Eating disorders: Masterclass lecture part I

In Episode 59 Patricia Westmoreland, MD, gives a masterclass lecture on managing severe and enduring eating disorder (SEERS).  Renee Kohanksi, MD, poses the question, "What do we want?" Contact us: podcasts@mdedge.com Twitter: @mdedgepsych  Show Notes By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington. Guest Patricia Westmoreland, MD: forensic psychiatrist at University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; and adjunct assistant professor at University of Colorado Denver in department of psychiatry. Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.   Introduction, definition, role of involuntary treatment, and novel treatment options Introduction: Prognosis: Anorexia nervosa (AN) has the highest mortality of any psychiatric disorder. Risk factors for death: Older age at first presentation, lower weight at presentation, greater duration of illness, comorbid alcohol or diuretic abuse, comorbid mood disorder, history of psychiatric hospitalization and suicide attempts, and self-harm. Less than 50% recover completely, about 30% improve somewhat but require frequent hospitalizations or treatments, and 20% develop a SEED. Eddy et al. longitudinal study of eating disorders (EDs):  AN patients can recover over the long term. Overall, 31% were better at 9 years; 63% better at 22 years of follow-up.  Treatment: Treat ASAP, especially if patient is seen at a young/pediatric age before symptoms are fully developed and weight loss is profound. Weight gain as the central treatment: Many patients are reluctant to get treatment that focuses only on food intake and weight gain. Predictors of improvement: Weight gain that is parallel to improvement in physical and psychological well-being, diagnosis at a younger age, and shorter duration of illness. Medications: Fluoxetine is the only Food and Drug Administration-approved treatment for EDs, including bulimia, at doses of 60 mg and above. Patients with EDs have poor response to selective serotonin reuptake inhibitors because of starvation and limited production of serotonin and serotonin receptor abnormalities.  Severe and enduring eating disorders (SEED) definition:   6-12 years of an ED can qualify as chronic. Lower likelihood of recovery with symptoms substantially interfering with quality of life.  Role for involuntary treatment in EDs: Few treatment centers do involuntary treatment of ED. Involuntary treatment can involve guardianship for medical decisions. Guardianship is useful for medical treatment and admission to a medical ward, for example, when a patient requires forcible tube feeding for life-threatening starvation. Commitment or certification is required for involuntary treatment in a psychiatric hospital. Commitment is sought by a psychiatrist and is a tool in cases when the patient is dangerous to self or others and is gravely disabled. It is useful to commit a patient who is refusing care and has not been sick for long. Often, commitment/certification is used as a last resort, and the patient is too sick to truly recover. Pros and cons of involuntary treatment: Pro: No difference in weight restoration in voluntary vs. involuntary treatment, and patients are often grateful after involuntary treatment. Cons: Involuntary tube feeding has unclear long-term outcomes. Some studies show poor outcomes for people who are treated involuntarily, though this is likely because of their comorbidities.  Novel treatment options: Ketamine has been used in EDs. Concerns remain about the drug’s addictive potential and inability to clearly change eating disorder pathology. Oxytocin: There are reduced cerebrospinal fluid levels of oxytocin in AN, and oxytocin restores during recovery. Experimentally in rats, oxytocin may reduce the fear and social phobias related to eating. Electroconvulsive therapy does not reduce ED symptoms such as restricted eating and fear of fatness, but it can improve depression. People with ED are often medically ill, so the patient must be physically able to undergo treatment. Because of medical comorbidities, AN patients are more likely to have complications like delirium. Transcranial magnetic stimulation: Dorsolateral prefrontal cortex involved in self-regulatory control, inhibitory control, and cognitive flexibility. Some studies show promising results of using this intervention with ED and mild side effects like syncope and headache. Deep brain stimulation (DBS): Treatment targets the nucleus accumbens and the subcallosal cingulate gyrus, which theoretically alter balance between reward and cognitive inhibitory and control systems that are related to pathological eating behaviors. DBS has strongest theoretical rationale in terms of neurocircuitry targets.  References  Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9.  Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37.  Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43. Cushla M. Is resistance (n)ever futile? A response to “Futility in chronic anorexia nervosa: A concept whose time has not yet come,” by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.   In part 2, Dr. Westmoreland will discuss harm reduction, palliative care, and futility.