Download Anorexia Nervosa: From Latency to Geriatrics

From Discovery to Recovery
Assessing, Conceptualizing, and Treating Adolescents with
Eating Disorders in a Multidisciplinary Approach: a Discussion
of Family Dynamics, Environmental Factors, and Genetic
Influences
Mathew Nguyen, MD
Medical Director and Associate Chief
Division of Child and Adolescent Psychiatry
Medical Director, Psychiatry and Psychology at Springhill Health
Center
Chief, Eating Disorders Recovery Center
Chief, Psychiatry Consultation-Liaison Services
Department of Psychiatry
University of Florida
Maria Constantinidou, PsyD
Assistant Professor
Eating Disorders Recovery Center
Department of Psychiatry
University of Florida
Boston University School of Medicine asks all individuals involved in the development and presentation of
Continuing Medical Education (CME) activities to disclose all relationships with commercial interests. This
information is disclosed to CME activity participants. Boston University School of Medicine has
procedures to resolve apparent conflicts of interest. In addition, presenters are asked to disclose when
any discussion of unapproved use of pharmaceuticals and devices is being discussed.
Drs. Nguyen and Constantinidou have no commercial relationships to disclose.
Jointly Sponsored by Boston University School of
Medicine and the Society for Adolescent Health and
Medicine
Goals and Objectives
 1. To be exposed to the clinical presentation of
adolescents with Anorexia Nervosa (AN)
 2. To become familiar with how environmental,
family, and personality factors contribute to the
development of eating disorders in adolescents
 3. To become familiar with basic theoretical
foundations of psychodynamic theories in treating
eating disorders
Diagnostic Criteria: AN1

A. Restriction of energy intake relative to requirements, leading to significantly low
body weight in the context of age, sex, developmental trajectory, and physical
health

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that
interferes with weight gain, even though at a significantly low weight.

C. Disturbance in the way in which one's body weight or shape is experienced,
undue influence of body shape on self-evaluation, or persistent lack of recognition
of the seriousness of the current low body weight.

Type: Restricting Type vs. Binge-Eating/Purging Type.

Severity:
Mild: BMI ≥ 17 kg/m2
Moderate: BMI 16-16.99
Severe: BMI 15-15.99
Extreme: BMI < 15
1 Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5), American Psychiatric Association, Arlington, VA, USA, 2013.
Diagnostic Criteria: AN
DSM-IV-TR (Fourth Edition)1A
DSM-5 (Fifth Edition)1B
A.
A.
Refusal to maintain body weight at or above a minimally normal
weight for age and height (e.g., weight loss leading to maintenance
of body weight less than 85% of that expected; or failure to make
expected weight gain during period of growth, leading to body
weight less than 85% of that expected).
B.
Intense fear of gaining weight or becoming fat, even though
underweight.
C.
Disturbance in the way in which one’s body weight or shape if
experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body
weight.
D.
In postmenarcheal females, amenorrhea, i.e., the absence of at
least three consecutive menstrual cycles. (A woman is considered to
have amenorrhea is her periods occur only following hormone, e.g.,
estrogen, administration.)
Specify type:
Restricting Type: during the current episode of Anorexia Nervosa, the
person has not regularly engaged in binge-eating or purging behavior (i.e.,
self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
Restriction of energy intake relative to requirements, leading to a significantly low
body weight in the context of age, sex, developmental trajectory, and physical
health. Significantly low weight is defined as a weight that is less than minimally
expected.
B.
Intense fear of gaining weight or of becoming fat, or persistent behavior that
interferes with weight gain, even though at a significantly low weight.
C.
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 persistent lack of
recognition of the seriousness of the current low body weight.
Coding note: The ICD-9-CM code for anorexia nervosa is 307.1, which is assigned regardless
of the subtype. The ICD-10-CM code depends on the subtype (see below).
Specify whether:
(F50.01) Restricting type: During the last 3 months, the individual has not engaged in
recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the
misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which
weight loss is accompanied primarily through dieting, fasting, and/or excessive exercise.
(F50.02) Binge-eating/purging type: During the last 3 months, the individual has engaged in
recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the
misuse of laxatives, diuretics, or enemas).
Binge-Eating/Purging Type: during the current episode of Anorexia
Nervosa, the person has regularly engaged in binge-eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics,
or enemas)
Specify if:
In partial remission: After full criteria of anorexia nervosa were previously met, Criterion A
(low body weight) has not been met for a sustained period, but either Criterion B (intense
fear of gaining weight or becoming fat or behavior that interferes with weight gain) or
criterion C (disturbances in self-perception of weight and shape) is still met.
In full remission: After full criteria for anorexia nervosa were previously met, none of the
criteria have been met for a sustained period of time.
1A Diagnostic and Statistical Manual of Mental Disorders, 4th ed., (DSM-4
TR), American Psychiatric Association, Arlington, VA, USA, 2013.
1B Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5),
American Psychiatric Association, Arlington, VA, USA, 2013.
Epidemiology: AN
 0.9% lifetime prevalence among females2
 12-month prevalence among females is 0.4%1
 ≥ 10:1 female-to-male ratio1
 Later onset in males (later onset of puberty) 3
 Peak age of onset is mid-teens
 Culture-bound syndrome
2 Dulcan MK. Dulcan’s textbook of child and adolescent psychiatry 1st ed. Washington DC: American Psychiatric Publishing, Inc; 2010
3 Wooldridge T, Lytle PP. An overview of anorexia nervosa in males. Eating Disorders 2012;20:368-378.
Comorbidity in adults: AN2

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50-80% have affective disorders
30-65% have anxiety disorders
Alcohol and drug use common
Personality disorders and traits
• High-functioning and perfectionistic
• Constricted and overcontrolled
• Emotional dysregulation
Medical Comorbidities1

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




Malnutrition. . . . Electrolyte abnormalities
Hypotension. . . . dehydration
Hypothermia
Hypothalamic hypogonadism. . . Stunting in growth and
puberty
Bone marrow hypoplasia. . . . osteoporosis
Structural Brain abnormalities
Cardiac Dysfunction. . . bradycardia
Gastrointestinal difficulties
Esophageal tears
Death
Prognosis: AN2




One-half achieve “full recovery”
One-third improve but continue to experience eating disorder symptoms
One-fifth remain chronically ill
Among those that achieve full recovery, one-third will relapse
 In one longitudinal study of adolescents receiving inpatient treatment for
AN, 75% achieved full recovery, with a median time to recovery of 5 years
following participation in an intensive 6-month inpatient treatment.
 Mortality for AN: 0.56% per year, with suicide accounting for at least half
of the deaths.
 AN has the highest lifetime mortality of any psychiatric illness.
Biological Treatment
 Stabilize the weight and comorbid medical
problems
 Medications: treat the psychiatric comorbidity
 Prozac has an FDA indication for the treatment
of BN,4 but no medication indicated for AN
 Lack of nutrition to synthesize serotonin5
 Be aware of the FDA blackbox warning
regarding SSRIs in patients under 256
 Nutrition Therapy
4 Fluoxetine hydrochloride [package insert]. Eli Lilly; Indianapolis, IN.; 1987.http://www.accessdata.fda.gov/drugsatfda_docs/label/2003/018936s064lbl.pdf
5 Sebaaly JC, Cox S, Hughes CM, Kennedy ML, Garris SS. Use of fluoxetine in anorexia nervosa before and after weight restoration. Ann Pharmacother 2013;
47(9):1201-1205.
6 US Food and Drug Administration (2007). http://www.fda.gov/drugs/drugsafety/informationbydrugclass/ucm096273
Family Factors
 AN, more than other psychiatric disorders, is
seen as result of family influences7
 Family involvement reduces medical and
psychological morbidity in young patients8
 Commonly held belief that families are
“manipulative” and “resistant to change”9
 May foster sense of battling instead of
cooperating
7 Fleming J, Szmukler GI. Attitudes of medical professionals towards patients with eating disorders. Aust N Z J Psychiatry 1992;26:436-443.
8 Le Grange D, Lock J, Loeb K, Nicholls D. Academy for Eating Disorders position paper: The role of the family in eating disorders. Int J Eat Disord 2010;
43(1):1-5.
9 Lackstrom JB, Woodside DB. Families, therapists, and family therapy in eating disorders. In W. Vandereycken & P. J. V. Beumont (Eds.), Treating Eating
Disorders: Ethical, Legal and Personal Issues (pp. 106-126). London, UK: Athlone Press, 1999.
Countertransference
 Therapist’s emotional reaction to a patient
 “Classical” = emotions elicited by
psychological construct of the patient10
 Reactions to patient’s unconscious processes
 “Totalistic” = includes emotions elicited by the
psychological construct of the therapist10
 Reactions to unconscious processes of both
patient and therapist
10 Kernberg O. Notes on Countertransference. J Am Psychoanal Assoc 1963;13:38-56.
Projective Identification (PI)
 Originally described by Melanie Klein, expanded by Otto
Kernberg11
 “Immature” unconscious defense mechanism
 Step 1: Projection of unwanted feeling from oneself onto
another
 Step 2: Projector “pressures” recipient to think, feel, and act
according to the projection
 Step 3: Re-internalization of the projection by the projector
after it has been psychologically processed by recipient12
 This involves a blurring of emotional boundaries between
projector/recipient
11 Goldstein, WN. Clarification of projective identification. Am J Psychiatry 1991;148(2):153-161.
12 Ogden TH. On projective identification. Int J Psychoanal 1979;60:357-373.
Projective Identification: Example
 New mother brings sick child to pediatric intern
 Mother doubtful of herself as new mom, worries
she should have brought child sooner (Step 1)
 Intern diagnoses virus, no antibiotics needed
 Mother becomes frustrated, says child needs
more help, intern not doing his job (Step 2)
 Intern doubts his abilities as new doctor,
prescribes antibiotic “just to be safe” (Step 2)
Projective Identification: Example (cont’d)
 Mother and intern now both feel anxious and
doubtful of their abilities (blurred boundaries)
 Prescription of antibiotic confirms mother’s
belief she should have brought child in sooner
(Step 3)
 Reaffirms mother’s initial anxiety, serves as
self-fulfilling prophecy, continues to doubt self
(Step 3)
 Intern may carry his doubts to next patient
Family Attributes
Associated with AN13
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Perfectionism
Critical family environment
Coercive parental control
Rigidity
Low levels of cohesion and emotional expression
Lack of problem-solving
Avoidance of emotional conflict
Sensitive to issues of blame and shame
13 Harper JM, Larson JH. Implicit family process rules in eating-disordered and non-eating-disordered families. J Marital Fam Ther 2009;35(2):159-174.
Projective Identification in AN: The Parent
 Parent has self-doubt, feels incompetent (Step 1)
 Parent projects onto child: incompetence, poor selfdirection, inadequacy (Step 2)
 Child internalizes projection, develops poor selfdirection, unable to care for self or make autonomous
decisions (Step 2)
 Parent feels helpless, doubt and incompetence, and again
projects feelings onto child (Step 3)
 Parent struggles with allowing for separation and
autonomy of the child14
14 Minuchin S, Rosman BL, Baker L. Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard University Press, 1978.
Projective Identification in AN: The Child
 Child harbors feelings of resentment at parent and herself
for perceived failures (Step 1)
 Child re-projects out these feelings of incompetence and
failure as failure to nutritionally sustain herself (Step 2)
 Parent feels helpless, becomes overprotective, enmeshed,
controlling due to illness (Step 2)
 Reinforces to child she is incompetent and failing, cannot
be autonomous/independent (Step 3)
 Parent continues to believe child not capable of
autonomy15
15 Newton M. Exploring the psychopathology of anorexia nervosa: a Mahlerian standpoint. Perspect Psychiatr Care 2005;41(4):172-180.
The Clinician’s Role
 Clinician/treatment team is entering family system with
significant projective identification
 Feelings of anger, incompetence, perfectionism, and
helplessness projected onto clinician16
 Can lead to confrontations with family, severing
therapeutic alliance, or abandoning care
 Must be aware of common family themes17
–
–
–
–
Perfectionism
Helplessness
Dichotomous Thinking
Avoidance of Affect/Conflict
16 Thomson-Brenner H, Satir DA, Franko DL, Herzog DB. Clinician reactions to patients with eating disorders: a review of the literature. Psychiatr Serv 2012;63(1):73-78.
17 DeLucia-Waack JL. Supervision for counselors working with eating disorders groups: Countertransference issues related to body image, food, and weight. J Couns
Dev 1999;77:379-388.
Perfectionism
 Setting/pursuing an unrealistic standard despite negative
consequences
 Two Dimensions:18
– Personal Standards (PS): setting high standards
– Self-Critical (SC): scrutiny of self-behavior and concerns of
approval
 AN patients and families show high perfectionism
 Family may not disclose all problems, try to appear as
“perfect family”9
 Physician may overlook small, but significant gains in
treatment
18 Dunkley DM, Berg JL, Zuroff DC. The role of perfectionism in daily self-esteem, attachment, and negative affect. J Pers 2012;80(3):633-663.
Helplessness
 Patients and families may feel helpless due to continued
cycle of PI and feel situation cannot change
 Treatment team may buy into the belief that the
situation is hopeless or cannot change9
 Family feel they are “losing control” as patient enters
treatment19
 Improvement during inpatient hospitalization may
emphasize to family they were not able to help patient,
reinforcing sense of parental failure19
19 McMaster R, Beale B, Hillege S, Nagy S. The parent experience of eating disorders: Interactions with health professionals. Int J Ment Health Nurs 2004;13:67-73.
Dichotomous Thinking
 “All or none thinking”
 “Everything must get better” vs “Nothing is better”
 Family may feel excluded from care during admission,
but then fear having to care for patient after discharge19
 Battles for control during treatment
 Frustrated clinicians may alternate between being
optimistic about treatment and giving up
Avoidance of Affect/Conflict
 Difficulty acknowledging negative affects – despair,
frustration, incompetence, humiliation20
 Extension of perfectionism
 Family often desires opportunity to express own
frustrations without feeling guilty19
 Clinicians also feel they cannot express frustration
 Clinicians trying to avoid letting countertransference
interfere with treatment may perpetuate family patterns
of conflict/affect avoidance
20 Collahan M. Being a therapist in eating disorder treatment trials: constraints and creativity. J Family Ther 1995;17:79-96.
Implications for Treatment
 Avoid the blame game – blame increases defensiveness,
rigidity, and inflexibility21
 Point out family is trapped in vicious cycle of behavior
without having to say “who started it”21
 Understand/express differences, focus on common
ground9
 Awareness of sensitive issues, willing to discuss openly22
 Serve role as “emotional coach” for difficult affects23
 Unconditional support
21 Espina A, Ochoa de Alda I, Ortego A. Dyadic adjustment in parents of daughters with an eating disorder. Eur Eat Disord Rev 2003;11:349-362.
22 Eisler I. The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa. J Fam Ther 2005;27:104-131.
23 Treasure J, Sepulveda AR, Whitaker W, Todd G, Lopez C, Whitney J. Collaborative care between professionals and non-professionals in the management of eating
disorders: A description of workshops focused on interpersonal maintaining factors. Eur Eat Disord Rev 2007;15:24-34.
Summary
 AN often involves complex, unconscious family dynamics
 Projective Identification plays important role in maintaining
function of eating disorder behavior
 Clinicians also experience results of PI
 Good working relationship with families is often crucial in
making gains in treatment, particularly with adolescents
 Understanding projective identification and how it impacts
family helps clinician to manage difficult situations and guide
family through treatment process