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

2. Overview Introduction-the range of eating disorder.
Update on Aetiology.
Evaluating risk.
Vocational and social functioning.
A summary evidence about change.

3. Spectrum of EDs Russell 1979 Gull 1873 Volkow 2007 Lasegue 1873
Binge-purging AN
Restricting AN
Purging Disorder
Purging BN
Non-purging BN
Simple obesity
Binge-eating
Russell 1979
Gull 1873
Lasegue 1873
Volkow 2007
Stunkard

4. The Comorbidity of eating disorders
Obesity
ADHD
Addiction Spectrum
Obsessive
Compulsive
Spectrum
Anxiety
E.g. social phobia
Anorexia
Nervosa
EDNOS
Bulimia
Nervosa
EDNOS
BED
Autistic
Spectrum
Disorders
Affective disorders
Bipolar
Spectrum
The Comorbidity of eating disorders

5. 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.

6. 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

7. Binge Eating Disorder: History
1994 DSM-IV: category deserving further study
Recurrent distressing binges
No food restriction
No compensatory behaviours
Obesity
Prevalence: 1-6%
Men & women affected equally
Peak age onset: and early 20s
I spent all my time thinking of food. I would wake in the night and want to eat

8. Lifetime prevalence of BN in 3 cohorts of twins
Epidemiology
Binge 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)
Kendler et al 1991 Am J Psych 148:

9. Eating Risk Factors Transla
Culture: Easy access palatable food, loss of social eating, idealisation thinness.
Perinatal
Adversity
Stress
Nutrition
Anoxia
Family & Peer Factors
Food & weight salience
Parental weight
Teasing, criticism-”shapism”
Life events
Loss
Pudicity
Transitions
Environment
Genetic risk
Gender
Appetite
Reward
stress
Personal Attributes
Negative Affect, poor emotional regulation. Stress sensitivity
Rigidity, weak central coherence
Coping strategies: avoidance, impulsivity, compulsivity, addictions
High weight concerns
Internalisation of thin ideal
Development

10. Eating Risk Factors Transla
Culture: Easy access palatable food, loss of social eating, idealisation thinness.
Perinatal
Adversity
Stress
Nutrition
Anoxia
Family & Peer Factors
Food & weight salience
Parental weight
Teasing, criticism-”shapism”
Life events
Loss
Pudicity
Transitions
Environment
Genetic risk
Gender
Appetite
Reward
stress
Personal Attributes
Negative Affect, poor emotional regulation. Stress sensitivity
Rigidity, weak central coherence
Coping strategies: avoidance, impulsivity, compulsivity, addictions
High weight concerns
Internalisation of thin ideal
Development

11. Four Maintaining Factors AN
Emotional style
Thinking Style
Interpersonal
Factors
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.

12. Four Maintaining Factors AN
Emotional style
Thinking Style
Interpersonal
Factors
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.

13. Poor Emotional Intelligence
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 )
↓ 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)

14. 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)

15. Four Maintaining Factors AN
Emotional style
Thinking Style
Interpersonal
Factors
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.

16. Information processing biases
Obsessive compulsive traits.
Weak coherence.
Weak flexibility.

17. Detail vs. Global Imbalance
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

18. Rigidity Once a rule is learned it is difficult to shift.
.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, 2006
Roberts et al 2007

19. Translating New Science into Treatment: Cravings & Desire

20. Subjective State of Desire
Cognitive- Emotional Theory of Desire: Kavanagh et al 2005
Food Cues
Salivation etc
Associated
Thoughts
Food Craving
Intrusive food thoughts. Imaging the smell, taste, appearance, mouth and stomach feel of food
Pleasure
Relief
Sense of
Deficit
Subjective State of Desire
Negative
Affect
Hunger
Automatic
Attentional awareness

21. How can desire for food be disrupted?

22. 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).

23. 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).

24. 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)

25. Subjective State of Desire
Cognitive- Emotional Theory of Desire: Kavanagh et al 2005
Food Cues
Salivation etc
Associated
Thoughts
Food Craving
Intrusive food thoughts. Imaging the smell, taste, appearance, mouth and stomach feel of food
Pleasure
Relief
Sense of
Deficit
Subjective State of Desire
Negative
Affect
Hunger
Automatic
Attentional awareness

26. Subjective State of Desire
Cognitive- Emotional Theory of Desire: Kavanagh et al 2005
Food Cues
Salivation etc
Associated
Thoughts
Food Craving
Intrusive food thoughts. Imaging the smell, taste, appearance, mouth and stomach feel of food
Pleasure
Relief
Sense of
Deficit
Reward sensitisation
Subjective State of Desire
Negative
Affect
Hunger
Automatic
Attentional awareness

27. 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.

28. 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.

29. Matching Process to Readiness. The Cycle of Change
Precontemplation
↑ awareness
Self reflection
Maintenance
Review
Prevent relapse
Contemplation
Struggle pros & cons
Preparation
Plan &Visualise
Implementation
Action
Do it
Learn from mistakes

30. 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.

31. What is the Health and Psychosocial Burden?

32. 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).

33. 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.

34. 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.

35. 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.

36. 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.

37. WWW.eatingresearch.com-health professionals

38. 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.

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

40. 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.
A motivational interviewing approach can help with patient's ambivalence about change
Guide the patient to an expert resource outlining the long-term effects of starvation, nutrition advice and general information about eating disorders.
Counseling about other issues -e.g., relationship problems, perfectionist, rigid and anxious traits.
Target the risk & maintaining factors: information processing traits, interpersonal factors, pro- ED beliefs

41. Cochrane systematic reviews: AN
Outpatient
psychotherapy
Specific >non specific
Hay et al 2008
Antidepressants
Little effect
Claudino et al 2006
Family therapy
In progress
Fisher et al 2008
Antipsychotics
Claudino et al

42. Cochrane systematic reviews: BN
Outpatient
psychotherapy
CBT large
Hay et al 2003
Antidepressants
CBT Large effect
Bacaltchuk 2003
Antidepressants & therapy
Large effects
Bacaltchuk 2001
Self help
Small effect
Perkins 2006

43. 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.

44. 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.