Eating Disorders and Body Image

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Eating Disorders and Body Image

• Dr Vicki Mountford
• SLaM NHS Foundation Trust
• vicki.mountford_at_kcl.ac.uk

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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

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Population 2 million
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Eating Disorder Service SLAM
Day-Care 9 places
Inpatient Unit
Guys Hospital Tertiary Outpatients
18 beds
Maudsley Hospital Adult Outpatients
Hostel 11 residents
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Definitions
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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

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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

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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

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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)

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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

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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

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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

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Incidence and Prevalence
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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
• Femalemale ratio
• approximately 201

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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

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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

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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
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What does this result tell us?

• That new cases of bulimia were identified by GPs
  more in the 1990s
• 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

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Causes and maintaining factors
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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.

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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)

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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)

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Risk factors

• Individual characteristics
• Low self-esteem
• Perfectionism
• Anxiety problems
• Obesity
• Early menarche

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What do we know about what works?
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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

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• Atypical (EDNOS)
• Follow guidance most closely resembling pts
  presentation
• Level A evidence for CBT-BN CBT-BED only

•  

Nice Recommendations www. NICE. org
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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)

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Outcome of therapy Bulimia nervosa(Fairburn et
al., 1995)
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Outcome of CBT for bulimic disorders

• Individualized CBT
• Driven by individual formulations
• Ghaderi (2006)
• Waller et al. (2006)
• Similar effects for atypical bulimic disorders

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What about those for whom it doesnt 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.)

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NICE guidelines for anorexiaWhere are we 6 years
later?

• 2004 No evidence for adult anorexia above Level
  C (expert opinion)
• Things have moved on...

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Comparison of CBT, IPT Specialist Supportive
Clinical Management in AN (n56)
Proportion of Patients with Good Outcome
Drop-out rates IPT 43, CBT 37, SSCM 31
McIntosh et al. (2005) Am J Psych
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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.

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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

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Treatment
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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

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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

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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

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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

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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.

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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

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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.

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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,

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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.

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• Body Image

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What is body image?

• Many definitions exist
• a persons 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

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What is body image dissatisfaction?

• a persons negative thoughts and feelings about
  his or her body
• Usually involves a perceived discrepancy between
  a persons evaluation of his/her body and their
  ideal body

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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

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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

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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

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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, 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.,
  OConnor, 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.

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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, 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.

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References

• Waller, G. (2009). Recent advances in therapies
  for the eating disorders. F1000 Medicine Reports,
  138