Session Eighteen (Eating Disorders) Flashcards
1
Q
According to DSM-5, what are the 3 main eating disorders?
A
- Anorexia Nervosa
- Bulimia Nervosa
- Binge Eating Disorder
2
Q
Explain the difference between the 3 core EDs?
A
AN = People restrict their caloric intake but do NOT sustain a healthy body weight
BN = Marked by binging and purging
BED = Marked by binging without purging
3
Q
At what age do eating disorders develop?
A
AN = early, mid or late adolescence (mean age = 18.9)
BN = late adolescence to early adulthood (mean age = 19.7)
BED = adult onset (mean age = 25.4)
4
Q
How common are the respective eating disorders?
A
All reasonably common.
BED most common, followed by BN and AN least common.
Prevalences:
- AN = 1-2% in Europe
- BN = 1-2% in Europe
- BED = 3-10% in Europe
5
Q
Distinguish between an eating disorder and an especially strict diet?
A
ED:
- Attempt to control life and emotions
- Self-esteem is based entirely on weight
- Weight loss is viewed as a way of achieving happiness
- Becoming thin is the primary concern, health is irrelevant
Dieting:
- Healthy dieting is an attempt to control weight
- Self-esteem is based on far more than your body image
- Weight loss is a way to improve health and appearance
- Goal is to lose weight but doing so in a way that optimises health
6
Q
What are the criteria for an AN diagnosis?
A
- Significantly low body weight within the context of age, sex and physical health
- Intense fear of gaining weight
- Disturbed body perception
- BMI below 18.5
- Commonly associated with depression, OCD and autism
7
Q
What are some consequences of the dietary deficiencies seen in AN?
A
- Amenorrhoea
- Low libido
- Growth retardation
- Osteopena
- Kidney damage
- Heart malfunction
8
Q
What are the criteria for diagnosis of BN?
A
- Recurrent binges
- Excessive preoccupation with food, shape and weight
- Methods to compensate for over eating (vomiting/laxatives/ exercise)
- Atypical BN = BN + exercise
9
Q
What is BN commonly associated with?
A
- Affective disorders
- Impulse control disorders
- Drug or alcohol dependence
- Anxiety disorders
- ADHD
10
Q
What are the criteria for diagnosing BED
A
Recurrent binge eating with control loss + 3 of the following:
- Rapid consumption of food
- Eating until an unpleasant feeling of fullness is reached
- Eating without being hungry
- Frequent food intake with the consequences of embarrassment, disgust, feelings of guilt
- Suffering pressure due to one’s eating habits
Importantly: no compensatory measures for weight reduction
11
Q
What are OSFED?
A
Other Specified Feeding and Eating Disorders:
- Atypical BN (non-purging BN)
- Atypical AN (An with a BMI above 18.5)
- Avoidant or`restrictive Food intake
- Bigorexia (muscle dysmorphophobia)
- Orthorexia
12
Q
Give some examples of behaviours seen in ED patients?
A
- Food rituals
- Keeping cold to encourage calorie burning
- Self-induced vomiting and rumination
- laxative and enema use
- Rigorous exercise
- Purging
- Insulin misuse
- Steroid use
13
Q
Give some examples of ED cognitions?
A
- Fear of fatness
- Food rules e.g. low fat, low carb, raw, clean…
- Over valuation of thinness or muscularity
14
Q
How common are eating disorders in children?
A
Moderately common, becoming more so.
- 40% of 9 year olds and 80% of 12 year olds report dieting
- AN is most common actual diagnosis, can onset as young as 8
- ARFID is common in this age range
15
Q
What is ARFID?
A
Avoidant or Restrictive Food Intake Disorder, extreme pickiness
16
Q
Why are eating disorders in childhood especially concerning?
A
Long term physical complications, resulting from malnutrition:
- Growth delay
- Pubertal delay
- Dental problems
- Osteoperosis
- Fertility issues long term
17
Q
What is distinct about eating disorders in men?
A
- Drive is more for increased muscularity than for thinness
- Increased proportion of men affected in childhood, and in BED
- Steroids use is commonly seen
- Harder to diagnosis in men as BMI rarely falls below 18.5
18
Q
Why might incidences of ED be rising?
A
- More people feel able to present to services
- Greater exposure to risk factors
- Higher levels of stress
- Onset occurring at younger age
19
Q
What etiological factors have been associated with eating disorders?
A
- Numerous epigenetic, social, psychological factors
- Although no one gene has been identified yet
- Recent research suggests the role of specific personality factors e.g. high levels of neuroticism
- Negative life events (e.g. childhood trauma or abuse) may be linked
20
Q
Give some physiological consequences of eating disorders?
A
Affects every system
- Low self-esteem, depression, anxiety
- Dental issues, swollen jaw, tooth decay, gum disease
- Chronic sore throat, indigestion, heartburn, damage to the oesophagus
- Cardiac arrest, arrhythmia, heart failure, low BP
- Ulcers, stomach pain, rupture
- Bowel problems, constipation
- Osteoperosis, spinal issues
- Irregular or absent periods and libido
- Kidney dance form dehydration
- Muscle weakness
- Dry skin
21
Q
Name some psychological effects of an eating disorder?
A
- Sexual disinterest
- Social isolation
- Relationship dysfunction
- Carer burn out
- Psychosocial dysfunction
- Suicidal ideation
- Depression
- Financial dependency
- Alcoholism
22
Q
What impact does an eating disorder have on the brain?
A
- This is of great concern as onset of illness is normally early to late adolescence, a time of significant synaptic pruning and myelination
- Disruption to these processes is associated with long term issues
Titova et al, 2013:
- AN linked to reduced grey matter volume, white matter volume
- Reduced structural development in regions of the brain associated with reward and somatosensory processes
- Regional decreases in the left hypothalamus, left inferior parietal lobe, right lentiform nucleus and right caudate
23
Q
What factors are important to consider when choosing a treatment pathway for AN?
A
- Severity
- Age
- Stage
- Psychosocial functioning
- Any relevant co-morbidities (if patient is depressed or self-harming, have to be careful which one to treat first)
24
Q
What are the NICE guidelines surrounding the treatment of children and young people with eating disorders?
A
- Consider AN family therapy (FT-AN) first
- Can be delivered either in single family format or with other families as well
- Involvement of family is really strongly related to positive outcomes in children with ED
- But also important to ensure young people are given the option to have sessions separately to their families
25
How does family based treatment work?
Rationale:
- Empowers the family to re-feed the child or adolescent
- Effective for children aged below 18 with less than 3 years of illness duration
Components:
- Weekly weighing
- Support of parents in facilitating changes in eating patterns
- Siblings are often involved
26
What therapies are available for adults with AN?
- CBT-ED
- Maudsley AN Treatment for Adults (MANTRA)
- Specialist supportive clinical management (SSCM)
If above are unacceptable, ineffective or contraindicated, consider:
- Eating disorder focused focal psychodynamic therapy (FPT)
27
Outline how CBT can be performed for AN or BN?
- Target behaviours (regular pattern of eating with no compensation)
- As well as the thoughts and emotions that maintain these symptoms
- Focus is on addressing dieting, food avoidance, over valuation of weight and shape
Components:
- Planned meals and snacks
- Psychoeducation
- Behavioural exposure-record
- Relapse prevention
28
Outline how MANTRA works?
Form of treatment that targets the key maintaining factors of AN. Involves challenging thinking styles relating to:
- Rigidity, fear of making mistakes
- Avoidance of interpersonal relationships
- Positive beliefs about the utility of anorexia
- Enabling of and accommodating the illness
29
What is distinct about MANTRA as a treatment methodology and why has it been so effective?
- Targets the maintaining factors of the condition
- Specific to the needs and characteristics of people with AN
- Effective as AN is a somewhat unique condition in terms of the behavioural rigidity and emotional distancing it creates, MANTRA aims to target that
30
Outline how SSCM can be used for AN?
Aim of this form of therapy is to help the patients make a link between their symptoms and their eating behaviour and weight, and to support them in a gradual return to normal eating.
Components:
- Combined clinical management like information giving, advice, encouragement, with a supportive therapeutic style
- Practical and supportive approach, unlike CBT o MANTRA which is more psychological
31
When would you consider inpatient treatment for Eating disorders?
- Severely low BMI
- Rapid weight loss
- Early signs of organ failure
- Dangerous co-morbidity (diabetes is the big one)
- Failure to respond to outpatient care options
32
What did the Cochrane review into the various therapies for An suggest?
Moderately effective: CBT, SSCM, MANTRA
Interpersonal therapy was weakly effective
Family involvement was good for teenagers, weak for adults
33
What therapies are available for BN?
- CBT-E (for eating disorders)
| - Guided self-help methods
34
Outline how Fairburn's Transdiagnostic model for eating disorders explains BN?
- Cognitive behavioural model
- Suggests binge/purge is induced by negative life events, mood intolerance
- Maintained by negative self evaluation, low self-esteem and perfectionism
- These all influence dieting and binge eating behaviours which then in turn lead to...
- Vomiting and laxative misuse
35
Outline the facets of guided self-help for BN?
- Education
- Behavioural change
- Often involves CBT aspects
36
What benefits are there to Guided self-help for eating disorders?
- Treatment skills can be taught
- Cost-effective, can be delivered by therapists with generic skills
- Sustainable changes, materials can be accessed if relapse occurs
- Scaleable to widespread population
37
Outline the 2017 NICE guidelines for BN?
- BN focused guided self-help programmes for adults with BN should use cognitive behavioural self help materials
- If self-help does not work or is contra-indicated, consider CBT-ED
38
Outline the 2017 NICE guidelines for BED?
- Refer to NICE guidelines on obesity assessment and management
- Guidance for weight loss and bariatric surgery
- Offer a BED focused guided self help programme
- Generally though, there is a lack of research into this field
- Most patients end up being treated as obesity and missing out on the psych/eating disorder component of their condition
39
How effective is CBT in the treatment of eating disorders?
Highly effective for BN
Moderately effective for BED
Not very effective for AN (although still some benefit, especially if paired with family therapy)
40
Outline what pharm therapy is currently available for the treatment of eating disorders?
NEVER prescribed in the absence of psych therapy
For BN:
- Fluoxetine
- Topiramate
For BED:
- Lisdexamfetamine (LDX)
41
What is the typical course of an ED, and what changes occur during this transition?
High risk, to Prodrome, to Early stage ED, to Established illness, to Late stage.
- As the illness progresses, changes begin to occur in the brain that become more and more difficult to reverse and the impact of ED symptoms become more intense
- However there is a period of time during the first 3 years of the condition where intervention extremely effective
- In spite of this early intervention remains rare
42
What brain changes are seen in late stage ED?
- Altered activity in the insula
- Changes to the mesolimbic reward and fear systems
- Altered activation in prefrontal regions
- Dysfunctional cortico-striatal systems that mediate self-regulatory control
- Dorsal circuits and ventral circuit changes
43
What is a promising new form of therapy for AN?
Repetitive Transcranial Magnetic Stimulation (rTMS). Safe and non-invasive form of brain stimulation, applied directly to the skull of awake and conscious subjects
Reasoning:
- The DLPFC is implicated in self-regulatory control difficulties of AN
- rTMS to the DLPFC demonstrates efficacy in other neuro-circuitry based disorders
44
Outline the findings of the McClelland et al RCT into rTMS for AN?
- Those given real rTMS reported reduction in core AN symptoms such as urge to restrict and feeling fat
- Real and sham groups did not however differ in terms of stress, anxiety or mood
- Safety; BP and pulse remained unchanged in both groups
- Tolerability; real found to be slightly more uncomfortable than sham, but not intolerable
- Acceptability; 82% who actually had the rTMS would consider having ti again
- Limitation: small and unbiased sample
45
How might rTMS help patients?
By increasing cognitive control over rewarding, habitual and compulsive symptoms, leading to reduced core AN symptoms
46
Name an early intervention mechanism for ED?
F:RE:ED:
- Aims to reduce duration of untreated eating disorder
- Delivers adapted evidence based treatments for age and illness stage
47
How does F:RE:ED work?
- Referral received
- Within 2 days receive a phone screening from a FREED champion, engage with the young person to assess their illness onset
- If suitable offer a FREED assessment within 2 weeks
- Within another 2 weeks aim to start with treatment
Overall process should take under 4 weeks
48
What are some benefits of the FREED programme?
Reduction in:
- down stream costs
- duration of untreated eating disorder
- waiting times
Leads to:
- earlier recovery
- best possible outcomes
- empowerment of patients
- greater engagement
49
What evidence is there to support the benefit of FREED?
McClelland et al, (not-published):
- 60% of FREED patients returned to normal BMI after 12 months
- vs 16.6% of audit patients
