eating disorders - treatments

Question 1

issues with treatments used for ED
- 5 key issues identified

Answer 1

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

Question 2

causes and maintenance of eating disorders (7)

Answer 2

• biology
• genes
• family interaction
• sociocultural influences
• trauma
• bullying and teasing
• negative life experiences

Question 3

maintenance factors of EDs (6) - interventions based on these

Answer 3

• safety behaviours
• cognitive behaviours
• emotional patterns
• social maintenance
• family accommodation of symptoms
• nutrition (neurobiology link)

Question 4

are ED treatments evidence based

Answer 4

often not
backed up by clinical practice rather than actual evidence

Question 5

prevention of eating disorders - potential targets for interventions (2)

Answer 5

reducing eating concerns in the present
reducing future development of EDs

Question 6

prevention of EDs - who, what approach, why

Answer 6

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

Question 7

risk of preventions of EDs - 2 studies

Answer 7

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)

Question 8

which prevention strategies of EDs work (4)

Answer 8

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

Question 9

is there evidence for preventative measures of EDs

Answer 9

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

Question 10

obesity - NICE recommendations for reduction

Answer 10

NICE = schools, local gov, families, tax policies → rather than psychological interventions

encouraging lifestyle changes → healthy eating, regular exercise

Question 11

obesity rates in England

Answer 11

almost 3/4 of people age 45-74 are overweight or obese

1998 = 14.9% obese
2021 = 28% obese

Question 12

NICE guidelines for who gets what ED treatment – 2 parameters

Answer 12

adults and children/adolescents

underweight vs non-underweight patients

Question 13

NICE adult treatments of anorexia (3)

Answer 13

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

Question 14

NICE child/adolescent treatment of anorexia (2)

Answer 14

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

Question 15

NICE adult treatment of BED and BN

Answer 15

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

Question 16

NICE child/adolescent treatment of BN (2)

Answer 16

family therapy for bulimia nervosa
CBT-ED as a second line therapy

Question 17

NICE treatment of OSFED

Answer 17

atypical cases so use the therapy recommended for most similar full syndrome

Question 18

NICE treatment of ARFID

Answer 18

avoidant and restrictive food intake disorder

not in NICE (2017) - new so limited evidence base

some early evidence for CBT-AR as treatment

Question 19

why are certain treatments of ED are included in NICE

Answer 19

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

Question 20

why aren’t some therapies in NICE guidelines

Answer 20

don’t meet NICE guidelines for high-quality research
or not found to be effective enough

weak research or unsupported clinician opinion

Question 21

why is case/risk management important

Answer 21

medical monitoring and management to address risks and allocate resources effectively

with intensive treatments (inpatients and day-patients)

Question 22

does length of treatment impact its effectiveness

Answer 22

shorter therapies can be just as effective for non-underweight EDs

Question 23

therapeutic alliance with ED - is it important?

Answer 23

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

Question 24

is early treatment necessary

Answer 24

early change was important with predicting positive outcomes of treatment

Question 25

does severity or duration of ED reduce effectiveness of treatments

Answer 25

no evidence for this -> shouldn't be defeatist

Question 26

intensive treatments of EDs (6) - eval

Answer 26

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

Question 27

medications for ED (2) - weaker old evidence

Answer 27

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

Question 28

physical interventions for ED (2) - old/weaker evidence

Answer 28

neuromodulation: * transcranial stimulation → reduce depression slightly - no evidence that this works yet leucotomy: * for chronic AN with extreme OCD * evidence is anecdotal and poor

Question 29

psychological therapies for ED - with some evidence (4)

Answer 29

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

Question 30

psychological therapies for ED - with little evidence (4)

Answer 30

mentalisation-based therapu acceptance and commitment therapy mindfulness-based approaches family therapies that aren’t food/eating focused

Question 31

effectiveness of best ED therapies (%)

Answer 31

mean effectiveness of evidence based therapies for adult psychological disorders 50% recover 25% improve 20% unchanged 5% deteriorate

Question 32

recovery rate in underweight and non-underweight cases

Answer 32

can get a 50% recovery rate → only in non-underweight cases 30% in underweight cases

Question 33

CBT-ED and family therapies - ED with psychobiology

Answer 33

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

Question 34

why address biology of EDs - positive impacts (5)

Answer 34

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

Question 35

multifaceted reasons for obesity

Answer 35

genetics, learning, social learning, social pressures, food industry and toxic environment → all in this context not due to choice

Question 36

do psychological therapies have good outcomes for obesity

Answer 36

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

Question 37

what to do about obesity (5)

Answer 37

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

Question 38

non-psychological treatments of obesity

Answer 38

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