Eating Disorders Lecture Notes PDF

Eating Disorders Introduction to Clinical Psychology (PSY1204) - Lecture 6 Dr Fidan Turk Stella Kozmér [email protected] [email protected] Office Office hours (205 WSL): hours (Smeall JS08) 1-2 pm Tuesdays 2-3 pm Thursdays  Definitions Ou...

Eating Disorders Introduction to Clinical Psychology (PSY1204) - Lecture 6 Dr Fidan Turk Stella Kozmér [email protected] [email protected] Office Office hours (205 WSL): hours (Smeall JS08) 1-2 pm Tuesdays 2-3 pm Thursdays  Definitions Outline Historical Landmarks Classification Risk factors & Etiology Epidemiology & Prevalences Identification Management and treatments Learning outcomes Understanding eating disorders Identify differential characteristics of between diagnosis Understanding risk factors and prevalences of eating disorder Gaining general knowledge of available treatment options for EDs Reminder Take care of yourself Resources Well-being services: https://www.exeter.ac.uk/students/wellbeing/ [email protected] BEAT: https://www.beateatingdisorders.org.uk/ GPs  What does normal eating look like? Regular Multiple meals, snack Feelings of hunger & fullness Balanced Variety of foods Nutritional value & taste Flexible Adopting to the needs of the situation Different time or different food What is the difference between an eating disorder and disordered eating? Normal Eating Disordered Eating Eating Disorders Food choices mainly influenced by Food choices strongly influenced hunger & preference by desire to maintain a certain Food choices weight or body type influenced by goals of No guilt or shame around restricting, losing food/eating Often feel guilt around eating certain foods weight, No difficulty eating in social binging/purging situations Some avoidance of or difficulty with eating in social situations Feel guilt and shame around food most of the time Frequent avoidance of eating or attending social situations involving food Historical Landmarks 15th Century In 1873, Sir William Gull Anorexia nervosa published “Anorexia Nervosa” 1979 Gerald Russell ominous course Bulimia nervosa Included in the 5th edition of 2013 Diagnostic and Statistical Binge eating disorder Manual of Mental Disorders Diagnosis and classification of EDs Question: What kind of eating disorders have you heard of?  Types of Eating Disorders In the DSM-V Binge Eating Disorder (BED) Others you may have heard of… Bulimia Nervosa (BN) Orthorexia nervosa – under Anorexia Nervosa (AN) consideration Pica Bigorexia (muscle dysmorphia) Rumination disorder Emotional overeating Avoidant/restrictive food intake disorder Diabulimia- abuse of insulin to (ARFID) promote WL Other specified feeding or eating disorder Obesity? (OSFED) -> Atypical AN, BED, night eating syndrome  Types of Eating Disorders Binge Eating Disorder (A) Recurrent episodes of binge eating. Characterised by a lack of control over eating, and eating in a discrete period of time. (B) The binge eating episodes are associated with 3 or more of: Eating much more rapidly than normal Anorexia Nervosa Eating until uncomfortably full Refusal to maintain body weight (self-starvation) Eating large amounts of food when not hungry Restricting vs. binge/purge Eating alone because of feelings of embarrassment At least 15% below normal weight Feeling disgusted with the self Intense fear of weight gain (C) Once a week for three months Disturbance of body image (D) Not associated with a compensatory behaviour e.g. purging Amenorrhoea (not requirement anymore) -Higher BMI? -N.B. severity is graded in terms of number of episodes per week (Mild-Severe) Bulimia Nervosa (A) Recurrent episodes of binge eating. (B) Recurrent compensatory behaviour to prevent weight gain (e.g. self-induced vomiting, laxative abuse, diuretics, fasting, excessive exercise) (C) Self-evaluation is unduly influenced by body shape and weight (D) Binge eating and compensatory behaviours both occur once a week for three months -Usually normal or higher BMI  Classification DSM IV/DSM-V vs ICD 11 Categorical vs. dimensional constructs Diagnostic drift Silén & Keski-Rahkonen (2022) Transdiagnostic approach Malnutrition AN BN BED Morbid obesity The etiology of Eating Disorders Genetic influence Genetic components Familial risk Twin studies Interaction of genetic dispositions and individual experiences (Bulik et al., 2000) Neurobiological factors Brain & serotonin function > changes in appetite, mood and impulse control in Eds Trytophan depletion Sociocultural influences  Tripartite model of Eating Disorders (Thompson et al., 1999) Influence of Peers on Body Image & Eating Disorders Weight related teasing People who do not overly Fat talk value appearance or dieting Friends who are on diet Diet industry & Media Unrealistic appearance ideals in the media: Thin & muscular Thinness ideals & weight stigma (Wolff 2015, Rubino et al 2020) Weight stigma The idea that 'fat' is bad and 'thin' is good Severe body dissatisfaction Restriction & dieting Prolonged disturbance to eating behaviors Puhl et al., 2015  Perfectionism Shyness Psychological & Neuroticism Dispositional Low self-esteem High introspective awareness factors (awareness of bodily sensations) Negative or depressed affect Dependence and non- assertiveness Transdiagnostic Model of Eating Disorders Fairburn et al, 2004 Prevalence & Epidemiology Galmiche et al., 2019 Eds no longer thin, white, middle class, girls stereotype Wide diversity Special issues for men Drive for muscularity vs thinness Eating differently to bulk up, steroid use Exercise, bradycardia (Nagata et al 2019) Community study in UK (Solmi et al., 2016): EDs 4.4 % BED 3.6% Prevalences in BN 0.8% the UK Age: BN 16–24 BED 44–65  Anxiety (up to 62%)and mood disorders (up to Comorbidity 54%) > across EDs Impulsivity (e.g. substance use disorders (27%), borderline personality disorder (29%-11%)) > BN OCD > more common in AN (19%) than BN (13%) (Mandelli et al., 2020; Zanarini et al., 2009) Let's have a break! (10 min) Identification of EDs  Case Study 1 Imagine you are a clinician seeing Alex about their anxiety. You receive this summary about Alex. What would you do? What diagnosis, if any, would you suspect? Alex is 21 years old and has a Nigerian heritage. Alex has a BMI of 38 and is described as someone with obesity. Based on prior discussions with their GP, Alex has been working on managing their obesity due to health concerns. Alex has lately had some stomach problems and has felt very tired. Alex visited their GP, who reassured Alex that this is a normal presentation when changing a diet and losing weight. One month later, Alex pays a visit to their GP to review their progress in managing obesity. Alex did complain about their stomach problem again and reported feeling anxious about hitting the target weight. The GP records a BMI of 32 and encourages Alex to continue their management plan. Alex continues to feel very anxious and raises concerns about not losing enough weight. The GP refers them to a mental health worker in primary care, however they are confident in Alex’s progress.  Lazare et al., 2019 Perceptions on EDs Clinician point of view Mixed-views Depends on the type of EDs and prior experience with the condition Lived experience point of view More negative Stigma- e.g. internalised, clinician-based, societal, cultural Isolation: "Really I’m just lonely here and everywhere else too". (Wooldridge et al., Citation2014, p. 106)  Perceptions on BED and BN identification and management in primary care “I remember quite plainly “I didn’t know men one GP (general could get eating practitioner) saying to me disorders then...... I ‘look don’t worry, I don’t didn’t know the think there’s anything symptoms, didn’t know going on, I usually get a anything, it was just, to feeling up the back of my me it was just neck when it’s something happening.” like an eating disorder and it’s not that’” Kozmér et al., (preparation for submission) We’ve been in a case recently with a patient in my practice where they were too sick for outpatient, they weren’t sick enough for inpatient......those patients fall through the cracks- who sees them, who takes care of them? It’s us, but we haven’t had the training to be able to do it. Case study of improving identification: Maori-led approach in New Zealand Relationship building is key -> ‘hui process’ builds trust -> more likely to increase adherence. Culturally appropriate screening tools -> meihana model. Acculturation and body image ideals also contribute Solution? -> Co-design! Case study of improving identification: Maori-led approach in New Zealand Conceptualisation of EDs by Indigenous populations Example of improving identification in minorities: New Zealand with Maoris  Reflections What can we learn from this approach? How can we improve the identification of EDs? Can co-designed methodologies improve out understanding of the topic? How would you apply this to the UK context? Identification pathways in the UK Management and treatment of EDs  Question: Can we “cure “ ED? Question: What treatment options are you aware of? Care pathway in the UK  What is the NICE recommended treatment for EDs in the UK? Anorexia Nervosa YA: family therapy / talking therapy (CBT-ED, MANTRA) + weight restoration. This can include inpatient stays and nasal refeeding (NG). Aim to restore BMI to around 20 ideally Adult: talking therapy (CBT-ED, MANTRA) + weight restoration. Can again lead to inpatient stay. Psychoeducation Bulimia Nervosa Guided self help, e.g. cognitive behavioural self-help materials CBT-ED YA: may have Family Therapy IF low weight, inpatient treatment can be used to restore weight, including NG Psychoeducation Binge Eating Disorder Guided self-help, e.g. cognitive behavioural self-help materials CBT-ED No difference between YA/Adults Psychoeducation Pharmacological treatment  Videos https://www.bbc.co.uk/iplayer/episode/b09d5nk2/louis-theroux-talking-to-anorexia - Full documentary https://www.youtube.com/watch?v=ng78sQQQ0hs&ab_channel=Duffy2013 - snapshot  Case study 2 Charlie is 27 and wants to make a lifestyle change to address their weight. However, some things are happening to Charlie that they wanted to discuss with you. Charlie came to see you about their low mood and struggles around eating. Charlie describes a sense of loss of control over eating, which happens to them an average of twice every week. They feel quite ashamed to talk about it and feel like they are failing in their journey to eat healthier and address their weight. Charlie is also struggling with low mood and describes a lack of motivation and difficulties around getting out of bed in the morning or finding joy in their day-to-day tasks. They feel confused about why these things are happening and are looking for your support. What ED diagnosis might Charlie have? Identify the main 3 issues you need to address. How would you help Charlie?  Importance of tackling eating disorders holistically- Minnesota experiment (Keys, 1950) Nov 1944 - WW2 coming to end Allies entering cities encountered starving emaciated civilians Ancel Keys (University of Minnesota) recruited to find out: How affected by starvation Best way to rehabilitate them 36 healthy young men selected from 12,000 conscientious objectors Final sample deemed to be psychologically ‘normal’ First 3 months ate normally (~3200 kcals) 6-month semi-starvation (~1800 kcals) Final 3 months nutritional rehabilitation Understanding that starvation dramatically affects – personality, the mind, and the body  Importance of tackling eating disorders holistically- Minnesota experiment (Keys, 1950) Changes during restrictive phase: Preoccupation with food e.g., +++ planning, cookbooks Changes in eating behaviours e.g., rituals, demanding hot food, unusual concoctions Emotional changes, including anxiety, irritability Cognitive changes, including impaired concentration, comprehension and judgement Social changes: including social isolation, low mood Physical changes, including decreased need for sleep, headaches, dizziness, GI discomfort, etc.  Back to Charlie....CBT-ED Goal focused talking therapy (NICE) Addresses the way our thoughts influence our behaviours, which in turn makes us feel certain ways Time limited Homework Example of Psychoeducation  Limitations of CBT-ED Long-term effectiveness? Suitability? o Co-morbidites o Complex trauma Continuity of care? Service delivery? Lack of focus on interpersonal relationships Dietary restraint? What are the future directions?  Collaborative and integrated care Autism + Eds = PEACE pathways ADHD + Eds -> still under development, research is continuous  Psychedelics and EDs Several trials across the globe Primarily AN-focused Limitations in generalisability Improving the understanding of psychedelics and EDs  ImpulsePal (van Beurden et al, 2021) FoodT Digital health Improve access Early intervention Kozmér et al., (in peer review) Mixture of techniques, e.g. behaviour change Acceptability study of ImpulsePal for BED/BN o Interviews o Prevention and/or support of treatment RecoveryRecord eClinic  Weight management and EDs Developing area Ozempic/Wegovy + EDs (Melissa Pehlivan, Inside Out) Calorie labelling in menus (Tom Jewell, KCL) Possible side effects → not all negative? HAPIFED – obesity management in BED/BN, promising results (Luz et al., 2017) Questions? References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Press Inc. Fairburn, C. G., Cooper, Z., Doll, H. A., O’Connor, M. E., Bohn, K., Hawker, D. M., Wales, J. A., & Palmer, R. L. (2009). Transdiagnostic cognitive- behavioraltherapy for patients with eating disorders: A two-site trial with 60-week follow-up. American Journal of Psychiatry, 166, 311-319. doi:10.1176/appi.ajp.2008.08040608 Fairburn & Harrison (2003). Eating Disorders. Lancet, 361, 407-416 Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2010). Cognitive BehavioralTherapy for Eating Disorders. Psychiatric Clinics of North America., 33, 611-627. doi:10.1016/j.psc.2010.04.004 Solmi, F., Hotopf, M., Hatch, S. L., Treasure, J., & Micali, N. (2016). Eating disorders in a multi-ethnic inner-city UK sample: prevalence, comorbidity and service use. Society Psychiatry Psychiatric Epidemiology, 51, 369 – 381. DOI 10.1007/s00127-015-1146-7 Stice, E., Nathan, C., & Rohde, P. (2013). Prevalence, Incidence, Impairment, and Course of the Proposed DSM-5 Eating Disorder Diagnoses in an 8-Year Prospective Community Study of Young Women. Journal of Abnormal Psychology, 122, 445-457. doi: 10.1037/a0030679 Stice, E., Gau, J. M., Rohde, P., & Shaw, H. (2017). Risk Factors That Predict Future Onset of Each DSM–5 Eating Disorder: Predictive Specificity in High-Risk Adolescent Females. Journal of Abnormal Psychology, 126 (1), 38-51. doi: 10.1037/Abn0000219