Katharine L. Loeb, PhD Fairleigh Dickinson University Mount Sinai School of Medicine

1. Katharine L. Loeb, PhD
Fairleigh Dickinson University

2. Outline of Talk
 WHAT
 Concept and history of early intervention for
psychiatric disorders
 Its application to eating disorders
 WHY
 Importance of early intervention in anorexia
nervosa (AN)
 HOW
 Early Case Identification
○ Using multiple informant methods
 Early Treatment
○ An adaptation of FBT for prodromal AN

3. Support and Disclosures
 K23MH074506: Early Identification and
Treatment of Anorexia Nervosa
 R21HD057394: Parent-Based
Treatment for Pediatric Overweight
 NIFA/USDA 2011-67002-30086:
Optimal Defaults and Parent
Empowerment in the Prevention of Early
Childhood Obesity: A Community
Center-Based Pilot Study
 No other financial disclosures

5. Continuum of Prevention to
Treatment
Relapse Prevention
Successfully Treated Individuals
Treatment
Early Identification
Diagnosed Individuals
Early Treatment
Clinically Significant Indicated Prevention
but Not (Yet?) High-Risk Individuals
Diagnostic
Presentations Selective Prevention
At-Risk Individuals
Universal Prevention
General Population

6. History of Early Intervention in
Psychiatry
 Originated in the study and treatment of
psychosis
 Impending syndrome severe enough to warrant “risking”
treating false positive cases
 Identifiable prodrome
 Emerging symptom profile is clinically significant in its
own right
 Promising results
○ Reduction of extant symptoms
○ Prevention of conversion to full syndrome
○ Fewer hospitalizations
 Bipolar Disorder
 Autism

7. Early Intervention in AN:
Do the Same Criteria Apply?
 Impending syndrome severe enough to
warrant “risking” treating false positive
cases?
 Identifiable prodrome?
 Emerging symptom profile is clinically
significant in its own right?
 Promising results?
○ Reduction of extant symptoms
○ Prevention of conversion to full syndrome
○ Fewer hospitalizations

8. How to distinguish between
indicated prevention vs. early
treatment in eating disorders?
 When specific risk factors (vulnerability
for progression to the full disorder) are
exhibited, targeted prevention is
appropriate
 Once symptoms diagnostically essential
for the full disorder are exhibited, the
prodrome is conceptualized and early
treatment is indicated
Stice et al., 2010

10. Early identification and treatment of
AN
 Positively skewed prevalence and onset
distributions of AN across age
 Early identification and treatment efforts
have therefore appropriately targeted
children and adolescents
 Such efforts appear to have a positive
prognostic impact on the course of
illness
 The optimal point of their application
remains unclear

11. Prevention of AN in high risk
youth
 New, AN-spectrum presentations are
associated with significant clinical
severity and medical risk, equivalent to
levels seen in AN
 Such presentations may reflect a
disorder in evolution (prodrome), rather
than a stable subsyndromal state or
transient phase
 Identifying and treating the AN prodrome
could prevent conversion to AN, which is
notoriously refractory to treatment

12. Identifying the AN
SAN
Prodrome within a Subsyndrome ~
Syndrome
Working Model of Severity
Subsyndromal AN Risk
Subsyndrome = Subsyndrome =
Prodrome Subsyndrome = Subsyndrome =
Syndrome
(Disorder in Subsyndrome Partial Remission
(Early Caseness)
Evolution) (Atypical AN) (Former AN)
Age-Specific
Limitations of
Manifestations
Current
Of Full Diagnosis
Assessment Stable/Chronic Transient
Not Accounted
Methods
For in DSM-IV
Le Grange & Loeb, 2007

13. Differentiation of prodromal vs.
atypical AN: Pilot data
 Twenty-seven adolescents with SAN
 SAN defined as:
 Meeting 2 of the 4 DSM-IV diagnostic criteria for AN
 If Criterion A is not met, participants must have engaged in dietary
restriction leading weight < 100% expected, in combination with 2-3
additional criteria
 Never met criteria for full AN
 Qualitatively subtyped sample as follows:
 High Risk for Conversion to AN (Prodromal AN)
○ Steady worsening of symptoms from point at which symptoms became
clinically significant
 High Risk for Chronic SAN (Atypical AN)
○ Following a period of symptom progression, symptoms have stabilized
for a period of 3+ months

14. Prodromal vs. Atypical cont.
Variable Prodromal AN Atypical AN t (df=25) Sig (2-tailed)
(n=13) (n=14)
Mean (SD) Mean (SD)
Age 14.54 (1.81) 14.57 (1.83) -.045 .963
Duration of 4.31 (2.78) 25.21 (18.37) -4.06 .000
Illness (months)
%IBW 88.75 (7.31) 82.48 (6.81) 2.31 .030
EDE Restraint 3.34 (1.74) 1.56 (1.52) 2.84 .009
EDE Shape 3.16 (1.72) 1.55 (1.64) 2.50 .020
Concern
EDE Weight 2.84 (1.82) 1.64 (1.52) 1.86 .075
Concern
EDE Eating 2.19 (1.72) 0.92 (1.21) 2.24 .035
Concern
Sum (max=16) 14.00 (6.61) 7.93 (6.89) 2.33 .028
EDE Dx Items

15. Prodromal vs. Atypical cont.
 Differences between subtypes suggest
that those patients who appear to be at
higher risk for developing AN by virtue of
a linear and often steep symptom
progression in fact exhibit more AN-like
psychopathology than their more chronic
and stable SAN counterparts
 Unclear whether intervention strategies
need to be tailored accordingly

18. Early Intervention is Predicated
on Case Identification…
 …which in turn is challenged by:
 The ego-syntonic nature of eating disorders, resulting in
denial and minimization
 Developmentally insensitive diagnostic criteria
 Normal adolescent development, which can obfuscate
awareness of an emerging eating disorder because of
shared features
○ preoccupation with appearance
○ individuation from parental support systems
○ expression of strong attitudes
○ mood lability
 Eating disorders can present with the strong will
and affect of typical adolescence, resulting in
alienation from family members and increased
space for the disorder to intensify.

19. Potential Sources of Case
Identification for Multiple Informant
Methods
 Patients
 Parents
 Physicians (e.g., pediatricians)
 Schools
 Teachers
 Guidance Counselors
 Adminstrators

20. Patient vs. Parents as Informants
Patients Parents
Deny Report
Minimize observable, behaviora
Often lack insight l indicators of
psychological features
Fear implications of their of the illness
symptom Consider information
endorsement reported by reliable
third parties, such as
the housekeeper or
the child’s
siblings, friends, or
teachers
Report “clues” to
behavioral
symptoms, even et al., 2011
Loeb
secretive ones

21. Parents as informants in case
identification: Examples (Loeb et al, 2011)
Patients Parents
I’m not bingeing. I find bags of junk food hidden in
her room.
I’m not vomiting. She runs to the bathroom right
after meals, and our
housekeeper finds vomit
residue on the toilet.
I’m getting my period regularly. I haven’t bought sanitary products
for her in 6 months.
I’m an athlete. I’m not exercising Her coach says she trains
to lose weight. beyond what her teammates
do.
I’m fine with my body. She wears only baggy clothes.
I’m fine with my weight. She weighs herself several times
a day.
I’m not scared of gaining weight. She won’t eat more than 500 kcal
per day.

22. Eating Disorder Examination
(EDE): Direct patient report
example
FEAR OF WEIGHT GAIN (Diagnostic item, Shape Concern subscale)
*Over the past four weeks have you been afraid that you might gain weight?
[With participants who have recently gained weight the question may rephrased as "..... have you been afraid that you
might gain more weight".]
How afraid have you been?
[Rate the number of days on which a definite fear (common usage) has been present. Exclude reactions to actual weight
gain.]
0 - No definite fear of weight gain
1 - Definite fear of weight gain on 1 to 5 days
2 - Definite fear of weight gain on less than half the days (6 to 12 days)
3 - Definite fear of weight gain on half the days (13 to 15 days)
4 - Definite fear of weight gain on more than half the days (16 to 22 days)
5 - Definite fear of weight gain almost every day (23 to 27 days)
6 - Definite fear of weight gain every day [ ]
[With participants whose weight might make them eligible for the diagnosis of anorexia nervosa, ask about each of the
preceding two months. Rate 9 if not asked.]
month 2 [ ]
month 3 [ ]
Cooper & Fairburn, 1987; Fairburn & Cooper, 1993; Fairburn, Cooper, & O’Connor, 2008

23. EDE – Parent Version
(Loeb, 2005)
FEAR OF WEIGHT GAIN (Diagnostic item, Shape Concern subscale)
*Over the past four weeks has your child expressed a fear of gaining weight or becoming fat?
....If yes:
What exactly has s/he said to indicate this?
....Re-rate this item taking into account behavioural evidence of fear of weight gain.
For children who are underweight or whom parents or doctors are concerned have lost too much weight: Have
you tried to encourage your child to eat more in order to gain weight? How has s/he responded? Has
s/he rejected advice or prescriptions (from you, doctors, or other professionals) to increase his/her
weight? In addition to taking notes, mark whether or not there was a negative response to efforts to increase
the child’s food consumption or weight by circling yes or no:
[Yes/No]
Has s/he refused attempts (by you, doctors, or other professionals) to increase his/her weight?
[Yes/No]
If yes:
…by passive resistance (e.g., by simply refusing to eat)? [Yes/No]
…and/or by active resistance such as…? [Yes/No]
…yelling? [Yes/No]
…throwing a tantrum? [Yes/No]
…throwing food or dishes? [Yes/No]
…running away? [Yes/No]
…threatening to hurt him/herself if made to eat? [Yes/No]
…other (specify)?.....

24. Parents as informants in case
identification: Data
Kappas for Parent-Child Agreement on the EDE and P-EDE DSM-IV Diagnostic
Criteria for AN
____________________________________________________________________
DSM-IV Criterion A Criterion B Criterion C Criterion D
Criteria for
AN
____________________________________________________________________
Cohen’s
Kappa .307* .210 .368** .795**
____________________________________________________________________
*p < .05 **p < .01
E.g., for Fear of Weight Gain, parents (+ behavioral indicators) can increase
diagnostic symptom identification by up to 50%
Loeb et al., 2009

26. FBT for SAN:
Modifications to the Foundation Approach I
 Dual focus of risk reduction (prophylaxis of AN) and the
resolution of extant symptoms (treatment)
 The risks of conversion to AN are emphasized, while
noting that science cannot yet predict which cases are
truly prodromal vs. misdiagnosed vs. atypical vs.
transient
 The clinical severity of SAN is emphasized in its own
right, addressing the general and the specific:
 The functional impairment associated with the overall presentation
 The dangers of each individual symptom
 Attention to a wider range of developmental stages to
encompass childhood cases. While AN typically onsets
in mid-late adolescence, prodromal AN by definition
precedes this.

27. Modifications to the Foundation Approach II
 Modifications to the language of the treatment to
emphasize risk, e.g.,
 Your daughter is at the precipice of a deadly disorder
 The eating disorder is like an octopus whose tentacles have
just taken hold and are squeezing harder and harder over
time
 Modifications to the family picnic meal (session two)
instructions to address the variability in SAN
presentation:
 In deciding what to bring for your daughter to eat, consider
her degree of weight loss and how you want to help her eat
normal, healthy amounts of food again. Please include at
least one food she used to like but has stopped eating.
 Quality of food eaten (e.g., a forbidden food) may be as
important as quantity (“one more bite”)

28. Modifications to the Foundation Approach
III
 A greater emphasis on the regulation of eating
patterns and the incorporation of a full range of
foods in the child or adolescent’s diet, especially
for adolescents who have lost significant weight
but do not yet meet the weight cutoff for AN
 Psychoeducation regarding the role of excessive
dietary restraint in the development and
maintenance of eating disorders, and the
ineffectiveness of extreme restriction and eating
disorder behaviors in achieving and maintaining a
healthy weight range
 Emphasis on deriving a positive self-concept from
domains other than body image

29. Modifications to the Foundation Approach
IV
 The prescription of regular family meals at
home
 While research on the negative correlation between
family meals and eating disorders does not tease
apart self-selection from effect, common sense
dictates that family meals at least provide the
following:
○ An opportunity to observe and correct unhealthy eating
habits in offspring
○ An opportunity for parents to model healthy, non-restrictive
eating habits
○ A forum in which to identify and discuss stressors that may
precipitate or exacerbate the onset of an eating disorder

30. Modifications to the Foundation Approach
V
 It is important that parents do not explicitly
exhibit behaviors and attitudes consistent
with an eating disorder
 The difference between AN and other
presentations (above-normative levels of
discontent regarding shape/weight, fad dieting)
is sufficiently stark that the illness offers a clear
target. With SAN, the boundaries between the
eating disorder and non-disordered but
unhealthy behaviors and attitudes may be more
diffuse from the family’s perspective, and
especially from the child’s perspective
 Given data on genetic risk for AN, for some
cases, treatment must attempt reshape a
genetically influenced environment

31. Hypothesized
Mechanisms
of Treatment
Loeb et al., 2012

32. FBT RCT for prevention of AN in
high-risk adolescents
 Sample: 60 children and adolescents with emerging
(prodromal) or atypical AN
 Two study interventions:
 FBT modified for prevention
 Individual supportive psychotherapy
 Using a partially randomized preference design
 Testing PEDE as an informant-based assessment
tool to complement direct evaluation
 Two primary questions:
 Is FBT effective for reduction of extant symptoms and
prophylaxis of AN?
 Are these cases in fact child/adolescent manifestations of full
AN?
Supported by 1 K23 MH074506-01

33. Assessed for eligibility (n = 78)
Excluded (n = 18)
Did not meet inclusion criteria (n = 13)
Declined to participate (n = 5)
Randomized (n = 22)
Parallel (n = 38)
FBT (n = 10) SPT (n = 12)
 In active tx (n = 1) •Completed (n = 5)
Completed (n = 2) •Drop out (n = 5)
Drop out (n = 6 ) •Investigator exited (n = 2)
 Investigator exited (n = 1)
FBT (n = 35) SPT (n = 3)
 Completed (n = 21) •Completed (n = 1)
Drop out (n = 10) •Drop out (n = 2)
 Investigator exited (n = 4) •Investigator exited (n = 0)

34. Preliminary FBT only
findings
 N=45 %IBW
 Mean (SD) age: 100
13.3 (2.1)
 83.3% female 95
 89.2% Caucasian
 85% from intact 90
families
 89% stabilized or 85
improved
 11% converted to 80
AN Baseline EOT

35. Case Study: “Bella”
 Seventeen year old monozygotic twin
 Twin sister unafflicted
 Two-parent household
 Identified and referred by general
therapist, who was treating the patient for
anxiety and perfectionism
 Four month history of weight loss, from 102%
IBW to 89.5% IBW
 Categorically denied a fear of weight gain, but
admitted to regarding her body as fat, her
thighs as “huge” and her hips as “wide”
 Missed two periods
Loeb et al., 2009

36. Bella’s IBW Trajectory
%IBW
105
102
100 99 100 100
95
93
90 89.5
86.35
85 84
80

38.  Parents are essential in the
 Diagnosis
 Prevention
 Treatment
of child and adolescent eating disorders
 Early Identification
 Informants of direct symptom expression and
behavioral indicators
 Early Treatment
 Agents of change with FBT principles and
techniques