eating disorders and body image dr vicki mountford slam nhs foundation trust...
TRANSCRIPT
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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
Population 2 million:
Eating Disorder Service SLAM:
Day-Care9 places
Maudsley HospitalAdult Outpatients
Guy’s HospitalTertiary Outpatients Inpatient Unit
18 beds
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
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
• Female:male ratio– approximately 20:1
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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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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?
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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
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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
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
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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)
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
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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.)
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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 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.
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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
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
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.
Body Image
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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
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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
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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
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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• 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
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• 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
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