Prof. Janet Treasure Prof. Janet Treasure Eating Disorders An Overview for the General Psychiatrist.

Prof. Janet Treasure www.eatingresearch.co

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Eating Disorders An Overview for the General Psychiatrist

Overview

• Introduction-the range of eating disorder.

• Update on Aetiology.• Evaluating risk.• Vocational and social

functioning.• A summary evidence

about change.

Spectrum of EDs

Increasing tendency to fatness

Gull 1873Lasegue 1873

Russell 1979 Volkow 2007

Purgi

ng D

isord

er

Stunkard

ADHD

Obsessive Compulsive

Spectrum

Autistic SpectrumDisorders

Addiction Spectrum

Anxiety E.g. social phobia

Bipolar Spectrum

Affective disorders

AnorexiaNervosa

EDNOSBulimiaNervosa

Obesity

EDNOSBED

The Comorbidity of eating disorders

Anorexia Nervosa• Illness defined 1860• Teenage onset• Avoid eating• Excess exercise • High mortality (up to 20%)

& disability

I had a voice in my head that criticised me. It told me I was

dreadful and did not deserve food. It became harder to ignore the voice.

Bulimia nervosa• 1979: Defined by Russell • Core Behaviours: Binge

>1000cal out of control• Compensatory Behaviours

eg Vomit, laxatives, exercise, drugs

• Teenage onset• 2-4% of population

I used to go to the kitchen and eat as much as I could as quickly as possible to

fill the hole I felt inside. I felt horrid afterwards and would make myself sick

Binge Eating Disorder: History• 1994 DSM-IV: category

deserving further study• Recurrent distressing binges• No food restriction• No compensatory behaviours• ObesityPrevalence: 1-6%• Men & women affected equallyPeak age onset: 13-15 and early

20s

I spent all my time thinking of food. I would wake in the night and want to eat

Lifetime prevalence of BNin 3 cohorts of twins

Kendler et al 1991 Am J Psych 148:1627-1637

EpidemiologyBinge form of Eating Disorders• BN: F=1.5%, BED & EDNOS

5% ↑ >1950 Cohorts(Kendler 1991, Jacobi et al 2004, Wittchen et al 2005, Hudson et al 2007, Hay et al 2008).

Anorexia Nervosa • AN F =2%, M=0.5% (Keski et al 2007)

BN: Urban> rural (9:1) (Van Sohn et al 2006) BN: ↑ Westernised cultures (Keel & Klump 2003)

Genetic riskGenderAppetiteRewardstress

Family & Peer FactorsFood & weight salience Parental weightTeasing, criticism-”shapism”

Personal AttributesNegative Affect, poor emotional regulation. Stress sensitivityRigidity, weak central coherence Coping strategies: avoidance, impulsivity, compulsivity, addictionsHigh weight concernsInternalisation of thin ideal

Transla Eating Risk Factors

Environment

Development

PerinatalAdversityStressNutritionAnoxia

Life eventsLoss PudicityTransitions

Culture: Easy access palatable food, loss of social eating, idealisation thinness.

Genetic riskGenderAppetiteRewardstress

Family & Peer FactorsFood & weight salience Parental weightTeasing, criticism-”shapism”

Personal AttributesNegative Affect, poor emotional regulation. Stress sensitivityRigidity, weak central coherence Coping strategies: avoidance, impulsivity, compulsivity, addictionsHigh weight concernsInternalisation of thin ideal

Transla Eating Risk Factors

Environment

Development

PerinatalAdversityStressNutritionAnoxia

Life eventsLoss PudicityTransitions

Culture: Easy access palatable food, loss of social eating, idealisation thinness.

Four Maintaining Factors AN

Thinking Style

InterpersonalFactors

Emotional style

Pro AN thinking

Schmidt U, Treasure J. Anorexia Nervosa: Valued and Visible. A Cognitive-Interpersonal Maintenance Model and its Implications for Research and Practice. Br.J.Clin.Psychol. 2006;45:1-25.

Four Maintaining Factors AN

Thinking Style

InterpersonalFactors

Emotional style

Pro AN thinking

Schmidt U, Treasure J. Anorexia Nervosa: Valued and Visible. A Cognitive-Interpersonal Maintenance Model and its Implications for Research and Practice. Br.J.Clin.Psychol. 2006;45:1-25.

Feelings not food• ED “full of feelings” and not physically full:

sadness, inadequacy, rejection, guilt are too uncomfortable to sit with.

• ED has +ve effects by purge or producing numbness

• High threat sensitivity. Intolerance uncertainty

↓ emotional awareness (Pietura et al 2005, Zonnevijlle-Bender, 2002, 2004, Lane et al 2005, Wallis et al 2008,Russell et al 2008, Oldershaw et al 2009 )↓ emotional regulation (Nock et al 2008; Gilboa-Schechtman 2006, Harrison et al 2008, Holliday et al 2006)Alexythymia: (Schmidt et al 1993)↓ Decision making (Cavendini et al , Tchanturia et al 2007, Liau et al 2008)

Poor Emotional Intelligence

Poor Social comparison

Neurodevelopmental Model: chronic stress of a interpersonal type (Connan et al 2003)

High submissive behaviours, poor social comparison (Connan et al., 2007, Troop et al., 2008, Troop et al., 2003).

Attentional bias to social cues (Harrison et al 2008)

Social Phobia (Godart et al., 2003, Halmi et al., 1991)

Social inferiority & striving (Bellew et al 2006)

Negative self evaluation (Fairburn et al 1998,1999, Jacobi 2003)

Four Maintaining Factors AN

Thinking Style

InterpersonalFactors

Emotional style

Pro AN thinking

Schmidt U, Treasure J. Anorexia Nervosa: Valued and Visible. A Cognitive-Interpersonal Maintenance Model and its Implications for Research and Practice. Br.J.Clin.Psychol. 2006;45:1-25.

Information processing biases

• Obsessive compulsive traits.

• Weak coherence.• Weak flexibility.

• Inability to see bigger picture i.e. Not seeing the wood for the trees.

• Heightened perceptual awareness.

• Analytical, detailed focus.

• Difficulty extracting gist.

Lopez et al 2008a, 2008b, 2008c, 2008d

Detail vs. Global Imbalance

• .Difficulty in changing cognitive set.

• Once a rule is learned it is difficult to shift.

• Mastery at adhering to laws of thermodynamics.

• Linked to childhood OCPD features

Tchanturia et al 2005, 2006Roberts et al 2007

Rigidity

Translating New Science into Treatment: Cravings & Desire

Food Craving Intrusive food thoughts. Imaging the smell, taste, appearance, mouth and stomach feel of food

Sense of Deficit

PleasureRelief

Food Cues Salivation etc Associated Thoughts

Negative Affect

Hunger

Subjective State of Desire

AutomaticAttentional awareness

Cognitive- Emotional Theory of Desire: Kavanagh et al 2005

How can desire for food be disrupted?

Animals models of binge eating

• A period of under nutrition.

• Divert food stomach • Intermittent availability

of highly palatable food• Stress. • Breeding (Rada et al 2005, Lewis et al 2005,

Avena et al 2005, Corwin 2006, Corwin & Hajnal 2005, Boggiano et al 2005; Avena & Hoebel 2003, Avena & Hoebel 2007, Boggiano et al 2007).

Animals models of binge eating(these animals also become addicted to other

substances eg amphetamine) • A period of under

nutrition.• Divert food stomach • Intermittent availability

of highly palatable food• Stress. • Breeding (Rada et al 2005, Lewis et al 2005,

Avena et al 2005, Corwin 2006, Corwin & Hajnal 2005, Boggiano et al 2005; Avena & Hoebel 2003, Avena & Hoebel 2007, Boggiano et al 2007).

Human models of binge eating• A period of under nutrition (Size 0 culture & promotion of dieting).

• Divert food stomach (Vomiting as compensatory method)

• Intermittent availability of highly palatable food

(Easy access to food disembedded from social eating)

Food Craving Intrusive food thoughts. Imaging the smell, taste, appearance, mouth and stomach feel of food

Sense of Deficit

PleasureRelief

Food Cues Salivation etc Associated Thoughts

Negative Affect

Hunger

Subjective State of Desire

AutomaticAttentional awareness

Cognitive- Emotional Theory of Desire: Kavanagh et al 2005

Food Craving Intrusive food thoughts. Imaging the smell, taste, appearance, mouth and stomach feel of food

Sense of Deficit

PleasureRelief

Food Cues Salivation etc Associated Thoughts

Negative Affect

Hunger

Subjective State of Desire

AutomaticAttentional awareness

Cognitive- Emotional Theory of Desire: Kavanagh et al 2005

Reward sensitisation

Opening Moves

• Normalise ambivalence about attendance. Who is the prime mover, peers, self, line manager?

• Elicit readiness to change.• Elicit concerns: physical, psychological,

spiritual, family, social, education/career, forensic.

• Assess medical risk.• Ethical responsibility: Discuss issues of

confidentiality. If high risk need to involve others, professionals.

Opening Moves

• Normalise ambivalence about attendance. Who is the prime mover, peers, self, line manager?

• Elicit readiness to change.• Elicit concerns: physical, psychological,

spiritual, family, social, education/career, forensic.

• Assess medical risk.• Ethical responsibility: Discuss issues of

confidentiality. If high risk need to involve others, professionals.

Matching Process to Readiness.The Cycle of Change

ActionDo it

Learn from mistakes

PreparationPlan &Visualise Implementation

ContemplationStruggle pros & cons

Precontemplation↑ awarenessSelf reflectionMaintenance

ReviewPrevent relapse

Opening Moves

• Normalise ambivalence about attendance. Who is the prime mover, peers, self, line manager?

• Elicit readiness to change.• Elicit concerns: physical, psychological,

spiritual, family, social, education/career, forensic.

• Assess medical risk.• Ethical responsibility: Discuss issues of

confidentiality. If high risk need to involve others, professionals.

What is the Health and Psychosocial Burden?

What is the Health and Psychosocial Burden?

• ↑ Morbidity (Johnson et 2002, Striegel Moore et al 2003,Patton et al 2008).

• Education: interruptions and lower level for AN. (Byford et al 2007).

• Vocational: 21% on state benefits (Hjern et al 2006).

• Social networks small (Tiller et al 1997).• Communication Skills impaired (Takahasi et al

2006).• Carers high burden and distress (Treasure et al

2001).

Opening Moves

• Normalise ambivalence about attendance. Who is the prime mover, peers, self, line manager?

• Elicit readiness to change.• Elicit concerns: physical, psychological,

spiritual, family, social, education/career, forensic.

• Assess medical risk.• Ethical responsibility: Discuss issues of

confidentiality. If high risk need to involve others, professionals.

Is there binge eating?

• There is often secrecy about the pattern of food intake and the various compensatory strategies.

• Other addictive and antisocial behaviours can also be present.

Physical Signs

· Parotid or submandibular gland enlargement.

· Eroded teeth.· "Russell's sign" callus on back of hand.

· Cold blue hands, nose and feet.

· Lanugo hair.

What is the Risk?The Brief Medical Risk Assessment

www.eatingresearch.com• Skeletal power to examine for myopathy

which is a good marker of severity.• Blood pressure and HR to measure

cardiac function and circulation. The fall in BP between sitting & standing & dizziness is a measure of dehydration.

• Core temperature- level of metabolism.

WWW.eatingresearch.com-health professionals

Opening Moves

• Normalise ambivalence about attendance. Who is the prime mover, peers, self, line manager?

• Elicit readiness to change.• Elicit concerns: physical, psychological,

spiritual, family, social, education/career, forensic.

• Assess medical risk.• Ethical responsibility: Discuss issues of

confidentiality. If high risk need to involve others, professionals.

•High risk carers statutory roles •Carers needs- distress, burden, confusion•Carers in matrix of maintenance

How to Manage Eating Disorders:

1. Help move the patient into the position where they are interested in considering change – eg discussing the pros and the cons of their behaviour.

2. A motivational interviewing approach can help with patient's ambivalence about change

3. Guide the patient to an expert resource outlining the long-term effects of starvation, nutrition advice and general information about eating disorders.

3. Counseling about other issues -e.g., relationship problems, perfectionist, rigid and anxious traits.

4. Target the risk & maintaining factors: information processing traits, interpersonal factors, pro- ED beliefs

Cochrane systematic reviews: AN

Outpatientpsychotherapy

Specific >non specific

Hay et al 2008

Antidepressants Little effect Claudino et al 2006

Family therapy In progress Fisher et al 2008

Antipsychotics In progress Claudino et al

Cochrane systematic reviews: BN

Outpatientpsychotherapy

CBT large Hay et al 2003

Antidepressants CBT Large effect

Bacaltchuk 2003

Antidepressants & therapy

Large effects Bacaltchuk 2001

Self help Small effect Perkins 2006

Technology: Guided Self Help

• Education and skills based self help.

• Books• DVDs• Web based programmes –

offer interactive element

Treasure, J. (1997). Anorexia Nervosa. A Survival Guide for Sufferers and Those Caring for Someone with an Eating Disorder. Psychology Press, Hove, Sussex. Schmidt U, Treasure J. (1993) Getting Better Bit(e) by Bit(e). A survival kit for sufferers of bulimia nervosa and binge eating disorder Brunner-Routledge. Treasure J, Smith G, & Crane A 2007, Skills-based Learning in Caring for a Loved One with an Eating Disorder: The new Maudsley Method. Routledge.

Conclusion• A spectrum of eating disorders now exist.• The risk of binge eating disorders has increased

for cohorts born after 1950.• Cognitive, emotional and physical factors can

impact on vocational functioning.• Engagement into treatment can be difficult for

AN. • Guided self care is a useful first step. • Good results for psychotherapy BN –majority AN

now manage out of hospital.