Early Intervention & Innovative Treatment for Adolescents with Eating
Disorders
Early Intervention & Innovative Treatment for Adolescents with Eating
Disorders
Steven F. Crawford, M.D.Center for Eating Disorders
at Sheppard Pratt
Steven F. Crawford, M.D.Center for Eating Disorders
at Sheppard Pratt
Educational ObjectivesEducational 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)
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)
Importance of AppearanceImportance of Appearance
1973 Survey: 29% Men 32% Women
1993 Survey: 63% Men 68% Women
1973 Survey: 29% Men 32% Women
1993 Survey: 63% Men 68% Women
Drive For ThinnessDrive 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
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
Drive For ThinnessDrive For Thinness
42% of 1st-3rd grade girls want to be thinner
81% of 10 yr olds are afraid of being fat
42% of 1st-3rd grade girls want to be thinner
81% of 10 yr olds are afraid of being fat
DietingDieting
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
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
DietingDieting 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
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
DietingDieting
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
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
Eating DisordersEating Disorders
Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder
Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder
History of Anorexia Nervosa
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.
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.
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 one’s 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
Anorexia Nervosa: Subtyping
Anorexia Nervosa: Subtyping
RestrictingRestrictingTypeType
Binge-Eating
Purging Type
Binge-Eating
Purging Type
AN - EpidemiologyAN - Epidemiology
Prevalence is estimated at 0.5 - 3.7% of populations at highest risk (adolescent females)
Female:male ratio 10:1 Significantly higher rates if sub-
threshold EDNOS cases are included Incidence in young women has
tripled in last 40 years
Prevalence is estimated at 0.5 - 3.7% of populations at highest risk (adolescent females)
Female:male ratio 10:1 Significantly higher rates if sub-
threshold EDNOS cases are included Incidence in young women has
tripled in last 40 years
AN: EpidemiologyAN: 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 (<10 yrs old) is relatively rare but increasing
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 (<10 yrs old) is relatively rare but increasing
AN - Medical ConsequencesAN - 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
Metabolic down-regulation - bradycardia, orthostatic hypotension, hypothermia, syncope
Dehydration, cardiac changes, arrhythmia
Gastric disturbances, constipation Osteopenia/Osteoporosis Anemia, leukopenia, electrolyte
disturbances Growth retardation
AN - Social ConsequencesAN - 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)
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)
AN - OutcomeAN - 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
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
AN - OutcomeAN - 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
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
AN - OutcomesAN - Outcomes
Third most common chronic illness among adolescents
12 times more likely to die than other women same age without anorexia nervosa
Third most common chronic illness among adolescents
12 times more likely to die than other women same age without anorexia nervosa
History of Bulimia NervosaHistory 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
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
Bulimia NervosaBulimia 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
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
Bulimia Nervosa: Subtyping
Bulimia Nervosa: Subtyping
PurgingPurging Non-purgingNon-purging
BN- EpidemiologyBN- Epidemiology
Lifetime prevalence is estimated at 1.1-4.2% of females
Up to 19% of college-aged women in America are bulimic
Female:male ratio 10:1 84% have a college education Incidence tripled between ‘88-’93
in 10-39 yr old women
Lifetime prevalence is estimated at 1.1-4.2% of females
Up to 19% of college-aged women in America are bulimic
Female:male ratio 10:1 84% have a college education Incidence tripled between ‘88-’93
in 10-39 yr old women
BN - EpidemiologyBN - Epidemiology
Age of onset between mid-adolescence and late 20’s
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
Age of onset between mid-adolescence and late 20’s
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
BN - EpidemiologyBN - 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
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
BN - Medical ComplicationsBN - Medical
Complications Electrolyte disturbances - hypokalemia Orthostatic hypotension Esophageal tear (Mallory-Weiss) Gastritis, gastric dilation, rupture Cardiac arrhythmias Menstrual irregularities Osteopenia Sudden death
Electrolyte disturbances - hypokalemia Orthostatic hypotension Esophageal tear (Mallory-Weiss) Gastritis, gastric dilation, rupture Cardiac arrhythmias Menstrual irregularities Osteopenia Sudden death
BN - OutcomeBN - 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
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
Binge-Eating DisorderDSM-IV-TR Research
Criteria
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
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
Binge Eating DisorderBinge 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 20’s 40% are male
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 20’s 40% are male
ClassificationClassification
Binge-eating Binge-eating disorderdisorder
EDNOSEDNOS
AnorexiaAnorexia nervosanervosa
Bulimia Bulimia nervosanervosa
The “Anorexogenic” Family
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”
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”
The “Anorexogenic” Family
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”
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”
The “Psychosomatic” Family
The “Psychosomatic” Family
In 1960’s, 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
In 1960’s, 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
The “Psychosomatic” Family
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
Child’s role in family was to serve as a go-between in cross-generational alliances
Minuchin placed emphasis on pathological interactive familial processes in the pathogenesis of AN
Focused on rigidity, enmeshment, over-involvement and conflict avoidance
Child’s role in family was to serve as a go-between in cross-generational alliances
The “Psychosomatic” Family
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
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
AN Risk Factor Research: Cross-Sectional Studies
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
Inappropriate parental pressures Early-life overprotection Greater incidence of separation,
arguments, criticism, high expectations, over-involvement, under-involvement, low affection
BN Risk Factor Research: Cross-Sectional Studies
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
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
Risk Factor Research:Cross-Sectional StudiesRisk Factor Research:
Cross-Sectional Studies Findings are inconsistent Growing support that families are
heterogeneous group with respect to socio-demographic characteristics, family relationships, etc.
Findings are inconsistent Growing support that families are
heterogeneous group with respect to socio-demographic characteristics, family relationships, etc.
Current Focus 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
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
The Maudsley Approach Family Based Treatment
(FBT)
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
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
The Maudsley Approach Family Based Treatment
(FBT)
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
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
Principles of Family Based Treatment
(FBT)
Principles of Family Based Treatment
(FBT) Parents are viewed as the most
useful resource in their child’s treatment
Parents play an active and vital role in the recovery process and in restoring their child’s weight
Parents are viewed as the most useful resource in their child’s treatment
Parents play an active and vital role in the recovery process and in restoring their child’s weight
Principles of Family Based Treatment
(FBT)
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
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
Family Based Treatment:Role of the Therapist
Family Based Treatment:Role 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
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
Family Based Treatment:Role of the Therapist
Family Based Treatment:Role 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
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
Family Based Treatment:Three Phases
Family Based Treatment:Three Phases
Phase 1: Weight Restoration Phase 2: Returning Control Over
Eating to the Adolescent Phase 3: Establishing Healthy
Adolescent Identity
Phase 1: Weight Restoration Phase 2: Returning Control Over
Eating to the Adolescent Phase 3: Establishing Healthy
Adolescent Identity
Weight RestorationWeight Restoration
Parents are supported in their efforts to restore their adolescent’s 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
Parents are supported in their efforts to restore their adolescent’s 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
Weight RestorationWeight 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
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
Returning Control to the Adolescent
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
Begins when adolescent has reached 90% of ideal body weight and is eating without much resistance
Process is gradual and age dependent
Establishing Healthy Adolescent IdentityEstablishing 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
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
Establishing Healthy Adolescent IdentityEstablishing 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
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