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EatingDisorders:Assessment,Understanding,andTreatmentStrategiesTerrySchwartzMDMedicalDirectorUCSDEatingDisordersProgramAsstClinicalProfessorUCSDEliseCurryPsy.D.ProgramManagerUCSDIOP石家庄监控维修ASSESSMENTANDTREATMENTSTRATEGIESFOREATINGDISORDERSTerrySchwartzMDMedicalDirectorUCSDOutpatientEatingDisordersProgramAssistantClinicalProfessorUCSDDeptOfPsychiatryDSMIVCriteriaforAnorexiaNervosaPreoccupationwithbodyshape,weight/size<85%idealBWFearofbecomingfatdespitelowweightLossof3consecutiveperiodsinwomenTypes:restricting,binge/purge,purgeAnorexiaNervosaMosthomogenouspsychiatricdisorder90-95%femaleOnsetteenageyears–pubertyMonotonouspuzzlingsymptomsPoorresponsetotreatmentHighestmortalityrate50%to80%contributionofgenesManywomendiet,fewdevelopAN:predisposingfactorsDSMIVcriteriaforBulimiaNervosaRecurrentepisodesofbingeeating,characterizedbyeatinganexcessiveamountoffoodwithinadiscreteperiodoftimeandbyasenseoflackofcontrolovereatingduringtheepisodeRecurrentinappropriatecompensatorybehaviorinordertopreventweightgain,suchasself-inducedvomitingormisuseoflaxatives,diurética,enemas,orothermedications(purging);fasting;orexcessiveexerciseThebingeeatingandinappropriatecompensatorybehaviorsbothoccur,onaverage,atleasttwiceaweekfor3monthsSelf-evaluationisundulyinfluencedbybodyshapeandweightPsychologicalCorrelatesofAnorexiaNervosaPoorselfconceptObsessivecompulsiveandavoidantpersonalitystylePerfectionistic,obsessive,harmavoidanttraitsFamilydynamics:enmeshment,anxiety,over-achieversTroubleswithmajorlifetransitionsanattempttoregress,avoiddevelopmentDifficultymanagingandexpressingangerCognitivedistortionsEgo-syntonicnatureofdiseasePsychologicalCorrelatesofBulimiaNervosaPoorselfconceptChaoticdevelopmentalhistory,parentaldeficitambiguouscommunicationstylesAffectiveregulationproblemsCognitivedistortionsEgo-dystonicnatureofdiseaseImpulsivity,substanceabuse,selfharm,sexualactingout,shopliftingCognitiveFlexibilityAnorexiaNervosa

PerceptualrigidityCognitiverigidityAN

Weightrecovery

Nochanges

AN

FullrecoveryPartialimprovementincognitiveflexibilitytasksBulimiaNervosaSlownessincognitiveshiftingtasksFluctuationsinPerceptualtaskScopeofTheProblemPrevalenceincreasingAN:.5-2%BN:3-4%ANBNMorecommonwesternizedcultures10%ofeatingdisorderedindividualsintreatmentaremale5%-20%ofANpatientsdie(disorderorsuicide)

Scopeoftheproblem:continuedHighestdeathratefromanymentalhealthcondition(AN)Increasingincidenceinelementaryagechildren(8-11yearold)Theincidenceofbulimiain10-39yearoldwomenTRIPLEDbetween1988and1993.Therehasbeenariseinincidenceofanorexiainyoungwomen15-19ineachdecadesince1930.PrimaryCausesofDeathinPatientswithEatingDisordersAN,RestrictingSubgroupAN,BulimiaSubgroupBulimiaNervosa1.Starvation+++2.Cardiacarrhythmia/failurefromhypokalemiaofipecacabuse+++++3.Suicide+++++4.GastricDilation++OutcomeDataforEDsDatamixedresultsduetodesignofstudiesAN10yr:50%rec,20-30%improvedbutstillsymptomatic,10-20%chronic,upto10%mortalityBN10yr:50%-70%rec,30%someimprovement,20%chronicOutcomesforEDSSomestudiesshowaveof7yearstorecLessthan1yearoftreatmenthaspoorerprognosisChronicity,OCPD,purginginANassociatedwithworseoutcomeBiologicalunderpinningsofeatingdisordersGeneticsNeurobiologicalcorrelatesNeuropsychiatricBrainimaginginANGeneticCorrelatesofBulimiaNervosa

Twinstudies5ht2AreceptorgenealterationFamilyhistoryofaffective,anxiety,substanceabused/oGeneticCorrelatesinAnorexiaNervosa

FamilyandtwinstudiesSerotoninreceptorgeneVariationinDopamine2receptorgeneChrom1and10FamilyhistoryofOCD,OCPD,AN

NeuroendocrinecorrelatesofBulimiaNervosaSerotonin(5HT1Areceptor)Endogenousopiateresponsetobingepurge?DANeuroendocrineCorrelatesofAnorexiaNervosaSerotonin(5HT2Areceptor)DopamineEndogenousopiateresponsetostarvationHypothalamusdysfunction(satiety,amenorrhea)AlteredDopaminefunctionandpsychiatriccorrelatesComparenormaltopsychiatricconditionsAN:increasedDAsensitivity,hyperresponsiveAddict:reducedDAsensitivity,takesalottostimulateObesity:DAsensitivityinverselyproportionaltoweight(highweight,lowDAsensitivity)AlteredRewardProcessinginWomenRecoveredfromAnorexiaNervosaRANmayhavedifficultiesdifferentiatingpositiveandnegativefeedback.Theexaggeratedactivityofthecaudate,aregioninvolvedinlinkingactiontooutcome,mayconstituteanattemptat“strategic”ratherthanhedonicmeansofrespondingtorewardstimuli.ResearchershypothesizethatindividualswithANhaveanimbalanceininformationprocessing,withimpairedabilitytoidentifytheemotionalsignificanceofastimulus,butincreasedtrafficinneurocircuitsconcernedwithplanningandconsequences.WagnerA.,AizensteinH.,VenkatramanV.,FudgeJ,(2007)AlteredRewardProcessinginWomenrecoveredfromAnorexiaNervosa.AmJPsychiatry2007:164:1842-1849NeuropsychiatriccorrelatesofEatingDisordersIowagamblingtask:ANvsCW:DifferencesseenonfMRIAN:Neuropsychtesting:difficultieswithsetshifting,flexibilityAN:Detailfocus,tothepointofmissingglobal(JanetTreasure)ANvsBNUseinclinicalpracticeDopaminefunctionandmotivation/behaviorDAcellfiresinresponsetosalientenvironmentalstimuli(rewarding,aversive,novel)DAencodesmotivationandappropriatechoicesPartofapparatusthatmakesvaluejudgmentsandmakes“correct”decisioninresponsetoastimuliDisturbancesofbrainDA-alteredactivity,reward,motivationIowaGamblingTaskCWdistinguishedbetweenwinsandlossesANhavesimilarresponsetowinsandlossesPerhapsoveractiveDAresponsetobothWinsandLossesDifficultydiscriminatingpositiveandnegativestimuli?ClinicalimplicationsANmaybeunabletodiscriminatepleasurableandaversivestimuliMaybeveryoversensitivetostimuliCannotlearneasilylearnfromexperienceMayexplainwhyitisdifficulttouserewardtomotivatepeoplewithANNancyZucker’sworkonSocialCognitioninANExperimentalTasks:1)RecAN’sratedpeopleasheavierthantheyare.Faceslessattractive(likeAutism)2)RecANvaluedfaceslessthancontrols,valuedheavybodiesless,valuedthinbodiesmore.3)Freeviewingeyetracking:ANspentlesstimeoneyesandmoretimeonthemouth(likeautism)KateTchanturia’sworkonANandTheoryofMindAN’swereimpairedonsocialcognitivetasks.Emotionaltheoryofmind:toknowwhatsomeoneelseisfeeling.AN’sshowedimpairmentintheabilitytoinferaboutanotherperson’sthoughts,beliefs,orintentions.Similaritiestoautism:reducedempathyandincreasedabilitytosystematizeTreatmentImplicationsPracticesocialproblemsolving(processgroup)AssertivenessroleplaysPracticesocialproblemsolvinginambiguoussocialsituationslikefriendmaking,datingetc.Practicedecisionmaking.Createsocialcompetencetrainingforskillbuilding(Autismresearch)BrainImaginginOCD

Saxena2003Structural(CT,MRI):variablefindingsRestingPETFDG:OFCisinvolvedinsensoryintegration,inrepresentingtheaffectivevalueofreinforcers,andindecision-makingandexpectation.[2]Inparticular,thehumanOFCisthoughttoregulateplanningbehaviorassociatedwithsensitivitytorewardandpunishment.5of9studies:elevatedmetabolisminOFC3foundelevatedactivityinbasalganglia,thalamusPETFDGbefore/afterSSRI,CBT,neurosurgery8of10pretopost-treatmentstudies:decreasesinOFCand/orcaudateinresponderstotreatmentSymptomprovocationusingPET,fMRI:consistentincreasesinglucosemetabolismorrCBFinOFC,caudate,anteriorcingulate,thalamusSuggestionofdysfunctionofOFC-subcorticalcircuitsPrimarytastecortex(rostralinsula)representtaste(temperature,texture)offoodinthemouththatisindependentofhunger,andthusofrewardvalue.

Secondaryregions(orbitofrontalcortex,OFC)computethehedonicvalueoffood

Rolls,2005RecoveredAN

AlteredfMRIResponsetofood“challenge”Picturesfood:anteriorcingulatecortexandmedialprefrontal(Uher2003)-anxiety/stressTastesugarandwater:insula,caudate-putamen,anteriorcingulate(Wagner2007)Tastesugarandartificialsweetener:insula,caudate(Oberndorfer,Frank,inpreparation)PsychopharminEDsPharmacologyforANNodrughasbeenFDAapprovedforANNodrughasshownmajorimprovementinthestarvationphaseMedstriedandfailedforappetiteenhancement(typicalantipsychotic,Li,THCderivatives)SSRIsgenerallynothelpfulinacutestarvation,thoughsomebenefitoncomorbiddisordersPharmacologyforANContinuedProzacmixeddataforrec-ANAtypicalantipsychoticmedicationsGImedstoaidphysicalsymptomsBCP/hormones:noevidenceofbenefitPharmacologyforBNSerotoninre-uptakeinhibitors?SNRIsAEDs(topiramate,?zonisamide)AntipsychoticsMoodstabilizersreglan,H2blockers??Stimulants(withcaution)BREAKMedicalConsequencesofANandBNPhysicalComplicationsofAnorexiaNervosa

OrganSystem

Symptoms

LabTestResults

1.Wholebody

Weakness,lassitudeLowweight/bodymassindex,lowbodyfatpercentage2.CNSApathy,poorconcentration

CT:ventricularenlargement;MRI:decreasedgrayandwhitematter

3.CVPre-syncope,palps,dyspnea,weakness,coldextremities,chestpainECG:sinusbradycardia,otherarrhythmia,QTcprolongation;cardiacecho(consider):MVP,silentpericardialeffusionPhysicalComplicationsofAnorexiaNervosa,Cont.

OrganSystem

Symptoms

LabTestResults

4.Muscular

Weakness,muscleachesMuscleenzymeabnormalitiesinseveremalnutrition

5.Reproductive

Prepubertalpsychosex-uallyHypoestrogenemia;prepubertalpatternsofLH,FSH;lackoffolliculardevel.6.Endocrine,metabolic

Fatigue,coldintolerance,diuresis,vomiting

Elevatedcortisol;euthyroidsick;dehydration;electrolyteabnormalities;lowphosonrefeeding;hypoglyc.(rare)PhysicalComplicationsofAnorexiaNervosa,Cont.OrganSystem

SymptomsLabTestResults

7.GIVomiting,abdom.pain,bloating,constipationDelayedgastricemptying;occas.abnlLFTs

8.RenalPittingedema

ElevatedBUN/Cr;renalfailure

9.SkeletalBonepainw/exerciseX-ray/bonescanw/stressfix;DEXAw/osteopeniaorosteoporosisPhysicalComplicationsofBulimiaNervosaOrgansystem

Symptoms

LabTestResults

1.Metabolic

Weakness;irritabilityDehydration;serumelectrolytes:↓K+,↓NA/Clalkalosisw/vomiting;↓Mg,↓K+,↓Phosw/laxativeabuse2.GI

Abdom.pain;constipation;bloating;refluxPhysicalComplicationsofBulimiaNervosa,cont.Organsystem

Symptoms

LabTestResults

3.Oropharyngeal

Dentaldecay;swollencheeksX-raysconfirmerosionofdentalenamel;elevatedserumamylase4.CVandmuscular(inipecacabusers)Palpitations;weaknessCardiomyopathyandarrhythmias;peripheralmyopathyAmenorrheaandOsteopeniaMostseriouscomplicationofprolongedamenorrheaisosteopenia,orreducedbonemassOsteopeniaandOsteoporosisOsteopeniareferstodecreasedquantityofnormallymineralizedboneOsteoporosisisclinicalsyndromeconsistingofdecreasedbonemass,disruptioninnormalbonearchitecturewithdecreasedbonestrength,pathologicalfractures,painanddisabilityOsteoporosisdefinedasgreaterthan2.5SDbelowthemeanforyoungadultwomenOsteopenia1-2.5SDbelowyoungadultrefBoneDensityandFracturesEachSDdecreaseinbonedensitydoublesthefractureriskDEXAismostwidelyusedmethodformeasuringbonedensityMaybecomparedwithage-matchedchildrenandadolescents(Zscores)BoneLossTreatmentStrategiesNotherapiesproveneffectiveforbonelossinwomenwithAN.Estrogen/BCP:

Decisiononestrogenindividualized,butnoconvincingdatathatestrogenaloneincreasesbonedensityinANpopulation.

Maygivefalsesenseofsecurity!Potentialtherapiesunderstudy:IGF-IDHEATestosteroneBisphosphonatesOsteoporosisTreatmentWeightgainCalciumsupplementationimprovesbonemass(1500-2000mg/day)VitaminDModerateweight-bearingexerciseincreasesbonemassWhenmedicallystable,wtbearingexercises3-4timesperweekMedical/PsychiatricevaluationandtreatmentstrategiesforAnorexiaNervosaAssessforcomorbidity+/-SerotoninreuptakeinhibitorsAtypicalantipsychoticsReglan,h2blockersScreeninglabs:electrolytes,Ca++,Mg+,Phos,BUN/Cr,CBC,LFTs,TFTs,UA,hematologyBonedensomitry(DEXA)ECG

MedicalevaluationforBulimiaNervosaAssessforcomorbidityScreeninglabs:electrolytes,Ca++,Mg+,Phos,BUN/Cr,CBC,LFTs,TFTs,UA,hematologyDexaECGDental

AN:HospitalvsOutpatientTreatment

FromAmericanPsychiatricAssociationGuidelinesfortheTreatmentofEatingDisordersOutpatientInpatientWeight>85%<75%MedicalcomplicationsnoneHR,BP,KetcSuicidal,comorbidpsychd.o.NotpresentsevereMotivation,insight,cooperationyesnoExcessiveexercise,purging,etcminimalsevereStress,familydynamicsminimalsevereLocalEDtreatmentresourcesavailablenoneReferraltoHigherlevelofcarePtisfailinglowerlevel.Pt’sweightlossiscontinuinginspiteoftreatmentPtisunabletostopbingeing/purging.Pt’sphysicalsymptomswarrantgreatersupervision(fainting,dehydration,heartpalpitations)PtisresistingcurrentlevelofcareREFEEDINGCOMPLICATIONSNormalfoodPeripheraledemaBloatingordiscomfortRefluxRaregastricdilitationNasogastricfeedingSeldomindicatedNasal,esophagealerosionCentralhyperalimentationRarelyindicatedPneumothorax,infection,metabolicdisturbancesEatingbehaviorinAN–AfterweightrestorationHypermetabolicevenafterweightrestorationRANneed50to60kcal/kg/dayBANneed40to50kcal/kg/day50kgwomen=2000to3000kcal/dayProbablynormalizesinlongtermProbablecontributiontohighrateofrelapseDegreeofosteopeniadependsonageofonsetanddurationofamenorrheaAdolescenceiscriticaltimeforbonemassacquisitionApprox60%ofpeakbonemassisaccruedduringadolescenceLittlenetgaininbonemassafter2yrspost-menarchePeakbonemassachievedbyendofseconddecadeStereotypicfoodchoices,ritualizedeating,caloriecountingDelusionaryqualityNothingelseismoreimportantMethodsofTreatmentRegularWeightrestoration2to3lbs/wkinpatient1to2lbs/wkday-hospital1lb/wkoutpatientNutritionalTeachingProvidepatientsupportPreventionfromvitaminandmineraldeficiencyPreventionofosteoporosisAimforhighCa++intakeVitaminDtoaidinCa++absorption;vegetariansmayneedsupplementsEatiron-containingfoods,especiallyimportantforvegetarianslunchCountertransferenceIssuesFeelingangryatthepatientfornotrecoveringThinkingthisis“willful”behaviorBlamingtheparentsFeelingincompetentGivinguphopeforthepatientNottakingthedisorderseriouslyCopingwithCountertransferenceIssuesPracticepatientacceptance:Theaveragerecoveryrateis7years.Havecompassionforthesufferingofthepatient.Seetheirbehavioraspartofthedisorder,notpersonaltowardyou.Practicegoodself-care.ImportanttipsforphysicianswhentalkingtopatientswithEDsTerrySchwartzMDLiveDemoProcesslivedemoObesity/BEDBingeEatingDisorderRecurrentepisodesofbingeeating(seeBN)Thebingeeatingepisodesareassociatedwiththree(ormore)ofthefollowing:EatingmuchmorerapidlythannormalEatinguntilfeelinguncomfortablyfullEatinglargeamountsoffoodwhennotfeelingphysicallyhungryEatingalonebecauseofbeingembarrassedbyhowmuchoneiseatingFeelingdisgustedwithoneself,depressed,orveryguiltyafterovereatingMarkeddistressregardingbingeeatingispresent2days/weekfor6monthsObesityBMI>3032.2%ofAmericanadults,increasinginchildrenIncreasinginpast30yearsby50%perdecadeMajorsuccessfultreatmentadvancesintreatmentofcomplicationsofobesity,butminimalsuccessintreatmentsforobesityitselfIsObesityapsychiatricdisorder(BED)?Medical/MetabolicissuesAmJPsych2007:IssuesforDSM–V:ShouldobesitybeincludedasabrainDisorderMajorlimitationtotreatmentofobesityislongtermbehavioralcomplianceDietsmajorcauseofED,includingBED(recallstarvationstudy)Individualbiologicalrisks:genetic/heritabilityBEDandNeurochemistrySerotonin,endogenousopiates,cannabinoidsCertainfoodsimpactnucleusaccombens:DA,opiateNeuropsych:similartoaddicts;ie;followimmedrewardoverlongtermresultsduringgamblingtypetasks(withexcitablereward)FoodforaffectregulationNeurochemicalstimulationAnxiety,depression,anger,boredom,agitationetcEndogenousresponsetofood(orstarvation)maypredisposetoANorBED/BNLiteratureReview:TreatmentforBEDInternationalJofEDsMay200726studiesreviewed:MedplusBWL,medsalone,BWLaloneMedsplusBWLbest,shorttermPsychosocialtreatmentsCBTCBTplusBWLBWLaloneGrouptherapyIndivtherapy12step/selfhelpMedicaltreatmentsforBED/obesityNomagicpill!SibutramineOrlastatAcompliaPhentermineGastricBipassStimulantsMedicaltreatmentsforBED/obesitycontinuedNomagicpill!?SSRIs,SNRIs?Wellbutrin?Topiramate?ZonisamideWhataboutpsychmedsandweightgainNeedtoknowandbetruthfulwithEDpatients!SSRIsSNRIsAtypicalAntipsychoticMedicationsTypicalAntipsychoticMedicationsMoodStabilizersTCAs,MAOIsBREAKEatingDisordersinspecialpopulationsChildrenTeensMalesEDINKIDSTEENSWhataboutthekids?Pre-pubertalEatingDisorderChildhoodOnsetEatingDisorderEarlyOnsetEatingDisorderWhatAreWeNOT

TalkingAbout?DSM-IVFeedingandEatingDisordersofInfancyorEarlyChildhoodPicaRuminationDisorderFeedingdisorderofinfancyorchildhoodAnorexiaNervosa

DSM-IVRefusaltomaintainbodyweightaboveaminimallynormalweightforageandheight.<85%ofIBWIntensefearofgainingweightorbecomingfatDisturbanceinthewayone’sbodyweightorshapeisexperiencedAmenorrhea:absenceofatleastthreeconsecutivemenstrualcyclesWeightLossvsWeightMaintenanceDSM-IVcriteriaexcludeschildrenwhohavenotreachedthecriticallevelof<85%FailuretogainappropriateweightwithgrowthMalnutritioncanleadtopoorgrowthBodyImageMaybemoretrickytoassessHowcanitbeevaluated?Children’sexpressionofbodyimageStandardtoolsClinicalInterviewSomaticsymptomsAbdominalpainordiscomfortFeelingoffullnessNauseaLossofappetiteAmenorrheaPrimaryvsSecondaryPubertaldelayEvaluationmayincludepelvicultrasoundHeightWeightWeight/heightratioOvarianvolumeUterinevolumeConventionaltargetweightandweight/heightmaybetoolowtoensureovariananduterinematurityAlternativeCriteriaforEDinChildren:Byant-WaughandLask1995Alternativeclassificationfortherangeofeatingdisordersofchildhood“Excessivepreoccupationwithweightorshapeand/orfoodintakewhichisaccompaniedbygrosslyinadequate,irregularorchaoticfoodintake”Byant-WaughandLask1995:CriteriaforAnorexiaNervosaFailuretomakeappropriateweightgains,orsignificantweightlossDeterminedweightloss(e.g.,foodavoidance,self-inducedvomiting,excessiveexercising,abuseoflaxatives).Abnormalcognitionsregardingweightand/orshape.Morbidpreoccupationwithweightand/orshape.RelatedEDBehaviorsinChildrenAnorexianervosaFoodavoidantemotionaldisorderSelectiveeatingFunctionaldysphagiaBulimianervosaPervasiverefusalsyndromeEarlybehavioralriskfactorsforEDsPICA–BNPickyEater–BN,someANDigestiveproblems–ANSubsyndromalsymptomsofEDscanpredateIncidenceandDemographicsAnorexiainthisagerangeisconsideredtoberare,butappearstobeincreasingMalesmayconstituteahigherproportionofcasesinchildhoodasopposedtoinadolescenceoradulthood19-30%ofchildhoodcases5-10%ofadolescentoradultcasesWHY?BiologicalGeneticsHigherrateofAN,BNandEDNOSinfirstdegreerelativesCross-transmittedHighheritabilityMedicationTrialssuggestserotoninanddopaminesystemscontributeImagingGordonetal,199715girlsages8-16withANRegionalcerebralbloodblowradioisotopescans13/15hadunilateraltemporallobehypoperfusionLasketal,2005significantassociationbetweenunilateralreductionofbloodflowinthetemporalregionandimpairedvisuospatialability,impairedvisualmemoryenhancedspeedofinformationprocessingPsychologicalPersonalitytraitsAnxiousObsessionalPerfectionisticSusceptibilityfactorsObsessionsPerfectionismSymmetryExactnessNegativeaffect,harmavoidancePreoccupationswithweight,bodyimageandfoodSOCIALPrognosisLongtermfollowupofpatientswithearlyonsetanorexianervosa(Bryant-Waughetal,1987)30childrenwithanorexianervosafollowedformeandurationof7.2yearsMeanageatonset11.7years19/30(60%)witha“good”outcome10/30remainedmoderatelytoseverelyimpairedPoorprognosticfactorsincludedEarlyageatonset(<11years)DepressionduringtheillnessDisturbedfamilylifeandoneparentfamiliesFamiliesinwhichoneorbothparentshadbeenmarriedbeforeTreatmentChallenges(especiallyfortheveryyoung)VerylittledataorliteratureontreatmentFewinpatientoroutpatientprogramsforkidsunder12or13yearsoldOnly1weareawareof.LittledataorclinicalexperienceFamilyTherapyFamilytherapyMaudsleyFamilyTherapySystemicFamilyTherapyFamilyTherapyRequiredwithAdolescentsMaudsleyFamilyTherapySystemicFamilyTherapyCouplesFamilyinvolvementtomotivateptfortreatment(caseexample)SystemicFamilyTherapyUnderlyingbelief:ifyoufixthesystem,thesymptomwillnolongerbeneeded.Theeatingdisorderisservingafunctioninthefamily.Thesymptombeareristryingtohelpthefamily(unconsciously).MethodsforSystemicFamilyTherapyCircularquestioningTherapistiscuriousobserver,notexpert.Discusscommunicationpatternswithinthefamily.Involveallfamilymembersinthediscussion,evensmallchildren.Donotpathologizefamilyorsymptombearer.MaudsleyFamilyTherapy“BehavioralFamilyTherapy”MaudsleyFamilyTherapyAgnostictowardetiologyInvolvesparents,ratherthanaparent-ectomyFoodismedicineInitialfocusonsymptomsParentsareresponsibleforweightrestoration.No