eating disorders - treatments Flashcards
issues with treatments used for ED
- 5 key issues identified
Lilienfeld et al (2013)
concerns with treatments of EDs
600 therapies identified
few actually evidence-based and some were strange
most clinicians didn’t deliver evidence-based treatments:
* only 38% used strongest therapy
* take out key elements of therapies
* 6% used evidence-based treatment manuals
* many do “eclectic” or “integrative” therapies
* many untrained in therapy
causes and maintenance of eating disorders (7)
- biology
- genes
- family interaction
- sociocultural influences
- trauma
- bullying and teasing
- negative life experiences
maintenance factors of EDs (6) - interventions based on these
- safety behaviours
- cognitive behaviours
- emotional patterns
- social maintenance
- family accommodation of symptoms
- nutrition (neurobiology link)
are ED treatments evidence based
often not
backed up by clinical practice rather than actual evidence
prevention of eating disorders - potential targets for interventions (2)
reducing eating concerns in the present
reducing future development of EDs
prevention of EDs - who, what approach, why
implement in late childhood/early adulthood
protect against development of EDs
limited investment -> e.g. implement into school curriculum so it is wide reaching
better to prevent than to treat it
risk of preventions of EDs - 2 studies
Carter et al (1997) & Baronowski & Heatherington (2001)
both tried psychoeducation about dieting and EDs
targeted school kids age 11-14
levels of pathology got worse - short and long term
Carter said it was a problem → but Baronowski said it was a success (it wasn’t → reporting issues)
which prevention strategies of EDs work (4)
Le et al (2017)
review and meta-analysis of 58 studies found:
media literacy approach:
* reduce shape and weight concerns for males and females in young population
cognitive dissonances approaches:
* reduces eating behaviours and attitudes in high-risk groups
CBT interventions:
* reduce risk of dieting
weight management interventions
* reduce some risk factors
is there evidence for preventative measures of EDs
there is evidence for reduction in risk factors/current pathology
limited evidence for prevention → unclear whether fewer people develop eating disorders
need to get better at reducing those numbers of cases - to justify effort on prevention work
obesity - NICE recommendations for reduction
NICE = schools, local gov, families, tax policies → rather than psychological interventions
encouraging lifestyle changes → healthy eating, regular exercise
obesity rates in England
almost 3/4 of people age 45-74 are overweight or obese
1998 = 14.9% obese
2021 = 28% obese
NICE guidelines for who gets what ED treatment – 2 parameters
adults and children/adolescents
underweight vs non-underweight patients
NICE adult treatments of anorexia (3)
CBT-ED (individual CBT for eating disorders) → 40 sessions
MANTRA → Maudsley Anorexia Nervosa Treatment for Adults → 20-30 sessions
SSCM → Specialist Supportive Clinical Management → 20-30 session
these are similarly effective to behaviour therapy
NICE child/adolescent treatment of anorexia (2)
AN-focused family therapy:
* non-blaming
* family takes control of child’s eating
* then move to give control back to child
* finish with relapse prevention
CBT-ED or adolescent-focused psychotherapy as a second option
NICE adult treatment of BED and BN
binge eating disorder:
group CBT-ED or individual CBT-ED → 16-20 sessions
bulimia nervosa:
individual CBT-ED or try self-help CBT-ED first → 16-20 sessions
NICE child/adolescent treatment of BN (2)
family therapy for bulimia nervosa
CBT-ED as a second line therapy
NICE treatment of OSFED
atypical cases so use the therapy recommended for most similar full syndrome
NICE treatment of ARFID
avoidant and restrictive food intake disorder
not in NICE (2017) - new so limited evidence base
some early evidence for CBT-AR as treatment
why are certain treatments of ED are included in NICE
NICE covers most strongly evidence based therapies
so prioritise these with limited resources
drives commissioning advice for NHS
addresses issues around case management and patient experience
why aren’t some therapies in NICE guidelines
don’t meet NICE guidelines for high-quality research
or not found to be effective enough
weak research or unsupported clinician opinion
why is case/risk management important
medical monitoring and management to address risks and allocate resources effectively
with intensive treatments (inpatients and day-patients)
does length of treatment impact its effectiveness
shorter therapies can be just as effective for non-underweight EDs
therapeutic alliance with ED - is it important?
more complex than just therapist getting on well with the patient
also need to get them to agree to the therapy
good alliance doesn’t necessarily predict good outcomes
is early treatment necessary
early change was important with predicting positive outcomes of treatment
does severity or duration of ED reduce effectiveness of treatments
no evidence for this -> shouldn’t be defeatist
intensive treatments of EDs (6) - eval
inpatient and day-patients:
- varies culturally (common in Germany, rare in UK)
- necessary for management of high-risk cases
- good for weight restoration
- almost no evidence for establishing recovery
- very expensive
- risk of creating dependence
medications for ED (2) - weaker old evidence
SSRIs at high doses for BN:
* enhances functional serotonin
* reduces binges for some people whilst taking it - not longer term
* potential withdrawal → SSR discontinuation syndrome
novel antipsychotics for AN:
* olanzapine, quetiapine, risperidone
* reduces anxiety, enhance weight gain through metabolic slowing
physical interventions for ED (2) - old/weaker evidence
neuromodulation:
* transcranial stimulation → reduce depression slightly - no evidence that this works yet
leucotomy:
* for chronic AN with extreme OCD
* evidence is anecdotal and poor
psychological therapies for ED - with some evidence (4)
DBT - dialectical behaviour therapy:
* reduce impulsive behaviours in BED/BN - limited change in core pathology
* limited evidence for AN
IPT - interpersonal psychotherapy:
* works for BN, lower and less effective than CBT
FIT - focused psychodynamic approaches:
* effective for AN, needs replication in other countries
integrative cognitive-affective therapy:
* less effective than CBT
psychological therapies for ED - with little evidence (4)
mentalisation-based therapu
acceptance and commitment therapy
mindfulness-based approaches
family therapies that aren’t food/eating focused
effectiveness of best ED therapies (%)
mean effectiveness of evidence based therapies for adult psychological disorders
50% recover
25% improve
20% unchanged
5% deteriorate
recovery rate in underweight and non-underweight cases
can get a 50% recovery rate → only in non-underweight cases
30% in underweight cases
CBT-ED and family therapies - ED with psychobiology
both therapy types target different core beliefs of EDs
help them restore homeostasis regarding eating behaviour
teach to eat in response to biological needs - keep energy graphs stable so you don’t purge or binge
not with toxic environment or inner psychological concerns
why address biology of EDs - positive impacts (5)
reduces anxiety, depression, impulsivity, compulsivity → serotonin levels
reduce alcohol levels → mood stability and starvation reduction
enhance cognitive flexibility → reduce starvation effects and safety behaviours
normalises and stabilises weight
enhance quality of life → result of all of the above
multifaceted reasons for obesity
genetics, learning, social learning, social pressures, food industry and toxic environment → all in this context
not due to choice
do psychological therapies have good outcomes for obesity
good at short-term weight loss
bad at keeping weight off long-term
Cooper et al (2010):
new CBT for obesity - but it didn’t work well
even 5-10% weight loss can have health benefits:
* struggle to achieve this → biology and toxic environment combined
what to do about obesity (5)
don’t blame individual → big quality of life change possible
politics → sugar tax, risk of fat shaming
lifestyle coaching → advice about food choices, but this doesn’t last when coaching stops
longer term therapy → still issue when therapy ends it doesn’t last
continuing care model → most likely to work
non-psychological treatments of obesity
bariatric surgery:
* gastric bypass
* sleeve gastrectomy
* gastric band
each has its own issues → adaptation to lifestyle changes and making slow progress
requires psychological preparation and maintenance strategies:
* psychological involvement with this to combine with the surgery
