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

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

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

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

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 Obesity Prevalence: 1-6% Men & women affected equally Peak 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 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 148:1627-1637

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

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

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.

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.

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 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 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 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.

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

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

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

Translating New Science into Treatment: Cravings & Desire

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

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)

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

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

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 Precontemplation ↑ awareness Self reflection Maintenance Review Prevent relapse Contemplation Struggle pros & cons Preparation Plan &Visualise Implementation Action Do it Learn from mistakes

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. 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

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

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

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.