FAMILY EDUCATION SERIES - Clementine Programs€¦ · •GERD / dyspepsia / PUD •Gluten...

FAMILY EDUCATION SERIES

o Eating Disorders Overviewo What Has to Be Addressed and Why: An Overviewo Levels and the Continuum of Careo Nutrition Overviewo Medical Overviewo Psychiatry Overviewo Traits, Temperament and Vulnerabilityo The Role of the Family in Treatment and Recoveryo Communication and Connectiono What Do We Do When …? Managing Behaviorso What Do We Do When …? Managing Emotions

FAMILY EDUCATION SERIES OUTLINE

SOUTH MIAMI, FL | PORTLAND, OR | BRIARCLIFF MANOR, NY

Medications used in the Treatment of Eating Disorders

o Introductiono Psychiatric symptoms and psychiatric disorders

often seen in patients with eating disordersoAnxietyoDepressionoCognitive flexibility / set-shiftingoRuminating thoughtso Substance abuseoMood lability

OVERVIEW


o Myths regarding psychotropic medicationso Psychotropic medications in the treatment of eating

disorderso Anorexia Nervosa (AN)

oAlterations in neurotransmitters due to malnutrition

oUse of atypical antipsychotic medications in the treatment of AN• Rationale for use / mechanism of action• Target symptoms• Examples

OVERVIEW


o Bulimia Nervosa (BN) & Binge Eating Disorder (BED)oMedications used to treat BN and BEDoSSRI’s• Target symptoms• Examples

oAntiepileptic drugs / “mood stabilizers”• Target symptoms• Examples

OVERVIEW


o Bulimia Nervosa (BN) & Binge Eating Disorder (BED)oMedications used to treat BN and BED

(continued)oOther “atypical” antidepressants• Target symptoms• Examples

oStimulants• Target symptoms• Examples

OVERVIEW


o Medications used to treat insomniaoTarget symptomsoExamples

OVERVIEW


Introduction

o Complex illnesseso Combination of medical and psychological issueso Patients not always happy about being in treatmento Patients often have difficulty trusting treatment providerso Inherent to the disorder

o Psychiatric comorbid illnesses • Depression• Anxiety• Obsessive-compulsive disorder• Bipolar disorder• Substance abuse

o Medical comorbid illnesses• Diabetes• IBS• GERD / dyspepsia / PUD• Gluten enteropathy• Polycystic ovary syndrome

EATING DISORDERS


o Detectiono Denial and resistanceo Ego syntonic symptoms

o Eating disorder symptoms feel “normal” and don’t feel “foreign” to patients

o Medical dangers, including mortality risko Untreated Anorexia Nervosa has mortality rate of 20%

o Legal and financial barriers to treatmento Frequent relapse after hospitalizationo Complex interplay of medical and psychiatric symptomso Inherent tendency of healthcare providers and insurance

carriers to classify symptoms as purely medical or psychiatric symptoms

CHALLENGES OF EATING DISORDERS


Psychiatric Symptoms and Disorders often seen in

Patients with Eating Disorders

o Comorbidity of eating disorderso Anxiety (23 - 75%)oMood disorders (14.3 - 55.2 %)o Suicidal ideation (31 - 57%)o Suicidal attempts (3.1 - 17%)o Substance abuse (alcohol: 19.8 - 35.5%)o Personality disorders (increased severity of symptoms with

BPD, and increased risk of AN in OCD PD)

EATING DISORDERS AND PSYCHIATRIC COMORBIDITY


Buhren et al Eur Eat Disorder Review 2014; Swinbourne et al. Aust NZ J Psych. Feb 2012; Kaye et.al. Americal J Psych. Dec 2004Root et al. Int. J Eat Disorders Jan 2010; Reas et al. Int. J Eat Disorders 2013; Rowe et al. Aust NZ J Psych. 2008

Psychiatric Symptoms inAnorexia Nervosa

o Cognitive flexibility or set-shiftingo Neurocognitive concept refers to ability to switch

between tasks and behaviors with flexibilityo The mental ability to change behavior in relation to

changing rules and demands o Several studies found adults with Anorexia Nervosa

have set-shifting deficits in that they tend to perseverate on previously applicable rules

o Such findings are consistent with clinical observation that these patients tend to be cognitively rigid and persistent

DIFFICULTY WITH COGNITIVE FLEXIBILITY / SET-SHIFTING


o APA criteria for level of careo Residential treatment: patient preoccupied with

intrusive, repetitive thoughts four to six hours a dayo Rumination is one of several forms of repetitive thinkingo Rumination

o Mode of responding to distress that involves repetitively and passively focusing on symptoms of distress and possible causes and consequences of symptoms

o Research suggests rumination is a particularly detrimental form of repetitive thinking, as it has been found to predict anxiety, binge eating, binge drinking, self-injury and especially depression

RUMINATING THOUGHTS


o Psychopathology happens when there is an inability to control or shut off ruminations

o Studies indicate ruminations of all types are generally associated with increased sustained amygdala activity

o When controlling for amygdala activity, distinct activity patterns in hippocampus were also associated with specific dimensions of rumination

RUMINATING THOUGHTS


AMYGDALA AND HIPPOCAMPUS


Psychiatric Symptoms inBulimia Nervosa

and Binge Eating Disorder

o Mood swingso Bipolar Io Bipolar IIo Borderline Personality Disordero Post substance use

o IrritabilityoDepressiono Bipolaro Borderline Personality Disordero Post substance use

MOOD LABILITY


Myths Regarding Psychotropic Medications

o “It will change who I am, I will be a zombie”o “I will have to take it forever”o “Uncle Henry took it and that is when he really

became crazy”o “Once I take it and stop, the depression will come back

because I have taken something now. My body will bedifferent and I will need to take it forever”

o “Psychiatric meds make you fat”

MYTHS REGARDING MEDICATION


o “My daughter is really smart and determined, she can do it on her own … our family does not need to do things the easy way … we come from a long line of success and have strong genes … we don’t need medications”

o “She is too young for medication … it is bad for her brain”

o “Eating disorders are not real illnesses that need medication, we both know all she has to do is eat”

o “Antipsychotics! She’s not crazy, that is way too strongfor her and doesn’t it have side effects?”

MYTHS REGARDING MEDICATION


o Psychotropic medications typically work on one of the three monoamine neurotransmitter systems that help regulate moodo Dopamineo Norepinephrineo Serotonin

o Psychiatric disorders and, to a large degree, response to medications are often highly genetico High probability medications that work for your family

members will also work for you (why we take a comprehensive family history)

o We can also use genesight testing (genetic testing that identifies genetic changes in liver enzymes which play a role in drug metabolism; gives a profile of medications you will likely respond to)

WHAT ARE THE FACTS?


o Psychotropic medications are meant to correct the imbalance that has occurred in the neurotransmitter system and should not in any way “change your personality” or “not make you feel like yourself ”

o Once you are on the correct medication and dosage you should “feel like yourself again”

o If you stop taking a medication you will not get depressed just because you “went off ” of the medication and your body went into “withdrawal”

o Taking medication is a choice. Clinicians can provide the facts and clinical expertise, but choosing to take medication is up to the patient and parents (just as in the case of taking medication for diabetes)

WHAT ARE THE FACTS?


o Once you start a medication, it is recommended to continue that medication for six months to one year. After that time period, an evaluation can be completed to see if further treatment is indicated

o Will I need the medication again?o Statistics in depression (adults)

o50% recurrence rate after first depressive episodeo70% secondo90% third

WHAT ARE THE FACTS?


Psychotropic Medications inTreatment of Anorexia Nervosa

o Target symptoms for medicationo Improve cognitive flexibility/set-shiftingoDecrease eating disorder ruminationsoDecrease the pathological focus on weight and food oDecrease obsessive-compulsive symptomso Reduce agitation

o Note: paradoxically in AN, atypical antipsychotics are not particularly useful in weight restoration (the doses we use are too low to promote weight gain)

ANOREXIA NERVOSA (AN)


o Aripiprazole (abilify)o Mechanism of action

oAripiprazole is a partial agonist at D2 receptorsoLowering dopaminergic neurotransmission in the

mesolimbic pathway (decreases ruminations / delusions)oEnhancing dopaminergic activity in the mesocortical

pathway (improves cognitive symptoms)oLower risk of extrapyramidal symptoms (EPS) and

hyperprolactinemia than other antipsychoticso Target symptoms

o Ruminating thoughts, cognitive flexibility, depression

ATYPICAL ANTIPSYCHOTICS


Psychotropic Medications in Treatment of Bulimia Nervosa

and Binge Eating Disorder

o Mechanism of actiono Blocks re-uptake of serotonin at presynaptic neuron, thus

allowing more 5HT to remain in synaptic clefto Target symptoms

o Bingeingo Depression (can also use in anorexia after patients are close to 90%

ideal body weight)o Anxietyo Ruminations

oAt higher doses SSRIs work on obsessions and ruminationsoExample: Fluoxetine (prozac), 80 mg daily

o Examples: Fluoxetine (prozac), Sertraline (zoloft), Escitalopram (lexapro)

SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRIS)


MECHANISM OF SSRIS


o Common side effectsoInsomniaoHeadacheoGI upsetoAnxiety or agitation oSexual dysfunctionoPotential to increase suicidality(?)

SEROTONERGIC SIDE EFFECTS


In October 2004, the Food and Drug Administration (FDA) issued a black-box warning on antidepressants indicating they were associated with increased risk of suicidal thinking, feeling and behavior in young people o Twenty-four trials, containing 4,400 children and adolescentso Nine antidepressants includedo No completed suicides in trialso More youth on a medication spontaneously reported suicidality vs.

youth on placebo (4/100 vs. 2/100)o Included suicidal thoughts and behaviors, but none of these studies

had any completed suicideso Experts questioned FDA analysis because studies they used were not

properly designed to measure suicidality

SSRIS AND BLACK BOX WARNING


o A more recent trial has shown a decrease in the amount of SSRI use has led to an increase in suicide rates in children and adolescents

o FDA mindful of the need to balance small risk associated with antidepressant treatment against its proven benefitso Changed black-box warning in 2007 stating

“depression itself was associated with increased risk of suicide”

o Bottom line: if you are prescribed an antidepressant and in any way feel worse, you should stop taking the medication and call your doctor immediately because this is not an normal response

SSRIS AND BLACK BOX WARNING


o Serotonin syndromeoGreatest risk of serotonin syndrome occurs if

taking two or more drugs and / or supplements together that influence serotonin

oPotential cases: SSRIs, SNRIs, MAOI, Buspar, Trazodone, Triptans, Demerol, Tramadol, Dextromethophran, Reglan, Zofran, St. John’s Wort, illicit drugs (LSD, MDMA, cocaine)

oCondition more likely to occur when you first start a medicine or increase the dose

SEROTONERGIC SIDE EFFECTS


o Mechanism of action: blockade of sodium channelso Acts pre- and post-synapticallyo Pre-synaptically it inhibits release of excitatory

neurotransmitters (glutamate and aspartate)o Post-synaptically it diminishes excitability of neuronso “Calming effect on neurons”

o Target symptomso Mood swings seen with mood disorders, substance use

disorders and borderline personality disorders o Decrease bingeing (i.e. Topiramate (topamax))

o Examples: Lamotrigine (lamictal), Topiramate (topamax)

ANTIEPILEPTIC AGENTS (AED)


o Lamotrigine (lamictal) is useful mood agent in patientso Used for chronically depressed and / or patients with

dysregulated moodo Used for patients with Borderline Personality Disordero Used for patients with Bipolar IIo Tolerated well with little side effects

o Topiramate (topamax) is helpful agent when patient has binge eating and is not doing intuitive eating modelo Stay below 200mg daily to minimize cognitive

effects (i.e. word finding difficulties)

ANTIEPILEPTIC AGENTS CLINICAL PEARLS


o Mechanism of action: norepinephrine and dopamine reuptake inhibitor (NDRI); increases dopamine neurotransmission in both nucleus accumbens and the prefrontal cortex

o Target symptoms: binge eating, depression, smoking cessation, ADHD

o Not appropriate for patients with bulimia due to purging

o Example: Bupropion (wellbutrin), Bupropion XL (wellbutrin XL)

OTHER ANTIDEPRESSANTS: BUPROPION


o Lisdexamfetamine (vyvanse)o Mechanism of action

oLisdexamfetamine is prodrug of dextroamphetamine

oAmphetamines block reuptake of norepinephrine and dopamine in presynaptic neuron and increase amount of active neurotransmitters in synaptic cleft

oDrug has less abuse potential because it is not activated until it reaches the gut

o Target symptoms: ADHD, binge eatingo Example: Lisdexamfetamine (vyvanse)

STIMULANTS


oUse with cautionoHelpful with Binge Eating Disorder and

Bulimia Nervosa due to appetite suppression and decreased tendency to binge oLisdexamfetaime (vyvanse) is preferred

because it has less abuse potential

STIMULANTS


o Start with melatonin and / or valerian rootoTrazodoneoDoxepinoTemazepamoAmbien, lunestao Seroquel

INSOMNIA: SLEEP CHAIN


o Start at low dose, but go as high as needed (children metabolize medications faster than adults)

o Use least amount of medication possibleo Unless patient is in crisis, abstain from doing

medication changes at initial visito Psychoeducation upfront is priority (patient and

family)oInform adolescents of what they will find

when they “google” the medication on the internet

CLINICAL PRINCIPLES


Conclusion

oEating disorders are complicatedoWith advances in neurobiology, we are

understanding more about underlying psychopathology and neurotransmitter abnormalities present in eating disorders

oUsing this information, we use psychotropic agents to better target abnormalities and aid in treatment of these notoriously hard to treat disorders

EATING DISORDERS AND MEDICATION


Clementine Psychiatryo Chief of Psychiatry: Dr. Lauren Ozbolt, MD

o [email protected] Clementine Miami: Dr. Marilyn Peraza, MD

[email protected] Clementine Portland: Dr. Alfredo Velez, MD

o [email protected] Clementine Briarcliff: Dr. Darlene Osipuk, MD

o [email protected]

CONTACT INFORMATION


WE HELP EACH ADOLESCENT

REPLACE THE EATING DISORDER

WITH HEALTHY SKILLS AND A DEEP

UNDERSTANDING OF HOW TO LIVE

A LIFE THAT REFLECTS THEIR

INDIVIDUALITY.

FAMILY EDUCATION SERIES - Clementine Programs€¦ · •GERD / dyspepsia / PUD •Gluten...

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