How can we predict & change the course and outcome of anorexia - - PowerPoint PPT Presentation

How can we predict & change the course and outcome of anorexia nervosa?

Anna Keski-Rahkonen Associate Professor University of Helsinki, Finland

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What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ?

How can we change the course and

• utcome of anorexia nervosa?

#1 By understanding the etiology of anorexia #2 By understanding the magnitude of the problem #3 By understanding is natural course #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

• utcome 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?”

What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ?

How can we change the course and

• utcome of anorexia nervosa?

#1 By Understanding the 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???

What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ?

How can we change the course and

• utcome of anorexia nervosa?

#2 By Understanding the 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

What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ?

How can we change the course and

• utcome of anorexia nervosa?

#3 By Understanding the 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

72%

Recovery from Anorexia Nervosa in Finland

Finnish women with Anorexia in the 1990s Half have received treatment, half have not. Can we predict who will get better?

time (years) 0 recovered 100% 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?

No depression DSM-IV depression p=0.0043

By 5 years: 74% recovered 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

What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ?

How can we change the course and

• utcome of anorexia nervosa?

#4 By Understanding the 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 Psychodynamic

Oatmeal 1 kg

Family Therapy Cognitive Behavioral 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?

What is the predicted course of the disease in this patient if I do not intervene What is the predicted course of the disease in this patient if I do not intervene? ?

How can we change the course and

• utcome of anorexia nervosa?

#4 By Understanding Individual Prognostic Factors

Hi , I’m

• Katja. I have

some issues with food… Hi, I’m

• Anna. I am

trying to help Ellie..

I hate the way I look. I don’t deserve food. I have no time for friends. Running feels good. I’ve eaten nothing today. Uh oh.. Drinking feels even better. II’m not telling her about cutting. I don’t want to be here.

PMID: 26171853 http://tinyurl.com/edprognosis

Favorable prognosis:

• Fewer

symptoms

• Shorter

duration

• Higher BMI
• Low

comorbidity

• High self

esteem

• Interpersonal

skills

• Greater

motivation

At risk of dropping out:

• Weight

suppression

• Bingeing and

purging

• Depressive

symptoms

• Impulsivity
• Comorbidity
• Low motivation

Predictors of Eating DisorderTreatment Outcome

Ideal World: Precise Models, Accurate Predictions

Simulation: rlanders.net Intake BMI 11 12 13 14 15 16 17 18 19 20 21 22 Final BMI 11 12 13 14 15 16 17 18 19 20 21 22

r=0.95

Real World: Weak Signals, Fuzzy Predictions

Simulation: rlanders.net Intake BMI 11 12 13 14 15 16 17 18 19 20 21 22 Final BMI 11 12 13 14 15 16 17 18 19 20 21 22

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…

What is the predicted course of the disease in this patient if I do not intervene What is the predicted course

• f the disease in this patient if I do not intervene?

?

How can YOU change the course and

• utcome of anorexia nervosa?

Practical suggestions Help those who are somatically in danger to get stabilized to reduce mortality Start building networks of experts on anorexia nervosa 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