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

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10

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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

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Partial RemissionF

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Weeks from Entry

Bulimia

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An-R

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Partial RemissionF

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Weeks from Entry

Bulimia

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An-R

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Full RemissionF

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Bulimia

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Weeks in Remission

fract

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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