Eating Disorders

1. Eating Disorders Professor Janet Treasure Guys Medical School 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 1979 Psychiatric Illness? Freak Saint Illness

4. Spectrumof EDs Binge-purging AN Restricting AN Purging BN Purging Disorder Non-purging BN Simple obesity Binge-eating Russell 1979 Gull 1873 Lasegue 1873 Volkow 2007 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 BNin 3 cohorts of twins 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) Kendler et al 1991 Am J Psych 148:1627-1637

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

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 • </b>

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

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

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

45. Social problems: The Vicious Circle ofimpaired social cognition Poor nutrition impairs aspects of social cognition 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

46. Social problems: The Vicious Circle of expressed emotion Person with AN observes anxiety and anger in others 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.

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

48. 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

49. 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)

50. 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) Human models of binge eating