Predittori di Esito della terapia Cognitivo-Comportamentale dei Disturbi dell Alimentazione

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1 Predittori di Esito della terapia Cognitivo-Comportamentale dei Disturbi dell Alimentazione Valdo Ricca SODc Psichiatria Azienda Ospedaliero-Universitaria Careggi Università degli Studi di Firenze Portogruaro, Maggio 2015

2 Disturbi dell Alimentazione: impatto Popolazione età superiore ai 14 anni la prevalenza lifetime dei Disturbi del Comportamento Alimentare è 1.32%. Esordio in età giovanile Alto rischio di cronicizzazione Gravi conseguenze mediche Elevato tasso di ospedalizzazione Tasso di mortalità più elevato di qualsiasi disturbo psichiatrico

3 Disturbi dell Alimentazione: esito a lungo termine

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7 Why such wide variability? Due to sample size, type of therapy, treatment history, concurrent treatments, symptom duration and severity (Jarman and Walsh 1999), but most of all to definition of outcome chosen by researchers and length of time from post-treatment to follow-up.

8 What is remission/recovery? Biological parameters (e.g. weight and menses for AN) (Morgan & Russell, 1975; Wagner et al., 2006), Biological parameters and behavioural indices of remission, such as absence of binge eating, compensatory behaviours and restrictive eating (e.g. Bulik et al., 2000; Bachner- Melman, Zohar, & Ebstein, 2006; Noordenbos & Seubring, 2006; Noordenbos, 2011) Psychological, emotional and social criteria are also relevant (Noordenbos, 2011). Patients see themselves as recovered when they can handle thoughts and feelings without resorting to eating-disordered behaviour (Björk & Ahlström, 2008) or when they improve their self-esteem and display a positive body attitude (Noordenbos & Seubring, 2006).

9 Eating cognitions and behaviors and body image measures: Fully recovered= controls Fully recovered partially recovered and active ED Partially recovered = active ED. Weight, shape, and eating concerns persisted altered in those patients who were considered only biologically and behaviourally but not cognitively remitted

10 Garner DM, Vitousek K, Pike KM: Cognitive behavioral therapy for anorexia nervosa. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of treatment for eating disorders (2nd ed., Chichester, England: Wiley, 1997, pp Pike KM, Loeb K, Vitousek K: Cognitive behavioral therapy for anorexia nervosa and bulimia nervosa. In: Body Image, Eating Disorders, and Obesity: An integrative Guide to assessment and treatment. Thompson JK (Ed), Washington, DC, American Psychological Association, 1996, pp

11 Fairburn, C.G.,Marcus,M.D.,&Wilson,G.T.(1993). Cognitive-behavioral therapyfor binge eating and bulimia nervosa:a comprehensive treatment manual. In: C.G. Fairburn &G.T.Wilson(Eds.), Binge eating:nature,assessment and treatment (pp ). NewYork,NY:GuilfordPress.

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13 EXTENDED THEORY (Fairburn et al, 2003) Certain external maintaining mechanisms operate in subgroups of patients and these are barriers to change Four sets of mechanisms appear to be especially important mood intolerance clinical perfectionism core low self-esteem interpersonal difficulties Predicted that the successful addressing of these mechanisms should improve outcome The broad form of CBT-E is based on this theory

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15 .Cognitive behavioral therapy is the most frequently tested individual treatment for Eating Disorders. CBT for BN and BED: Grade A Anorexia Nervosa: No recommendations

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22 Possibili predittori di esito nell Anoressia Nervosa - età d esordio - età di inizio trattamento - storia di un precedente DCA - fattori genetici - comorbidità psichiatrica (asse I e asse II) - durata di malattia - storia del peso - distorsioni sul peso corporeo - distorsioni sulla forma corporea

23 Possibili predittori di esito nella Bulimia Nervosa - età d esordio - età di inizio trattamento -storia di un precedente DCA -familiarità -eventi traumatici -gravità di dissociazione e impulsività -comorbidità psichiatrica (asse I e asse II) -durata di malattia -BMI all esordio

24 Possibili predittori di esito nel BED Anthropometric measures BMI Body composition Anamnestic variables Age at onset Overweight during childhood Previous use of amphetamines Number of diet attempts Eating Psychopathology Restraint Concerns about eating, weight and body shape Emotional Eating Psychiatric Comorbidities Mood Disorders Anxiety Disorders Axis II

25 Perché le terapie funzionano solo in una parte dei pazienti? Quali caratteristiche rendono alcuni pazienti refrattari alla terapia?

26 Moderatori: Indicano per chi e in quali circostanze i trattamenti sono più o meno efficaci Mediatori: Individuano come e perchè i trattamenti sono più o meno efficaci

27 Moderatori: Indicano per chi e in quali circostanze il trattamento è più o meno efficace Mediatori: Individuano i meccanismi attaverso I quali i trattamenti sono più o meno efficaci Precedono il trattamento Non sono correlati ad esso Spiegano in senso statistico le differenze individuali nella risposta al trattamento Sono una conseguenza del trattamento Correlano con il trattamento Spiegano in senso statistico alcuni degli effetti del trattamento sull esito del disturbo Vengono modificati durante il periodo di trattamento

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31 Lockwood et al 2012 No correlation between weight gain and age, initial BMI, eating attitudes More severe restraint and shape concerns, and higher levels of anxiety and phobic anxiety are associated with lower levels of weight change Because I did not eat that meal, I am not about to lose control Because I can only keep my weight low if I starve, I am vulnerable to gaining huge amounts of weight if I eat anything at all, and other people are pushing me to eat

32 Aim: To evaluate the effectiveness of individual CBT and the possible predictors of outcome in outpatients suffering from threshold and subthreshold AN (s-an) Methods: 53 subjects with AN (27.48±10.3 ys) and 50 with s-an (all DSM-IV criteria except amenorrhea or underweight) (29.86±8.93 ys) - at the beginning (T0) and at the end of treatment (T1), and 3 years after the end of treatment (T2) -face-to-face clinical interview and by self-reported questionnaires (EDEQ, BUT, SCL-90,STAI) -Outcomes: (1) Recovery (evaluated at T1 and T2). Not fulfilling criteria for any DSM-IV diagnosis of ED (including EDNOS) (2) Treatment resistance (evaluated at T1). Absence of a diagnostic change or s-an AN (3) Change in ED diagnosis (evaluated at T1 and T2). Diagnostic crossover.

33 Treatment resistance at the end of treatment: - High levels of EDE-Q shape concern and restricting subtype at baseline. Recovery at 3 years follow-up: - Low levels of EDE-Q shape concern and BUT GSI scores at baseline.

34 Reduction of Shape Concern (%) Reduction of Shape Concern (%) Mediators of weight gain Baseline end of treatment End of treatment Follow up BMI increase (%) R square = 0.18; p<0.01 BMI increase (%) R square = 0.14; p<0.01

35 Aims: 1. To evaluate the psychological and psychopathological features of remitted AN subjects 6 years after the end of a CBT 2. To identify the predictors of remission. Methods: AN subjects (97 ANR, 37 ANBP) - evaluated at baseline, at the end of treatment, 3 and 6 years after the end of treatment. Response to treatment: Full remission, partial remission, active ED (according to DSM IV criteria) Full response: BMI >18.5 and a minimal residual eating disorder psychopathology, defined as having a global EDE-Q score below 1 SD above the community mean global score 1.52 (1.25 SD) (Mond et al., 2006; Bardone-Cone et al., 2010).

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37 Changes in ED psychopathology across different time points

38 Is CBT different in Bn and Bed? Fairburn, C.G.,Marcus,M.D.,&Wilson,G.T.(1993). Cognitive-behavioral therapyfor binge eating and bulimia nervosa:a comprehensive treatment manual. In: C.G. Fairburn &G.T.Wilson(Eds.), Binge eating:nature,assessment and treatment (pp ). NewYork,NY:GuilfordPress.

39 Hypothesis: Eating core psychopathology, impulsivity and mood modulatory mechanisms would show a different pattern of association between BN and BED patients, and could act as different moderators of treatment effects in the two syndromes. Aims: To evaluate the effects of different sociodemographic and clinical variables on objective and subjective binge eating in BN and BED patients, before treatment, after an individual CBT, and 3 years after the end of treatment.

40 OBEs and SBEs at baseline Higher objective binge eating frequency at baseline: - BN: anger/frustration (EES) and impulsivity - BED: depression/emotional eating (EES) and eating concerns (EDE-Q) Higher subjective binge eating frequency at baseline: - BN: anger/frustration (EES) and shape concern (EDE-Q) - BED: depression/emotional eating (EES) and depressive symptoms.

41 OBEs and SBEs reduction across time

42 Different kinds of emotions seem to be associated with binge eating. Emotional eating might act in a different way in BN and BED patients. BN Shape concern BED Depressive emotional states Unrealistic dietary restraint All-or-none thinking Anger/frustration Binge eating Binge eating

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44 Predictors of outcome Treatment resistance at the end of treatment Full recovery after 3 years of follow up OR 95% C.I. age, gender adjusted OR 95% C.I. age, gender adjusted

45 Predictors of Outcome BMI reduction (>5% of initial BMI) after 3 years of follow up R square=0.07; p=0.001 BMI reduction(%) At the end of treatment R square=0.08; p<0.001 BMI reduction(%) After 3 years follow up OR 95% C.I. age, gender adjusted EES at baseline

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49 Cambiamento disfunzione sessuale dopo CBT A B Figure 2 Section A reports Female Sexual Function Index (FSFI) total scores at baseline and at 1-year follow-up, according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnoses, presence/absence of physical and sexual abuse. Section B reports linear mixed models effects for FSFI scores. At first, time by moderator variables (DSM-IV diagnosis, physical and sexual abuse) interactions were reported. For each moderator variable, the interaction was broken down, and time effects of FSFI scores were reported within each group of patients.

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51 Conclusioni L intervento Cognitivo-comportamentale è uno strumento terapeutico in grado di migliorare in modo significativo il decorso dei DCA nella maggior parte dei pazienti. Gli studi di follow-up mostrano risultati nel complesso buoni per BN e BED, discreti per AN. Tali interventi possono dare risultati migliori qualora tengano conto delle diverse caratteristiche anamnestiche, psicopatologiche e cliniche dei pazienti. I predittori di esito appaiono sostanzialmente differenti per le tre tipologie principali di DCA.