Eating Disorders and Substance Abuse

1. Eating Disorders and Substance Abuse James M. Greenblatt, M.D. Chief Medical Officer Walden Behavioral Care

3. Anorexia – ALife Threatening Illness • Anorexia Nervosa has the highest mortality rate of any psychiatric disorder. The most common causes of death are complications of starvation and suicide. • The mortality rate at five years is 5%, increasing to 20% at 20 years F/U (APA 2000) • The highest predictor of mortality is?

4. Eating Disorders and Substance Abuse • One of the strongest and most consistent predictors of fatal outcome for patients with Anorexia Nervosa was severity of alcohol abuse during follow-up!

5. The highest rates of suicide attempts are reported among bulimic individuals who have co-morbid alcohol abuse (54%). (Eating Disorders 2002; 10:205)

6. Eating Disorders and Substance Abuse The National Center on Addiction and Substance Abuse (CASA) • between 30 and 50% of individuals with Bulimia Nervosa abuse or are dependent on drugs or alcohol • 12-18% with Anorexia Nervosa abuse or are dependent on drugs or alcohol • compared with 9% of the general population

7. Eating Disorders and Substance Abuse • 35% of people who abuse drugs and alcohol have an eating disorder, compared to 3% of the general population.

8. The lack of awareness and understanding of the link between eating disorders and substance abuse has led to limited treatment options for patients. Despite their high rates of co-occurrence few treatment programs exist that address both eating disorders and substance abuse simultaneously and effectively.

9. Similarities Between ED and SUD • Life Threatening • Chronic Relapsing Course • Long Term • Compulsiveness • Ritualistic Behaviors • Resistant to Treatment • Begin with experimentation; only a small percentage lose control • Lead to chronic compromised nutritional and medical complications

10. DIFFERENCES - CRAVINGS Alcohol/Drugs Driven by the on-going craving to get another drink or drug. Eating Disorders Driven by the need to avoid or overcome the substance (food). Driven by the feeling following binge Driven by the feeling following purge

11. Eating Disorders and Substance Abuse Drugs that Decrease Eating Alcohol Amphetamine Cocaine Diet Pills Caffeine Nicotine Drugs that Increase Eating Marijuana

12. Eating Disorders and Substance Abuse Drugs that Increase Purging • Alcohol • Caffeine • Ipecac • Laxatives • Diuretics

13. While substance abuse and eating disorders have much in common, their treatment is based on very different philosophical approaches.

14. DIFFERENCES – RECOVERY Alcohol/Drugs Restrict or abstain from substance. Abstinence – external imposed structures of control. Eating Disorders Food as ally to sustain life. Inner Strengths with little external controls. CONTROL

15. Treatment of one disorder often leads to exacerbation of the other. Is it not uncommon for patients being treated for bulimia to increase the use of alcohol or drugs as they decrease binging and purging. Likewise, patients might find it harder to curb a binge eating disorder or a restrictive eating disorder after substance abuse treatment.

16. A majority of young woman diet at some point in time yet only a small fraction develop eating disorders. Why?

17. Misplaced Blame • Eating disorders have traditionally been viewed as psychiatric illnesses that are strongly influenced by social pressures towards thinness. • Recent research suggests a substantial influence of genetic factors on the development of an eating disorder. • Family Twin and molecular genetic studies support substantial genetic influences on eating disorders

18. Family Studies • 7 – 12x increase in the prevalence of Anorexia and Bulimia in relatives of eating disorder patients • Personality traits & genetic susceptibility Perfectionistic, Obsessional, Meticulous

19. Twin Studies • 58 – 76% of the variance in the liability to AN and 54 – 83% of the variance in the liability to BN can be accounted for by genetic factors. • No genetic factors in weight preoccupation and eating pathology in 11 year old twins • 52 – 57% variance in eating pathology in 17 year old twins

20. Twin Studies Prevalence, Heretability and Prospective Risk Factors for Anorexia Nervosa 31, 406 twins born between 1935-1958 Arch Gen Psychiatry. 2006;63:305-312

21. Twin Studies

22. Twin Studies • No genetic factors in weight preoccupation and eating pathology in 11 year old twins • 52 – 57% variance in eating pathology in 17 year old twins

23. Twin Studies • 11 year old twins were divided into a pre- and post-pubertal group • Genetic factors accounted for 0% of variance in weight preoccupation and overall eating pathology in pre-pubertal twins • Genetic factors accounted for 26 – 35% of the variance in post-pubertal twins

24. The Genetics of Eating Disorders • Activation of the heritability of eating pathology may be mediated by hormones in puberty. • Cultural attitudes toward thinness have relevance to the psycho-pathology of eating disorder, but they are unlikely to be sufficient to account for the pathogenesis of these disorders

25. Puberty and Onset of Anorexia Nervosa “My childhood was perfection. It was full of vacations and love and family time. Something must have been lacking that no one was aware of. Something must have gone wrong. Maybe it was puberty.”

26. Psychotropic Medication in the Treatment of Eating Disorders

27. Comorbidity of Anorexia Nervosa • The lifetime rates of psychiatric comorbidity among patients with Anorexia are approximately 80% • Affective disorders • Anxiety Disorder • Substance Abuse • ADHD • Personality Disorder

28. Comorbidity of Bulimia Nervosa • The lifetime rates of psychiatric comorbidity among patients with Bulimia are approximately 83%

29. Bulimia Nervosa: A Chronic Persistent Illness Approximately 50% of bulimic patients including those who have been treated continue to show eating disorder features on long term follow up.

30. Treatment Recommendations • Antidepressants: SSRI’s: Higher than “usual” antidepressant dosage may be required. - Prozac 60mg/day considerably more effective than 20mg/day for reducing binge eating behavior and vomiting frequency. - Celexa 40-60mg, Zoloft 100 – 200 mg. - The only medicine approved by the FDA for BN is Fluoxetine.

31. Binge Eating Disorder – Pharmacologic Treatment Celexa 40-60 mg x 6 weeks Prozac 40-80 mg x 6 weeks Luvox 100-300 mg x 9 weeks Zoloft 100-200 mg x 6 weeks All medication resulted in significant reduction in binge eating and body weight.

32. Augmenting Agents • Antidepressants alone rarely lead to complete remission of Bulimic symptoms. 1. T3 2. Topamax 3. Lithium 4. Naltrexone 5. Ondonsetron – (Zofran) 6. Inositol 7. Strattera

33. Psychopharmacology of Anorexia Nervosa

34. Psychopharmacology – Anorexia Nervosa Antidepressants • Controlled studies have failed to demonstrate any advantage to adding an SSRI to nutritional and psychosocial interventions in the treatment of malnourished patients with AN

35. A retrospective study of SSRI treatment in adolescent Anorexia nervosa: insufficient evidence for efficacyK. Holtkamp, K. Konrad, N. Kaiser, Y. Ploenes, N. Heussen, I. Grzella, B. Herpertz-Dahlmann In conclusion, our results challenge the efficacy of SSRI medication in the treatment of eating disorder psychopathology as well as depressive and obsessive-compulsive comorbidity in adolescent AN. Clinicians should be chary in prescribing SSRI in adolescent AN unless randomized controlled trials have proofed the benefit of these drugs. Journal of Psychiatric Research 39 (2005) 303-310

36. Fluoxetine After Weight Restoration in Anorexia Nervosa A Randomized Controlled Trial This study failed to demonstrate any benefit from fluoxetine in the treatment of patients with Anorexia Nervosa following weight restoration. Future efforts should focus on developing new models to understand the persistence of this illness and on exploring new psychological and pharmacological treatment approaches. JAMA. 2006; 295:2605-2612

37. Anorexia? • Delusions – a rigid system of beliefs with which a person is preoccupied and to which the person firmly holds, despite the logical absurdity of the beliefs and a lack of supporting evidence... - a fixed false belief

38. Anorexia • Is Anorexia Nervosa a Psychotic Disorder? - Patients believe they are overweight when they are dramatically under weight - Misperceptions about body size and shape - “ED Voice” telling patients not to eat

40. A New Model Referenced EEG

41. The Referenced EEG • A patient’s pretreatment QEEG data is obtained and statistically compared with similar QEEG data from patients with known medication responsivity. • The result is a prediction of the patient’s likely responsivity to particular medications. • This, in turn, informs the treatment strategy for the patient.

42. The rEEG Conjecture • Resting EEG is stable • (abundant literature references support this) • Resting EEG Changes with Medications • (Abundant literature references support this) • Use Medications to normalize the EEG • (CNSR proprietary rEEG technology) • Normalized EEG leads to normalized behavior • (CNSR clinical results)

43. Case Two: Noelle R. Anorexia Nervosa, Bipolar Disorder, Posttraumatic Stress Disorder, Alcohol Abuse • I: History: • 33 year old female with a 20 year history of an eating disorder and compulsive exercising • Onset occurred after a sexual trauma in teen years • Flashbacks, hypervigilance, nightmares, mood lability • Bingeing and purging from 9am to 2pm daily and then from 2pm until 6pm she will consume alcohol. Cocaine use, drinks 1 pint of vodka per day. • Hospitalizations: 5 inpatient eating disorder admissions • II: Past Medication Trials: • Ativan, , Effexor XR, Klonopin, Lexapro, Neurontin, Prozac, Topomax, Trileptal, Seroquel, Lithium, Zoloft, Risperdal, Xanax, Zyprexa • III: Reference EEG Medication Prediction: • Anticonvulsant, Antidepressant and Stimulant combination • Prescribed • Dexedrine, Neurontin, Prozac • IV: Response: • Free of Eating Disorder behavior for first time in 20 years • Patient engaging voluntarily in outpatient treatment • No mood swings • No cravings for alcohol

45. Treatment Options There are no research studies to support an optimal treatment program for patients with substance abuse and co-morbid eating disorders.

46. A multidisciplinary approach has to recognize that eating disorders and co-morbid substance abuse are complex and require: • Integrated, concurrent medical, nutritional and psychiatric treatment. • A combination of different types of therapy, including group therapy, family therapy, individual counseling, dialectal behavioral therapy (DBT) and other methods of treatment. • Treatment of co-morbidities. Co-morbidities exist more often than not. They should be assumed to exist until absence can be demonstrated. • Changing treatment as the patient progresses. • Continuum of Care

47. Aggressive treatment is crucial as these disorders affect children and young adolescents when they are most vulnerable, quickly destroying their foundation for psychological development.

48. Thank You Thank You