Developments in diagnosis and clinical implications Rachel Bryant-Waugh Consultant Clinical Psychologist Joint Head of Feeding and Eating Disorders Service 28 th June 2014, Padova, Italy

 Focus on changes to diagnostic criteria and consider implications for assessment and treatment of eating disorders  Pay particular attention to changes and implications of DSM 5  Mention proposals for ICD 11 as relevant  Pay particular attention to implications for working with children and adolescents  Refer to adults as relevant Aims for this talk

Acknowledgments DSM 5 Work Group ICD 11 Advisory Group

Improvements to patient care Development of effective interventions Improved clinical utility Education Improved assignment to appropriate treatment Diagnostic changes

Improvements to patient care Development of effective interventions Improved clinical utility Education Improved assignment to appropriate treatment Diagnostic changes

 Anorexia Nervosa  Restricting and binge-purge subtypes  Bulimia Nervosa  Purging and non-purging subtypes  EDNOS  Binge Eating Disorder, plus descriptions of ‘other’ presentations DSM-IV Eating Disorders

 Pica  Rumination Disorder  Feeding Disorder of Infancy or Early Childhood DSM-IV Feeding and Eating Disorders of Infancy or Early Childhood

 Diagnostic instability - Shared clinical features across diagnoses; High rates of diagnostic crossover  Narrowly defined categories – EDNOS +++  Application of ED criteria to younger populations problematic  Many clinically significant presentations did not ‘fit’, particularly in children/adolescents  Feeding disorder categories very unsatisfactory (Feeding Disorder Infancy and Childhood; Pica; Rumination Disorder) Problems with DSM-IV

 Changes must be supported by research evidence  Adoption of lifespan approach; child only diagnoses dropped  Introduction of indicators of course and severity  Recognition that categorical classification is flawed but alternatives at present considered scientifically premature  Consistency where possible with ICD Some principles guiding change

DSM-IV to DSM-5 Feeding & Eating Disorders of Infancy or Early Childhood Pica Rumination Disorder Feeding Disorder of Infancy or Early Childhood Avoidant/Restrictive Food Intake Disorder Eating Disorders Anorexia Nervosa Bulimia Nervosa Not Otherwise Specified -Binge Eating Disorder -Purging Disorder -Night Eating Syndrome

 Pica  Rumination Disorder  Avoidant/Restrictive Food Intake Disorder  Anorexia Nervosa  Bulimia Nervosa  Binge Eating Disorder  Other Specified Feeding and Eating Disorders (APA, 2013) DSM-5 Feeding and Eating Disorders

Improvements to patient care Development of effective interventions Improved clinical utility Education Improved assignment to appropriate treatment Diagnostic changes

A. Persistent eating of non-nutritive, non-food substances over a period of at least 1 month. B. The eating of non-nutritive, non-food substances is inappropriate to the developmental level of the individual. C. The eating behavior is not part of a culturally supported or socially normative practice. D. If the eating behavior occurs exclusively in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention. Pica Clarification Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright (c) 2013). American Psychiatric Association. All rights reserved.

A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. B. The repeated regurgitation is not attributable to an associated gastrointestinal or other general medical condition (e.g., gastroesophageal reflux, pyloric stenosis). C.The eating disturbance does not occur exclusively during the course of Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, or Avoidant/Restrictive Food Intake Disorder. D. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention. Rumination Disorder Clarification Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright (c) 2013). American Psychiatric Association. All rights reserved.

A.Eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs leading to one or more of the following: 1.significant weight loss (or failure to gain weight or faltering growth in children); 2.significant nutritional deficiency; 3.dependence on enteral feeding or oral nutritional supplements; 4.marked interference with psychosocial functioning. B. The disturbance is not better explained by lack of available food or an associated culturally sanctioned practice. C. The eating disturbance does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. D. The eating disorder is not attributable to a concurrent medical condition or not better explained by another mental disorder. If the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. Avoidant/Restrictive Food Intake Disorder ↓ EDNOS Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright (c) 2013). American Psychiatric Association. All rights reserved.

 Eating disturbance characterized by avoidance or restriction due to, for example, lack of interest in eating or food; sensory characteristics of food; fear of consequences of eating. Restriction is NOT due to weight/shape concerns  Failure to meet nutritional needs and/or energy needs  Associated with one or more of the following:  weight loss/failure to gain weight/growth impairment  nutritional deficiency  supplement dependence  impairment to psychosocial functioning ARFID

ANOREXIA NERVOSA A.Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected. B.Intense fear of gaining weight or becoming fat, or persistent behavior to avoid weight gain, even though at a significantly low weight. C.Disturbance in the way in which one's body weight or shape is experienced, undue influence of body shape or weight on self- evaluation, or persistent lack of recognition of the seriousness of current low body weight. D.Amenorrhea Current subtype: Restricting vs. Binge/Purge Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright (c) 2013). American Psychiatric Association. All rights reserved. Clarification ↓ EDNOS

A. Recurrent episodes of binge eating. B. Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise. C. The binge eating and inappropriate behavior both occur, on average, at least once a week for three months. D. Self evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Subtype: Purging vs Non-Purging BULIMIA NERVOSA ↓ EDNOS Not Used Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright (c) 2013). American Psychiatric Association. All rights reserved.

A. Recurrent episodes of binge eating. B. The binge-eating episodes are associated with three (or more) of the following: 1.eating much more rapidly than normal 2.eating until feeling uncomfortably full 3.eating large amounts of food when not feeling physically hungry 4.eating alone because of being embarrassed by how much one is eating 5.feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. Binge Eating Disorder ↓ EDNOS Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright (c) 2013). American Psychiatric Association. All rights reserved.

 To replace EDNOS  Atypical Anorexia Nervosa  Subthreshold Bulimia Nervosa  Subthreshold Binge Eating Disorder  Purging Disorder  Night Eating Syndrome  Other unspecified Other specified feeding and eating disorders

Improvements to patient care Development of effective interventions Improved clinical utility Education Improved assignment to appropriate treatment Diagnostic changes

 Are the changes proving to be useful to clinicians and to patients?  Correct use of revised diagnostic categories should lead to:  reductions in use of ‘left-over’ categories  people with clinically significant presentations receiving an appropriate diagnosis  For children and adolescents, in particular, the introduction of ARFID and changes to AN criteria do seem to be promising Improved clinical utility?

DSM-IV vs DSM-5 in children/adolescents Adolescent Medicine Eating Disorders Collaborative n = 220 Pinhas et al n = 164 Attia et al n = 103 From B.T.Walsh by kind permission

 ARFID emerging as demographically and clinically distinct from AN and BN in relation to:  Age of onset; duration; % males; likelihood co-morbid medical and/or psychiatric symptoms (Fisher et al, 2014; J Adol Health)  ARFID not over-inclusive in relation to other populations likely to have high incidence of feeding/eating issues  Not overrepresented in paediatric gastroenterology population  Some refinement needed to assist standardized application of criteria in medical settings (Eddy et al, 2014; in publication IJED) ARFID and AN/BN

 ‘Significantly low weight’  Emphasis on clinical significance of weight loss for individual  Atypical anorexia nervosa:  “All of the criteria for Anorexia Nervosa are met, except that, despite significant weight loss, the individual’s weight is within or above the normal range.”  Both contribute to more appropriate association between diagnosis and clinical implications for the individual Changes to weight thresholds

Improvements to patient care Development of effective interventions Improved clinical utility Education Improved assignment to appropriate treatment Diagnostic changes

 Where they do not exist (e.g. ‘selective eating’, ‘food avoidance emotional disorder’) or where they are not useful (e.g. Feeding Disorder of infancy or Early Childhood) there is NO clear evidence base for interventions  Standardization of terminology and uniformity in presentation is important in moving a field forward  Recent diagnostic change offers new possibilities, especially in relation to ARFID Can diagnostic criteria aid the development of effective interventions?

 AN, BN, BED changes – unlikely to have much direct effect on the content of therapeutic interventions  Should allow a greater number of patients to access services (through reduction of EDNOS)  Should allow more rapid access, thereby potentially improving outcomes Direct effects

 Pica and Rumination Disorder – might result in an increase in identification and greater impetus to refine and standardize intervention protocols  ARFID – considerable possibilities for developing interventions  In children and adolescents current practice suggests combination of behavioural/ CBT/ anxiety management/ parent interventions Direct effects

Improvements to patient care Development of effective interventions Improved clinical utility Education Improved assignment to appropriate treatment Diagnostic changes

 Requires a sufficient body of evidence from treatment trials to determine what most effective intervention(s) should be  Takes some time to establish – so how best to proceed in the meantime?  Should proceed according to current best practice – theoretically driven to include proposed mechanism(s) for change Most appropriate treatment?

Evidence based practice (Sackett et al, 2002)

WHAT ? Intervention HOW BAD? WHY?? Elimination/reduction of impairment/subjective distress Clinical Expertise

Recognition Assessment Diagnosis Intervention Severity of impairment, distress and burden Formulation / understanding of disorder Elimination/reduction of impairment/subjective distress Maintaining factors – internal and external Core psychopathology – cognitions and behaviour Urgency and risk - self and family I: emotional; personality; cognitive style; physical predispositions; co- morbidities E: family; social; cultural; school

Ongoing research and evaluation vital!

Improvements to patient care Development of effective interventions Improved clinical utility Education Improved assignment to appropriate treatment Diagnostic changes

Job well done??

Improvements to patient care? Time will tell!