ICED 2017 Plenaries

Plenary I (Treatment)
Thurs, June 8, 11:15 a.m. – 1:00 p.m.

Setting the Stage: Clinical Staging and Personalized Approaches to Treating Eating Disorders 
Forum Hall, Second Floor
Simultaneously translated to Spanish

Chairs: Kelsie Forbush, PhD and Kelly Bhatnagar PhD

Clinical Staging across the Illness Spectrum: From Emerging Psychopathology to Chronic and Enduring Psychopathology
Professor Stephen Wood, PhD, Orygen & The Unversity of Melbourne, Melbourne, Victoria, Australia

Clinical staging models have been used in medicine for decades to define illness progression. Within the field of psychiatry, burgeoning research has sought to develop similar trans-diagnostic models to characterize symptoms across the illness course in order to better link to appropriate prevention and intervention. Clinical staging models help to define mild manifestations of the illness from later, impairing features. Within the field of depression and psychosis, clinical staging models are supported by several lines of research, including research from treatment and neuroimaging studies. However, despite the promise of clinical staging models, there are also a number of alternative explanations for differences that occur along the continuum of illness, including effects of medication and symptom heterogeneity. The field of eating disorders has much to gain by learning about how clinical staging models have been applied to other serious forms of mental illness. The implications for developing and testing new clinical staging models for eating disorders will be discussed.

This Time it’s “Personal”: Adapting Empirically Based Therapies in the Era of Personalized Medicine
Daniel Le Grange, PhD, FAED, University of California, San Francisco, San Francisco, CA, USA

A staging model for anorexia nervosa (AN), albeit preliminary, is helpful in terms of prognostic information as well as matching stage of illness with intervention. Such a model remains absent for bulimia nervosa (BN). One corollary of a staging model is that the identification of eating disorders when they onset, typically in early to mid adolescence, provides advantages in terms of positive outcomes. For instance, early interventions for subsyndromal AN hold great promise. Similar findings for adolescents with subsyndromal BN remain elusive. However, empirically based interventions have been evaluated for adolescents with full syndromal presentations of both AN and BN. In particular, the prognostic value of early change in treatment, e.g., the critical 4-week intervention period, has been demonstrated in several recent studies. This, as well as moderator analyses, allow us to better match adolescent patients and their families with treatment. Moreover, empirically based therapies such as FBT have been adapted for early non-responders, e.g., FBT plus Intensive Family Counseling (FBT+IPC), with promising findings in terms of improved remissions rates. Going forward, personalized approaches should be emphasized, e.g., stepped care models, delivering empirically based therapies via Telehealth, determining when a separated rather than conjoint family intervention is more suitable, or whether multi-family therapy rather than single family therapy holds greater advantage. Taken together, it is clear that ‘one size does not fit all’.

Get “SMART”: Using Innovative Methods to Test Sequential (Stepped) versus Simultaneous Clinical Change in Eating Disorders
Carlos Grilo, PhD, Yale University School of Medicine, New Haven, CT, USA

Although research has identified specific psychological and pharmacological approaches that are effective for treating binge eating (i.e., binge eating disorder (BED) and bulimia nervosa (BN)), many patients fail to derive sufficient benefit. The clinical strategy of combining methods has generally failed to enhance outcomes and identifying reliable moderators of treatment response to inform treatment-matching has been elusive. There exists a need for novel research designs to inform evidence-based guidelines for selecting sequential or additional treatment approaches for patients in general and especially for those who are non-responsive to initial treatments. A typical strategy might involve comparing stepped-care approaches (e.g., “least costly” or “most scalable”) to an established effective approach. In addition to reviewing relevant issues and studies, a recently-completed RCT testing a “SMART” or “ADAPTIVE” approach for patients with BED will be presented. In this approach, rather than “typical” strategies of starting with “less intensive” treatments first or prescribing “more intensive” treatments to “more complex” patients, patients “early response” to treatment determined the sequence. Within the stepped-care approach, all subjects started with standard behavioral weight loss (BWL) treatment; treatment rapid-responders continued with BWL, while non-responders moved on to a specialist treatment (CBT) combined with pharmacotherapy.  Acute outcomes for the 6-month treatments and longer-term maintenance outcomes through 18 months of follow-up (i.e., 12 months after completing and discontinuing treatments) will be presented along with implications for both clinical practice and future “SMART” designs.   

Discussant: Embarking On New Adventures – Are We Ready to Use a Staging Model to Map the Course of Eating Disorders?  
Heather Thompson-Brenner, PhD, FAED, Boston University, Somerville, MA, USA

In recent years, there has been growing concern over the utility of existing diagnostic procedures in psychiatry. Namely, the procedures categorize symptoms appearing only in the later stages of illness when it has already been consolidated. Some believe this method hampers the development of treatments geared towards earlier forms of the illness and thus, increases the risk of illness progression (Treasure et al., 2015). Clinical staging offers an alternative to conventional diagnostic practice in that it a) defines the extent of a progression of a disorder at a particular point in time and b) identifies where a person lies at any given time along the continuum of the course of an illness (McGorry et al., 2007). Clinical staging has the potential to allow clinicians to select treatments relevant to earlier stages of an illness and assumes that such interventions will be more effective than treatments delivered later in the course of illness (McGorry et al., 2007). The clinical staging framework has been used with some success in other psychiatric disorders (Cosci et al., 2013; Hickie et al., 2013; Scott et al., 2013), which begs the question – Is it time for a staging model to map the course of eating disorders? This plenary strives to examine the evidence surrounding this question and explore treatment implications that may come about as a result.

1. Explore the utility of using a staging approach to map the course of illness in eating disorders. 
2. Examine how a staging or adaptive (personalized) model may influence treatment recommendations and approaches during different phases of illness. 
3. Describe new methods for testing personalized approaches and propose ways in which these methods could be applied to eating disorders.

Learning Objectives

The goals of this plenary are to:

1. Explore the utility of using a staging approach to map the course of illness in eating disorders.
2. Examine how a staging or adaptive (personalized) model may influence treatment recommendations and approaches during different phases of illness.
3. Describe new methods for testing personalized approaches and propose ways in which these methods could be applied to eating disorders.

Plenary II (Wildcard)
Friday, June 9, 8:30AM - 10:15AM

Atypical Eating Disorders: Addressing the Overlooked and Misunderstood
Forum Hall, Second Floor
Simultaneously translated to Spanish

Chairs: Angela Celio Doyle PhD and Leah Dean

Seeing Atypical Eating Disorders in Young Children: Identification and Treatment of Atypical Eating Disorders in the Clinic
Richard E. Kreipe, MD, FAED, University of Rochester Medical Center, Rochester, NY, USA

The goal of this presentation is to provide an overview of atypical eating disorders presentations in young children, highlight recent research describing this population, and present a series of clinical examples. The DSM 5 has reflected our changing notion of atypical eating disorders and it is important to consider how our developing understanding informs early intervention strategies. This talk will highlight genetic, neurobiological, and behavioral aspects, when appropriate, to better conceptualize how the phenotypes may relate to more common eating disorder presentations.

Looking for Signs and not Symptoms: Improving Precision in the Measurement of Eating Disorders
Kamryn T. Eddy, PhD, FAED, Massachusetts General Hospital, Boston, MA, USA

Boundaries between frank eating disorders and normality, among the different eating disorders (e.g., full threshold versus other specified feeding and eating disorder [OSFED] presentations), and within the OSFED presentations can be difficult to discern. Symptoms, including dietary restriction, binge eating, purging, and overvaluation of weight and shape used to define the eating disorder diagnoses can occur trans-diagnostically and change across time. Whereas symptoms are subjective and must be self-reported by patients, signs are objectively measurable indicators of illness. Identification of signs may improve evaluation and management of these complex and heterogeneous illnesses. Using a cross-disciplinary approach, our team is investigating neural, endocrine, and behavioral signs of hunger, reward, sensory perception, and cognitive control that we hypothesize underlie eating disorder symptoms and, in turn, diagnoses. Taken together, this line of research can identify neurodevelopmental mechanisms of illness and inform development of targeted sign-based treatments.

Never Too Old for Eating Disorders: Eating Disorder Onset and Symptoms in Middle Aged Men and Women
Hans Wijbrand Hoek, MD, PhD, FAED, Parnassia Psychiatric Institute, The Hague, The Netherlands

In the past we have overlooked eating disorders in non-western countries and in males. Nowadays, we still overlook and misunderstand eating disorders in elder women and men. The onset of eating disorders, especially anorexia nervosa, most frequently occurs during adolescence, but older adults also develop eating disorders quite frequently. On many indices of disordered eating, older persons with eating disorder resemble younger people with similar conditions, although older persons exhibit certain unique concerns, such as dealing with menopause and with aging. The goal of this presentation is to provide a summary of the research on older women and men with later-onset eating disorders in order to optimally assess and treat individuals in this more atypical group.

Discussant: Can atypical presentations of eating disorders be better understood and treated?
Pamela K. Keel, PhD, FAED, Florida State University, Tallahassee, FL, USA

Atypical eating disorders comprise a large proportion of eating disorder syndromes. DSM 5 changes have more effectively captured varied presentations of disordered eating with the inclusion of Avoidant/Restrictive Food Intake Disorder (ARFID) and named examples of Other Specified Feeding or Eating Disorder (OSFED); however, there remains great heterogeneity within these groups and in the category of Unspecified Feeding and Eating Disorders. Dedicated research on these more unusual patterns of disordered eating and related experiences is essential for addressing suffering within individuals with atypical presentations and may help to create more valid and reliable phenotypes as more research integrates genetics, neuroscience and behavioral components. In this plenary, speakers will present on our growing understanding of eating disorder phenotypes and chart a course for how the field will forge ahead in the assessment, treatment, and further study of atypical eating disorders.

Learning Objectives
Participants will be able to: 

1. Describe efforts being made to increase precision in the measurement of eating disorders using Research Domain Criteria (RDoC) and what impact this might have on treatment. 
2. Summarize the research on older men and women with later-onset eating disorders as well as young children for more optimal assessment and treatment. 
3. Synthesize key topics in the understanding of atypical eating disorder phenotypes, taking into consideration the contributions of genetics, neuropsychiatry, and behavioral methods.

Plenary III (Sociocultural)
Friday, June 9, 4:00PM - 5:45PM

Reframing Conflict as Collaboration: Bringing Together Food, Weight, and Eating Science
Forum Hall, Second Floor
Simultaneously translated to Spanish

Chairs: Kendrin Sonneville ScD RD LDN and Rachel Rodgers PhD

The Intersection between Weight-Related Disorders
Caroline Braet, PhD, University of Gent, Gent, Belgium

The purpose of this talk is to provide an introduction to the overlap between obesity and eating disorders and to provide a framework for understanding the role of the sociocultural context in the comorbidity of eating disorders and obesity. Starting at the individual level, the presentation will first highlight key shared characteristics of weight-related disorders (such as emotional eating and reward/sensitivity). These characteristics and risk factors will then discussed within the broader sociocultural context, specifically describing how environmental triggers (e.g. the overabundance of food in food environment) may exacerbate risk across the spectrum of weight-related disorders. Finally, this talk will contribute to highlighting opportunities for collaboration and integration of efforts across fields dedicated to the prevention and treatment of weight-related disorders.

Eating Disorders, Obesity, and Addiction: A Critical Analysis
G. Terence Wilson, PhD, Rutgers University, Piscataway, NJ, USA

Obesity is not an eating disorder, and eating disorders are not a form of addiction. Viewing them as an addiction ignores the socio-cultural and environmental forces involved in their cause and maintenance, and undermines the most effective form of evidence-based treatment - CBT. The well-documented efficacy of CBT for Bulimia Nervosa is mediated in part by the reduction of dietary restraint, with the inclusion of so-called “trigger” or avoided foods being planned and deliberate – which is diametrically opposed to the addiction model. Binge Eating Disorder is not a biologically-based phenotype of obesity that is well-suited to the addiction model as often claimed. CBT with its core focus on reducing dietary restraint and overvaluation of body shape and weight is, contrary to an addiction model, highly effective in treating BED.

Food Addiction
Ashley N. Gearhardt, PhD, University of Michigan, Ann Arbor, MI, USA

Our food environment has changed drastically in the last 50 years. Highly processed foods that strongly activate reward and motivation systems have become cheap, easily accessible, and heavily marketed. Rising levels of overeating and difficulties controlling food intake have accompanied these changes to our food system. There is growing evidence that certain types of foods may be capable of triggering neurobiological and psychological responses that parallel drugs of abuse. This has led to growing interest in the role of addictive processes in certain types of eating pathology. This perspective is highly controversial, in part due to the potential treatment implications that stem from an addiction perspective. In this talk, the evidence that addictive processes may be playing a role in some types of disordered eating will be evaluated and implications will be discussed. Future directions to more fully investigate the role of addictive processes in disordered eating will be outlined.

Discussant: Collaborative Conversations Towards Successful Solutions
Kelly D. Brownell, PhD, Duke University, Durham, NC, USA

Eating disorders and obesity share both clinical and conceptual overlap, and frequently are linked to the broader sociocultural discourse around weight and eating. Are our goals contradictory or are we really all trying to achieve the same outcomes, but just saying the same thing in different ways? What can we learn from other fields, and how can we best integrate our efforts? How does the “noise” around food, nutrition, appearance, fitness, and health created by for-profit industry create a confusing and harmful sociocultural context? This session aims to start a conversation that will contribute to reframing issues around risk factors, prevention, and treatment of eating and weight-related disorders. Specifically, this plenary will aim to discuss the overlap between obesity and eating disorders and how this comorbidity may be produced by the sociocultural context, and how this can inform our understanding and efforts to address weight-related disorders. In addition, the usefulness of food addiction models in conceptualizing the role of the food industry in the emergence of weight-related disorders will be considered and argued. Finally, these issues will be brought together in a discussion of how different aspects of the environment contribute to eating and weight-related concerns, and the role of the eating disorder field in helping to advance the conversation and develop successful collaborative solutions.

Learning Objectives
Participants will be able to:

1. Understand the role of the sociocultural context, including appearance stereotypes, in the comorbidity of eating disorders and obesity. 
2. Understand the food addition model and its potential implications for eating disorders.
3. Critically analyze the empirical evidence in support of, or not, the food addition model. 
4. Understand the need for collaborative conversations with the aim of decreasing sociocultural pressures contributing to eating disorders and other comorbid disorders.

Plenary IV (Biology)
Saturday, 9:00AM - 10:45AM

Neuroimaging and Beyond: The Clinical Value of Eating Disorders Brain Research
Forum Hall, Second Floor
Simultaneously translated to Spanish

Chairs: Anja Hilbert PhD, Annemarie van Elburg MD PhD FAED, and Hana Papezova MD PhD

Background of Neuroimaging and Clinical Applications: Evidence of These Approaches in Psychiatric Disorders and Their Application to Eating Disorders
Damiaan Denys, MD PhD, Amsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands

To discuss the findings of neuroimaging in psychiatry and the effects of those findings on clinical outcomes and treatment techniques, in general and more specific, those with relevance to eating disorders. In this presentation a brief overview of the state of neuroimaging findings will be given and evidence of these approaches for clinical use. Although neuroimaging has shown various abnormalities and deficits, replication and meaning of these findings has proven difficult and translation from one psychiatric disorder to another a challenge. Apart from non-invasive methods that have been developed and will be discussed later in this symposium; more invasive methods like Deep Brain Stimulation will be given attention. In some parts of the field progress has been made in this more invasive translation to clinical applications, i.e. in the use of DBS in OCD. Recently the first findings of DBS in ED have been published.

Empirical Evidence from Brain-Directed Interventions and/or Treatments for Eating Disorders
Hans-Christoph Friederich, MD, Medical University Hospital Dusseldorf, Dusseldorf, Germany

The presentation provides empirical evidence from no n-invasive brain-directed interventions and/ or treatments in eating disorders. The most common non-invasive techniques are transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS). These techniques are used to target brain regions of the cortical cognitive control network to modulate self-regulatory control of food intake. Findings from proof-of-concept studies as well as from first clinical trials will be presented. Another promising non-invasive intervention is real-time neurofeedback that allows patients to learn to self-regulate their brain activity in specific brain regions. Combining neurofeedback and cognitive treatment strategies may enhance clinical outcomes. Additionally, brain directed neuropsychological treatments such as cognitive remediation therapy and cognitive bias modification will be highlighted. The presentation addresses questions regarding ethics, potential complications, patient selection criteria, and future developments. The potential of multimodal neuroimaging to inform neuromodulation targets and protocols in the scope of personalized medicine is discussed.

An Overview of New Research into Food Choice and Habit Formation and the Effect Seen in the Brain
Joanna Steinglass, MD, Columbia University, New York, NY, USA

To provide an overview of the new research into food choice and habit formation and the effect seen in the brain. Eating disorders are defined, in part, by disturbances in eating behavior. While much is understood about the appetitive and inhibitory controls of normal eating, the brain mechanisms of maladaptive eating behavior are just beginning to be characterized. A critical advance in cognitive neuroscience has been the increasing understanding of the basic neural mechanisms of decision-making and choice. Application of these tools to the study of eating disorders has been fruitful in linking neuroimaging with actual disturbances in behavior. One promising line of investigation has used a range of neurocognitive tasks to test disturbances in reward processing among individuals with anorexia nervosa. Reward processing is critical for shaping behavior, therefore understanding general disturbances in reward has yielded insights about how these neural mechanisms may contribute to the development and persistence of maladaptive eating behavior. Furthermore, examining decision-making about food directly has identified that individuals with anorexia nervosa use these circuits differently when choosing what foods to eat. These approaches to the study of AN can link brain and behavior, and identify mechanisms of illness that will open new avenues of investigation for treatment.

Discussant: Neuroimaging in Eating Disorders – Has the Money Been Worth it for Our Patients?
Ursula Bailer, MD, FAED, Medical University of Vienna, Vienna, Austria

To provide an integration of the three previous talks and to try to answer controversial questions regarding the money spent on imaging research and the resulting meaning to clinical treatment strategies for eating disorders. What does the field need to do in order to translate brain imaging data to clinical practice?

Over the past decade, research on neuroimaging of eating disorder-related brain circuitry has been accruing. Volumetric evidence suggests increased volumes of the left medial orbitofrontal gyrus rectus and of the right insula in anorexia nervosa and bulimia nervosa, deemed important in the regulation of food intake and interoception. The white matter integrity of the fornix, a limbic pathway involved in the regulation of food intake and emotions was decreased. Functional brain imaging studies found reward pathways to be involved in the processing of food stimuli, including insula and striatum, which could contribute to over- and undereating in eating disorders. The main aim of this plenary will be to provide an overview of the clinical value of neuroimaging research on eating disorders. The contributions and limitations of neuroimaging techniques, such as functional magnetic resonance imaging (fMRI), positron emission tomography, and single photon emission computed tomography will be discussed. Non-invasive intervention strategies, including realtime fMRI or EEG neurofeedback, repetitive transcranial magnetic stimulation, and transcranial direct-current stimulation will be presented. Brain-directed psychological treatments such as cognitive remediation therapy will be highlighted. These approaches will be discussed against the background of recent evidence, while addressing practical questions. Their potential as therapeutic tools in brain-directed treatment of eating disorders will be discussed, focusing on applicability and ethics. These approaches will be discussed against the background of their meaning for clinical use.

Learning Objectives
Participants will be able to:

1. Understand the scope and clinical implications of neuroimaging research in the eating disorders. 
2. Understand food choice and habit formation in relation to brain research. 
3. Understand the scope, content, and effects of non-invasive brain-directed interventions and brain-oriented psychological treatments as well as their ethical implications. 
4. Understand necessary adaptations for translation of brain research into practice.