Eating Disorders

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Eating Disorders
Professor Janet Treasure Guys Medical School
www.eatingresearch.com Janet.treasure_at_kcl.ac.uk
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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

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Historical Framing Of Eating Disorders
1600 1700 1860
2000
1979
Psychiatric Illness?
Freak
Saint
Illness
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Spectrum of 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
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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)
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Lifetime prevalence of BNin 3 cohorts of twins
BN BED ? gt1950 Cohorts (Kendler 1991, Jacobi
et al 2004, Wittchen et al 2005, Hudson et al
2007, Hay et al 2008).
BN Urbangt rural (91) (Van Sohn et al 2006) BN
? Westernised cultures (Keel Klump 2003)
Kendler et al 1991 Am J Psych 1481627-1637
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Time Trends in the Incidence of AN and BN in
Primary Care in the UK
Turnbull et al., 1996 Currin et al., 2004
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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?

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The Fiji Experience

• Introduction of television and Western media
  imagery was followed by an increase in weight
  concerns disturbed eating (Becker et al.,
  2002)

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Candidate cultural risk factors

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

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However what about AN?

• This culture change model does not explain AN
• Other factors play a role

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My Story Melissa Wolfe
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• 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

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• 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?

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• Size 0 and the media not a cause but a
  contributor
• No obsessing about models (Beryl the Peril was
  no Kate
• Moss).
• Size zero hadnt even made it over the Atlantic
  when I got
• ill

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• The causes of my eating disorder
• No one cause but a complicated mixture of
• Emotional factors
• My personality
• Social pressures
• Getting addicted

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• The wrong media message
• Glamorising anorexia
• Hiding the real cause
• lt/bgt

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• 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

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• An enabling factor
• Ammunition. Its a double whammy it arms both
  the
• anorexia and the anorexic.

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• Arming the anorexic
• Size Zero normalises the abnormal. It helps you
  dismiss
• the concern

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• Arming the anorexia
• Anorexia preys on insecurity size zero gives
  you an idea
• when youre not sure where youre heading..
• It thrives on perfectionism - size zero is a
  great
• example of a physical standard that youve failed
  to attain.

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• 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 its 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.

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• Size 0 and the media complicating recovery
• The reality of size 0
• Fighting against the tide
• False Ideals

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• The reality of size 0
• Its 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.
• Its the loneliness thats the real killer.
• The longer youre ill, the worse it is.

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• 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 cant
  control it.

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• Fighting against the tide
• A little taunt at every step of the way...

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• False ideals
• airbrushing is lying to a whole generation.
• and theyre not likely to live up to it.

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• 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

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• 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.

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• melissa_at_findingmelissa.co.uk
• www.findingmelissa.co.uk

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Translational Treatments

• Understanding the underlying mechanisms.
• How does the environment interact with biology?
• Developing treatments that target factors that
  perpetuate illness

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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.
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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)

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• Teasing critical comments about weight shape
  eating (Jacobi 2004, Fairburn 1997, Stice 2002,
  Taylor et al 2006)

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The role of Fathers
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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).

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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
Puberty
Childhood
Genes
Infancy
The Biological Matrix
Personal Attributes Negative Affect, Inhibition.
Stress sensitivity Rigidity, perfectionism High
weight concerns Internalisation of thin ideal
Development
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Triggers

• Weight loss.
• Extreme oscillations in food intake or energy
  expenditure.
• Chronic stress negative affect.
• Values relating to weight/shape.

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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.
2006451-25.
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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.
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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.
2006451-25.
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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.

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. Nutritionally deprived brain at critical phase
of development
Lenroot and Giedd, 2006. Neurosci Biobehav
Reviews 30718-726
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Olsson A. The role of social cognition in emotion
Trends in Cognitive Sciences 12 feb2008

• Starvation impairs complex reflective tasks
• Social cognition.
• Emotional recognition and regulation.
• Flexibility.
• The ability to see the bigger picture.
• Planning.
• Decision making.

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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
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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.
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Reward Reactivity Food reward centres become
disrupted by intermittent oscillations of food
intake on a deprived background
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Animals models of binge eating

• 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).

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Animals models of binge eating(these animals
also become addicted to other substances eg
amphetamine)

• 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).

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Human models of binge eating

• 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)

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Prevention
Offspring of ED mothers
High Weight and shape concerns
Fashion Industry
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Conclusion

• A spectrum of eating disorders now exist.
• The risk of binge eating disorders has increased
  for cohorts born after 1950.
• Cognitive, emotional and physical factors can
  impact on vocational functioning.
• Engagement into treatment can be difficult for
  AN.
• Guided self care is a useful first step.
• Good results for psychotherapy BN majority AN
  now manage out of hospital.

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Help Required

• We are always needing to have people with and
  without an eating disorder history to help with
  our research into understanding causes of eating
  disorder and how to treat them please get in
  touch if you can help.
• Janet.treasure_at_kcl.ac.uk

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• At present there seems to be a lot of media and
  research interest in the deleterious effects of
  (airbrushed) media images of thin women on girls'
  self esteem and the possible development of EDs
  (as based upon the hypothesis that these images
  cause body dissatisfaction and disordered eating
  or full blown EDs) - however (unless I looked in
  the wrong place...) I could find little published
  research about the dangers of constant
  bombardment of children with messages about
  'healthy eating/exercise'. I, for one, have never
  felt affected by media images of thin women and
  my AN was not caused by body shape dissatisfaction
  , but I was very vulnerable to media/educational
  messages about 'healthy living' and obesity.

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• A big part of my AN was about seeking control,
  routine and meaning in a chaotic and confusing
  world where I felt I didn't fit socially. I used
  anorexic behaviours to regulate my world - even
  create my own, personal, comprehensible world. As
  a child I took media messages about healthy
  eating and exercise (which were just emerging in
  the early 1980s) too literally and operated on
  the basis of 'more is better' and engaged in a
  lot of categorising foods by their calorie, fat,
  protein, carbohydrate and fibre content. I made
  lists of 'good' and 'bad' foods. I made lists of
  everything I would eat every day at certain times
  and ticked the food off the list when I had
  consumed it. This provided me with an illusory
  sense of control in my life and reduced my
  anxiety.