Eating Disorders Professor Janet Treasure Guys Medical School [email protected].

55
Eating Disorders Professor Janet Treasure Guys Medical School www.eatingresearch.c om [email protected] c.uk

Transcript of Eating Disorders Professor Janet Treasure Guys Medical School [email protected].

Page 1: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Eating Disorders

Professor Janet Treasure

Guys Medical School

[email protected]

k

Page 2: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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

Page 3: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Historical Framing Of Eating Disorders

1600 1700 1860 2000

Saint Freak Illness

1979

Psychiatric Illness?

Page 5: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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)

Page 6: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Lifetime prevalence of BNLifetime prevalence of BNin 3 cohorts of twinsin 3 cohorts of twins

Kendler et al 1991 Am J Psych 148:1627-1637

BN & BEDBN & BED ↑ >1950 Cohorts(Kendler 1991, Jacobi et al 2004, Wittchen et al 2005, Hudson et al 2007, Hay et al 2008).

BN: Urban> rural (9:1) (Van Sohn et al 2006) BN: ↑ Westernised cultures (Keel & Klump 2003)

Page 7: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Time Trends in the Incidence of AN and BN in Primary Care in the UK

0.0

25.0

50.0

75.0

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

Inci

den

ce r

ates

per

100

,000

fem

ales

ag

ed 1

0-39

Bulimia Nervosa

Anorexia Nervosa

Turnbull et al., 1996; Currin et al., 2004

Page 8: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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?

Page 9: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

The Fiji Experience

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

Page 10: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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

Page 11: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

However – what about AN?

• This culture change model does not explain AN

• Other factors play a role

Page 12: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

My Story

Melissa Wolfe

Page 13: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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

Page 14: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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?

Page 15: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Size 0 and the media: not a cause – but a contributor

“No obsessing about models (Beryl the Peril was no Kate

Moss).”

“Size zero hadn’t even made it over the Atlantic when I got

ill”

Page 16: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

The causes of my eating disorder

No one cause but a complicated mixture of:

• Emotional factors

• My personality

• Social pressures

• Getting addicted

Page 17: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

The wrong media message

• Glamorising anorexia

• Hiding the real cause

</b>

Page 18: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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

Page 19: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

An enabling factor

“Ammunition. It’s a double whammy – it arms both the

anorexia and the anorexic.”

Page 20: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Arming the anorexic

“Size Zero normalises the abnormal. It helps you dismiss

the concern”

Page 21: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Arming the anorexia

“Anorexia preys on insecurity – size zero gives you an idea

when you’re not sure where you’re heading..”

“It thrives on perfectionism - size zero is a great

example of a physical standard that you’ve failed to attain.”

Page 22: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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 – ‘it’s 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.”

Page 23: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Size 0 and the media: complicating recovery

• The reality of size 0

• Fighting against the tide

• False Ideals

Page 24: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

The reality of size 0

“It’s 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.

It’s the loneliness that’s the real killer.

The longer you’re ill, the worse it is.”

Page 25: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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 can’t control it”.

Page 26: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Fighting against the tide

“A little taunt at every step of the way...”

Page 27: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

False ideals

“airbrushing is lying to a whole generation….

and they’re not likely to live up to it.”

Page 28: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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

Page 29: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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.”

Page 30: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

[email protected]

www.findingmelissa.co.uk

Page 31: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Translational Treatments

• Understanding the underlying mechanisms.

• How does the environment interact with biology?

• Developing treatments that target factors that perpetuate illness

Page 32: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Bullet: Predisposing Factors

Genes.Environment.Stress pregnancy/birth. Values re shape, eating. Teasing, bullying especially shape weight. Competition, comparison, expectations.TemperamentAnxious. Low self esteemEnjoy structure, plans, rules and detail.

Page 33: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Events During Pregnancy Events During Pregnancy

Life events and Life events and stressstress

– Shoebridge et al.,2000, Shoebridge et al.,2000, – Favaro et al., Arch Gen

Psychiatry 2006

– HormonesHormones Male- female twinsMale- female twins

(Culbert et al 2008)(Culbert et al 2008)

Page 34: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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

2006)

Page 35: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

The role of Fathers

Page 36: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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).

Page 37: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Family, peers, responsible adultsFood &/or weight salience Teasing, criticism-re body or eating

Personal AttributesNegative Affect, Inhibition. Stress sensitivityRigidity, perfectionismHigh weight concernsInternalisation of thin ideal

Transla

Environment

Development

PerinatalAdversityStressNutritionAnoxia

Life eventsLoss Transitions

Culture: Easy access to palatable food, loss of social eating, idealisation thinness.

Infancy PubertyChildhoodGenes

The Biological Matrix

Page 38: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Triggers

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

Page 39: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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. 2006;45:1-25.

Page 40: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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.

Page 41: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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. 2006;45:1-25.

Page 42: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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.

Page 43: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Lenroot and Giedd, 2006. Neurosci Biobehav Reviews 30:718-726

. Nutritionally deprived brain at critical phase of development

Page 44: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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.

Page 45: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Unhelpful behavioursDysregulated emotion↓ Reading emotion

↓ Emotional Attunement

Worsen how they feelLonely Isolated

AN only friend

Create or worsen problems↓ intimacy

↓ quality of relationships

Poor nutrition impairs aspects of social cognition

Social problems: The Vicious Circle ofimpaired social cognition

Page 46: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Unhelpful behavioursPerson with AN mirrors

anxiety and anger

Worsen how they feelBecause of

dysregulated emotionalreaction

Create or worsen problemsPerson with AN has poor Emotion regulation skill

Because starvation damages this area.

Person with AN observes anxiety and anger in others

Social problems: The Vicious Circle of expressed emotion

Page 47: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Reward ReactivityFood reward centres become disrupted by intermittent oscillations of food intake on a deprived background

Page 48: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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).

Page 49: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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).

Page 50: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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)

Page 51: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

Prevention

Offspring of ED mothers

High Weight and shape concerns

Fashion Industry

Page 52: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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.

Page 53: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

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.

[email protected]

Page 54: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

• 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.

Page 55: Eating Disorders Professor Janet Treasure Guys Medical School   Janet.treasure@kcl.ac.uk.

• 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.