Download slides bit.do/annakeski How can we predict & change the course and outcome of anorexia nervosa? Anna Keski-Rahkonen Associate Professor University of Helsinki, Finland
How can we change the course and outcome of anorexia nervosa? #1 By understanding the etiology of anorexia #2 By understanding the magnitude of the problem What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the #3 By understanding is natural course disease in this patient if I do not intervene? ? #4 By understanding whether treatment can change the natural course of anorexia nervosa #5 By understanding prognostic factors #6 By understanding each other
How can we change the course and outcome of anorexia nervosa? #1 By showing that the problem exists and that it is real (local prevalence studies, personal stories, media) #2 By thoroughly understanding the etiological mechanisms of anorexia nervosa -> tailoring precision interventions #3 By having a detailed understanding of the natural course of anorexia nervosa (” What happens if I DO NOT INTERVENE”? #4 By understanding factors that can change the natural course of anorexia nervosa. These include – Treatment choices (” Will this treatment help?”) – Patient-related prognostic factors (” Who will benefit ?”
How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if #1 By Understanding the I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ? Etiology of Anorexia
Why do people get anorexia nervosa? • Various psychological theories • Various biological theories • Genetic, neurobiologial, animal research BOTTOM LINE:
Genes load the gun, the environment pulls the trigger Anorexia: 2-3% complete
Triggering factors: sociocultural factors + whatever slings & arrows life sends your way Gossip Girl
Personal, possibly inherited, biological vulnerability???
How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if #2 By Understanding the I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ? Magnitude of the Problem
A bunch of high school students. Who will get anorexia nervosa?
Prevalence of Anorexia Nervosa in Finland Anorexia nervosa, 3.6% 0.3%? Mustelin et al 2016 PMID 27014849 , Raevuori et al 2009 PMID 19204790
How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if #3 By Understanding the I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ? Natural Course of the Problem
Natural course: The common cold Will the child get better if we don’t intervene?
Natural course: Anorexia nervosa Will the child get better if we don’t intervene?
Prevalence of Anorexia Nervosa in Finland Anorexia nervosa, 3.6% 0.3%? Mustelin et al 2016 PMID 27014849 , Raevuori et al 2009 PMID 19204790
Who is still ill at age 30? Mustelin et al 2016 PMID 27014849 , Raevuori et al 2009 PMID 19204790
Life after anorexia nervosa: How are women in their 30s doing? • Weight restoration • University degree • Employment • Marriage/cohabitation ? • Pregnancy Mustelin et al, Int Journal of Eating Disorders 2015
Recovery from Anorexia Nervosa in Finland 72%
Finnish women with Anorexia in the 1990s Half have received treatment, half have not. Can we predict who will get better? 100% 0 recovered time (years) Data based on analyses in the Finnish Twin Cohorts (Keski-Rahkonen et al 2007, Keski-Rahkonen et al 2009)
What does this mean? Possible interpretations • Treatment was not available widely • Available treatment was not long enough • Available treatment was not frequent enough • Available treatment was not effective enough • Available treatment was not based on correct etiological models
Finnish women with Anorexia. Can we predict who will get better based on Comorbidity? By 5 years: 74% recovered No depression p=0.0043 DSM-IV depression By 5 years: 52% recovered
Risk of Death from Anorexia Nervosa AN, no comorbidity: 2.8 x AN, depression: 4.7 x AN, personality: 5 x AN, alcohol: 12 x (Kask et al 2016, PMID 27136502)
Anorexia & the risk of death • 6 x the mortality of the general population • Leading causes of death: suicide, starvation-related causes, infections • Indirect evidence from Swedish registries that specialized eating disorder treatment reduces mortality Lindblad et al Am J Psychiatry 2006 Arcelus et al Arch Gen Psychiatry 2011
How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if #4 By Understanding the I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ? Treatment Altenatives
How to Save Lives: Detection & Diagnosis of Eating Disorders Lataa talteen itsellesi: bit.do/edinfo BMJ 2017;359:j5245
Choice of Treatment
Basic Clinical Management Psychodynamic Approaches Oatmeal Psychodynamic 1 kg
Cognitive Behavioral Therapy Family Therapy
Evidence-based Treatment of Anorexia Nervosa Adults: No sufficient evidence of any psychotherapeutic approach Adolescents: Family therapy may be superior Inpatient treatment and outpatent treatment Antidepressants not useful for treating anorexia
Full bowl and empty bowl: http://www.alamy.com/stock-photo-full-bowl-of- cornflakes-and-empty-bowl-60495794.html
Cookbooks for Beginner Cooks
Cookbooks for Advanced Cooks
Can we predict who responds to treatment?
How can we change the course and outcome of anorexia nervosa? What is the predicted course of the disease in this patient if #4 By Understanding I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ? Individual Prognostic Factors
Hi, I’m Anna. I am Hi , I’m trying to Katja. I have help Ellie.. some issues with food…
I’ve eaten nothing I don’t I hate the today. want to Uh oh.. way I look. I be here. don’t deserve food. I have no time for friends. Running feels good. Drinking I I’m not feels even telling her better. about cutting.
PMID: 26171853 http://tinyurl.com/edprognosis
Predictors of Eating DisorderTreatment Outcome Favorable prognosis: At risk of • Fewer dropping out: symptoms • Shorter • Weight duration • Higher BMI suppression • Bingeing and • Low purging comorbidity • Depressive • High self symptoms esteem • Impulsivity • Interpersonal • Comorbidity skills • Low motivation • Greater motivation
Ideal World: Precise Models, Accurate Predictions Final BMI 11 12 13 14 15 16 17 18 19 20 21 22 r=0.95 Intake BMI 11 12 13 14 15 16 17 18 19 20 21 22 Simulation: rlanders.net
Real World: Weak Signals, Fuzzy Predictions Final BMI 11 12 13 14 15 16 17 18 19 20 21 22 Intake BMI 11 12 13 14 15 16 17 18 19 20 21 22 Simulation: rlanders.net
Try to achieve symptom reduction early on Focus on motivation Identify individuals with *severe symptoms * binge/purge behaviors *driven exercise *depression *personality problems * longstanding symptoms
Which Patients Need Us Most? Patients with severe symptoms, comorbid disorders, personality problems, poor interpersonal skills, suicidal behaviors, substance use …
How can YOU change the course and outcome of anorexia nervosa? Practical suggestions Help those who are somatically in danger to get stabilized to reduce mortality What is the predicted course of the disease in this patient if I do not intervene What is the predicted course Start building networks of experts on anorexia nervosa of the disease in this patient if I do not intervene? ? Train professionals (multiple methods = good) Conduct research on locally relevant questions (for example, track local prevalence of eating disorders or treatment outcomes) Educate the public
Thank you! anna.keski@gmail.com
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