So, welcome to our clinical updates on eating disorders. Just out of curiosity, how many of you have attended more than one clinical update session this meeting? Oh, good. A lot. Okay. So, this is the first year. You might have heard me say this if you've been to these. This is the first year we've started the clinical updates track. We really, really, really want your feedback on this. Hopefully enough of you enjoyed it so that we will continue to do this every year. So, please give us your feedback on this track. So, without further ado, I'm going to bring up Dr. Atiyah. Thanks, Dr. Williams, and really welcome to everybody. We feared that being asked to present on the very last day was not going to get us more than half a dozen folks in the room, but the APA is the APA. So, thanks so much for being here, and hopefully this will be an interesting session. I am here to do just a few things before we begin for real. I want to introduce you to today's wonderful faculty, and I want to outline what we're going to try to do over the course of the next 90 minutes. So, I'm Evelyn Atiyah. I'm Professor of Psychiatry at Columbia University and Weill Cornell Medical Centers and Director of the Center for Eating Disorders that we have across the two medical schools. Tim Walsh, you can wave, is Professor of Psychiatry at Columbia University and Founding Director of the Eating Disorders Research Unit at the New York State Psychiatric Institute. Joanna Steinglass, Professor of Psychiatry, and she heads up the Eating Disorders Research within our division. Eric Williams, who you just heard a hello from, is on faculty at the University of South Carolina in Columbia. I think that's how they put you together with us, is there's the Columbia theme, and here really with the APA as our moderator. So, we were asked by the APA to provide this clinical update, offering nuggets of information that we hope you'll be able to use in practice, and that, we found, is kind of a challenge when it comes to eating disorders. They're complex illnesses, often referred out to specialists or treated by large teams of providers from different disciplines. And sometimes we've found that our APA audience thinks eating disorders won't exactly come their way, and they stay focused at these meetings on more common conditions, but we've all seen a significant rise in mental health issues affecting youth and young adults, the prime age of onset for eating disorders, and very specifically, several reports from U.S., from Europe, from Australia, that suggest an increase in cases of eating disorders presenting for treatment during the last two years of this pandemic. So we imagine these patients are indeed in your offices, and we're hoping to offer up a few new aspects that are relevant to proper identification and clinical management of individuals with eating disorders, and we hope it'll be helpful. Tim Walsh is going to begin with the setup, what's new in diagnosis, and a relatively recent hypothesis about how these illnesses, and specifically anorexia nervosa, may develop. Next, Joanna Steinglass will speak about how we've taken Tim's hypothesis and other psychobiological findings and started to test new treatments. She's also going to say a few words about what is and isn't yet known about digital health strategies for helping folks with eating disorders. I'm going to wrap up with a brief mention of a couple of medications that are used to treat eating disorders, as well as a bit more about the psychotherapy treatments that Dr. Steinglass will have introduced. Hopefully we're going to be able to do all of this in 90 minutes and still have time for questions. So with that, I'm going to turn things over to Tim. Thank you, Evelyn. So as Evelyn suggested, I'm the setup guy. I'm just here to introduce in broad strokes the topics that you're going to hear about from us. And then I'll get out of the way and let my two wiser colleagues take the floor. So I am hoping to be brief, so this is going to be a pretty quick skim through some topics that each of which we could spend significant time on. My disclosures, publications, I get an occasional few dollars from doing some writing. Okay, so the topics I'm going to try to touch on are, as Evelyn alluded to, COVID and eating disorders, the habit hypothesis that our group has developed and become fond of in the last 10 or 15 years, a few words about two new categories, or at least newly named categories in DSM-5, ARFID, Avoidant Restrictive Food Intake Disorder, and atypical anorexia nervosa. And I think Evelyn in particular is going to be talking more about the latter two in her talk. No? Oh, well. You can ask her anyway. Okay, a few things about COVID and eating disorders. There are a number of publications, but we should recognize that nobody knew COVID was coming, so nobody did an impressive epidemiological study in, you know, December of 2019 and repeated it now, so we really have hard numbers. But nonetheless, there are many reports of increased frequency in hospital admissions. And just to pick one example, and this is true across the world, but one example from the very good adolescent children eating disorders program at Boston Children's, this is the number of inpatient admissions. And you can see after, you know, at the onset of COVID in April, does that work? Yeah. There it is. At April, we had a real shoot up in inpatient admissions. And not surprisingly, outpatient admissions dropped to a very small number, but then came back up pretty rapidly, so that they're now back, they were back in, when is that, July 21, to a, to where they were before. Interesting in terms of inquiries, I assume these are phone calls. They dropped briefly, but then again, surged again. So there's this one indication, among a number of others, that the number of cases presenting, at least at some facilities, for treatment of eating disorders has bumped up during COVID. And some studies, which I won't go through, suggest that the impact on eating disorders appears to be greater than that of other mental disorders. Now, why has all this happened? Probably lots of things. Anxiety and depression related to the pandemic, the lack of structure, certainly for almost all folks with eating disorders, a structured routine, including eating, is important. And certainly structure fell out as everybody's life kind of fell apart and got reorganized. Social isolation and increased social media use probably played a role. Change in the venue, moving back home. Increased access to food, sitting at home with the fridge provides more opportunities for eating than sitting in the office. And decreased access to treatment. Mike? Yeah. Can I hear you? Oh, the mic's not working. Sorry, people. If you have trouble making noise or something, let me know. Okay. So, oh, and one of the potentially very few useful things to fall out of COVID has been the increased provision of treatment, particularly psychological treatment, by Zoom, by virtual methods. And I think Joanna's going to comment on that briefly. But it's had an impact on everything, is the first face-to-face meeting I've been to in over two years. But it includes eating disorders and their treatment. Okay. Habit. And again, this is a topic and an idea that we have become interested in in the last 10 or 15 years to help us understand some of the real puzzles presented by some of our more challenging patients, especially with anorexia nervosa. This model has been most fully developed for anorexia nervosa. Turns out that we are wired very well to develop habits, as are other animals like mice and rats, but we really can develop habits very quickly. We're all creatures of habit, and it's all over the place, including the Berenstain bears. This is a very good description of habits and how to break them in a cartoon motif, but it's actually very sophisticated. The easiest habits to describe or to relate to are motor habits. For example, we all drive on the right side of the road. I mean, that is habitual. That's what we're taught to do. We don't even think about it when we get into a car. We're on the right side of the road. But if you go to the UK, you get cars in front of you on the left side. Just looking at this quickly, you get a little jolt, saying, what's wrong with this picture? That's because the folks in the UK are trained to drive on the left side of the road. If you take a trip to London and rent a car, your frontal lobe will be very devoted to making sure you don't pay attention to the well-developed habit that you've learned here in the US of A, and pay attention to the street signs. Anyway, so habits are very powerful and very easy to form, and it makes sense. If you can do things habitually, you don't have to think about them, and you can use the relatively limited resources of your frontal lobes to think about other topics like what's for lunch. But there really is a strong rationale that the routine things that we all do are rewired into a lower part of the brain and don't require much thought. So we came up with the notion that the persistent mood restriction of anorexia nervosa might be usefully viewed as a habit. The definition of a habit is it's a learned behavior, not innate. So we're talking about things that you're not born with. These are newly learned behaviors. And the way habits are learned is people engage in a behavior that is initially rewarding. It feels good, and so they do it again. And they keep doing it enough until it becomes overtrained. The secret to development of habit is training, like driving a car. And over time, it becomes less sensitive to the receipt of the reward. I can go through that if you want, but it becomes cue-induced. You don't really think about it. You show up at the car, you get in the left side of the car, and you drive on the right side of the road. It's induced by those cues. So for anorexia, the thought is that when it starts, typically in adolescence, the dieting is very rewarding. The folks who develop this illness at the beginning feel really good about the dieting. A sense of control, a sense of loss of weight being something that's an amazing accomplishment. They might even get some compliments. And so they continue to diet. They continue to restrict food intake. It continues to be, at least to some degree, rewarding. And the hypothesis is it becomes habitual and governed by a different part of the brain than other decisions that are not habitual. Neural mechanisms. The initial learning is ventral striatum, the nucleus accumbens, while the dopamine, when habits are formed, they move into the dorsal striatum, dorsolateral prefrontal cortex. We could get into the slides on that, but this is the big picture, which we continue to think has merit, including thinking about how to treat anorexia nervosa. Habitual behaviors, it turns out, are not forgotten. I mean, like, once you've learned to ride a bike, you don't forget, no matter how long it's been. Therefore, what you've got to do is substitute a new behavior. The wiring is there, the rewiring is there, so you've got to substitute some new wiring to override the old. So we, that's the royal we, really Joanna, who will speak next, and members of our team have been thinking hard about how best to establish a new behavior, particularly in folks with persistent anorexia nervosa. So stay tuned. Okay, two other topics, quickly. One, and both from DSM-5. One of the things that happened in the eating disorders section of DSM-5 was that a disorder that was in DSM-4 called feeding disorder of infancy or early childhood was renamed and reworked into avoidant restrictive food intake disorder, because the former DSM-4 category was very rarely used, and the committee in charge of DSM-5 realized that there were people out there coming for treatment who didn't have a label that fit. And that led to the development of these criteria, which I won't go through in gory detail. I'll point out a few. The A is the big one. Criterion A is where all the action is. B are just exclusionary criteria, B, C, and D. So it's a disturbance, including, and it's not one specific disturbance, but a lack of interest in eating, avoidance based on sensory characteristics of food, I only eat white food, I don't eat food with lumps, things like that, or concern about aversive consequences. A kid throws up after having a meal and decides that the way to avoid throwing up again is to avoid meals. And these things happen. I mean, we get calls. Before this was articulated, we would get calls. And these changes in eating are associated with weight loss or failure to gain weight, nutritional deficiencies, dependence on enteral feeding, you know, a tube, or more commonly, oral nutritional supplements. People or kids who are only maintained nutritionally on Ensure. And or, a marked interference with psychosocial functioning, that is the family is going crazy trying to get the foods that this kid will actually eat. And so it really disrupts all facets of family and social life. And there's no evidence that a disturbance of weight or shape occurs like is characteristic of anorexia nervosa. So this guy was newly described. So characteristics of knowledge of the characteristics of ARFID is limited. The features are heterogeneous, as I mentioned, because there are different ways, different types of food disturbance, typically begins in childhood, but may persist into adulthood. It's not just picky eating. Picky eating is very normative at about ages 7, 8, 9, 10. I had a son who wouldn't drink orange juice because it had things in it. And that was the pulp. So he didn't drink orange juice with pulp for a while. He's quite hale and hearty now. So it's not just picky eating. It's sort of picky eating on steroids. I mean, it's really outside the normal range. It's unclear what happens to these folks, really. For one question that's still out there, I think, is can it turn into anorexia nervosa? I don't, I just don't think we know that. Treatment approaches currently rely primarily on behavioral interventions or cognitive behavioral interventions. So some of what you're going to hear about from Joanna and Evelyn is also relevant to the treatment of ARFID. Finally, last topic for me, atypical anorexia nervosa. The brief history is decades ago, maybe some of you are as old as I am and can remember, Hilda Brook was the American psychiatrist who really characterized anorexia nervosa as a distinct psychiatric syndrome with the characteristic psychopathology, the characteristic desire for control and concerns about self-esteem. In her classic book, she used the term atypical anorexia nervosa to refer to people who were significantly underweight but didn't have the concerns about shape and weight characteristic of AN. So folks with schizophrenia who weren't eating because of delusions of food being poisoned. So they didn't have anorexia nervosa, she called them atypical. In the process of the development of DSM-5, a major goal was to reduce the high frequency of EDNOS. Remember EDNOS? Eating disorder not otherwise specified. That was very prominent in clinical populations in the DSM-4 era. So DSM-5 recognized binge eating disorder, articulated and recognized ARFID as just mentioned. And then studies started to see there were still people showing up who didn't meet any of the newly recognized criteria for disorders, but met criteria for anorexia nervosa. They had all the psychopathology, but they weren't underweight. And what the DSM-5 committee did was provide in the OSFED, the Other Specified Feeding and Eating Disorder section of DSM-5, this was described as atypical AN. And this is it. This is all that's in DSM-5 about atypical anorexia nervosa. All the criteria for anorexia nervosa are met except that despite significant weight loss, the individual's weight is within or above the normal range. These folks are out there and they are presenting for treatment and we're starting to learn a little bit about them. For example, my problem is there's no real consensus definition of what is meant by significant weight loss. In many of the published papers, it's just we saw these patients whose weights are above normal and they have all the psychopathology of anorexia. But people have tried, some groups have tried to use criteria and 5 or 10% of the high body weight loss has been used. The eating disorder psychopathology, the level of over-concern with shape and weight appears to be as high or higher than in typical anorexia nervosa, which is quite a finding. The severity of non-eating disorder psychopathology like depression appears to be roughly the same as that of typical anorexia. Physiological abnormalities like hypotension can be as severe as anorexia nervosa and I think that may be particularly true in adolescent populations. But on average, it's less frequent and less severe. The physiological disturbance are not as bad or as uniform. So for example, amenorrhea is more common than in a normal population but is less frequent than anorexia nervosa. Bone density is less severely impacted, for example. So it's sort of in between. There's a little bit of abnormalities in the direction of anorexia nervosa but not the full bore level of abnormalities. And what's really missing, I think, is no information or information on long-term outcome or treatment response and in particular, a major question is how much weight should the person regain to get back to normal? Somebody starts at 200 pounds, loses to 125, is clearly distressed, what do they go back to? 150? 200? It's like a lot. But there is, to my knowledge, no clear way to know how to decide what such a number should be. My colleagues are going to discuss that, I hope. And that's me. So thank you. I can take some questions or I can just pass the baton on to my buddies. Pass it and then we'll do questions at the end. Okay. Thanks. Thank you. It is a pleasure to be here with you all this morning but also it's a real pleasure for me to be back on the stage with two of my two main mentors who I have not presented with for possibly a decade. So this is fun for me. My job today is to talk about what's new or newish in the world of behavioral treatments across eating disorders and I want to begin by kind of making sure that we're all taking it on faith that the central problem here or at least a central problem in eating disorders is behavior, that really kind of at the end of the day, what we're dealing with is problems in eating. And so those are behavioral, and so we need some strategies to change behavior. Sometimes I start out by really trying to convince you of that, and really demonstrating what the data are about the behavioral disturbances. I'm gonna kind of gloss through that, and just get us to talking about how to help change behavior. And I'm gonna talk first about restrictive eating behavior, and then about binge eating. These are my disclosures. Okay, so restrictive eating. Restrictive eating is limiting your amount that you take in, or limiting the types of food that you take in. And it happens across anorexia nervosa, most notably, most significantly in anorexia nervosa, but as you just heard, it also comes up in ARFID, and in atypical anorexia nervosa. And we have, over the decades, quantified this, which is really helpful. It's nice to know exactly what happens. It's really helpful to be able to see that it really is a disorder of intake, and that it's not just calories that come in, but in anorexia nervosa, it's very specifically the calories from fat that people take in. We have not yet fully looked at what happens with atypical anorexia nervosa, but we've started to, and a young scientist in our group has just started to look at the data from our patients with atypical anorexia nervosa, and we see the same pattern. We see real limits in calories, and limits in calories from fat. We also have quantified, over the years, that patients with bulimia nervosa, when they're not having a binge meal, are also restricting their intake. And we know that this dietary pattern is predictive of long-term outcomes. So it's a problem during the illness, and it's a problem for the chronicity of illness. So what can we do to change it? So this is a behavioral problem, and it turns out that by focusing on it and by using behavioral strategies, we can improve intake. We know this from, this is the mainstay of structured treatment programs, right? Every inpatient unit, day program, IOP, any treatment program that's set up to help patients with eating disorders and with anorexia in particular, focuses on using the environment and using the structure to reinforce things that promote regular and consistent and healthful eating, and do not reinforce the kinds of behaviors that interfere with eating. And these programs have good success rates at getting people weight restored, but they have high relapse rates. So we do, we know how to help, but we don't necessarily do as good of a job yet as we'd like to. So I'm gonna talk about a couple of strategies that we have developed and tested that look at, that take a kind of a closer look and really zoom in on what's happening with behavior to try to improve intake. I wanna highlight two aspects of this. One is that this work, all of this work, really leverages, builds on the massive amounts of evidence that behavioral interventions are helpful for patients with eating disorders. So there's all this data out there that this helps, and we just wanna do it better. And to do it better, it leverages the approach that's really being highlighted or asked for by NIH, which is to think about development of treatment with an understanding and an iterative experience with what the mechanisms of psychiatric illness in general is, so that if we can get a better grasp at things like habit that Tim was talking about, if we know what the problem is, we can focus in with a more target approach with the treatment. And I'm gonna talk about two potential targets. One is eating-related anxiety and some exposure interventions, and then also about habits and the CH, so the CH stands for changing habits. The rest of the acronym sorta keeps changing in our hands, so just focus on the CH part and you'll be able to follow me here. Okay, so why do we focus on anxiety about eating? So patients have a lot of anxiety. Patients with anorexia nervosa have tons of anxiety, and in particular, we've shown that their anxiety before a meal predicts how much they eat. So on the y-axis, let's see if I can figure this out, you're looking at, nope, yes, you're looking at intake, eh, forget it, on the y-axis and you're looking at anxiety on the x-axis, and this is a very old study, but has also been shown more recently by a postdoctoral fellow in our group. So in the red, you're looking at the patients with anorexia nervosa, in the blue, you're looking at the healthy controls, and again, on the x-axis, how anxious they are, and on the y-axis, how much they eat, and the bottom line is how anxious they are right before a meal is related to eating less at the meal. But what Caitlin went on to show is that how much you eat isn't related to anxiety. So she looked at anxiety after the meal, and for the patients in red, you see that anxiety's higher after the meal for patients than controls, but it has nothing to do with how much you ate. So anxiety interferes with eating, but isn't actually related or impacted by intake. So that gives us a nice target for exposure therapy. Exposure therapy is the gold standard for treatment for anxiety disorders. The basic principles, what I'm gonna talk about, actually, for both of these behavioral approaches is I'm gonna sort of say the what and the why, and then Evelyn is gonna dig in more to the how. So we will get into more details of this. And I know we all keep saying, someone else is gonna talk about that, so hopefully it's true. So the exposure therapy, the main idea here is that you approach rather than avoid the things that are the anxiety-provoking stimuli, and that in so doing, you disconfirm the feared consequences. That's standard from anxiety disorders. In our treatment, the focus is on eating in session, so the idea is that's what the fear is, that's what we're gonna do in all the sessions. Along the way, patients learn to tolerate distress, and very importantly, to interrupt the safety behavior. We have shown that doing this supports better intake. So the patients who got the exposure therapy were able to consume more in our meals than the patients who got the active control. And consistent with that NIMH piece about mechanisms, the people who showed the biggest reductions in anxiety with treatment were the ones who showed the most improvement in their eating behavior. One thing that I don't think I mentioned at the beginning is that it is tremendously hard to change eating behavior outside of the inpatient unit. So patients can go the whole treatment, they're eating, they're doing well in these behavioral programs, they gain weight, they're doing well, but when confronted with an opportunity to make choices about eating, they find it very, very hard. So having these behavioral interventions that support better eating, it always surprises me when it works. There have been advances in exposure therapy in the field of exposure as well as in eating disorders. So in the field more broadly, there's a move towards reconceptualizing the target and not trying to necessarily help people decrease anxiety, but rather to tolerate. So it's not necessarily the case that exposure therapy will make you less anxious about eating, but it will build your skills to eat anyway, which is incredibly useful. That information from the rest of the field is really important because our patients, we really don't see much change in anxiety. Anxiety's hot. So that will improve some of the thinking for exposure for eating disorders. I wanted to mention that our work and a lot of the enthusiasm in the eating disorders field lately has been mostly focused on exposure to eating and really trying to build skills around eating, but there are also other exposure-related approaches and that there are those who've shown that mirror exposure can help with body image concern. The next steps, the things that are coming along in eating disorders, there is a study run by Sherry Levenson where, and she's published the description of what the study will be, that is administering imaginal exposure, so in an online approach, giving people the opportunity to do these imaginal exposures at home and seeing if that can improve outcomes with treatment, and that the manual for CBT for ARFID relies very heavily on exposure approaches. So for that, the third phase of the ARFID treatment involves exposures to the feared stimuli, which can be the fear of aversive consequences, which is pretty similar to anorexia nervosa, but can also be some of those other domains like sensory sensitivity or lack of interest. Okay, habits. Habits, you heard, are learned, not innate, they're repeated frequently, they're semi-automatic, and what we have shown is that the kinds of behaviors that we worry about in anorexia nervosa, so things that relate to restrictive eating, compensatory behaviors, delay of eating, and rituals show a greater degree of habit strength. So the self-report habit index measures those automaticity and frequency things, but it measures this construct that actually predicts how likely the behavior is to occur, even when you kind of didn't want it to. And we see that patients with anorexia nervosa have a greater habit strength than healthy controls. So to change behavior, this is the kind of broad strokes of the how that we're gonna get into more detail about in a moment, but the idea of this habit-changing approach is to build cue awareness, help people know what set off the behavior, enhance cognitive control, meaning you need to notice the behavior, you need to kind of stay present enough to decide to do something different, you need to have something different to do, so you have to develop alternate strategies, and then you need to, we still have this issue of tolerating distress, because change is hard. And I will say that the first three boxes here really are outlined very well in the Berenstain Bears book. So the first thing we did was looked at this in the inpatient unit, and here we called it regulating emotions and changing habits. And this was a real proof of concept, taking those kind of new, I mean, behavior treatments have been around forever, so in some ways there's nothing new under the sun, but putting them together in this particular way felt new and focused, and really zooming in on giving people something else that they can do. And we compared it with a supportive psychotherapy, and we found that it did indeed significantly decrease the habit strength, and somewhat miraculously also improves eating. So these targeted interventions have a hope of helping people actually improve their restrictive choices. So now we're studying it, so this is a new study that Evelyn and I are running that allows us to take that very focused behavioral approach and build it into a package of treatment to help prevent relapse and anorexia nervosa. So this is a post-acute, after inpatient treatment for adults, and incorporates all the things that we hope will be helpful. And I'm gonna talk a little bit more about the eHealth component in a minute, but it gives six months of a package of relapse prevention care that focuses on those principles of how you change habits. The study is a little complicated. It uses a kind of a state-of-the-art, most multi-phase optimization strategy design. And the reason I'm mentioning that is only to kind of highlight that it's this behavioral intervention with some very specific components, but we're able to study it in the context of a whole package of care that we're hoping will move the needle on relapse prevention. Our little website just went live yesterday, so I had to add it to the slide. It's, I don't know, we don't usually design websites, so that's fun. Here's the layout, the overly complicated layout of the study. Again, I just want you to note that while we're doing this very targeted behavioral thing that you see at the top, the whole, now I really wish I could use the laser pointer. We're just using it to see how this whole package of five things together work to help prevent relapse. I don't know, oh, there we go, how this relates to this overall. See, that's why you need mentors. Okay, and now I'm gonna switch to what's sort of new-ish in binge eating. So binge eating happens across bulimia nervosa, binge eating disorder, and an anorexia nervosa binge purge subtype, and we have good treatments. We have good behavioral treatments to help people interrupt binge eating habits, if you will, and these include cognitive behavior therapy, interpersonal therapy, and ICAT, which also includes some cognitive affective therapy. And still, we could do better, and we wish that these treatments helped more than they do. So what really has been the next wave of trying to do better for treatment for binge eating has been a kind of wealth of digital health approaches. So the digital interventions that have aimed to address binge eating include phone-based apps, e-health interventions, I'm gonna focus on those two, but there's also these other ways of kind of using platforms, I mean, we're doing it in our study as well, using technology in any way we can think of to help people do better with the treatments that we have, to build the skills, to consolidate learning, to make self-help more available, et cetera. So I'm gonna focus in on these two and mostly highlight where the research is or where it's going. There is a study in Australia looking at the idea of online support. So there, the idea is to take CBT, but add in ways that you can kind of extend the treatment between sessions by giving people online support, things that they can access. And then another way to augment the CBT is with this JITAI, which is just-in-time interventions that's been, for eating disorders, has really been mostly studied at Drexel, where they have CBT. So the idea is that you learn the skills and treatment with your therapist, then your phone starts asking you lots of questions, how do you feel now, how do you feel now? And then it gathers information about you so that when you indicate that you're feeling X, Y, and Z, it says, oh, here's that skill that you learned in therapy, use that skill now. And the hope is that by delivering the reminder, the therapist goes back to kind of cue you to do the alternate thing or to use the skill. And they have a little data that it'll help, it's a little hard to get people to do it. In the world of apps, there are, I have learned, at least 65 apps for eating disorders, and yet a mere 13 published papers only covering six of the apps, and those aren't even all randomized controlled trials. So what we actually know about the apps is that, so there's Noom, which has been targeting binge eating, and in combination with CBT and guided self-help, there have been these two papers from Tom Hildebrand showing that it decreases objective binge eating episodes, and for Recovery Record, which is very popular to accompany therapy for anorexia nervosa and bulimia nervosa, there are two papers, and they don't actually show, weren't able to find an effect of the app. And then there's one called Break Binge Eating, which I'm not familiar with, but they found that in comparison to a wait list, it was associated with a decrease in the EDEQ. The thing is, so this is almost no data, and even these data still have weaknesses. It's really early days, so it's worth noting that a couple of those papers, half of them, were written by the authors who also created the apps. So more information than that is gonna be needed to really figure out whether these things are helpful. And the control conditions are still, it's kind of early days to figure out how to study these and how to know if they're helpful, but there are, so there's more to say that these are feasible approaches than there is to say that these are helpful approaches. So the bottom line to me is that these, by taking these more mechanistic, targeted approaches and really digging into the behavior, we are finding strategies, we are learning that there are ways to help people behaviorally with this behavioral disorder, and the more we learn about that and the more that informs mechanism and the more that informs treatment, the more opportunities we're gonna have also to figure out what works best for whom. And as that continues to grow, hoping we'll be able to help people more. With that, let's give a round of applause. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. So I think that part of what got me mixed up was presenting to some of you yesterday and tackling some of the topics that I knew that somewhere along the way I wanted to make sure I presented to some folks at this meeting, but we may have to get during questions to some of the issues around atypical anorexia or some of the other items that came up. What I wanted to do today is talk about a couple of newish elements. One, to say something about medications. Is there anything new? And then to say a little bit more about the behavioral treatments that Joanna just described how to use them to some extent, show you a few more details. My disclosure slide. So in terms of medications, we're gonna talk a little bit about olanzapine for anorexia nervosa, and we're gonna talk about lisdexamphetamine for binge eating disorder. And those are probably the two newest developments in the medication literature. I'll start with olanzapine. And while this trial is not brand new, it was published in 2018, I continue to mention it, not just because our group did it, but because it is the largest medication trial that's been done to date for anorexia nervosa, and it's the only medication trial that has a positive finding, describing what happens to weight over a period of time. So this was an NIH-supported trial. It took 16 weeks. We were taking a look at what happened over a 16-week period. We targeted 10 milligrams of olanzapine, although we had in the protocol some flexibility so we could make dosage adjustments based on side effects and patient experience and such. We really wanted patients to remain in the study. This was done across five sites. It took us six years. And the primary outcomes were the change to BMI and a change to obsessive-compulsive symptoms as measured by the Y-box. And we took a look at other psychological measures and other medical measures as well. So here was the major finding. And you can see what happened to BMI for those receiving olanzapine compared with those receiving placebo. Those receiving olanzapine, on average, increased their BMI by about a quarter of a BMI unit per month. And those receiving placebo made a much lower increase to their BMI over time. What does any of that mean in terms of pounds, weight in pounds? Well, for an average-height person, average-height female, if randomized to olanzapine, she would be increasing weight by about a pound and a half per month. And if randomized to placebo, about half a pound per month, so a difference of about a pound per month. And again, we were examining this over a relatively short period of time, 16 weeks of the trial. That was statistically significantly different, however. We were disappointed to see that we didn't have significant differences between groups in psychological symptom change, not that primary outcome measure of obsessive-compulsive symptoms, nor other psychological assessments that we conducted. We did actually find a difference in some somatic symptoms experienced by the participants, mostly taken from our side effect assessments that we were doing every week with these patients. Those assigned to olanzapine reported less difficulty falling asleep, less difficulty staying asleep, less difficulty concentrating, less difficulty sitting still than those receiving the placebo. We found no difference, and this was a notable negative finding, between the olanzapine and placebo groups regarding changes to metabolic factors, no change to cholesterol, no change to triglycerides, and no change to hemoglobin A1c, no differences between those two groups. That was a nice finding, because there certainly were concerns, how were these medications going to affect the patient population? Interesting finding about these patients being quite different from other clinical groups that received this medication. We demonstrated that olanzapine achieves modest weight improvement in 16 weeks, that there might be some somatic symptom improvement associated with the medication, no changes to psychological measures during this period of time, no changes to metabolic factors. Move on to binge eating disorder. There certainly is longstanding literature supporting the efficacy of medication compared with placebo for individuals with BED. Most of the medications studied have been antidepressants. Binge frequency increases with medication more than it does with placebo. Weight, not so much. So there really does not seem to be a discernible impact of the antidepressant medications on weight, even though we're seeing in those populations significant decreases in binge frequency. So it's a bit of a puzzle. There's a high placebo response rate in this population across most of these studies, and that means to us that there are likely a number of nonspecific factors that individuals with binge eating disorder respond to when they are asked to come in and participate in a regular set of sessions or given certain tasks to do, food logging and other kinds of things. Until recently, there's not been a medication that had a specific FDA indication for the treatment of BED until Shire, and now I think that they're Takeda, took Vyvanse, a listexamphetamine that had been indicated for ADHD, and decided to sponsor some studies to see whether this medication could be helpful for the treatment of binge eating. This was one of the publications, it was in JAMA Psychiatry. Three of their doses, 30mg, 50mg, and 70mg, were compared with placebo. You can see that 30mg doesn't separate out all that significantly from what happens with placebo, but 50mg and 70mg did, and are thought to represent a statistically significant improvement compared with placebo at decreasing, this is binge eating days per week. That's what the frequency measure is for this study. The y-axis is binge eating days per week, any day where there's at least one episode. You can see a pretty rapid decrease in that frequency, and it's sustained for the duration of this 11-week trial. There also was an improvement in obsessive-compulsive symptoms specific to binge eating, and there was a change to weight that was associated with the medication on the order of about 5% of baseline weight that was sustained for the duration of taking the medication. There have been a couple of studies, but the larger ones are all sponsored by industry. This did lead the FDA, though, to create an indication, and this is currently the only medication with such indication for the treatment of bed. The rest of what I wanted to talk about that's new-ish is quite connected to what Joanna was describing, and that's our trying to take the research findings that we're interested in and that you heard about, pre-meal anxiety as a possible marker or target, and the habit hypothesis for anorexia nervosa, and use these findings to develop these hopefully more effective psychotherapies, and we will say a little bit more about exposure response prevention and about REACH Plus in its current form. No question that the state of mechanism-based treatment development is still early, so we wish we had more to say, but that'll be in future American Psychiatric Association meetings. A little bit of a blueprint to describe EXRP and how I think about what we're doing in the different components of care. This is a treatment with different components. They're each important components, and it's not as though we can do exposure therapy without all parts. I think sometimes when providers are delivering exposure therapy, there's a thought that if we just have the individual confront something that's new and different, we've done an exposure. So yeah, you bring them into a treatment facility, you hand them a lunch, they didn't make the lunch, you give them the lunch, I guess they've just had exposure therapy. I actually think it's more than that for it to work well and have some chance to last. There's definitely a lot of planning in an exposure therapy treatment. We need the patient or participant to understand this rationale, to understand how anxiety is playing a role in what it is they're doing, and build some real buy-in from them. We use a hierarchy. We work really hard at helping a patient develop a very individualized hierarchy. As we're working with eating disorders, a lot of what we're asking them to load into their hierarchy are specific foods, but it may also be specific experiences that relate to eating. They're going to very carefully rate what they think are the easiest things to work on, and we want to work on those things on the early side, and what feels next to insurmountable to them, and we want to have them rate those as something that we're going to tackle much later on, and really let somebody know that we're not going to start with what's the hardest, but we hope to get to things that are indeed quite hard. We're inviting emotion, and I think that's one of the hardest things to teach a therapist who may have just come out of general training, because we're all grown to sort of reassure and support and help make somebody's great distress go away, and this treatment is asking something very different of us. When we get started with approaching exposures and approaching the individual items on a patient's hierarchy, we want to start with something that's easy. We want them to be successful as they get started, so that there really is some reinforcement that this is something that they can do, but then we want to progress up this hierarchy, and we're only going to be getting somewhere if the patient really does experience some of that distress that has gotten in their way before. We've had some patients who participate in exposure therapy with anorexia nervosa, and they'll sort of say, okay, here's my hierarchy. It's really hard for me to do lettuce, lettuce, and lettuce, and lettuce, and we really have to move them to some very different part along the range, so that we know that we're getting to what is very hard for them. We use subjective units of distress and really ask that they create a scale, a SUDS scale, and so that there really is a numerical measure for each of the things on their list, and we're dialing it up. This is only going to work if they're not just doing this within session, and if they're practicing, practicing, practicing in between sessions, and that's the homework piece of these treatments, and maybe we can get into some particular examples when we get to the questions. Hierarchy, I've already said a fair amount, could be a 0 to 10 or a 0 to 100 scale. We do a lot of this work in the sessions. We want there to be eating in the session, so we figure out what is doable in the session, and then we listen as we're hearing about the week from the patient about what comes up repeatedly outside of session. You've heard that we start with the easier items first. It's definitely this hierarchy, something that we use flexibly to guide treatment. It's not as though we have to hit every single item on the hierarchy and make sure that we're doing this in an exact order. We really collaborate with the patient and figure out what they're ready for next. You heard a mention from Joanna about imaginal exposure, so sometimes something that's very tough for a patient isn't exactly feasible to study in the session. Somebody who says, if my mother walks into the room, I have to stop eating, I can't possibly eat, I feel her glare, I can't take that next step, and we're not having mother walk into the room in our session, so we're asking the patient to work with us to think about what they can put together using their imagination that allows us to work on that very, very tough situation even when they're with us. You can imagine lots of other examples for patients. We need to use creativity because we really want patients to be able to tackle a whole range of things when they're with us, when they're doing homework on the outside, in order to really have the best outcome. Interoceptive exposures, that's working on an exposure having to do with the physical sensations that accompany the eating-related anxiety. Somebody may say, it's the feeling of fullness that gets in my way, it's the feeling of clothes on my body that gets in my way, and so we'll create exercises where we're asking someone to puff out their abdomen so that they feel the waistband on their clothes in a different kind of way, or consuming something before we do the exposure so that they have that sense of fullness, and we're working on the very thing that they say that they are afraid of at the point in the hierarchy that they're ready to do that. We have said in both of the prior presentations a little bit about ARFID, Avoidant Restricted Food Intake Disorder, no question that elements of behavioral approaches, cognitive behavioral therapy and exposure therapy, can be very useful and are trying to manage patients with these difficulties. These are behavioral disturbances, and we all are borrowing behavioral strategies, including CBT, to try to help people change what they do when they've gotten themselves into these rigid patterns, either the sensory issues that get in their way or the associated issues that make somebody afraid to engage in a meal. As you heard, Cameron Eddy and Jenny Thomas from Mass General have written a very user-friendly guide for CBT and ARFID that actually is terrific for us providers, it's also terrific for families, it's got some self-help elements to it, and it's got a very nice sensitivity to younger patients and adult patients. In terms of using specifically interceptive exposure, I find that very helpful in working with somebody with ARFID who may have the fear of choking or the fear of vomiting that you heard about before. What would that look like? We would do a very careful assessment of the sensation, we would create a hierarchy of the sensations that get in somebody's way, the experiences that get in somebody's way. We've done throat exercises, gargling exercises, seltzer in the throat exercises for somebody who's afraid that their throat's going to close down and that they're going to choke. I've used olfactory experiences, and very specifically for an 11-year-old with ARFID, a jelly bean flavor hierarchy to get us across a threshold regarding her fear of vomiting. And lucky for me, there's a Harry Potter jelly belly series of weird flavors of jelly bean, and we were able to put vomit-flavored jelly bean at the very top of the hierarchy, and we marched our way through and giggled our way through the different flavors to get this young lady closer to doing something that she thought was going to be next to impossible for her. So relapse prevention, I think I used the wrong preposition. You had and changing habits, I had with changing habits, and that's because we keep changing what REACH stands for, but the changing habits never changes. And this is, as you heard, an outpatient treatment for anorexia nervosa that follows a structured weight restoration, remotely delivered individual sessions that are paired with educational materials. So we're really emphasizing habit change, we're really targeting eating disorder behaviors. Patient and therapist here, too, are really collaborating on behavioral challenges. And we do a lot of eating during session in this treatment as well, and this is something that we're excited to be in the middle of an NIH-supported study to do. This website that just got launched, and I haven't actually looked at it since it actually got launched in real time, looks like this and has these educational materials behind each of these tiles. We are hoping that in addition to the sessions, a web-based platform of adjunctive materials is going to be useful to folks, and we organize the materials in categories of watching and listening, reading and learning, tracking and planning. There are a whole bunch of resources that patients can access at any time that are consistent with what's happening in those sessions. So just giving you some examples of what any of that looks like, there are downloadable fact sheets, what's a habit, what sets a habit in motion. They can take a look at this, they can receive psychoeducation around some of these issues, and we really work to engage them so that they think this is a cool hypothesis and they want to try to use this science to help motor them to try something so different. We use videotapes. Let's see if I can get this one to play. I'm just going to show you a couple seconds of this. So the variables that set a habit in motion are referred to as cues. These variables come pretty early in a whole chain of events, and they can really take the form of either external or internal elements. So an external cue is something about the environment or something that would be observable to an outsider that is having an impact on a habit sequence. This could be something like a setting. So it might be being at the dining table, could be preparing foods in the kitchen. All right, I didn't mean to move to the next slide, but you get the idea. And certainly if there's an interest in seeing more of that video, happy to show it. But we've got a whole series of our talking heads saying various things that for somebody who's more of a visual learner that way and wants to see something in terms of video. We also have podcasts. We have excerpts from people's recovery storybooks. We've got a whole set of resources that we're hoping will keep people engaged. We use this tool a lot as a habit chain form. In our web version of this treatment, actually, the participant as well as the therapist can go into the site and can work on this form together and type in particulars. And we think about in a much more granular way than this is what gets me into trouble or more granular even than this is the food that gets me into trouble. We're really looking at what are the many, many steps that get somebody to the point of having a difficult time making a food choice that's helpful. We talk about off-ramp issues that can get you out of the chain of events that go generally in a very particular way. I'm going to say some about some examples for folks. But we'll have patients who say when we really are asking them to drill down that the difficulty in getting through lunch starts an hour before lunch when they're checking the clock many, many times to see when exactly is it going to be lunchtime. And that may then lead to a whole set of things that they need to do before lunch is to start, a certain way that they enter into the kitchen area, and all sorts of pieces that are preceding the experience. And it happens like that every single day. And if we can start to help them make changes to that pattern, we're hopeful that we can actually have better success with their ultimate eating and food choice decisions. There are printable versions of the habit chain. And again, drilling down, really understanding details around food intake, around compensatory behaviors, around the delay of eating. A lot of these things are, as we start to talk to patients, understood as elements that they'll put into the schedule that really just get in the way of ultimately getting to the meal and getting through the meal. When we did our pilot study, the other REACH study that you heard about, five participants had identified five very different target behaviors. And we worked differently with each one of these folks. For one, it was eating quickly and actually the process of ruminating the food that was that individual's issue. For somebody else, it was pacing and fidgeting and a lot of behaviors around that. For some, it was delayed tactics like reading calorie labels and really having a lot of preoccupation and thinking. And we really came up with strategies where they were turning things around. They came up with ways to really interrupt some of that, eating foods in particular order with somebody else's, all sorts of things that they did with water and filling up on water before the meal began, et cetera. You get the sense. Again, a timeline that somebody had written out where very specifically they're putting in a whole bunch of things that are happening before they actually get to that eating experience. Another example of somebody listing all the things that they had experienced in a social situation around food that got in their way. The eating itself and what was served was actually just the end point. I think that gives you some sense of some of our particular, some of what we grapple with, some of which we hope will become useful to patients described in more user-friendly fashion like manuals that will be able to be disseminated and used by everybody else. But we're a few steps away from that now. What I think that we're going to do is take some questions. I'm going to turn things over to Dr. Williams who will help us moderate a bit of a discussion. If everybody could use the microphones, that will make it easiest for us to respond. Thank you. Yes, I guess I'll go first. I just want to bring up a case. I was informally consulted on this case. It's a 15-year-old girl whose anorexia started in January of 2021, right during the pandemic. The issue, she's been about 10 times hospitalized since that time and so forth. The problem is that she also has oppositional defiant disorder and is selectively mute. So what happens is that she doesn't talk to any of the providers, doesn't talk to her parents, only to peers. Every time she's hospitalized, she needs to be given Ativan and sedated, and essentially restrained The only time that she broke that was when she overdosed on Tylenol about five months ago It may have been accidental, because she stated she took it because she had menstrual cramps And she went to her mother, and she started talking, and her mother felt like maybe this might be a breakthrough Well, it wasn't. Afterwards, she just reverted back to being in a position of selectively mute and not eating And residential facilities will not take her because she doesn't talk and refuses Outpatient providers give up on her The mother doesn't know what to do, and I've been talking to the mother, trying to help her herself just to deal with it I've been giving her advice in terms of how to take care of herself So I was wondering if any of you have run into a case like this, where you have a combination of ODD, selective mutism, and severe anorexia nervosa And she kind of falls through the cracks because the eating disorder providers don't really know what to do with the ODD And the people who deal with cognitive disorder and ODD are not going to refeed her So, you know, it's always humbling to come to a conference and think together about the real-world cases Because without question, there are always many steps different from some of the pure interventions we may describe Some of the theoretical approaches we may be developing Many of the patients who have eating behavioral disturbances have many other aspects that they struggle with at the same time And I would imagine everyone in the room has seen some combinations which so add to the challenge It's not even going to be so useful, I don't think, to say, yes, yep, yep, I once saw, I once saw Because we've all seen some combo here, and it's always challenging And our systems don't help because we have systems that, exactly, they're going to want a patient if they seem likely to respond And they're going to be reluctant to take a patient if they're not likely to respond, if they've been through treatment many times before You know, it is our belief, and there are some data, that if we can help people approach normal weight one way or another Even when there's some restraint, some structure, some involuntary treatment for these younger patients That if we really can get BMIs closer to normal, there is a greater likelihood that ability to use psychotherapy becomes more likely That outcome over the longer term is improved So we're fans of really, really, really, really trying But there's no question that some of these cases are challenging beyond what we can easily use And you're right, supporting the family so that they can tolerate it, so that they can feel good about whatever little parts of improvement they can help with And then the question is, are there other treatments for the other things that are wrong that maybe will be helpful And of course those are hard situations, so I don't have answers on all that for sure No, I understand that, my sense is that the problem is you're trying to keep her alive But really what she needs treatment for probably first is the obsession defiant Because you're not going to get anywhere without treating that And if she does talk to peers, then maybe a residential setting where she can be away from the family for a period of time with peers and work on some of those issues Because I've seen working with, I used to work as a child psychiatrist, I don't anymore But I've seen residential facilities do very well with obsession defiant conflict disorder girls, but they don't have eating disorder Right, right, right, sometimes we have system issues there too I'm going to need to get to the rest of the folks online, thanks for the question Hi, thank you so much for this lovely presentation, I really, really appreciated it I'm from Montreal, I'm a geriatric psychiatrist, but do an outpatient general practice setting And what stands out to me with eating disorder patients is the cognitive style There's a tendency towards perseveration at times and concrete thinking And the reflection I have is a notable lack of abstractive thinking And where my mind often turns to is wondering how can in the treatment, is there a room We know that this is a de-nourished brain, that the brain circuits that are most active are, as you mentioned, the striatum, the dorsolateral And so on, so can we activate those brain circuits that are more involved in abstractive thinking And if so, this is just a general reflection question, and if so, how can we do that in both non-pharmopharmacological interventions and pharmacological interventions And then the next reflection I had was non-pharma interventions for this I don't know if you guys read books, but this to me, you know, I'm just saying this out loud I'm kind of speaking to myself when I say that, I know you guys read books But specifically fiction work, and Haruki Murakami, I find he is such a great writer I don't know if you guys know him, he's a Japanese writer, and he writes in a very surreal way There's a show on Netflix that recently came out based on one of his short stories He writes really, really in a surreal way, and for me, encourages this abstractive thinking process So with eating disorder patients, I realize they're undernourished And for me, I tend to experience some hopelessness with these patients because I say they're undernourished, they can't think And then when I look at my artistic people, who are not, of course, a psychiatric necessarily patient But just in social settings, they tend to be undernourished and over-caffeinated But they're still in a state of being able to think abstractly, produce art So non-pharma, but also pharma, the thought that happens as well is, can we look at psychedelics? So sorry for that spiel I just won the bet Joanna just won the bingo bet, who said it's going to take maybe one question and they're going to ask about psychedelics So there we go Thank you for the question Haruki Murakami, he wrote, I could tell you after, tens of books Okay, so there's a lot of inroads there to respond to I'll get to the psychedelic, can't wait to get to psychedelic But before that, the concept of what do you do with the thinking styles, it comes up a lot It's so important As part of the pitch, I would say, I think what we tried to do was build that into some of the relapse prevention stuff The data are that tackling that first doesn't get you anywhere So there's a whole field of cognitive remediation therapy that has tried to say Well, what if we help people realize exactly the things you're talking about Perseveration, the focus on the detail How can you get people to think more globally and less locally And you can do that, and you can help a patient make a nice relationship with you while doing that It doesn't help with the eating disorder So mostly people use that to try to work on alliance and engage And get somebody interested and curious about themselves so that they can then do the behavior work So there's just kind of no getting around the need to do the behavior work piece So what we tried to do for this reach thing was build in what are the different ways that we can do the behavior work And offer people a range of different types of material to see who engages with what Slightly different approaches to cognition and see which ways are going to be most helpful to people So hopefully we'll get an answer for you on what works best But then the psychedelic question, so I mean it's the obvious question And there's a lot of reason to think that we should test that There is absolutely no information yet on whether or not it will be helpful The reasons to think it I think have a little bit to do, I care about the mechanism So have a little bit to do with the serotonergic approach of serotonergic disturbances And it's at least plausible that something like psilocybin could be doing the right kinds of things But it's really just a good question to ask next and there's certainly plenty of people starting to ask And I'll say that in addition to medications there's a question of whether TMS That does offer some promise for targeting particular circuits might be useful We've done one small pilot study, it was published by our wonderful junior colleague Alex Moratore And changes to food choice were discernible after just one TMS probe versus sham And we're going to roll out a bigger study, but the questions are such important ones We just don't have those answers yet. Thanks. Thank you so much Thank you all so much for the work you all are doing I don't have a lot of experience with this, but I do have a friend that's probably 5'9 and 78 pounds And it's been a long journey watching her, she's on hospice now So I do have a very personal interest My question is, I understand the habit forming and the reward from dieting And I understand that to some extent My question is about control issues And I figure that probably, at least that's what I remember learning Is that control issues kind of are in the beginning And so what role does that play? And I guess my concern is, you know, therapy is a way of controlling the person And they feel controlled more, and does it backfire? Is that possibly a reason for relapse as they get out and they're able to control again? So inpatient is very controlling And the dysfunction of relationships, the personality disorders also come into play I just wonder how much is backfiring in a controlled setting If there is, and I may be wrong, a control aspect Would you speak to that, please? Yeah, I guess we could Complicated set of questions I do agree with you that I think that term and that way of organizing the behaviors Is most relevant for the very start of the illness That there is that initial cycle and experience that people will describe That things were feeling like life was changing I was about to go off to college, I was mad at my parents Whatever was going on in that phase where these illnesses typically begin And there's something that someone was able to do Where they were able to see the results of their action quite specifically on a scale And that felt reinforcing in some way And you'll commonly have patients use that word I was trying to get control over something, I was trying to get control over my life No question that as we work with these folks going forward They feel very out of control They sometimes need to work within the therapy to realize That that old mantra that they were using at the beginning of the illness Doesn't have great relevance for what's going on to happen later Some of them take that on and believe it and say, hey, yeah, you're right I've got to get to a different way of understanding the condition And for some, they keep going back to what it felt like near the beginning We always have the question of how much does a structure That's sometimes needed to move people along, behavioral change How much is that a good thing? We think that in the early parts of the illness As things are beginning or things haven't been present for all that long It's not a terrible thing And if we can get people back to being nourished And if we can offer them the supports needed to get there Outcomes are very, very good Sometimes it's the outcome for having gotten there And we'll see that in that year that follows up Sometimes we're getting that information from longer-term, longitudinal studies That are looking at populations of folks who went to these very structured inpatient units There's a Boston group that has published over now, I think, 22 years Of what's gone on to happen And even between, I don't know, the 9 or 15 year mark And then the 22 year mark There was a significant surge of additional improvement That went on to happen And people were, you know, to whatever extent Looking back and saying that elements of that earlier treatment Was a part of that course forward On the other hand, we've got some people who They are pushed, they feel pushed They are responding to being that pushed And they run round and round and round I was very sad to hear the word hospice It's something that's getting more into the literature And more reached for by some individuals and some families And there was a very controversial publication By someone in the Midwest Named Guardino, right? Is that her name? Who was publishing a series of cases And she created the label Terminal Anorexia Nervosa I really don't like that term And I don't think I ever give up on one of the patients Who comes to a structured program I've been associated with But it's hard to know Are we actually saving a life? Are we doing more even than just an acute saving a life? Are we really giving somebody a chance to move forward from that structure? Have we done anything negative in pushing hard? I think it's harder the older somebody gets In terms of the control issue, it's a tough one I recall data from Hopkins Which has got a very good eating disorders program Where they compared the outcome of folks Who had been involuntarily committed And treated for their eating disorder To the outcome of folks who had signed in voluntarily It wasn't much different And also an improvement They did the MacArthur Perceived Coerciveness Scale And they were looking at teens in one of their publications And teens who felt highly coerced When they first came in Felt less coerced as they were closer to normal weight So their big fear is they're going to feel worse When they get all this to have happened And actually they felt better So we look for the glimmers there To say it seems as though Some of these interventions really are doing good Thanks for this great talk A lot of great educational value This is definitely a growing problem So I have two quick questions The first one is semaglutide was just recently approved For weight gain Has anybody looked into its effect on binge eating behavior? And my second question is Regarding a subset of heart faith patients Who have the alter sensation I just wonder if SLP would have any additional input Would that be helpful? I don't know the medication The first medicine was what? Semaglutide Ozepic I don't know anything about its impact But it's worth highlighting We want a medication It would be great to have a medication Sorry, for binge eating There are other weight management medications That have been found to be helpful in binge eating disorder But I don't know that anyone has studied this It's very new Thank you very much for the presentations My questions are actually quite similar I would like to know more about other medications For binge eating disorder Because obviously I know about lisdexamphetamine But I work in Poland and we do not have this one We can import it from other European Union countries But it's still too expensive for a lot of patients I try some antidepressants But as you said, patients do not lose weight A lot of weight with them And also I would try some medications for diabetes Ozepic, for example But it's also not perfect I have a slide But not with me The only other medication That I can remember That affects both binge eating and weight Is topiramate The picture I think is pretty simple If you want to affect weight In folks with binge eating disorder Use a medication that affects weight In people who don't have binge eating disorder It's not specific to the disorder Including Vyvanse Kids on Vyvanse don't grow quite as fast as kids off Vyvanse So topiramate causes weight loss But it has the side effect of cognitive Especially when they are depressed Something going on cognitively But there are good data That topiramate works And that's the only other one I can think of Other ones were taken off the market Subutramine was very helpful But it was taken off the market There are other stimulants That are available But it's also not perfect They don't work a lot I will say that sometimes we really have to help a patient Not need to have weight loss Be the treatment goal So if we can really help them Normalize their eating behaviors first And structure their eating And get better control over eating Sometimes the satisfaction that comes with that is really well worth doing And then we can talk about optimizing If they need to for health reasons Thank you very much I was just wondering In your olanzapine trial What the doses were So olanzapine we started at 2.5 mg And we targeted 10 mg On average our patients got to about 7.5 mg So they were able to dial that Or not go up as consistently If they had certain side effects That were lasting for a couple of weeks But also if patients were highly reluctant We would keep them in the trial And not go up quite as fast So we were trying to march them from 2.5 up by 2.5 increases But overall the group landed at about 7.5 mg In this trial Ranging from 2.5 to 10 In terms of vivance The doses that are found to be helpful Are 50 and 70 So you start as low as you can go It's not likely that at 30 mg you're going to see anything There are 40 mg listed as amphetamine Doses available out there You might want to try something that's modest Before you move up I don't start at 70 on anybody I don't think I've ever treated anybody at 70 I've treated at 40, 50 and 60 Just going through the various options Thank you Thank you to all of our presenters today Thank all of you

clinical updates

eating disorders

COVID-19 pandemic

restrictive eating behavior

exposure therapy

habits

olanzapine

lisdexamphetamine

binge eating disorder

BMI

psychological symptoms

somatic symptoms

antidepressant medications