Psychological Interventions Lecture 4

Risk factors for eating disorders: Biological

• Genetics and family history

• Neurochemical imbalances

• Starvation syndrome

Risk factors for eating disorders: Psychological

• Anxiety

• Perfectionism

• Poor emotion regulation

Risk factors for eating disorders: Social

• Pressure to be thin

• Stressful life events

• Ballet, rowing

Eating disorder intake

• Demographics information

• Help request

• History

• Eating disorder symptom screening

• Risk assessment and differential diagnosis

ED symptoms present at intake

• ✓ Restriction of energy intake leading to low body weight

• ✓ Fear of gaining weight or becoming fat

• ✓ Disturbances in body image and/or preoccupation with body weight

• ✓ Eating large amounts in a short while feeling a loss of control (binges)

• ✓ Inappropriate compensatory behaviours (laxatives, vomiting, exercise)

• X Avoidance of eating due to a lack of interest in food

• X Avoidance of foods based on sensory characteristics (slimy, seedy)

Transdiagnostic Model

• Different eating disorders (e.g., anorexia, bulimia) share the same underlying processes

• People can move between disorders over time

• Core mechanism (cycle)

  1. Overvaluation of weight/shape

  2. → Restricting food

  3. → Binge eating

  4. → Guilt/shame

  5. → Purging

  6. → Back to restriction (cycle repeats)

• Symptoms are interconnected and maintain each other

• Treatment targets the whole cycle, not just one behaviour

Treating an eating disorder: Choosing a focus

• Stopping with binge-eating

• Improving confidence in self/body

• Weight re-gain

• Eating more variety

• Stopping laxative use

• Stopping with excessive exercise

• Treating OCD rituals

• Somethingelse?

Evidence-based/recommended care

• Cognitive behavioural therapy - enhanced

• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)

• Specialist Supportive Clinical MAnagement (SSCM)

Cognitive behavioural therapy - enhanced

• Problem-focused on behaviour and psychopathology

• Highly structured protocol with stages

• Core idea: The main problem is: Overvaluing weight and shape

• Goal: Break the cycle of eating disorder

Two types of CBT-E

• “Focused” Version:

  • Exclusively addresses eating disorder psychopathology

• “Broad” Version:

  • In addition addresses one or more “external” (to the core eating disorder) processes that may maintain eating disorder

  • E.g. clinical perfectionism, core low-self-esteem, or marked interpersonal problems

MANTRA

• Cognitive and personality traits (rigidity, avoidance)

• Semi-structured, workbook with tailored modules

• Focus = broader personal and emotional factors

• Anorexia continues because of:

  • Thinking style (e.g., perfectionism)

  • Emotional and social difficulties

  • Beliefs about anorexia (e.g., “it helps me cope”)

• There is a mismatch between challenges and resources:

  • Challenges = stress, problems

  • Resources = support, coping skills

SSCM

• Support and weight restoration

• Less structured, patient led

Key pillars of treatment

• Psychoeducation (risks of being malnourished, starvation syndrome)

• Somatic + psychological support

• Start & end well

• Multidisciplinary

• Consistency

• Quality of life

• Self-directed

• Less-restrictive setting

• Transparency

CBT-E treatment journey

1. Motivation + understanding the eating disorder (ED)

2. Medical stabilisation

3. Normalised eating

4. Address maintaining factors (thoughts & behaviours)

5. Setbacks & mindset work

6. Relapse prevention

• 20-40 weeks (depending on weight gain)

• Weight/BMI and recovery improve gradually (not in a straight line)

• Important features

  • Focus on understanding the ED throughout treatment

  • Regular monitoring of progress

  • Expect ups and downs

CBT-E Stage 0: Motivation

• Very first stage of treatment, before real behaviour change starts: getting the person ready and safe to begin treatment

• Physical safety first

  • Check health

  • Monitor heart (ECG) and potassium (K+)

  • Give supplements if needed

• Build motivation

  • Talk about pros and cons of the eating disorder

• Understand the eating disorder

  • Psychoeducation (learning about the disorder)

  • Create a personal explanation (formulation) of what keeps the problem going

  • Other potential barriers should be explored

Cost/benefit of an ED

• Pro

  • Feeling of control

  • Sense of accomplishment

  • Temporarily lowers anxiety

  • Affirmation from some people

  • Predictable future

• Con

  • Out of control binges

  • Always thinking about food

  • Less focus in class

  • Tired

  • Hair loss and weak nails

  • Isolated from friends

Cost/benefit of recovery

• Pro

  • Better focus

  • More spontaneous and social

  • Hair re-growth

  • Not thinking about food all the time

  • More confident

• Con

  • Facing fear of weight gain

  • Loss of tight control

  • Letting go of ED identity

  • Fear of judgment

  • Fear that noting will change mentally

CBT-E Stage 1: Starting well

• Keep motivation

• Understanding the ED

• Eating 5-6x per day

What factors should be included in the progress review

• Frequency of ED symptoms

• Regularity of meals

• Medical stability

• Changes in clinical impairment

• Changes in overall functioning

• Readiness for change

CBT-E Stage 2: Taking stock

• Review progress

• Eating diaries

• Symptom severity

  • Frequency of laxative use

• Impairment and functioning

• Medical stability

CBT-E stage 3: Maintaining mechanisms

• Learn better coping skills

  • Handle difficult feelings (e.g., stress, sadness, loneliness)

  • Instead of using eating behaviours to cope

• Break strict food rules

  • Challenge beliefs like:

    • “If I eat this, I will lose control”

  • Start eating feared foods in a flexible way

• Work on body image

  • Reduce:

    • comparing yourself to others

    • checking your body all the time

  • Use exposure (e.g., looking in the mirror without judgment)

CBT-E Stage 4: Ending well

• Preparing for the future: Create personalised plan for the future

  • Further work on body checking, food avoidance, and practice problem solving

  • Continue develop new interests and activities

• Troubleshooting

• Preventing relapse: Patient needs to have realistic expectations for the future

CBT-E throughout

• Keeping and reviewing eating diary

• Monitoring weight weekly with therapist

Ethical dilemmas in eating disorder treatment

• Eating disorders can directly affects a patient’s ability to recognize the need for treatment

• Does the patient have adequate decision-making capacity?

• How immediate and severe are the risks?

• Is there a less coercive option?

• Forced treatment saves lives, but it can also be traumatic and damage trust

Areas of treatment innovation

• E-health

  • Guided self-help

• Integrated care

  • PTSD + anorexia treatment

• Brain stimulation

  • Deep brain stimulation

  • rTMS

• Psychedelics

  • Ketamine

  • MDMA

Online Guided Self-Help for Binge-Eating Disorder

• Most common eating disorder (3–4%)

• Often underdiagnosed and undertreated

• Study Design

  • N = 187 patients

  • Compared:

    • Online guided self-help (12 weeks)

    • CBT-E (20 weeks, therapist-led)

• Results: Both treatments reduced binge eating significantly

• No difference in:

  • Treatment effectiveness

  • Therapeutic alliance

  • Dropout rates

• Advantages of E-health

  • Shorter (12 vs 20 weeks)

  • Cheaper

  • More accessible

Combine treatment for anorexia nervosa and PTSD

• ~23% AN patients have PTSD

• ~55% have childhood trauma

• PTSD can worsen and maintain the eating disorder

• Problem with usual care

  • Treat AN first, trauma later

  • → PTSD remains → risk of relapse

• New approach

  • Treat AN + PTSD at the same time

  • Inpatient AN treatment + trauma therapy

• Findings

  • Feasible: 7/10 completed

  • Safe but challenging: ↑ anxiety, sleep issues, some self-harm

  • Acceptability: patient report benefit, healthcare workers emphasise the need, engagement and focus across sessions was high

Neuromodulation

• = Changing brain activity to help treat eating disorders

• Non-invasive (rTMS / iTBS)

  • Magnetic stimulation (no surgery)

  • Targets self-control & emotion areas

  • Effects:

    • ↑ eating in anorexia

    • ↓ impulsivity in bulimia/BED

  • Safe and well tolerated

• Invasive (DBS)

  • Brain surgery (electrodes)

  • For severe, treatment-resistant cases

• Findings

  • rTMS/iTBS: promising and safe

  • DBS:

    • Small studies

    • Some side effects

    • Improvements in BMI, mood, anxiety

Psychedelics and their effects in therapy

• Psilocybin

  • Cognitive flexibility

  • Anorexia and binge-eating disorder (Sweden Lund University)Binge-

    eating disorder (University of Florida)

  • Long-standing anorexia nervosa (UCSF)

• MDMA

  • Shame and fear

  • ED + PTSD: where trauma may be an underlying factor

• Ketamine

  • Rapid effect on mood

  • Anorexia + MDD (EDEN Study at King’s College)

• Ayahuasca / DMT

  • Neuroplasticity, interoception and emotional processing

  • Mostly speculative and self-report

Psychedelic-assisted therapy: MDMA

• Randomised controlled trial

• N = 90 with PTSD & ED symptoms (no purging)

  • n = 15 with BED or OSFED

  • n = 13 with history of anorexia or bulimia

• 80-180mg MDMA + psychological support

• Findings

  • Dropout n = 7

  • Reduction in disordered eatingat titudes

  • No change in BMI within or between groups

More to explore

• Brief and online treatments

• Guided self-help for other eating disorders

• Treatments for severe overweight and obesity

• Neuromodulation

• Medications and off-label prescribing