Transcript Treatment of adolescents with severe anorexia nervosa

The severely ill young person
with anorexia nervosa
Nyborg, Denmark, March 2011
Simon G. Gowers
University of Liverpool
Cheshire and Merseyside Tier 4 ED Service
Treatment of adolescents with
severe anorexia nervosa
 What is meant by severity?
 Case examples
 What are the implications for treatment?
 Positive
 Negative
 Compulsory treatment
 Psychiatric v Paediatric (medical)
 Some do’s and don’t’s
Severity of anorexia nervosa
 Physical
 Weight compared to expected weight
 Behavioural
 Frequency of abstinence, purging, exercising
 Psychological
 Self-report measures (e.g.EDI-2)
 Motivation
 Co-morbidity
 Temporal
 Chronicity
 Global
 ED Specific (Morgan-Russell scale, EDE)
 Generic (HoNOSCA, CGAS)
Treatment uncertainties
 About in-patient treatment
 When to admit
 For how long
 Unwanted effects
 Merits of different psychological
therapies
 Effective treatment of unmotivated
patient
 Compulsory treatment
Treatment of adolescents with
severe anorexia nervosa
 The low weight patient who is barely
eating
 The patient with fixed beliefs about
the importance of weight
 The patient who has had three
admissions over three years
 The unmotivated patient
Planning treatment
 Little research evidence to guide us
 Principles to follow
 Traps to avoid falling into
Sarah –
Can live on ‘fresh air’ alone
 A restricting
perfectionist
 Barely eating
/drinking
 Very low weight
 Physically frail
 Exercising
 Losing weight
steadily
Pitfalls & Principles
 Pitfalls
 Principles
 Preoccupation with
physical issues to
exclusion of the whole
person
 Working at cross
purposes e.g. with
control issues
 Physical monitoring is
important
 Acknowledge sense of
achievement
 Psycho-education
 Motivational assessment
of pro’s & con’s
 Aim to be on the same
side
 Manage physical risk
using least coercive
approach
Jane –
‘Psychotic’ beliefs about weight
 Convinced she is fat
 Believes someone has
changed the labels in her
clothes
 ‘Sees’ fat globules
bubbling up on her arms
 A voice tells her not to eat
 Believes calories pass
from her mother into her
food when she stirs it
Pitfalls & Principles
 Pitfalls
 Principles
 Confusing ‘as if’ with
delusional belief
 Disregarding her
experience
 Adopting mental
illness model
 Pharmacological
solution
 Severe ‘weight phobia’
 Wants to be
interesting / different
 Engageable
 Cognitive behavioural
approach
 Possible role for
tranquillisers
Sophie –
Been there, done it, got the t shirt
 Professional patient
 Had three previous
admissions
 Stuck in the ‘sick
role’
 Parents feeling deskilled
 Missed two years
of school
Pitfalls & Principles
 Pitfalls
 Principles
 Popular patient
 ‘Revolving door’
 It hasn’t worked
before, let’s see if it
will next time
 General rehabilitation
is as important as
specific treatment
 Parental
empowerment
 Sophie should make
case for further
treatment
Catherine –
Who the hell are you?
 Very difficult to
engage
 Contemptuous and
scornful of clinical
staff
 Talks very little
 Lacks motivation
Pitfalls & Principles
 Pitfalls
 Principles
 Difficult to like
 Getting angry /
punitive
 Joining a battle of
wills
 Promoting
conformity
 Engagement is
crucial
 Work ‘with’
adolescent
rebellion
 Promote
individuality
Psychiatric v Paediatric
Management
 Psychiatric
 Longer Term
 Holistic
 Can manage
behavioural
disturbance
 Requires larger
‘catchment area’
 Paediatric
 Physical emphasis
 NG feeding
 May give ‘wrong
message’
 Difficult to gain and
maintain skills
 Requires liaison
‘paediatric protocol’
So….some do’s & don'ts
…….but first, the don’t knows
10 don’t knows
 Antidepressants
 Tranquillisers
UK Eating Disorders Consortium
study
 Retrospective case note study
 1 year of consecutive cases – 7 specialist
eating disorder services.
 N=308 cases
 Prescribing by primary care / CAMHS before
specialist service
 Prescribing by specialist ED services

Gowers S.G. et al (2010) Drug prescribing in C&A eating disorder services. CAMH 15, 1, 18-22.
Results
308 cases (90% female)
 Mean age 15 years, (range 8 -19 yrs).
 An equal number of referrals came from primary care
and secondary CAMHS services.
Diagnosis
Anorexia nervosa (56%), Bulimia nervosa (7%) EDNOS
(37%).
 71 (23%) had a co-morbid psychiatric problem
depression being the most prevalent (n = 23).
 246 cases (80%) were offered treatment at the
specialist eating disorder services, 63 as in-patients
(26%).
Results (cont)
 Drug Prescribing
 Eighty three cases (26.9%) either at
assessment or later within an EDS, were
prescribed psychotropic medication.
 Prescribing was uniform across all ages 1219 years.
 There were no drug prescriptions below the
age of 12.
38
On drugs
at
assessment
14
59
Prescribed
new
medication
at EDS
Both on medication at assessment
and prescribed new medication at EDS
Drug Types
26 different drugs used
Antidepressants – 10 Antipsychotics – 6 Anxiolytics – 6 Other – 4
Antidepressants
Prior
EDS
Amitriptyline
2
0
Citalopram
2
4
Escitalopram
0
2
Fluoxetine
22
30
Lofepramine
1
0
Mirtazapine
2
4
Reboxetine
0
2
Sertraline
7
5
Tryptophan
0
2
Venlafaxine
0
1
Antipsychotics
Prior EDS
0
1
Chlorpromazine 0
2
Aripripazole
Anxiolytics
Prior
EDS
Buspirone
1
0
1
2
0
1
0
3
4
3
1
0
Clonazepam
Diazepam
Lorazepam
Propranolol
Zopiclone
Haloperidol
1
1
Olanzapine
5
19
Risperidone
3
5
Quetiapine
0
2
Others
Prior
EDS
Carbamazepine
3
0
1
1
1
1
0
0
EPA
Lamotrigine
Ritalin
Beneficial and adverse effects
Fluoxetine
 52 cases (17% of total series)
 In 32 cases (62%) beneficial effects were reported.
 In 10 cases (19%) adverse effects were reported
(increased self harm in 4).
Olanzapine
 24 cases (8% of total series)
 In 16 cases (67%) beneficial effects were reported.
 In 9 cases (38%) adverse effects were reported predominantly drowsiness, hunger and constipation
Conclusions
 A significant proportion (27%) of adolescents with
eating disorders are prescribed psychotropic
medication.
 Surprisingly, 1/3 are prescribed psychotropic
medication prior to assessment at an eating disorder
service, but the majority (2/3 of prescriptions) are
made in specialist services.
 The most used psychotropic drug is Fluoxetine followed
by Olanzapine.
 Indications: mainly co-morbid psychiatric problems
such as depression.
 Drugs appear to be tolerated quite well, even at low
weight . However, it is possible that both beneficial and
adverse effects may not have been recorded in some
cases.
10 don’t knows










Antidepressants
Tranquillisers
Family therapy
CBT for AN
Target weights
In-patient psychiatric
treatment
Length of in-patient stay
Prognostic indicators
Socio-cultural aetiology of AN
Prevalence of adolescent BN
10 don’ts
 Investigate for diagnostic
reasons
 Make aetiological
assumptions
 Reassure /monitor /delay
treatment
 Work against the patient
 Enter battle of wills
 Punish
 Collude
 Offer only family therapy
 Exclude parents
 Forget siblings
10 Do’s




Acknowledge don’t knows
Make diagnosis on history
Empathise
Motivate

.
Enhancing the effectiveness of
therapies
Motivation
Motivation (for treatment)
 Stages of readiness for change




Pre-contemplation
Contemplation
Action
Maintenance
Are motivated patients less ill than
poorly motivated ones?
- baseline measures
Mean
Poor
Better
motivation motivation
(n=20)
(n=22)
p value
% expected
weight
74.4
75.1
73.5
0.69
EDI total
HoNOSCA
95
34
19
107
36
19
84
32
19
0.04
0.24
0.45
HoNOSCA-SR
16
15
16
0.63
Age
16.1
15.7
16.5
0.31
MFQ
But does motivational status
predict outcome? (6 weeks)
Mean
Poor
Better
motivation motivation
(n=20)
(n=22)
p value
Weight
+1.2kg -0.2kg
+2.0kg
0.03
EDI total
HoNOSCA
-23
-5
-4
-28
-3
-3
-21
-6
-5
0.31
0.30
0.56
HoNOSCA-SR
-2
-1
-3
0.56
MFQ
Gowers S.G., Smyth B. (2004) The impact of a motivational assessment interview
on initial response to treatment in adolescent anorexia nervosa.
European Eating Disorders Review. 12, 87-93.
What can we do about motives & to
improve motivation?
Can we enhance motivation?
 Motivational Assessment:
 Mean motivational score before i/v =
12.5
 After assessment = 14.2
 Giving patients power and choice in
negotiable areas
 Identifying distant aims and agreeing
them
Using the patients’ strength of will
and using it to your advantage
10 Do’s
Acknowledge don’t knows
Make diagnosis on history
Empathise
Motivate
Mobilise parental strengths
Offer parental guidance
Monitor physical health
during re-feeding
 Set non-negotiables
 Liaise and communicate








.
10 Do’s
Acknowledge don’t knows
Make diagnosis on history
Empathise
Motivate
Mobilise parental strengths
Offer parental guidance
Monitor physical health
during re-feeding
 Set non-negotiables
 Liaise and communicate
 Use BMI centile charts







Conclusions - traps
 Something’s got to be done – here’s
something
 Taking on others’ anxiety
 Burn-out
 Being deflected off course by physical
concerns / confusing symptoms
 Joining a battle of wills
 Promoting conformity
Conclusions (cont)
 Importance of reviewing case mix & staff
support
 Follow universal principles






Engagement
Maximise motivation
Attend to physical issues – but not exclusively!
Address faulty cognitions
Manage behaviour
Family involvement as appropriate
Do’s & Don’ts in the management
of Eating Disorders
Publications:
Hanssen-Bauer K., Heyerdahl S., Bilenberg N., Brann P., Garralda E., Merry S.
& Gowers S. (2006) Health of the Nation Outcome Scales for children and
adolescents (HoNOSCA). Training vignettes including recommendations and
ratings. Australian Mental Health Classification. Melbourne.
Roots P., Hawker J. & Gowers S. (2006) The use of target weights in the
inpatient treatment of adolescent anorexia nervosa. European Eating
Disorders Review 14, 5, 323-328.
Gowers S.G. & Battersby L. (2007) Models of Service Delivery – In Jaffa A. (Ed)
Eating Disorders in Children and Adolescents – Cambridge Univ Press. P248-259.
Gowers S. & Doherty F. (2007) Prognosis & Outcome. In: Lask B & BryantWaugh R. (Eds)., Anorexia Nervosa & Related Eating Disorders in
Childhood and Adolescence, Third Edition. Hove Brunner-Routledge.p75-96
Gowers S.G., Clark A., Roberts C., Griffiths A., Edwards V., Bryan C.,
Smethurst N., Byford, Barrett B. & Harrington R.C.. (In Press) Two year
outcomes of a randomised controlled trial for adolescent anorexia nervosa – (the
TOuCAN trial). Brit J Psychiatry.
Fairburn C.G. & Gowers S.G. (In Press) Eating Disorders In Rutter M (Ed)
Rutter's Child and Adolescent Psychiatry (5th edition), London, Blackwell.
Byford S., Barrett B., Roberts C., Clark A., Edwards V., Edwards V., Harrington
R.C., Smethurst N. & Gowers S.G. (In press) Economic evaluation of a
randomised controlled trial for adolescent anorexia nervosa – the TOuCAN trial .
Brit J Psychiatry.
[email protected]
The severely ill young person
with anorexia nervosa
Nyborg, Denmark, March 2011
Simon G. Gowers
University of Liverpool
[email protected]