Eating Disorders and Body Image

Dr Vicki Mountford

SLaM NHS Foundation Trust

vicki.mountford@kcl.ac.uk

June 2010 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

Population 2 million:

Eating Disorder Service SLAM:

Day-Care9 places

Maudsley HospitalAdult Outpatients

Guy’s HospitalTertiary Outpatients Inpatient Unit

18 beds

Hostel 11 residents

June 2010 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

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 12

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

Currin, Schmidt, Treasure, & Jick (2005). Time trends in eating disorder incidence. British Journal of Psychiatry, 186, 132-135

Are the eating disorders on the increase?

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

 

 Level "A"

Level "B”

Level "C"

AN 0 1 49

BN 1 7 9

BED 2 5 2

EDNOS 0 0 1

Nice Recommendations www. NICE. org

•Atypical (EDNOS)Follow guidance most closely resembling pts presentation

•Level A evidence for CBT-BN & CBT-BED only

June 2010 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)

0

10

20

30

40

50

60

Beginning oftreatment

End oftreatment

One year posttherapy

Long-termfollow-up

Per

cent

age

of r

ecov

ered

cas

es

Behaviour therapy Cognitive-behavioural therapy Interpersonal therapy

June 2010 29

Outcome of CBT for bulimic disorders

0

20

40

60

80

100

Per

cent

age

of c

ases

with

dia

gnos

is

Beginning treatmentEnd of treatment

Final follow-up

• Individualized CBT• Driven by individual

formulations– Ghaderi (2006)– Waller et al. (2006)

• Similar effects for atypical bulimic disorders

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 30

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 31

Comparison of CBT, IPT & Specialist Supportive Comparison of CBT, IPT & Specialist Supportive Clinical Management in AN (n=56)Clinical Management in AN (n=56)

0

10

20

30

40

50

60

70

80

90

ITT Completers

IPT

CBT

SSCM

McIntosh et al. (2005) Am J Psych

Proportion of Patients with Good Outcome

Drop-out rates:IPT: 43%, CBT: 37%, SSCM: 31%

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.

June 2010 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

Treatment

June 2010 35

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

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 42

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 43

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.

Body Image

June 2010 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

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 49

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 50

June 2010 51

• 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, 216-221.

• Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders. Lancet, 361, 407-416.

• Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A ‘transdiagnostic’ theory and treatment. Behaviour Research and Therapy, 41, 509-528.

• 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, 304-312.

• 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, 273-288.

References

June 2010 52

• 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, 741-747.

• 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, 383-391.

• 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, 334-350.

• 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. 383-418). 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.

References

References

• Waller, G. (2009). Recent advances in therapies for the eating

disorders. F1000 Medicine Reports, 1:38

June 2010 53