websites
Local
www.edleague.com
www.uofmhealth.org/eatingdisorders
National
www.maudsleyparents.org
www.aedweb.org
www.nationaleatingdisorders.org
www.train2treat4ed.com
www.edreferral.com
www.feast-ed.org
www.anad.org
Books and resources
www.bulimia.com
39