Panel Discusses Advances for Low-Weight, Normal-Weight, and Obese Patients
Reprinted from Eating Disorders Review
November/December 2010 Volume 21, Number 6
©2010 Gürze Books
The message was clear: patients with eating disorders come in all sizes and ages, and treatment must be tailored to the individual. At a plenary session at the International Conference on Eating Disorders, held last June in Salzburg, Austria, three eating disorders experts posed challenging questions and reviewed research for patients with anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and obesity.
Touyz: Anorexia Nervosa Needs to Be Taken Seriously
Stephen Touyz, PhD, from the University of Sydney, Australia, stressed that underweight is not synonymous with AN, and added that "anorexia nervosa is not a byproduct of the fashion industry, but instead is "a malignant disease that must be taken more seriously." He said one of the issues with patients with AN is its current diagnostic criteria, and this problem may be addressed with some significant and helpful changes in the DSM-V.
AN is highly heritable and is a distinct disorder, and not a transdiagnostic disease, he said. He added that research is not keeping up with the disease, and that leading researchers feel that they are from 30 to 100 years behind where they should be in research on the causes and treatment of the disease. Part of the delay has been caused by the small number of patients in studies and by the lack of controlled studies. And, few studies have been done in adults with long-term AN.
For adolescent patients, one "shining light" is the success cited with the family-based treatment using the Maudsley method, he noted. However, Dr. Touyz said if the Maudsley data are analyzed for outcome measures for recovery and not based on weight gain alone, the data doesn't look so promising. Rather than the 70% success rate, the real success rate is closer to 50% to 60%, he said.
Dr. Touyz and colleagues are currently conducting the Strong Without Anorexia Nervosa (SWAN) trial, a randomized control trial of Australian men and women 18 years of age or older with body mass indexes (BMIs) lower than 18.5 kg/m2. The study is comparing three outpatient approaches to treating AN: manual-based cognitive behavioral therapy (CBT), an enhanced form of CBT (CBT-E; see other article in this issue), and Specialist Supported Clinical Management, or SSCM. “We are studying all three approaches head-on,” he said.
He pointed out that many of his colleagues use the Maudsley approach very effectively for patients who weigh less than 75% of their ideal body weight. Early detection is one key: if AN can be identified in an adolescent within 12 months of the development of the disease, 50% to 60% can have a better outcome.
Dr. Touyz used the analogy of the current approach to treating malignant cancer versus treating AN. He said, "When we treat AN, most treatment approaches don't get the patients to weight restoration," adding that just as in a malignant lesion, there is a risk of secondary psychological and social risks, and always the risk of death with AN. He compared toxic thoughts among those with AN to malignant cells, noting that such patients may retain such toxic thoughts after weight is restored. Patients then have to turn to coping with these unhealthy thoughts. "Just because someone has gained weight, this doesn't mean they have recovered from AN," said Dr. Touyz, adding, "They will need further treatment to recover."
In adult patients with longer-term illness, a type of "anorexia madness" can emerge, and the best a clinician can hope for is a form of harm reduction, Dr. Touyz said. Then, he said, the treatment goal becomes an effort to improve the patient's quality of life. He noted that in a large controlled study of the sickest AN patients in London and in Sydney, a 60-minute session of CBT or SSCM seemed to help patients respond better. However, he added that clinicians need to work harder to help patients improve what are "terrible lives." He pointed out, "These patients are lonely, and have no friends and family." A 40-hour program of treatment is not enough, he added, and such patients should stay in treatment until the toxic thoughts are gone.
Dr. Touyz closed by urging clinicians to remember that "AN is a malignant toxic illness and we don't take it seriously enough—even families don't always realize how serious it is. We need to explore different kinds of treatment, including day hospital treatment, which is cheaper and patients can integrate their lives with friends." Noting that the "knockout punch against AN probably won't come in the next few years," he urged eating disorders professionals to collaborate, to share their findings, and to work to get their patients into larger trials.
Schmidt: Self-Help CBT Combats Bulimia Nervosa and Binge Eating Disorder
CBT and mindful eating techniques are proving helpful for patients with BN and BED, according to Ulricke Schmidt, MRCPsych, PhD, FAED, Professor of Eating Disorders at the Institute of Psychiatry, London.
Dr. Schmidt told the audience that over the past 31 years, since Russell first described BN, there have been many trials for BN and eating disorders not otherwise specified (EDNOS). She noted that CBT is recommended for most adults with BN, and 30% to 40% will recover. Self-help, mainly manual-based self-help, has been effective for some patients, and some newer approaches have used the Internet and email in self-help programs. In one study, Sanchez-Ortiz, of the Maudsley group, used eight online sessions and some guidance by email for a group of college students with BN or EDNOS (Psychol Med 2010; 21:1). "With a motivated population, you can get good results," Dr. Schmidt said. Antidepressants have been studied in 30 randomized controlled trials, but only about one-fifth of patients achieve remission with such medication, she said. One of the keys to success is early response, and she noted that Walsh and colleagues at Columbia University have found that non-responders can be reliably identified by the third week of treatment.
Comorbidity is another element to consider among these patients, Dr. Schmidt said. She pointed out that most patients have one or two comorbidities, including anxiety and substance abuse disorder. Many patients with multiple comorbidities are challenging, she said, as shown in a study by Crow in which one-third of patients had attempted suicide (Am J Psychiatry 2009; 166:1309).
As for treatment, CBT and CBT-E have been about equally helpful, according to Dr. Schmidt. In a study of more than 150 patients, there was no difference in outcome, although patients with greater comorbidities responded better to CBT-E.
Although BN was once thought to be a disorder only of adults, Favaro and colleagues recently showed that one-third of patients with BN present before 15 years of age (J Clin Psychiatry 2009; 70:1715). One strategy for these young patients is to build upon family-based treatment, including family therapy or individual counseling. Dr. Schmidt urged clinicians to get better at developing forms of adolescent therapy that also address the comorbidities these patients so often have.
Dr. Schmidt told the audience that biological and brain research has been plentiful, and there is much interest in imaging and isolating biomarkers to help predict individual treatment response and to design more targeted treatment. "We can also learn a lot from animal research," she said, "particularly research into the biology of binge eating." Dr. Schmidt told the plenary session audience that rats can be addicted to sugar and fatty foods by fasting and binge eating. No two rats are alike, she said, and a subgroup has been found to be binge-prone. This group overeats when high-sugar foods are available and will tolerate punishment to do so. To make the rats binge-prone, they are first stressed, then exposed to foods high in fat or sugar. "This kind of model resonates with BN patient profiles, "she said. The discovery of this animal model can be helpful, she said, because patients who binge eat and their families often believe the problem is that patients are merely weak-willed. She told the audience that patients with BN and BED often have an overwhelming sense of shame; if clinicians are compassionate and responsive, this goes a long way to help these patients.
Patients can be taught to manage cravings with CBT and a strong focus on mindful eating. Cravings-addiction models are also important because they might lead to brain-directed treatment. In laboratory animals, the use of high-frequency radio signals applied to the prefrontal cortex results in a reduction in bingeing, cravings, and stress levels. "While this is not a full-fledged treatment, it is a pointer of where treatment for patients with BN and binge eating may go in the future," she said.
Dr. Schmidt predicts that over the next 10 years interactive computerized technology will allow users to assess physical and psychosocial levels of stress and to give immediate feedback. Dr. Schmidt's group and others have internet-based treatment and one program even uses text messaging to respond more quickly to patients.
Marcus: Obesity and Overweight Have a Strong Genetic Basis
The good news about obesity or overweight patients is that much of the progress found in treatment for BN and BED will also hold true for patients with weight problems, said Marsha Marcus, PhD, Professor in the Department of Psychiatry at the University of Pittsburgh.
Dr. Marcus told the audience that obesity is simply an overabundance of body fat in relation to lean body mass; there is no clear demarcation between normal and abnormal body fat. She also said that the BMI is still the best screening tool, and it is strongly associated with other measures of fatness and with health risk.
She noted that obesity is caused by long-term positive energy balance and that from 60% to 90% of adult body weight is determined by genetics. The rest is explained by environment. The only way to become overweight is to consume more calories than you expend, she said, adding that liking fatty foods or disliking physical activity are both very much affected by genetic makeup. "Remember," she added, "obesity is a gene-environment interaction and vulnerable people will develop obesity in an environment that promotes overeating and underactivity."
For most if not all patients, obesity is highly associated with other kinds of medical comorbidities, and as obesity increases so do problems with heart disease, cancers, gynecologic abnormalities and liver problems. Overweight persons need to be referred for treatment of hyperlipidemia or hypertension, and these patients often want treatment for obesity as well as for their eating disorder. Treatment often has very little effect on body weight, and Dr. Marcus told the audience that clinicians need to have frank discussions with patients about this and to ask patients how they feel about deferring treatment because treatment will not impact weight.
As for treatment, CBT provides the strongest evidence base, according to Dr. Marcus. Other interventions that may be helpful include interpersonal and mindfulness-based treatments. How does obesity treatment affect BED? Weight loss interventions are associated with decreases in binge eating, which is not surprising, she said, because stage 1 CBT for BN is derived from behavioral management, state- of the art behavioral and cognitive skills, and regular eating. In many ways CBT for obesity resembles treatment of BN, which helps patients manage their triggers and the consequences of binge eating. The benefits of obesity treatment also result from bariatric surgery and medication treatment, she said, adding that emerging data note that if loss of control of eating recurs after surgery, the outcome may be poorer.
Dr. Marcus cited a recent study by Drs. Ruth Streigel-Moore and Terry Wilson on guided self-help for recurrent binge eating (J Consult Clin Psychol 2010; 78:312; see related story elsewhere in this issue). This was a combined treatment and efficacy trial conducted in a primary care setting. Individuals had BED, BN, or recurrent binge eating (occurring at least once a week). The patients were given 10 sessions of CBT guided self-help right in the primary care setting. Compared with treatment as usual, guided self-help was associated with good rates of remission. In the future, she said, it may be that primary care physicians will screen patients for aberrant eating, whether they are of normal weight or not, and then make CBT available for those who need it.
Most pharmaceutical approaches to BED, including use of fluoxetine, are only modestly helpful, she said. When the anti-obesity agent is withdrawn, the problem recurs.
Dr. Marcus noted the future of obesity treatment may lie with identification of specific obesity phenotypes. The regulation of human body weight is not just over-determined, but extremely over-determined, she said, adding that the body defends its weight. Our understanding is growing exponentially but the implications for treatment are less progressive. One question that remains concerns determining whether obesity or aberrant eating is an addiction.There are parallels between active addiction and obese persons, and persons with eating disorders may have increased reaction to palatable foods, and a decreased response to food reward.
Dr. Marcus said that currently only a few general studies in humans actually have shown in-vivo weight changes. "We don't know the exact parallels in lab and in-vivo eating behavior, but I am hopeful that these studies will lead to new treatment targets," she said. She also pointed to the human stress response system, and asked the audience to consider the relationship between obesity and other psychiatric disorders, including attention deficit hyperactivity disorder, or ADHD. Dr. Marcus presented this possibility to challenge clinicians to think intuitively of an overlap between obesity and other conditions. That is, many people eat out of inattention or boredom or restlessness; these may have psychological or biological underpinnings and underlying depression may also be a factor.
Dr. Marcus predicts that neurobiological investigations may identify obesity phenotypes strongly associated with psychiatric disorders, and while efficacious treatments may be elusive for a while, self-management techniques will remain for the overweight and obese patient.
Finally, she said," We all need to self-manage our eating and exercise."