1. Eating Disorders and Body Image
Dr Vicki Mountford
SLaM NHS Foundation Trust

2. Overview SLaM Eating Disorder Service Definitions
diagnoses
transdiagnostic approach
Incidence and prevalence
Causes and maintaining factors
Models of the eating disorders
Treatments and outcomes
Body image
June 2010

3. Population 2 million:

4. Eating Disorder Service SLAM:
Day-Care
9 places
Inpatient Unit
Guy’s Hospital
Tertiary Outpatients
18 beds
Maudsley Hospital
Adult Outpatients
Hostel
11 residents

5. Definitions
June 2010

6. Diagnosis (DSM-IV, 1994) Anorexia nervosa Subtypes
A. Refusal to keep body weight above minimal healthy level (e.g., 85% of expected weight)
B. Fear of weight gain
C. Disturbance of body experience
D. Amenorrhea x 3 consecutive cycles (or comparable hormonal disturbance)
Subtypes
restricting
binge-eating/purging subtypes
June 2010

7. Diagnosis (DSM-IV, 1994) Bulimia nervosa
A. Recurrent episodes of binge-eating
(large amount of food; sense of lack of control)
B. Compensatory behaviours
(vomiting, diuretics, laxatives, speed, fasting, exercise)
C. Bingeing & compensation happen twice per week over at least 3 months
D. Self-evaluation is unduly influenced by body shape & weight
E. Not simply a phase of anorexia
Purging and non-purging subtypes
June 2010

8. Diagnosis (DSM-IV, 1994)
Eating Disorders Not Otherwise Specified (EDNOS)
Atypical bulimia nervosa
Atypical anorexia nervosa
Binge eating disorder
Chew and spit
Purging disorder
Disorders more common in child cases
food avoidance emotional disorder
food faddiness
June 2010

9. Does the diagnostic system work?
What do we know about current diagnostic categories?
It does not do what it should
40-50% of cases do not fit neatly into diagnoses
atypical cases (EDNOS) are the largest group, & they are comparable in severity to BN (Fairburn et al., 2007)
many fail to stay in one diagnosis (Milos et al., 2005)
June 2010

10. DSM V
Change should be conservative to minimise disruption & potential loss of established knowledge
Current limitations, e.g.
Amenorrhea
Criteria – such as twice weekly bingeing for BN
Binge eating disorder
Two EDNOS subgroups (Fairburn)
Those that closely resemble AN/BN but just fail to meet criteria
‘Mixed’, in which clinical features are present but combined in a different way to AN/BN
June 2010

11. DSM V – potential solutions
Fairburn & Bohn (2005) 3 potential solutions;
Relax the diagnostic criteria for AN & BN
Drop amenorrhea criteria
‘core psychopathology’ redefined to include o/e of controlling eating without shape/weight concerns
Reclassifying EDNOS
A new diagnostic category ‘mixed ED’
The transdiagnostic solution
Create a single unitary ED diagnostic category
June 2010

12. Transdiagnosis Some have proposed a shift away from rigid diagnoses
transdiagnostic model (Waller, 1993; Fairburn et al., 2003)
focus on symptoms and cognitions
Some argue that anorexia is a distinct illness and should be treated so
Cognitive interpersonal model (Schmidt & Treasure)
Palmer, Touyz
June 2010

13. Incidence and Prevalence
June 2010

14. How common are the eating disorders?
All figures are taken from westernized cultures
similar across countries
Peak age of onset is slightly younger in anorexia
14-16 years vs years
but many cases are younger or older
Female:male ratio
approximately 20:1
June 2010

15. How common are the eating disorders?
Prevalence
Number of cases in the population at any one time
Anorexia nervosa
% of teenage girls
Bulimia nervosa
1-2% of women aged 16-35
EDNOS
2-3% of women aged 16-35
June 2010

16. How common are the eating disorders?
Incidence
Number of new cases in a year
Anorexia nervosa
21 new cases per 100,000 population
Bulimia nervosa
30 new cases per 100,000 population
EDNOS
Similar to bulimia nervosa?
not known yet
June 2010

17. Are the eating disorders on the increase?
Currin, Schmidt, Treasure, & Jick (2005). Time trends in eating disorder incidence. British Journal of Psychiatry, 186,
June 2010

18. What does this result tell us?
That new cases of bulimia were identified by GPs more in the 1990’s
while anorexia nervosa rates were stable
That its increase in incidence faded thereafter
Not clear that this reflects a real increase
labelled the ‘Diana effect’ in the press
June 2010

19. Causes and maintaining factors
June 2010

20. Is there a single cause of the eating disorders?No
There are multiple factors that converge on two key elements
low self-esteem
high levels of perfectionism
These contribute to a need for control
focused on eating, weight and shape
due to psychosocial factors
social/cultural expectations, media images, teasing, social comparison with others appearance and behaviours, etc.
June 2010

21. Risk factors General Western culture Female Adolescent/young adult
Biological
Genetic predisposition?
various findings, but none have been replicated
Neuropsychology
Central coherence, set shifting (Tchanturia)
June 2010

22. Risk factors Family history of: Experiences Depression
Substance/alcohol abuse
Eating disorder
Obesity
Chronic dieting
Experiences
Poor parenting (invalidating environment)
Abuse
Critical comments re eating, shape and weight
Pressures to be slim (e.g., ballet, gymnastics)
June 2010

23. Risk factors Individual characteristics Low self-esteem Perfectionism
Anxiety problems
Obesity
Early menarche
June 2010

24. What do we know about what works?
June 2010

25. What does NICE say? NICE guidelines (2004)
Anorexia nervosa
Can consider Cognitive Analytic Therapy (CAT), Cognitive Behaviour Therapy (CBT), Interpersonal Therapy (IPT), focal psychodynamic therapy & family interventions
Bulimia nervosa
Can consider guided self help (GSH), CBT-BN, IPT.
Binge eating disorder
GSH, CBT-BED
June 2010

26. Nice Recommendations www. NICE. org
Atypical (EDNOS)
Follow guidance most closely resembling pts presentation
Level A evidence for CBT-BN & CBT-BED only
Level "A"
Level "B”
Level "C" AN 1 49 BN 7 9
BED 2 5
EDNOS
Nice Recommendations www. NICE. org

27. Evidence-based psychological therapies for bulimic problems
Similar for bulimia nervosa & binge-eating disorder
Cognitive-behavioural therapy
most effective/fastest to outcome
Fairburn et al. (1995)
Interpersonal psychotherapy
Dialectical-behaviour therapy
Safer et al. (2001)
Structured, short-term focal psychotherapy with a behavioural element
Murphy et al. (2005)
June 2010

28. Outcome of therapy: Bulimia nervosa (Fairburn et al., 1995)
June 2010

29. Outcome of CBT for bulimic disorders
Individualized CBT
Driven by individual formulations
Ghaderi (2006)
Waller et al. (2006)
Similar effects for atypical bulimic disorders
June 2010

30. What about those for whom it doesn’t work?
Just under half (Fairburn et al. 2009)
? More complex, multi impulsive presentation
CBT-Eb (enhanced – broad) targets additional problems – mood intolerance, perfectionism, low self-esteem, interpersonal difficulties
NOURISHED: Multi-Centre RCT of Mentalisation-Based Therapy and SSCM in ED patients with borderline traits (Robinson, Fonagy, Bateman, Schmidt et al.)
June 2010

31. NICE guidelines for anorexia Where are we 6 years later?
2004 – No evidence for adult anorexia above Level C (expert opinion)
Things have moved on...
June 2010

32. Comparison of CBT, IPT & Specialist Supportive Clinical Management in AN (n=56)
Proportion of Patients with Good Outcome
Drop-out rates:
IPT: 43%, CBT: 37%,
SSCM: 31%
McIntosh et al. (2005) Am J Psych

33. Current & future research
MANTRA: Pilot RCT of SSCM and Maudsley Model of AN treatment (Schmidt, Startup, Tchanturia, Treasure)
MOSAIC: Multi-centre RCT of SSCM and Maudsley Model of AN treatment (Schmidt, Startup, Tchanturia, Treasure)
A randomised control trial of nonspecific supportive clinical management (NSCM) versus cognitive behaviour therapy (CBT) in long standing anorexia nervosa (Touyz, LeGrange, Lacey & Hay)
Psychological therapies for anorexia nervosa: What works for whom and does patient choice matter (beat, Waller & Mountford)
SWAN: Australia. CBT-E, SSCM and MANTRA in AN
ANTOP: Germany. CBT-E, psychodynamic psychotherapy and TAU.

34. What about the other eating disorders?
Previously, a lack of good evidence for most atypical cases (except BED)
More researchers now including this group
Not significantly different from ‘full’ syndrome cases in terms of severity
Eg Fairburn; Schmidt
June 2010

35. Treatment
June 2010

36. Physical needs are a priority
Re-feeding for nutritional deficits
Risk assessment
Rapid course of weight loss
High levels of purging
Medication
some impact of SSRIs on bulimic symptoms
June 2010

37. Key issues in psychological treatment of eating disorders
Ambivalence & motivation
To be expected due to ego-syntonic nature of disorder
Fluctuates throughout treatment
Work with it, not against it
Stage of Change Model
Need for behavioural as well as cognitive & emotional change
Reduction in behaviours, normalisation of weight
June 2010

38. Key issues in psychological treatment of eating disorders
Over evaluation of eating, shape and weight
The core maintaining mechanism
Needs to change to reduce risk of relapse
Treating the person as an individual, not just the eating disorder
Change may be slow and individuals may need more than one treatment episode
June 2010

39. Treatment setting & format
Out patient, day care (partial hospitalisation), in patient
Individual therapy or group work
Self-help
guided is better
using technological developments
internet, CD, text messages
June 2010

40. Cognitive behaviour therapy (CBT)
CBT focuses on the principle that our perception of ourselves, the world & our future shape our emotions and behaviour.
Proposes that among people with psychological disturbance (e.g., dep, anx, EDs), thinking is often distorted or dysfunctional, leading to distress & unhelpful behaviours.
CBT works with individual to challenge & modify thoughts and change behaviours.
June 2010

41. Outline of CBT for the eating disorders
Engagement
Motivation
Psychoeducation
Formulation
Self-monitoring
food diaries; emotion diaries; regular weighing
Cognitive restructuring
Behavioural experiments
Relapse prevention
June 2010

42. CBT-E Enhanced CBT, a specific form developed by Chris Fairburn.
Transdiagnostic but underweight pts get 40 sessions
A focused and broad version (perfectionism, mood intolerence, interpersonal difficulties, self esteem)
Overevaluation of E, S, W.
June 2010

43. MANTRA Maudsley Model of Anorexia Nervosa Treatment for Adults
Developed by Ulrike Schmidt & Janet Treasure
20 session workbook based Rx
Uses a motivational interviewing stance
Covers risk management, formulation, nutrition,
Complete slide
June 2010

44. Specialist Supportive Clinical Management (SSCM)
Developed by Virginia McIntosh & NZ team
Combines features of good clinical management & supportive psychotherapy
Includes education, care and support
Provides information on normal eating habits and weight restoration.
Sessions are patient led.
June 2010

45. Body Image

46. What is body image? Many definitions exist
‘a person’s perceptions, thoughts, feelings and behaviours about his or her body’
Multi-faceted & interlinked
What we see (perceptual)
What we think (cognitive)
How we feel (emotional)
What we do (behavioural)
Attitudes gathered throughout life and influenced by others
June 2010

47. What is body image dissatisfaction?
‘a person’s negative thoughts and feelings about his or her body’
Usually involves a perceived discrepancy between a person’s evaluation of his/her body and their ideal body
June 2010

48. Body image in the eating disorders
Disturbance is not always present or invariant
Three types
disturbance of body percept
the patient sees a grossly distorted view of their body
disturbance of body concept
the patient may or may not have an accurate perception, but is dissatisfied with what they see
fear of fatness
an image of the body as being potentially out of control, where the patient is petrified of becoming overweight
June 2010

49. Cognitive behavioural treatment of disturbed body image
Assessment & formulation
Psychoeducation
Functions of the body
Set point hypothesis
Cognitive restructuring
Cognitive challenging
Behavioural experiments
Practical steps
Alternative perspectives
Imagery
June 2010

50. Future directions
Continued development of psychological therapies for BN/EDNOS-BN Eg, CBT, DBT, MBT
To improve existing outcomes & move into everyday clinical practice
Treatment outcomes for AN
Matching therapy to individual
So individual gets offered most effective Rx for their difficulties
Continue work with carers
Determine Rx effects generalise across settings
Alternative models of care – rehab, day services
June 2010

51. References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington: American Psychiatric Association.
Dare, C., Eisler, I, Russell, G., Treasure, J. & Dodge, L. (2001). Psychological therapies for adults with anorexia nervosa; randomised control trial of outpatient treatments. Br J Psychiatry 178,
Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders. Lancet, 361,
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A ‘transdiagnostic’ theory and treatment. Behaviour Research and Therapy, 41,
Fairburn, C. G., Norman, P. A., Welch S. L., O’Connor, M. E., Doll, H. A., & Peveler, R. C. (1995). A prospective outcome study in bulimia nervosa and the long-term effects of three psychological treatments. Archives of General Psychiatry, 52,
Ghaderi, A. (2006). Does individualization matter? A randomized trial of standardized (focused) versus individualized (broad) cognitive behavior therapy for bulimia nervosa. Behaviour Research and Therapy, 44,
June 2010

52. References
McIntosh, V., Jordan, J., Carter, F., Luty, S., McKenzie, J., Bulik, C., Frampton, C. & Joyce, P. (2005). Three psychotherapies for anorexia nervosa: a randomized controlled trial. Am J Psychiatry, 162,
Murphy, S., Russell, L., & Waller, G. (2005). Integrated psychodynamic therapy for bulimia nervosa and binge eating disorder: Theory, practice and preliminary findings. European Eating Disorders Review, 13,
National Institute for Clinical Excellence (2004). Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders (Clinical Guideline 9). London: National Collaborating Centre for Mental Health.
Serfaty, M., Turkington, D., Heap, M., Ledsham, L & Jolley, E. (1999). Cognitive therapy versus dietary counselling in the outpatient treatment of anorexia: effects of the treatment phase. Eur Eat Dis Rev, 7,
Vitousek, K. B. (1996). The current status of cognitive behavioural models of anorexia nervosa and bulimia nervosa. In P. M. Salkovskis (Ed.) Frontiers of cognitive therapy. (pp ). New York: Guilford.
Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V. & Russell, K. (2007). Cognitive behavioural therapy for eating disorders: A comprehensive treatment guide. Cambridge; Cambridge University Press.
June 2010

53. References
Waller, G. (2009). Recent advances in therapies for the eating disorders. F1000 Medicine Reports, 1:38
June 2010