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Eating Disorders and Body Image

Eating Disorders and Body Image. Dr Vicki Mountford SLaM NHS Foundation Trust vicki.mountford@kcl.ac.uk. Overview. SLaM Eating Disorder Service Definitions diagnoses transdiagnostic approach Incidence and prevalence Causes and maintaining factors Models of the eating disorders

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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 vicki.mountford@kcl.ac.uk

  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 • 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 18-20 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 • 0.5-1.0% 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, 132-135 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 ofthe 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: • 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. Atypical (EDNOS) • Follow guidance most closely resembling pts presentation • Level A evidence for CBT-BN & CBT-BED only 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 • Fairburn et al. (1995) • 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 anorexiaWhere 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, 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

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