E ATING D ISORDERS Hana Papežov{ S ERVICES ( REALITY ) AND EVIDENCE - BASED TREATMENT Department of Psychiatry, First Faculty of Medicine, Charles University and General University Hospital in Prague GUIDELINES EEEDN 2018 Kaunas Kaunas
History – beauty ideal AED CONFERENCE 2017 1989 1983 Body shape Sexuality Fertility the Paleolithic period (35,000 B.C.E).
Charles University Prague, CR • Founded in 1348 as one of the oldest universities in Europe. • Contains 17 faculties, 3 collegiate institutes, 6 additional establishments for educational, scientific, research • The Faculty of Medicine has been part of Charles University in Prague since 1348 and is the oldest faculty of Medicine in Central Europe.
Psychiatric Department 1st Medical School • The oldest psychiatric clinic in our country, Arnold Pick, described the brain degenerative disorder “Morbus Pick” Jan Janský , discovered of the fourth blood group AB Kurt Freund, author of phalopletysmographic examination
Eating Disorder Center • Frantisek Faltus established Eating Disorders Unit in 1982-3 as the first one in the Central and Eastern Europe. • Hospitalization program 1-12 beds 1982-3 • Developed following European and Czech evidence-based standards. • Day care center 2002-3 • Collaboration with Child and Adolescent Day Care Center • Outpatient clinic , consultation and short motivational psychoeducation interventions, MFT • Collaboration with Self help organisation 1992
Epidemiology and planning ED services
Hospitalisations for ED in the Czech Republic / 100 000 (1981-2005) Pavlova et al. 2007
Hospitalisations 2008-2015 Vývoj počtu hospitalizací pro poruchy příjmu potravy (PPP) 600 500 400 ment{lní anorexie 300 ment{lní bulimie ostatní PPP 200 100 0 2008 2009 2010 2011 2012 2013 2014 2015
Out-patients services in the CR 2011-2015 Incidence of F.50 diagnoses 123 new cases /100 000 inhabitants
Psychiatric hospitalisation and age distribution 2006 - 2011 *GB: Proportion of AN cases fulfilling MKN-10 criteria for admission: 70% of adolescents; 50% of adults
Eating Disorder Service Czech Republic 10 millions inhabitants • in 2011: 339 hospitalisations in 272 pts • Proportion of new referrals by diagnosis AN* BN BED 63% 20% 0,1-9% atypical 7%
Hospitalisations and refusals from the wating list (WL) 1998-2008
Inpatient Service • Psychiatric Ward; 12 beds for ED, • 12 for somatoform and rehabilitation • Treatment 24-hours per day, 7 days per week. • Age 18 upwards; exc. from 16 • Severe AN, BN, BED acute or chronic; local or national • Patients are realimented back to a healthy weight • Supportive structured group milieu • Regular medical reviews • Group therapy : motivational enhancement therapy; CBT, cognitive remediation • Links to Child and Adolescent Univerzity hospital Motol and Day Care Center for Child and Adolescent Unit at our Clinic.
Day-care for Adults (8-12 places) • Age 17 upwards • Patients with moderately severe AN (BMI 16),BN, BED • 8-hours per day, 5 days per week • Regular meals in a friendly, non-institutional setting, and Multiple group activities . • Comprehensive program: CBT regime and dynamic approaches, relapse prevention and post hospitalization program. • Clubs for patients ,family members, MFT.
Day Care Centers (Chudobov{, Papežov{, 2003) DHP TCE OLOL DSPPPP Toronto Munich Los Angeles Prague Foundation 1986 1990 1991 2002 Program 4 days 7 days 5 days 5 days 10-18,15 h 8-17 h 9,30-17,30 h 8,00-16,30 h Connected to yes yes yes yes In- and out- patients services 12 24 13 12 Max. No of patients Meals Lunch, Breakfast, Lunch, diner Breakfast, diner, snack lunch, diner, Lunch, diner, snack 2x snack 2x
Day Care Centers - program (Chudobov{, Papežov{, 2003) DHP TCE OLOL DSPPPP Toronto Mnichov Los Angeles Praha CBT l l l l Dynamic PT l l l Art therapy l l Body work l l l l Manuals l l l l (meal plans spec. nurse) FT l Psychoeducat l l l ion Relaxation l l
Outpatient Services for Adults Out-patient care (short interventions): • Different time-limited individual diagnostic, educational and psychotherapeutic interventions • Consultations and supervisions • MFT • CBT • Self-help/guided groups 1/month • Clubs and On line services for patients, carers, schools
Therapeutical quidelines
INTERNATIONAL RESEARCH • COST ACTION B6 1995-2001 • INTACT 2005-2011 (Genetic Study GCAN)
COST B6 ACTION (ED multicentric study on treatment efficacy - 1993-2001) country % positive outcome % positive outcome AN BN CZ 31,5 32,2 D 20,6 32,2 F 25,7 - GB 17,7 23,3 NL 49,5 56,2 PL 16,6 23,5 Spain 29,9 40,4
Pro-youth.eu Primary care doctors, Specialists, Pediatrists Nutrition therapists Specialized ED team
Limitations and new treatments
SEAN & comorbidity • CHRONIC SEVERE EATING DISORDERS : >50% of patients with AN need long-term multi-disciplinary care and long-term involvement from specialist services • DUAL DIAGNOSIS : Many cases of AN& BN have significant co-morbid disorder (OCD, anxiety disorders, PTSD, alcohol & substance misuse, personality disorder)
Comorbidities personality disorders and abusers • H. Lacey, St. George Hospital, London (Multi-impulsive forms of ED) Important preparation and quality of evaluation of the patient o Stable and structured care o Multidisciplinary collaboration o Culture of the ward Hohenneg, Switzerland 2003
Treatment cost • 1,9 milion men and 2 milion women žen • Hospitalized 21,5% AN, less BN a EDNOS • AN $6045, • BN $2962, • EDNOS $3207, • Schizophrenia $4824, • OCD $1930 Striegel-Moore RH et al., 2000 In EUROPE 680 million Euro/year
„ Adequate therapy “ Crow & Nyman 2004 • As usual $36 200 • Adequate $119 200 • 1 year survival $30 180 Calculation /mortality, age, treatment response and mean duration of life/ • Drake RE et al., Implementing evidence-based practices in routine mental health service settings. Psychiatr Serv, 52, 2001,179-82.
ED cost in the CR
Limitations of implementation EDU - under-resourced – more and more new strategies • are political decision. Pessimism regarding changes in ED behaviour • Agras and al., Int J Eat Disord, NIH, 2004 List of new developments not comprehensive (e.g. what • about BED) Implementation of research to clinical practice. • Decrease of young medical doctors interest in the topic. Vandereycken 2011 Manualized programs and quidelines are not realised as • expected, refusal to change Faiburn 2004, AED konference
New technologies and social network
Technology-enhanced interventions for step-up and step-down care
Prevention and early intervention • CD-ROM for BN, BED • CD-ROM for body image work • CD-ROM for carers • Web-based relapse prevention and support •
PREVENCE ŠKOLY A SPECIALIZOVAN[ ZAŘÍZENÍ Zaměření na rizikovou populaci Debra Franco Praha 2003
Online pro-Youth: Promotion of young people‘s mental health through technology-enhanced personalization of care WWW.PROYOUTH.EU
The PRO-YOUTH network Germany: Center for Psychotherapy Research Czech Republic: Charles University, Prague Romania: University of Babes-Bolyai, Cluj-Napoca Italy: Studi Cognitivi, Milan Ireland: Trinity College, Dublin Hungary: Semmelweis University, Budapest Netherlands: Stichting Rivierduinen, Leiden PRO YOUTH Projekt 2011- 2014
The PRO-YOUTH platform Updated software, based on Es[s]prit and YoungEssprit (Bauer et al., 2009; F2F Lindenberg et al., in press) Counseling New: Involvement of young Consultation Chat people in development and delivery Monitoring Psychoeducation & Peer Support Screening PRO YOUTH Projekt 2011-2014
Comics by peers „I was just a normal young girl“. (Aneb co se může stát, když se zvrtne jídlo). Autorka kreseb i textu: A. Tejklová
Healthy and free
PC game application focused on • the prevention of the eating disorder . www.divcivalka.net The primary objective of this • application is to address the teenage girls in the age of 13- 16, to offer them the information about eating disorder in the form of a PC game as well as the contact details for professional help. The interactive photo comics with • music and spoken commentary. The main character of this comics • suffers from eating disorder and her classmates try to find out, why she is absent from school. Step by step, they learn what are • the symptoms and the consequences of this serious disease, what is the risky behaviour related to it and how they could help their friend. From the perspective of the • player, it is a detective story; at the very start the player doesn’t know that it is related to the theme of eating disorder. Logical riddles and mini • games, orientation tests for the players. The player has the possibility to • influence the storyline, the story moves forward depending on the player`s decisions. Informal elements, colloquial • language of the teenagers. Distribution: online free of charge •
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