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Harvard Medical School
Do Adolescents with Eating Disorders Ever Get Well?
David B. Herzog, M.D.
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
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
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
Taylor Swift
Cast of Pretty Little Liars (CW)
Miley Cyrus
aka Hannah Montana
Assessment ToolsAssessment Tools Clinical InterviewsClinical Interviews Collateral contact with parents, treatment Collateral contact with parents, treatment
team (including pediatrician)team (including pediatrician) Structured InterviewsStructured Interviews
Eating Disorder Examination (child version)Eating Disorder Examination (child version) SCIDSCID
Self-report QuestionnairesSelf-report Questionnaires EDE-QEDE-Q Beck Depression InventoryBeck Depression Inventory Anxiety questionnaires?Anxiety questionnaires?
Psychiatric ComorbidityPsychiatric Comorbidity
DepressionDepression Anxiety disordersAnxiety disorders
OCDOCD GADGAD Social PhobiaSocial Phobia
Substance use disordersSubstance use disorders Dissociative disordersDissociative disorders KleptomaniaKleptomania Personality disordersPersonality disorders
TreatmentTreatment
TeamTeam Multi-modalMulti-modal Continuum of ServicesContinuum of Services Safety ContractSafety Contract
Treatment ModalitiesTreatment Modalities PsychotherapyPsychotherapy
IndividualIndividual GroupGroup
Family TherapyFamily Therapy PharmacotherapyPharmacotherapy Nutritional CounselingNutritional Counseling Medical ManagementMedical Management
For whom, what?For whom, what?
Assessment guides treatment decisionAssessment guides treatment decision
Acute hospitalizationAcute hospitalization
Residential treatmentResidential treatment
Partial hospitalizationPartial hospitalization
Intensive outpatientIntensive outpatient
Outpatient treatmentOutpatient treatment
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 much Allow 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
Clinical Tools Clinical Tools (continued)(continued)
Anticipate:Anticipate: Mistrust Mistrust IntellectualizationIntellectualization DenialDenial LyingLying
Be aware that many ED symptoms may be Be aware that many ED symptoms may be benignbenign
Be aware that some body image Be aware that some body image disturbance may persistdisturbance may persist
Addressing Denial and Addressing Denial and Low MotivationLow Motivation
Small statureSmall stature Confusion about Confusion about
why others perceive why others perceive them as being too them as being too thinthin
LonelinessLoneliness Family tensionFamily tension
Boredom in routinesBoredom in routines Lack of pleasureLack of pleasure Domination of life by Domination 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:
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
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
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
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
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
Cognitive Behavioral Therapy
Psychoeducation and self-monitoring Building a personalized formulation Establishing regular eating Preventing relapse
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
Psychoeducation on Purging
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 ConsBeing thin Preoccupied with food and
weightFeeling 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”
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)
Regular Eating: Alternative Pleasurable Activities
Phoning a friend Painting nails Timed urge “surfing”
Arts & crafts “Incompatible” music Journaling
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
Pharmacotherapy for AN
No significant clinical effects with:
Amitriptyline (Biederman et al., 1985)
Risperidone (Hagman et al., 2011)
Olanzapine (Kafantaris et al., 2011)
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
Outcome in Adolescent AN
57
26
17
2
0
10
20
30
40
50
60
70
80
Percent
Recovered Improved Chronic Mortality/decade
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?”
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
0 100 200 300 400 500
0.0
0.2
0.4
0.6
0.8
1.0
Partial RemissionF
ract
ion s
till i
ll
Weeks from Entry
Bulimia
An-BP
An-R
0 100 200 300 400 500
0.0
0.2
0.4
0.6
0.8
1.0
Partial RemissionF
rac
tio
n s
till
ill
Weeks from Entry
Bulimia
An-BP
An-R
0 100 200 300 400 500
0.0
0.2
0.4
0.6
0.8
1.0
Full RemissionF
ract
ion s
till i
ll
Weeks from Entry
Bulimia
An-BP
An-R
Weeks in Remission
fract
ion
stil
l we
ll
0 100 200 300 400 500
0.0
0.2
0.4
0.6
0.8
1.0
AN-BPAR-RBulimia
Relapse
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
“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