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1、Eating Disorders: Assessment, Understanding, and Treatment Strategies Terry Schwartz MDMedical Director UCSD Eating Disorders ProgramAsst Clinical Professor UCSDElise Curry Psy.D.Program ManagerUCSD IOP石家庄监控维修 http:/ASSESSMENT AND TREATMENT STRATEGIES FOR EATING DISORDERSTerry Schwartz MDMedical Dir

2、ector UCSD Outpatient Eating Disorders ProgramAssistant Clinical Professor UCSD Dept Of PsychiatryDSM IV Criteria for Anorexia Nervosa Preoccupation with body shape, weight/size 85% 30 32.2% of American adults, increasing in children Increasing in past 30 years by 50% per decade Major successful tre

3、atment advances in treatment of complications of obesity, but minimal success in treatments for obesity itselfIs Obesity a psychiatric disorder (BED)? Medical/Metabolic issues Am J Psych 2007: Issues for DSM V: Should obesity be included as a brain Disorder Major limitation to treatment of obesity i

4、s long term behavioral compliance Diets major cause of ED, including BED (recall starvation study) Individual biological risks: genetic/heritabilityBED and Neurochemistry Serotonin, endogenous opiates, cannabinoids Certain foods impact nucleus accombens: DA, opiate Neuropsych: similar to addicts; ie

5、; follow immed reward over long term results during gambling type tasks (with excitable reward)Food for affect regulation Neurochemical stimulation Anxiety, depression, anger, boredom, agitation etc Endogenous response to food (or starvation) may predispose to AN or BED/BNLiterature Review: Treatmen

6、t for BED International J of EDs May 2007 26 studies reviewed: Med plus BWL, meds alone, BWL alone Meds plus BWL best, short termPsychosocial treatments CBT CBT plus BWL BWL alone Group therapy Indiv therapy 12 step/self helpMedical treatments for BED/obesity No magic pill! Sibutramine Orlastat Acom

7、plia Phentermine Gastric Bipass StimulantsMedical treatments for BED/obesity continued No magic pill! ? SSRIs, SNRIs ?Wellbutrin ? Topiramate ? ZonisamideWhat about psych meds and weight gain Need to know and be truthful with ED patients! SSRIs SNRIs Atypical Antipsychotic Medications Typical Antips

8、ychotic Medications Mood Stabilizers TCAs, MAOIsBREAKEating Disorders in special populations Children Teens MalesED IN KIDS TEENSWhat about the kids? Pre-pubertal Eating Disorder Childhood Onset Eating Disorder Early Onset Eating DisorderWhat Are We NOT Talking About? DSM-IV Feeding and Eating Disor

9、ders of Infancy or Early Childhood Pica Rumination Disorder Feeding disorder of infancy or childhoodAnorexia NervosaDSM-IV Refusal to maintain body weight above a minimally normal weight for age and height. 85% of IBW Intense fear of gaining weight or becoming fat Disturbance in the way ones body we

10、ight or shape is experienced Amenorrhea: absence of at least three consecutive menstrual cyclesWeight Loss vs Weight Maintenance DSM-IV criteria excludes children who have not reached the critical level of 85% Failure to gain appropriate weight with growth Malnutrition can lead to poor growthBody Im

11、age May be more tricky to assess How can it be evaluated? Childrens expression of body image Standard tools Clinical Interview Somatic symptoms Abdominal pain or discomfort Feeling of fullness Nausea Loss of appetiteAmenorrhea Primary vs Secondary Pubertal delay Evaluation may include pelvic ultraso

12、und Height Weight Weight/height ratio Ovarian volume Uterine volume Conventional target weight and weight/height may be too low to ensure ovarian and uterine maturityAlternative Criteria for ED in Children: Byant-Waugh and Lask 1995 Alternative classification for the range of eating disorders of chi

13、ldhood “Excessive preoccupation with weight or shape and/or food intake which is accompanied by grossly inadequate, irregular or chaotic food intake”Byant-Waugh and Lask 1995 :Criteria for Anorexia Nervosa Failure to make appropriate weight gains, or significant weight loss Determined weight loss (e

14、.g., food avoidance, self-induced vomiting, excessive exercising, abuse of laxatives). Abnormal cognitions regarding weight and/or shape. Morbid preoccupation with weight and/or shape.Related ED Behaviors in Children Anorexia nervosa Food avoidant emotional disorder Selective eating Functional dysph

15、agia Bulimia nervosa Pervasive refusal syndromeEarly behavioral risk factors for EDs PICA BN Picky Eater BN, some AN Digestive problems AN Subsyndromal symptoms of EDs can predate Incidence and Demographics Anorexia in this age range is considered to be rare, but appears to be increasing Males may c

16、onstitute a higher proportion of cases in childhood as opposed to in adolescence or adulthood 19-30% of childhood cases 5-10% of adolescent or adult cases Biological Social PsychologicalBiological Genetics Higher rate of AN, BN and ED NOS in first degree relatives Cross-transmitted High heritability

17、 Medication Trials suggest serotonin and dopamine systems contribute Imaging Gordon et al, 1997 15 girls ages 8-16 with AN Regional cerebral blood blow radioisotope scans 13/15 had unilateral temporal lobe hypoperfusion Lask et al, 2005 significant association between unilateral reduction of blood f

18、low in the temporal region and impaired visuospatial ability, impaired visual memory enhanced speed of information processing Psychological Personality traits Anxious Obsessional Perfectionistic Susceptibility factors Obsessions Perfectionism Symmetry Exactness Negative affect, harm avoidance Preocc

19、upations with weight, body image and foodPrognosis Long term follow up of patients with early onset anorexia nervosa (Bryant-Waugh et al, 1987) 30 children with anorexia nervosa followed for mean duration of 7.2 years Mean age at onset 11.7 years 19/30 (60%) with a “good” outcome 10/30 remained mode

20、rately to severely impaired Poor prognostic factors included Early age at onset (11 years) Depression during the illness Disturbed family life and one parent families Families in which one or both parents had been married beforeTreatment Challenges (especially for the very young) Very little data or

21、 literature on treatment Few inpatient or outpatient programs for kids under 12 or 13 years old Only 1 we are aware of. Little data or clinical experience Family Therapy Family therapy Maudsley Family Therapy Systemic Family TherapyFamily Therapy Required with Adolescents Maudsley Family Therapy Sys

22、temic Family Therapy Couples Family involvement to motivate pt for treatment (case example)Systemic Family Therapy Underlying belief: if you fix the system, the symptom will no longer be needed. The eating disorder is serving a function in the family. The symptom bearer is trying to help the family

23、(unconsciously). Methods for Systemic Family Therapy Circular questioning Therapist is curious observer, not expert. Discuss communication patterns within the family. Involve all family members in the discussion, even small children. Do not pathologize family or symptom bearer.Maudsley Family Therap

24、y“Behavioral Family Therapy”Maudsley Family Therapy Agnostic toward etiology Involves parents, rather than a parent-ectomy Food is medicine Initial focus on symptoms Parents are responsible for weight restoration. Non-authoritarian therapist stance Separation of child from illnessMaudsley Family The

25、rapy Phase I: (sessions 1 - 10) Weight restoration, re-feeding focus. Phase II: (sessions 11 - 16) Transfer control back to adolescent gradually. Phase III: (sessions 17 - 20) Focus on adolescent developmental issues, termination.Maudsley Family Therapy Session 1: Funeral session Goals: engage the f

26、amily, obtain history of how AN came to be, find out how AN has affected each family member, assess family functioning, reduce blame, raise anxiety concerning AN. Interventions: Greet family in sincere but grave manner, externalize the AN, orchestrate intense scene, charge parents with the task of r

27、e-feeding.Session 2: Family Meal Instructions to parents: bring a meal that would be appropriate for your childs nutritional needs. Goals: assess family structure as it may affect ability of parents to re-feed patient, provide an opportunity for parents to successfully feed patient, assess family pr

28、ocess during meal. Interventions: bring the symptom alive and present in the room, one more bite, align patient with siblings for support.Males and EDSMales and EDs Less common than in females, but increasing (approx 10% of EDS occur in men) They have a job or profession that demands thinness. Male models, actors. Cultural pressures to be V shapedMales and EDS More in common with female EDs than differences Lower testosterone may predispose to ED Fears regarding sexuality More common in homosexual men Conflict over sexual identity Avoidant, passive, negative reactions from peers as ch