1. Eating Disorders Professor Janet Treasure Guys Medical School www.eatingresearch.com www.eatingresearch.com Janet.treasure@kcl.ac.uk

2. Talk map Historical Framing Epidemiology An over view of causal factors A clinical case- a personal account of interactions with the environment Looking at causes in more depth

3. Historical Framing Of Eating Disorders 1600 1700 1860 2000 Saint Freak Illness 1979 Psychiatric Illness?

4. Spectrum of EDs Gull 1873 Lasegue 1873 Russell 1979 Volkow 2007 Purging Disorder Stunkard

5. Anorexia nervosa lifetime prevalence 0.5-2% Bulimia nervosa lifetime prevalence 2-4% Eating disorder not otherwise specified 2-10% (Hudson et al 2007, Jacobi et al 2001, Hay et al 2008)

6. Lifetime prevalence of BN in 3 cohorts of twins Kendler et al 1991 Am J Psych 148:1627- 1637 BN & BED ↑ >1950 Cohorts (Kendler 1991, Jacobi et al 2004, Wittchen et al 2005, Hudson et al 2007, Hay et al 2008). BN: Urban> rural (9:1) (Van Sohn et al 2006) BN: ↑ Westernised cultures (Keel & Klump 2003)

7. Time Trends in the Incidence of AN and BN in Primary Care in the UK Turnbull et al., 1996; Currin et al., 2004

8. Epidemiological questions? What has caused the emergence and rapid increase in bulimia nervosa and binge eating disorders in cohorts born since 1950? Why Western cultures? Why urban/rural risk?

9. The Fiji Experience Introduction of television and Western media imagery was followed by an increase in weight concerns & disturbed eating: (Becker et al., 2002)

10. Candidate cultural risk factors Size 0 culture & promotion of dieting. Vomiting/purging as a method of weight loss Easy access to high palatable food disembedded from social eating

11. However – what about AN? This culture change model does not explain AN Other factors play a role

12. My Story Melissa Wolfe

13. Eating Disorders and the Size Zero Phenomenon : My Story Size 0 and the media: not a cause – but a contributor Size 0 and the media: helping the illness to last Size 0 and the media: complicating recovery

14. Size 0 and the media: not a cause – but a contributor 1993 and the social context The causes of my eating disorder The wrong media message?

15. Size 0 and the media: not a cause – but a contributor “No obsessing about models (Beryl the Peril was no Kate Moss).” “Size zero hadn’t even made it over the Atlantic when I got ill”

16. The causes of my eating disorder No one cause but a complicated mixture of: Emotional factors My personality Social pressures Getting addicted

17. The wrong media message Glamorising anorexia Hiding the real cause

18. Size 0 and the media: helping the illness to last An enabling factor: arming the anorexic An enabling factor: arming the anorexia Behind size 0

19. An enabling factor “Ammunition. It’s a double whammy – it arms both the anorexia and the anorexic.”

20. Arming the anorexic “Size Zero normalises the abnormal. It helps you dismiss the concern”

21. Arming the anorexia “Anorexia preys on insecurity – size zero gives you an idea when you’re not sure where you’re heading..” “It thrives on perfectionism - size zero is a great example of a physical standard that you’ve failed to attain.”

22. Behind Size Zero “A dangerous mirage that makes anorexia all about vanity and fashion and superficial surface level things – when really it goes far deeper than that” “feeling belittled – ‘it’s all about vanity’ – just makes you want to shout even louder” "It means that people are looking at the wrong cause – and therefore providing the wrong treatment.”

23. Size 0 and the media: complicating recovery The reality of size 0 Fighting against the tide False Ideals

24. The reality of size 0 “It’s the loneliness that will get you. Not the hunger, or the worrying, or the rituals, or the paranoia. Not even the fear of getting fat. It’s the loneliness that’s the real killer. The longer you’re ill, the worse it is.”

25. The reality of size 0 “Osteoporosis. More common in the elderly. Diagnosed at 19. Hair growth. Like a gorilla. Cheeks, back, arms and stomach. Skin. Dry, grey, bleeds easily in cold weather. As do the lips. Internal organs. Wasted. They give way. You can’t control it”.

26. Fighting against the tide “A little taunt at every step of the way...”

27. False ideals “airbrushing is lying to a whole generation…. and they’re not likely to live up to it.”

28. Summary My eating disorder was not caused by the media Size 0 and the media helped maintain my illness Size 0 made it difficult to view recovery as a positive

29. Summary “my self esteem plummeted for 16 years and only began to re- emerge as I finally saw the eating disorder for what it was. And me for what I am.”

30. melissa@findingmelissa.co.uk www.findingmelissa.co.uk

31. Translational Treatments Understanding the underlying mechanisms. How does the environment interact with biology? Developing treatments that target factors that perpetuate illness

32. Bullet: Predisposing Factors Genes. Environment. Stress pregnancy/birth. Values re shape, eating. Teasing, bullying especially shape weight. Competition, comparison, expectations. Temperament Anxious. Low self esteem Enjoy structure, plans, rules and detail.

33. Events During Pregnancy  Life events and stress  Life events and stress –Shoebridge et al.,2000, –Favaro et al., Arch Gen Psychiatry 2006 –Hormones –  Male- female twins (Culbert et al 2008)

34. Teasing & critical comments about weight & shape & eating (Jacobi 2004, Fairburn 1997, Stice 2002, Taylor et al 2006 )

35. The role of Fathers

36. ED -paternal maladaptive behaviour (dose response relationship) mediated by low paternal identification. ( Johnson et al 2002) Fathers who highly value thinness can transmit this to daughters (Agras et al., 2007). Paternal teasing increase risk bulimia and was predictive of (male) sibling teasing (Keery et al., 2005).

37. Family, peers, responsible adults Food &/or weight salience Teasing, criticism-re body or eating Personal Attributes Negative Affect, Inhibition. Stress sensitivity Rigidity, perfectionism High weight concerns Internalisation of thin ideal Transla Environment Development Perinatal Adversity Stress Nutrition Anoxia Life events Loss Transitions Culture: Easy access to palatable food, loss of social eating, idealisation thinness. Infancy PubertyChildhood Genes The Biological Matrix

38. Triggers Weight loss. Extreme oscillations in food intake or energy expenditure. Chronic stress & negative affect. Values relating to weight/shape.

39. Risk x Environment: Perpetuating Factors Positive aspects. Values weight/shape. Family & other reactions. Negative Aspects Damage to brain-general & specific eg reward & appetite centres. Damage to body Damage to relationships with social isolation. 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.

40. A focus on perpetuating factors is helpful for treatment as they remain in action and can be remediated. The most effective forms of psychotherapy, CBT and motivational interviewing, family work focus on perpetuating factors.

41. Damage to the brain 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.

42. The Brain Needs 500 Kcal /day for running costs To facilitate plasticity and new learning. To develop new connections. To strengthen synaptic links. To develop long myelinated connections.

43. Lenroot and Giedd, 2006. Neurosci Biobehav Reviews 30:718-726. Nutritionally deprived brain at critical phase of development

44. Olsson A. The role of social cognition in emotion Trends in Cognitive Sciences 12 feb2008 Starvation impairs complex reflective tasks : Social cognition. Emotional recognition and regulation. Flexibility. The ability to see the bigger picture. Planning. Decision making.

45. Unhelpful behaviours Dysregulated emotion ↓ Reading emotion ↓ Emotional Attunement Worsen how they feel Lonely Isolated AN only friend Create or worsen problems ↓ intimacy ↓ quality of relationships Poor nutrition impairs aspects of social cognition Social problems: The Vicious Circle of impaired social cognition

46. Unhelpful behaviours Person with AN mirrors anxiety and anger Worsen how they feel Because of dysregulated emotional reaction Create or worsen problems Person with AN has poor Emotion regulation skill Because starvation damages this area. Person with AN observes anxiety and anger in others Social problems: The Vicious Circle of expressed emotion

47. Reward Reactivity Food reward centres become disrupted by intermittent oscillations of food intake on a deprived background

48. 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).

49. 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).

50. 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)

51. Prevention Offspring of ED mothers High Weight and shape concerns Fashion Industry

52. 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.

53. Help Required We are always needing to have people with and without an eating disorder history to help with our research into understanding causes of eating disorder and how to treat them please get in touch if you can help. Janet.treasure@kcl.ac.uk

54. At present there seems to be a lot of media and research interest in the deleterious effects of (airbrushed) media images of thin women on girls' self esteem and the possible development of EDs (as based upon the hypothesis that these images cause body dissatisfaction and disordered eating or full blown EDs) - however (unless I looked in the wrong place...) I could find little published research about the dangers of constant bombardment of children with messages about 'healthy eating/exercise'. I, for one, have never felt affected by media images of thin women and my AN was not caused by body shape dissatisfaction, but I was very vulnerable to media/educational messages about 'healthy living' and obesity.

55. A big part of my AN was about seeking control, routine and meaning in a chaotic and confusing world where I felt I didn't fit socially. I used anorexic behaviours to regulate my world - even create my own, personal, comprehensible world. As a child I took media messages about healthy eating and exercise (which were just emerging in the early 1980s) too literally and operated on the basis of 'more is better' and engaged in a lot of categorising foods by their calorie, fat, protein, carbohydrate and fibre content. I made lists of 'good' and 'bad' foods. I made lists of everything I would eat every day at certain times and ticked the food off the list when I had consumed it. This provided me with an illusory sense of control in my life and reduced my anxiety.