Impulsivity and Eating Disorders: Clinical Correlates and Therapy Approaches

Fernando Fernández-Aranda

Professor University Barcelona, Head of Eating Disorders Unit

Head of Group CIBEROBN University Hospital of Bellvitge,

Barcelona, SPAIN e-mail: ffernandez@bellvitgehospital.cat

Impulsive-compulsive Spectrum Disorders

OCD AN-R AN-BP BNGambling Disorders

Compulsive buyingBDD

KleptomaníaOther ICDs

ADHD

Food Addicti

on

ED

Anxiety64-71%

Substance Use

7-69%

Personality

27-77%

ICD9-18%

Affective 20-83%

Comorbidity and Eating Disorders

Impulse related disorders and Eating disorders

In individuals with IRD and ED, higher impulsivity has been associated with:

▪ Specific disorder subtypes ▪ Severity of symptoms ▪ Greater comorbidity ▪ Genetic and biochemical factors ▪ Poorer psychological functioning ▪ Altered executive functions ▪ Less effective coping strategies ▪ Poorer treatment outcome

Impulse related disorders and Shared Vulnerabilities

Probst & van Eimeren: Curr Neurol Neurosci Rep (2013) 13:386

Impulse related disorders and Shared Vulnerabilities

Impulse related disorders and Shared Vulnerabilities

Probst & van Eimeren: Curr Neurol Neurosci Rep (2013) 13:386

Impulse related disorders and Shared Vulnerabilities

591 participants (194 HC, 178 GD, 113 OB, 106 SUD)

Mallorqui-Bague et al., Plos One (2016), 30-09

Probst & van Eimeren: Curr Neurol Neurosci Rep (2013) 13:386

Impulse related disorders and Shared Vulnerabilities

Shared features underlying ED with comorbid Impulse related disorders

• Higher Impulsivity • Lower tolerance to frustration • More difficulties to cope with stress. • Difficulties for regulating emotions. • Comorbid Axis II (PD-cluster B) and Axis I (Affective dis + Anx.

Dis.) • Low capacity for future planning • Shared personality traits and reward sensitivity • Shared biological vulnerabilities (dopaminergic, seritoninergic

pathways).

0

15

30

45

60

Tobacco Alcohol Drugs A+D

72

22

9

16

10

58

34

ED HC

Krug et al. Drug and Alcohol Dependence;2008;97: 169-179

PrevalenceforlifetimeandcurrentSubstanceuseinEuropeanED

InsteadofEating ED=879 HC=785

OR 5.11

OR 6.10

OR 6.0OR 6.0

Impulse Control Disorders and Eating Disorders

Impulse control disorders in Eating Disorders

Jimenez-Murcia. Comprehensive Psychiatry;2013; 1053-1060

Emotion Regulation and ED

Wolz et al., Front. Psychol., 30 June 2015

Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004)

(Hervas & Jodar Clínica y Salud, 2008, vol. 19 n.° 2 - Págs. 139-156)

Impulse Related disorders and Eating Disorders

BN-CB=50 BN+CB= 49

GD=53 CB=36 HC=50

Comparison of general psychopathology (measured by SCL90R) between the groups

Results

Comparison of personality traits (measured by TCI-R) between the groups

Results

ADHD and ED

43 AN 95 BN EDNOS 13 BED 82 HC

• Although studies have showed overlap between ED and Impulse related disorders, etiology and shared vulnerabilities, limited research is available about the treatment of these comorbid conditions.

• In the few studies where this topic is being specifically addressed, two therapy strategies are being considered: –Individual therapy vs. Integrated therapy strategies. –Symptom oriented vs. non-symptom oriented therapies.

Therapy strategies in ED with comorbid Impulse related disorders

Therapy strategies in ED with comorbid Impulse related disorders

• Symptom oriented strategies: – Transdiagnostic CBT (self-monitoring, behavioural management of

symptoms, coping with irrational beliefs, problem solving strategies, cues exposure..)

– CBT + pharmacological therapy – Dialectical Behavior Therapy – Motivational therapy

• Non-symptom oriented strategies: – Emotional regulation – Mindfulness/CFT – Neurocognitive training

Techniques used in ED with high Impulsivity

• Emotional regulation: – Self-regulation skills (self-soothing, imagery, distracting,

meditation, self-awareness). – Stress management and self-control strategies (relaxation,

biofeedback, breathing techniques). • Behavioral/cognitive area: – Delay of response – Planning skills – Cognitive remediation strategies

CBT- Group therapy: • Learning self-monitoring and structured meal patterns. •Motivational interviewing •Awareness of the “binging-escaping from problems” vicious circle •Cognitive reestructuring • Problem solving • Achievement of behav. goals •Response prevention strategies

16 WEEKLY SESSIONS 90 MIN. DURATION 7-10 PATIENTS

CBT Outpatient GT

Group Therapy for Bulimia nerviosa/BED

BN-P: 327 BN-NP: 40 BED: 87

Results

Response to treatment (completers)

0

17,5

35

52,5

70

Full-rem Partial-rem Non-resp

10

20

70

293536

26

43

31

BNP BNNP BED

Agüeraetal.,2013.BMCPsychiatry.

Results

Dropout from treatment

0

10

20

30

40

Yes

34

1513

BNPBNNPBED

Limitations of Therapy in ED with comorbid Impulse related disorders

• Higher relapses and drop-out rates • Lower motivation and therapy adherence • Poorer prognosis (basically due to higher severity,

dysfunctional personality traits and additional comorbid Axis I and II disorders).

• Lower social support and higher isolation. • More medical complications and higher mortality rates. • Impulsive traits seem to be difficult to be modified.

ANTECEDENTES PlayMancer: A European Serious

Gaming 3D Environment

E. Kalapanidas C. Davarakis T. Ganchev O. Kocsis C. Breiteneder H. Kaufmann J. Jacobsen J. Krabbe

T. Lam T. Raguin M. Vollenbroek R. Huis in 't Veld Konstantas, D. M. Ben Moussa S. Jimenez-Murcia K. Gunnard, J. Santamaría A. Soto F. Fernandez-Aranda

ICT - INFORMATION AND COMMUNICATION TECHNOLOGIES- FP7-ICT-2007-1

Enhanced CBT for BN (plus Serious Video Game)

Fernandez-Arandaycols,2012MentalHealthFagundoetal.,2013EuropeanEat.Dis.Rev.,21:6Fagundoetal.,2014JMIR,2014,16(8):e183.21:6

Keywords: Bellvitge Playmancer YouTube

CBT+ SVG: 20 CBT-SVG: 18

Enhanced CBT for BN (plus Serious Video Game)

Fernandez-Arandaetal.,2015Cyberpsychology

Treatment of VGT before CBT and influence on binge/vomiting episodes

Giner-Bartoloméetal.,2015FrontiersPsychology

Enhanced CBT for TRI (plus Serious Video Game)

Diseminación I

5

10 Publicaciones internacionales 2 Proyectos FIS 1 Proyecto PM7

2 Premios: 2011 Mejores ideas DM

Best European Serios VG For health-2011

2011-2017

RETOS FUTUROS e-ESTESIA: APP PARA REGULACION EMOCIONAL

PSI2015-68701R

2016-2018

101.035 Euros

Challenges for the next decade in the management of Eating Disorder

• Chronicity and aging in ED

• Impulsivity and how to deal with emotions and perfectionism

• SUD/Comorbities and ED: a comprehensive approach?

• Lifetime obesity and ED: categorical vs. dimensional

• How to deal with drop-out

e-mail: ffernandez@bellvitgehospital.cat

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