conoscere e ri-conoscere i disturbi del comportamento

CONOSCERE E RI-CONOSCERE
I DISTURBI DEL COMPORTAMENTO ALIMENTARE
NELL'INFANZIA E NELL'ADOLESCENZA
PARMA 18 SETTEMBRE 2015
IN VOLO
RESIDENZA SOCIO RIABILITATIVA ACCREDITATA PER DCA
VIA I MAGGIO,8 PELLEGRINO P.SE
CONTATTI:
TEL 0524594927
FAX 0524594607
EMAIL [email protected]
SITO www.involodca.it
INFO RESIDENZA 3931549740
INFO CONSULENZE 05211562148
Residential ED rehabilitation
in young patients: rationale and
effectiveness
Dr. Monica Baiano M.D., PhD
Psychiatrist
Center for Eating and Weight Disorders,
Portogruaro (Ve), Italy
ED in adolescents:
problematic nodes
for treatment
interventions
3
1. Early diagnosis and treatment
4
Espie and Eisler, Adolescent Health, Medicine and Therapeutics 2015; 6: 9-16
2. Novel clinical features
Stice et al.,
118(3):587-597
J
Abnorm
Psychol
2009;
Hopwood et al., Compr Psychiatry
2010; 51(6): 585-591
Neumark-Sztainer et al., J Am Diet Assoc 2011; 111(7): 1004-1011
5
3. Body weight history
4. ED derivability and development
N
%
AOR
Nessun
disturbo
34
3.1
1.00
MDD
10
20.0
5.92
2.61-15.33
GAD
7
4.3
4.67
1.75-15.59
CD
4
2.9
0.48
0.12-1.84
OPD
0
0
-
-
ADHD
1
20.0
1.26
0.18-8.75
4.7
1.51
0.37-6.25
AUD
95%CI
7
Modificato da Shivola et al., Compr Psychiatry 2009; 50(1): 20-25.
5. Psychiatric and behavioral complications
Peebles et al., J Adolesc Health 2011; 48(3): 310-313
Greydanus & Apple, J Multidisc Healthcare 2011;
4: 183-189
8
6. Treatment setting
Who seeks residential treatment?
….for
both ED adolescents
and adults
thein
SF-36
showed average
•Inpatients
treatment
of AN
adolescents
does
population
scores for the physical
butanorexic
very low mental
scores…
not significantly
modifyscale
core
thoughts
and perceptions. This may explain high relapse
rates.
Twohig et al., Eat Dis 2015; 23 (1): 1-14
•Changes in core psychopathology
may be
crucial for recovery and prevention of
recurrences in adolescents
Fenning et al., 2015 Early Interv Psychiatry doi 10.111
Madden et al., Psychological Medicine 2015; 45: 415-427
9
7. Best treatment choices
Pharmachological management
AN
BN
BED
SSRI/NRI
Ongoingtherefore
studies ?
should
also
be? viewed
and
incorporated
SGA
Ongoing studies ? as one?
component
of a ?
CBT
?
?
multidisciplinary
IPT
?
?
?
comprehensive treatment plan
FBT
“strong research Partial research
?
support”
(APA)
support
for specific
requirements
Van den
& Jordaan,
J Child
Adolesc
Ment
Health 2014;
FBTHeuvel
is the only
well established
treatment
for AD
adolescents
(Lock,26(2):
J
Clin Child Adolesc Psychol 2015: 44(5):707-721
125-137
10
Modificato da Brown & Keel, Substance Abuse:
research and treatment 2012; 6: 33-61
Rehabilitation in ED:
talking points
11
1. Developing an individualized treatment plan
Level 4: Residential treatment center
• •Medical
To our
knowledge,
few
studies
status with no need of intravenous fluids, NTF, multiple day
lab
tasting
exploring
the clinical effectiveness of
•Suicidal
behavior: inpatient
monitoring
and treatment may
be
residential
treatment
programs
in
ED
needed depending on the estimated level of risk
haveasbeen
•Weight
< 85% ofconducted.
healthy body weight:
•Poor-to-fair motivation to recover, intrusive thoughts, cooperation
influenced by highly structured programs
•Co-occurring psychiatric disorders
•Structure needed to gain weight
•Constant meal supervision
•Require help and support as well as use cognitive-behavioral skills
to avoid purging
•Environmental stress (unsupportive or conflictual family)
•Geographical distance
APA Guidelines
2. A possible answer to unmet needs:
the RPPTM model
COOPERATION
MINDFULLNESS
MOTIVATION
THERAPEUTIC
ALLIANCE
3. RPPTM : philosophy
• Specialized multidisciplinary
team treating ED and
comorbid psychiatric
disorders
• Evidence-based treatment +
continuous outcome
monitoring
• Favorable cost/effectiveness
ratio
• Care - continuum model
• To avoid/prevent
hospitalization especially in
paediatric subjects
4. RPPTM : specific goals
• Weight restoration
• Control or remove
weight and food
phobias
• Body acceptance
• Enhance motivation
to change
• Self-discipline of
bingeing/purging
• Prevention of body weight
fluctuations
• Development of awareness
regarding thought patterns
and emotional
dysregulation sustaining
abnormal eating behaviors
Stepped and targeted refeeding strategies
(assisted Flexible
meals, staffprotocol
supervision in the
kitchen)
Tolerance of periods
of weight
+
maintenance
Psychotherapeutic and psychosocial
interventions
Initial abstention
+ from eating
fearful foods
Pharmachological treatment when necessary
+
Gradual increase of caloric
Constant monitoring of physical status
intake and experience of new
foods
Increased exposure and responsibility
(preparation of meals, outside snacking,
spending time at home)
5. RPPTM : admission criteria to intensive
residential/hemiresidential treatment program
The RPP™ program was applied to outpatients referring to our
outpatient service after a close assessment of clinical and
psychopathological conditions
Exclusion criteria
• Severe physical
complications (i.e.: serum
potassium levels < 2.0
mEq/L, very low BP <
60/30 mmHg)
• Life-threatening
behaviours (i.e.
reiterative self-harming,
suicide attempts) or acute
comorbid psychiatric
condition requiring
hospitalization
RPP™ outcomes in a sample of
adolescents admitted to the
residential facility “Casa delle
Farfalle”
18
2007-2015
Tot 108
DCA diagnosis
EDNOS
BN
M/F: 6/102
BED 0,93%
AN sub t ype
n=1
9,26%
n=10
12,96%
n=14
76,85%
n=83
AN
19
Year s
20
7,41%
n=8
3,70%
n=4
discharge
ordinary
self-discharge
discharge for other reasons
88,89%
n=96
21
Clinical features
AN (83)
BN (14)
EDNOS (10)
Statistics
p
Age at
onset
13.53 1.52
14.15 1.07
14.90 1.10
Χ2=8.66
0.013
Age at
admission
15.26 1.41
16.15 0.90
16.40 0.84
Χ2=11.83
0.003
Lenght of
illness
1.74 1.31
2.00 1.08
1.50 1.08
Χ2=2.01
0.365
Lenght of
stay
117.43 65.02
86.08 69.69
99.50 30.18
F=1.047
0.375
§Kruskal-Wallis test, with α set at p<0.05
22
*one-way ANOVA, with α set at p<0.05
Neuropsychiatric records
Psychiatric comorbidity at
admission
pd_type * DCA code Crosstabulation
Count
Count
AN
pd_type schizoid
schizotypal
histrionic
narcissistic
borderline
OC
nos and mixed disorders
Total
13
0
7
2
2
2
3
29
DCA code
BN
EDNOS
BED
Total AN
3
0
1no
17 32
0
1
0yes
1 48
0
1Total
0
8 80
2
0
0
4
3
1
0
6
0
0
0
2
0
0
0
3
8
3
1
41
DCA code
BN
EDNOS
3
2
11
8
14
10
BED
Total
0
1
1
37
68
105
Depressive disorder
Personality disorder
23
Self-harm behaviors
Case Processing Summary
N
self-harm * psichiatric
comorbidity
Valid
Percent
75
69,4%
Cases
Missing
N
Percent
33
30,6%
Total
N
Percent
108
100,0%
self-harm * psichiatric comorbidity Crosstabulation
type SH * DCA code Crosstabulation
Count
self-harm
Total
Count
no
yes
psychiatric comorbidity
no
yes
24
34
1
16
25
50
Total
type
SH
Total
AN
self scratching/ cutting
58
suicide attempt
17
75
5
1
6
DCA code
BN
2
0
2
EDNOS
2
0
2
Total
9
1
10
25
Within group analyses:
BMI trend
BMI trend AN
Wilcoxon’s Test: Z=-7.50 p<0.001
19
18,5
18
17,5
17
16,5
16
15,5
15
14,5
14
BMI_T0
BMI_T1
BMI trend BN
Paired Sample T Test: t=-1.22 p=0.248
22,50
22,00
21,50
21,00
20,50
BMI_T0
BMI EDNOS
Wilcoxon’s Test: Z=-1.43 p=0.153
22
21,5
21
20,5
20
BMI_T0
BMI_T1
BMI_T1
Within group analyses: caloric intake trend
AN
Paired Sam ples Statistics
Pair
1
KcalT0
KcalT2
Mean
1426,2429
1997,7143
N
Std. Deviation
382,86186
305,59124
70
70
Std. Error
Mean
45,76074
36,52514
T test: p<0.001
2500
2000
1500
Kcal T0
1000
Kcal T1
500
0
Kcal T0
BN
Kcal T1
Paired Samples Statistics
T test: p=0.089
1800
1750
1700
1650
1600
1550
1500
Pair
1
Kcal T0
Kcal T0
Kcal T2
Mean
1608,18
1760,9091
Kcal T0
Kcal T2
Mean
1437,14
1900,0000
11
11
Std. Deviation
362,762
283,17678
Kcal T1
EDNOS
Paired Samples Statistics
Pair
1
N
N
7
7
Std. Deviation
359,013
211,89620
Std. Error
Mean
135,694
80,08924
T test: p=0.018
2000
1500
1000
500
0
Kcal T0
Kcal T1
Std. Error
Mean
109,377
85,38101
Menstrual cycle at admission
primary amenorrhea
3,13%
irregular menses/spotting
n=2
1,56% no data
n=1
15,63%
n=10
6,25% regular menses
n=4
73,44%
n=47
Menstrual cycle at discharge
secondary amenorrhea
primary amenorrhea
5,33% irregular menses/spotting
n=4
13,33%
n=10
4,00% no data
n=3
22,67%
n=17
regular menses
54,67%
n=41
secondary amenorrhea
Within group analyses:
EDI-2
EDI AN
Wilcoxon’s: all p<0.001
14,00
12,00
10,00
Surviving Bonferroni’s
8,00
T0
6,00
T1
4,00
2,00
EDI-2 BN
0,00
Wilcoxon’s: all p<0.05
DT
22,00
20,00
18,00
16,00
14,00
12,00
10,00
8,00
6,00
4,00
2,00
0,00
BU
BD
IN
P
IS
A
MF ASC IM
SI
Not surviving Bonferroni’s
T0
T1
EDI-2 EDNOS
All Wilcoxon’s but * (paired T test)
DT
BU
BD
IN
P
IS
A
MF ASC IM
Not surviving Bonferroni’s
SI
16,00
14,00
12,00
10,00
8,00
6,00
4,00
2,00
0,00
T0
T1
*
*
DT BU BD
IN
P
IS
A
MF ASC IM
SI
Within group analyses: SCL-90
SCL-90 AN
Surviving Bonferroni’s
Wilcoxon’s: all p<0.001
2
1,5
Wilcoxon’s: all p<0.001
T0
1
T1
0,5
0
SOM OC
IS
DEP ANX
AH
PHO PAR
PSY SLE
GSI
SCL90 BN
All p <0.05, only
Bonferroni’s
All paired T test but * (Wilcoxon’s)
surviving
2,50
2,00
1,50
1,00
0,50
0,00
T0
T1
*
SOM OC
INS
*
DEP ANX
AH
*
*
PHO PAR PSY SLE
GSI
SCL90 EDNOS
2,50
2,00
1,50
1,00
0,50
0,00
All paired T test but * (Wilcoxon’s)
T0
T1
* INS
*
SOM OC
DEP ANX
AH
*
*
PHO PAR PSY SLE
GSI
p <0.05, but not surviving
Bonferroni’s
Take home messages:
Intensive RPP™ delivered in
residential/hemiresidential setting:
a) reduces core ED psychopathology,
b) reduces general psychiatric
symptomatology
c) Induces weight recovery/stabilization
especially in AN patients
31
Take home messages:
d) Treating adolescent ED patients in a
highly specialized ED unit admitting
also adult patients can be an effective
treatment setting
Naab et al., Eat Weight Disord 2013; 18(2): 167-173
e) Day programs can assist in weight and
psychological restoration in
adolescents
Green et al., Australas Psychiatry 2015; 23(3):249-253
32
Grazie a voi per l’attenzione
e
grazie a tutti i colleghi del DCAP per il
loro costante, paziente lavoro
34