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Eating Disorders and Body Image

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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

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