Lecture 9: Eating disorders 2

Lillienfeld (evidence based practice vs actual practice)

-identified some concerns about treatment of eating disorders

-over 600 therapies were identified

-a few were wacky

-many were described as ‘evidence-based’ → very few were evidence'-based

-most clinicians do not deliver evidence-based treatments

review of studies of clinical practice (Lillienfeld)

-only 38% reported using the strongest therapy

-even if they do use the strongest therapy, take out key elements

-only 6% report using evidence-based treatment manuals

-more deliver unevidenced therapies

-many are untrained in the therapy they are using

-clinician characteristics get in the way

empirically grounded interventions

-links between clinical guidelines, evidence, theory and actual practice

-start with theory → then do experimental studies to test theory → use to develop treatments → then do feasibility and RCTs → then wider efficacy and cost-effectiveness trials

matching interventions to the condition

-different therapies have focused on different elements in the aetiology and maintenance of EDs

• biology

• genes

• family interaction

• sociocultural influences

• trauma

• bullying and teasing

• negative life experiences

maintenance factors

-most effective interventions focus on maintenance factors:

• safety behaviours

• cognitive patterns

• emotional patterns

• social maintenance

• family accommodation of symptoms

• nutrition

prevention of EDs

-ideal for implementation in late childhood/early adolescence

-inoculate the individual against the development of eating pathology

-massive potential benefits for limited investment

potential targets of prevention of EDs

-lowering of eating and other concerns in the present

-a lower level of future development of EDs

risks of prevention strategies

-Carter and Baronowski & Heatherington

-psychoeducation about dieting and EDs

-in both cases the level of pathology got worse

• Baronowski - short term

• Carter - long term

-Carter reported this as a problem and suggested not doing this sort of psychoeducation

-but Baronowski did not and reported it as a success

Le (meta-analysis on prevention strategies)

-many of the studies were weak

-media literacy approaches reduce shape and weight concerns for everyone in the whole young population

-cognitive dissonance approaches reduce eating behaviours and attitudes in high-risk groups

-CBT interventions reduce risk of dieting

-weight management interventions reduce some risk factors

effectiveness of prevention strategies

-some evidence for reduction of risk factors and developing eating disorders → dissonance-based approaches

-need to get better at reducing numbers of cases to justify the effort spent on prevention work

NICE - obesity recommendations

-family interventions involving schools, local government, families, policies such as taxation → rather than specific psychological interventions

-encouraging lifestyle changes healthy eating - amounts and choices, routine exercise

obesity rates

-3/4 people aged 45-74 are overweight or obese

-proportion has risen from 14.9% to 28% since 1993

NICE guidelines

-strongest evidence

-match most other guidelines internationally

-primary differences are between:

• adults vs children/adolescents

• underweight vs non-underweight patients

effective treatments for anorexia - adults (NICE)

• individual CBT - 40 sessions

• Maudsley anorexia nervosa treatment for adults (MANTRA) - 20-30 sessions

• specialist supportive clinical management (SSCM) - 20-30 sessions, case management approach to reduce problematic eating behaviour

• similar level of effectiveness to behaviour therapy

effective treatments for anorexia - children and adolescents (NICE)

-AN-focused family therapy

• non-blaming

• stop accommodating patterns

• family starts by taking control of the child’s eating

• then moves to giving that control back to the child

• finishes with relapse prevention

-CBT-ED or adolescent-focused psychotherapy as a second option

effective treatments for BN and BED - adults and adolescents (NICE)

-group CBT-ED or individual CBT-ED - 16-20 sessions

effective treatments for BN - children and adolescents (NICE)

-family therapy

-CBT-ED as a second line therapy

effective treatments for atypical cases (NICE)

-use the therapy recommended for the most similar full syndrome

effective treatments for ARFID (NICE)

-not addressed by NICE → too new to have an evidence base

-some early evidence for CBT-avoidant/restrictive

correcting common myths

-briefer therapies can be as effective for non-underweight EDs

-therapeutic alliance does not work in the way that clinicians assume

-early change is critical

-no evidence that severity or duration reduces effectiveness

common elements of effective treatments

-start with food as the key element

• single most important element is nutrition/exposure to foods

-underweight cases → not clear whether the rest of these therapies does much more

-non-underweight cases → extra value in the psychological element of therapy

effective treatments (NICE)

-covers the therapies that are most strongly supported by the evidence

• so is what should be used as a priority and in a resource-limited setting

• drives commissioning advice for NHS

• addresses issues around case management and patient experience

-some other approaches may have evidence to support them

• not meeting the NICE criteria of enough high-quality research

• not as effective as what the guidelines recommend

• still not including very weak research or unsupported clinician opinion

need for case management

-medical monitoring and management

-intensive treatments varies across cultures

-necessary for management of high-risk cases

-can be good for weight restoration

-almost no evidence of establishing recovery

-very expensive

-risk of creating dependence

weaker evidence (for certain treatments)

-therapies that have been recommended in the past but have not been retained because they were overtaken by stronger evidence

SSRIs (weaker evidence for use)

-at high does for BN can:

• enhance functional serotonin

• reduces binges for some people while taking, but not for long-term

• potential withdrawal effects → SSRI discontinuation syndrome

novel antipsychotics (weaker evidence for use)

-for AN

-reduce anxiety

-have dampening effect, range of side effects such as weight gain through metabolic slowing

neuromodulation (weaker evidence for use)

-transcranial stimulation methods seem to reduce depression slightly

-no evidence that this works specifically in ED

leucotomy (weaker evidence for use)

-brain surgery, rarely used

-has been used for chronic AN with extreme OCD

-evidence is anecdotal

dialectical behaviour therapy (weaker evidence for use)

-reduces impulsive behaviours in BED/BN, but little change in core pathology

-evidence for AN is very limited

interpersonal psychotherapy (weaker evidence for use)

-works for BN

-slower and less effective than CBT

focussed psychodynamic approaches (weaker evidence for use)

-effective for AN in a German study

-needs to be replicated in other countries

integrative cognitive-affective therapy (weaker evidence for use)

-less effective than CBT

mentalisation-based therapies (weaker evidence for use)

-mainly used in personality disorders

-effectiveness for EDs lower than CBT - takes 18 months

acceptance and commitment therapy (weaker evidence for use)

-small number of studies - only 5 RCTs but poorly designed

-mindfulness-based approaches

-family therapies that are not food/eating focussed

mean effectiveness of evidence-based therapies (adult psychological disorders)

• 50% recovery

• 25% improvement

• 20% unchanged

• 5% deteriorate

mean effectiveness of evidence-based therapies (eating disorders)

-can still hit 50% recovery rate in treating EDs → only for non-underweight cases

-lower for underweight cases - 30%

CBT targets (where therapies have impact)

-targets areas to break cycle perfectionism

-low self-esteem, need for control, starvation, restriction, fear of loss of control

family therapies targets (where therapies have impact)

-target low self-esteem, need for control, restriction, starvation, positive outcome and sense of control

homeostasis

-encourage the person to overcome their reasons for not eating healthily

-supporting the person to eat in response to biological need

• not to toxic environment or to inner psychological psychological concerns

-aim to restore homeostasis

addressing nutrition

-wide range of effects:

• reduces anxiety, depression, impulsivity, compulsivity → serotonin levels in particular

• reduces alcohol levels → mood stability plus reduction in starvation

• enhances cognitive flexibility, social skills → reduction in starvation effects and safety behaviours

• normalises and stabilises weight

• enhances quality of life

factors contributing to obesity

• factors contributing to hunger → genetics, learning, social learning

• satiety → social pressures, food industry, toxic environment

Jeffrey (psychological therapies have poor outcomes)

-can support people to lose weight in the short term

-but poor at keeping weight down in the long term, whatever the therapy

issues with treating obesity

-even a 5-10% loss of weight can have major health benefits

-but have trouble achieving that

-biology meets the toxic environment, and obesity is difficult to change

supporting people with obesity

• political/social changes - but does carry risk of fat shaming

• lifestyle coaching → food choices and exercise

• longer therapy → relatively limited benefits

• continuing care model seems most likely to work

bariatric surgery

-most effective long-term route to weight loss

-different methods and only to be conducted by surgeons

-most issues about adaptation to lifestyle changes and making slow progress → requires psychological preparation and maintenance strategies

-where psychologist can be usefully involved