At the 2017 International Conference on Eating Disorders (ICED) Conference in Prague early in June, eating disorders experts shared innovative approaches to better access to treatment, challenged some longstanding tenents about patient care, and presented new data about improving ways to measure atypical eating disorders.
A Global Approach to Psychological Care
Keynote speaker Dr. Vikram Patel, Director of the Department of Global Health and Social Medicine, Harvard Medical School, and Director of Socorro Village, Bardez-Goa, India, described two innovative programs designed to address alcoholism and depression in remote sections of India. Dr. Patel and his colleagues developed and used local resources to overcome the lack of psychologic care in geographically challenging areas. Although Dr. Patel is not an eating disorders specialist, he told the audience that he hoped “to infect your community with new ideas from other disciplines to confront and address health inequalities with every tool at our disposal.”
Dr. Patel noted that innovations and technologic advances are helping clinicians to reimagine what mental healthcare can look like. The field of eating disorders has been at the forefront of a number of those innovations, he said. Dr. Patel told the audience that it is a scandal that virtually no one in the lower or middle income levels in India has access to psychological treatment. The two main barriers are a lack of specialists and a gap between reality and the way most people in the lower income levels view disorders such as depression and anxiety. Many don’t regard mental health problems as unusual. This is a second barrier to care, he said.
Dr. Patel then described two innovative programs that are bridging the gap between lack of access to care and patients with psychological health needs. Brief psychological treatment is delivered by lay counselors trained in primary care treatment for depression and alcoholism (the Healthy Activity Program, or HAP) and the Counselling for Alcohol Problems, or CAP. In a controlled study, CAP was provided to 188 men. When Dr. Patel and colleagues evaluated their results after 3 months, CAP delivered by the lay counselors was more effective for harmful drinking than was usual care alone (Lancet online, January 14, 2017). The CAP program had strong effects upon abstinence and remission rates, but no effect on other alcohol-related outcomes.
The HAP program is specialist community model using primary-level workers (PHWs) who work with men with depression. Aides are trained to provide community support and treatment for persons with severe mental disorders. About 8 years ago, working with the Wellcome Trust, Dr. Patel set up a program, Premium, which he said was inspired by leading figures in the ED field, including his mentor, Dr. Christopher Fairburn. The theory behind Premium was to devise a method of scalable psychological treatment.
Dr. Patel said he and others initially mistakenly thought that Western mental therapies wouldn’t work in remote areas of India but would first need to be adapted for the local population. One realization was that the adaptation needed was not changing fundamental diagnostic and treatment approaches, but instead improving access to care. Thus, treatment was not so much cross-cultural but cross-social classes.
Dr. Patel credited the eating disorders field for being a leader in the forefront of using techniques such as guided self-help, self-help manuals, and web-centered training to reach patients. He told the audience that his hope is that lessons for global mental health and shared goals mean improving health for all people, everywhere, and the hope that specialists will learn from one another across varied fields of knowledge. Thus, he said, the key is not to change the fundamentals, but to change access to care.
Atypical Eating Disorders: Overlooked and Misunderstood
In a wild-card plenary session, “Atypical Eating Disorders: Addressing the Overlooked and Misunderstood,” four ED experts shared clinical and neurobiological research that is better defining Avoidant/Restrictive Food Intake Disorder, or ARFID. New ways of looking at atypical eating disorders, coupled with new data from brain imaging are changing approaches to diagnosing and treating atypical eating disorders. A strong case was made for avoiding the traditional approach of fitting the patient to an adult description of an eating disorder such as AN.
Viewing ARFID through the Eyes of Patients and Parents
Richard E. Kreipe, Elizabeth R. McNerney Professor of Pediatrics at the University of Rochester (NY) Medical Center, told the audience that, just as Dr. Bryan Lask reported more than 18 years before, presentations of EDs among children and adolescents don’t fit neatly into adult descriptions of those disorders. Instead, Dr. Kreipe challenged clinicians to try to see things from the patient’s and parents’ perspectives.
Symptoms reported by patients are real and not imaginary, he said. Dr. Kreipe stressed the value of assuming that parents of a child with an eating disorder are doing the best they can, and also not to automatically assume that reported symptoms in a child are “just part of his or her eating disorder” or that symptoms “are just the disorder talking.” Also, he noted, ARFID can continue into adulthood, and it may only be in midlife that adults realize they have had ARFID for many years.
Dr. Kreipe said that ED specialists are realizing that symptoms often attributable to psychological problems may have origins in physiological disorders such as swallowing problems, disrupted neural circuits, or to non-eating-disorder-related problems, such as autism spectrum disorders. He urged clinicians to expand their professional contacts to other specialties, “to go beyond our understanding.” He added, “We can realize that other areas of science can inform what we are seeing as an emotional disorder.” He also urged the audience to expand the circle of professionals they work with. For example, one promising area in ARFID research has come from interventions in autism spectrum disorders, he said.
Finding a More Precise Way to Measure Eating Disorders
Kamryn T. Eddy, PhD, Co-director of the Eating Disorders Clinical and Research Program, Massachusetts General Hospital, and Assistant Professor of Psychiatry at Harvard Medical School, Boston, described preliminary results from neurobiological studies that are helping researchers more precisely define and differentiate ARFID from eating disorders such as AN.
Dr. Eddy told the audience that clinicians should heed signs, not just symptoms, when approaching suspected cases of ARFID because a divergent biology may underlie AN and ARFID. Preliminary results from two studies have shown two distinct patterns. First, high food motivation, defined as hunger and reward, along with control, and thin-internalization are implicated in adolescent AN. In contrast, low-weight ARFID patients have low motivation for food and thin-ideal internalization is absent. She said a new direction in the diagnosis and treatment of ARFID involves the neurobiology of low appetite levels, sensory sensitivity, and phobic anxiety.
Early results from two ongoing studies
Dr. Eddy also shared some preliminary results of her team’s cross-sectional study of AN patients. In the first study, there are data for 34 females with AN and 25 healthy control patients. All the young subjects are being studied with brain scans at baseline, 9 months, and then at 18 months.
Using functional magnetic resonance (fMRI) scans, Dr. Eddy and colleagues compared patient reactions to images of high-calorie food, low-calorie food, and static objects among patients with AN and control subjects. The expectation was that AN patients would show robust reactions to high-calorie foods that could be seen in increased activity in the insula, amygdala, and orbital frontal cortex, a region of homeostatic and hedonic food motivation. As expected, there was increased reaction to high-calorie foods. But, if there was increased reaction to high-calorie foods, why weren’t the AN patients eating? The researchers also found higher signals in cognitive control centers in the anterior cingulate cortex and dorsolateral prefrontal cortex. Among patients with binge-purge type AN, the signals from the cognitive control centers were even higher. When tested, AN patients had higher-than-normal levels of the orexigenic hormone ghrelin. No such increases were seen in the control subjects.
The researchers are also evaluating restrictive eating among ARFID patients in an ongoing NIH R01 study aimed at recruiting 100 ARFID patients and 50 healthy controls, who will be followed for 2 years. The subjects are child and adolescent females and males aged 10 to 22 years. Thus far, data are available for 7 ARFID patients.
Dr. Eddy noted that the very preliminary results are showing that AN patients have very different patterns on brain scans than do youths with ARFID. Children with ARFID have hypoactivation of the insula and low levels of ghrelin, levels closer to those of the healthy controls. “There is a divergent biology between ARFID and AN,” she said. She also noted that such clinical data can be used to validate the patients’ experiences and can also reduce stigma. Preliminary findings are indicating hypoactivation in appetite neural circuitry (the anterior insula) in ARFID patients vs. controls.
Dr. Eddy also commented that clinicians often tend to rely on symptoms, which are subject to patient minimization and denial. She also briefly described the NIH RDoC Matrix, and ways in which this newer approach is improving diagnosis of eating disorders and ARFID. She and her colleagues have identified possible candidate signs in AN. For example, AN patients have high neural activation in homeostatic and hedonic food motivation circuitry, high ghrelin levels, implicit biases toward thinness and weight-shape control, and preference for larger delayed rewards over smaller immediate rewards. Another candidate sign for AN was high neural activation in cognitive control regions of the brain.
The group’s fMRI scans also showed that the pattern of hyperactivation in the insula shows greater hunger and food reward in patients who binge/purge versus restrictors. She found that orexigenic ghrelin levels are higher in patients with AN than in controls and these levels do not differ among restrictors and binge/purge patients. Restrictors and those with binge-purge type AN have thin-ideal internalization. Those with restricting-type AN show a preference for larger delayed rather than smaller immediate rewards.
In contrast, ARFID patients had low neural activation in homeostatic and hedonic food motivation circuitry in the brain, low ghrelin levels, and high brain-derived neurotrophic factor (BDNF) levels. Unlike patients with AN, ARFID patients have no implicit biases toward thinness and weight-shape control. They also have a preference for smaller immediate rewards, not larger, delayed rewards.
Dr. Eddy pointed out that longitudinal studies will help shed light on the state versus trait aspects of signs, and will help reconcile adolescent and adult findings. Psychoeducation can validate patient reports in ARFID and AN, which will reduce stigma and help motivate patients and caregivers as well. Few clinicians have an MRI scanner immediately nearby, she said, but the hope is that results of ongoing longitudinal studies of ARFID will give clinicians more accessible signs of the disorder.
Never Too Old for an Eating Disorder
Hans W. Hoek, MD, PhD, of Columbia University Mailman School of Public Health, and Director of the psychiatric residency program and chair of the Parnassia Bavo Academy at the Parnassia Bavo Psychiatric Institute, The Hague, highlighted groups of ED patients who are often overlooked and misunderstood, including males, non-Caucasians, and older women.
Dr. Hoek first reminded the audience of the gradual evolution of knowledge about EDs. With each decade, our understanding of EDs has been clarified, he said. For example, in the 1980s it was believed that there was a sudden epidemic of eating disorders; then in the 1990s, there was a belief that EDs were just female disorders. In the early 2000s, there was a belief that only westerners were affected by EDs. Then, in the 2010s it was believed that EDs were a disorder of young people only.
He advised clinicians to remember that eating disorders also occur in older persons. For example, in one Austrian study, Mangweth-Matzek et al. (Int J Eat Disord. 2014; 47:320) reported a prevalence of 4.6% of eating disorders in a group of 715 women 40 to 60 years of age. While none of the women currently could be diagnosed with AN, 1.4% had BN, 1.5% had BED, and 1.7% had EDNOS. In a more recent study (Int J Eat Disord. 2017; 50:793), there was a prevalence of EDs of 3.6% in a group of 342 women 65 to 94 years of age. The prevalence in 5658 women aged 40 to 50 years in a study in the United Kingdom was also 3.6% (BMC Med. 2017; 15:12). Dr. Hoek pointed out that EDs are still overlooked in older persons and new-onset AN is rare among older women. And, as for EDs in older men, prevalence rates have ranged from 0.02% to 1.5%, he said. In one questionnaire-based study of 470 Austrian men, the incidence of ED symptoms was 6.8% (Int J Eat Disord. 2016; 49:953).
BED and Other Specified Feeding or Eating Disorder (OSFED) are common among older women, he said. Sadly, Dr. Hoek noted, very few of these women receive treatment during their lifespan. He added, “What is also now known is that there is a higher risk of developing an eating disorder during times of life transition, such as adolescence, menopause or andropause, times when age-related changes can affect self-worth and body acceptance, and can also produce medical issues.”
Improving Understanding and Treatment of Atypical Presentations of EDs
The final speaker on the panel, Pamela Keel, PhD, Professor of Psychology at Florida State University, Tallahassee, explored ways in which atypical presentations of eating disorders can be better understood and treated. She also spotlighted the RDoC project (http://www.nimh.nih.gov/research-funding/rdoc/nimh-research-domain-criteria-rdoc.shtml ), which integrates many levels of information, from genomics to self-reports.
Dr. Keel said that in sociodemographic groups who are subjected to the greatest pressure to adhere to a thin ideal in obesogenic environments, EDs will be characterized by an intense fear of fatness, and this psychopathology must be understood and treated. However, such fears are not meaningful in other sociodemographic groups not preoccupied by weight and shape. Instead, a patient’s distress may center on choking (ARFID), gastrointestinal symptoms (AN in non-Western cultures) or inability to control eating (BED), all situations that are meaningful to an individual within their cultural context.
Dr. Keel echoed the contribution of key clinical skills that Dr. Kreipe had stressed earlier, including understanding heuristics (mental “rules of thumb” based on experience) and biases, and listening to patients because their symptoms are real, not imaginary. She said, “When we require patients to conform to an experience of illness they do not have, we misunderstand them.” She also pointed out ways that heuristics can influence the way EDs are viewed. For example, when young and very thin women restrict their food because they wish to be thin, clinicians may only detect AN in those who fit the stereotype. BED is also a good example of this trend, she said. An example of this is when a clinician does not emphasize the stereotype of preoccupation with weight loss and fear of fat, it becomes clear that BED affects proportionately more men, a proportionately older population, and more ethnic/minorities. ARFID affects proportionately more boys and a proportionally younger population.
Dr. Keel reiterated that “We see eating disorders in all racial, ethnic, gender, age, and socioeconomic groups. No one is immune, and no two people have exactly the same eating disorder,” she added. Finally, Dr. Keel said, “We face several challenges in eliminating these debilitating illnesses, and some of these challenges are internally imposed.”