eating disorders -> treatment + prevention

what did Linienfeld et al. (2013) identify as concerns surrounding the treatment of eating disorders

out of 600 therapies identified in total, many were described as, but few had substantial evidence supporting them

• found therapies e.g. dolphin-assisted therapy (???), which were not published in peer-reviewed journals

what are empirically-grounded interventions + what is the process of how they’re made (Salkovski, 2002)

refers to the process of formulating a theory of what causes a particular health condition, then performing experimental studies to test the theory (e.g. specific cognitions/schemas)

• results of validity of these theories are therefore used to develop particular therapies to treat said causes

• therapies are tested in clinical practice via case studies + outcome research through RCTs + efficacy trials → implemented in practice + informs clinical guidelines, which can be used to inform patients of appropriate treatment

what 4 problematic facts did Lilienfeld’s review find surrounding clinicians in practice

• only 38% of clinicians reported using the strongest therapy, and some of those who did removed the key elements of it (if scared to deliver particular aspect of treatment, treatment isn’t properly conducted)

• only 6% reported using evidence-based treatment manuals

• more (majority) delivered eclectic or integrative therapies → not supported by evidence-based theory

• many were untrained in the therapy they were using

what 5 factors in aetiology + maintenance have different therapies focused on

• biology/genes

• family interaction, e.g. communication style

• sociocultural influences

• trauma/negative life experiences

• bullying

what 5 maintenance factors do effective ED treatments often feature

• safety behaviours

• cognitive + emotional patterns

• social maintenance

• family accommodation of symptoms

• nutrition

what are benefits of implementing prevention of eating disorders

implementation of strategies in late childhood/early adolescence inoculates the individual against the development of eating disorder psychopathology

• has massive potential benefits for limited investment, e.g. integration into school curriculum

what are two potential targets of prevention strategies

• a lowering of eating + other concerns in the present

• a lower level of future development of eating disorders

what prevention strategy did Carter et al. (1997) + Baronowski et al. (2001) evaluate + what were the findingsq

attempted to implement psychoeducation about dieting + eating disorders in schoolchildren ages 11-14

• found pathology (significant eating problems) got worse in both cases → short term for one + long term for another

what 4 prevention approaches did Le et al. (2017) identify as effective in their meta-analysis

based on 58 studies (some with weak evidence, limiting conclusions):

• media literacy approaches reduced shape + weight concerns for everyone in the young population

• cognitive dissonance approaches reduce problematic eating behaviours + attitudes in high-risk groups

• CBT interventions reduce risk of dieting

• weight management interventions reduced some risk factors

what is the only intervention approach that has been evidenced to reduce number of people developing eating disorders

dissonance-based approaches

what does the national institute for health + clinical excellence (NIHCE) recommend as interventions for obesity

rather than specific psychological interventions, recommends ones on a wider scale including schools, local governments, families + policies e.g. taxation

• this encourages lifestyle changes that reduce/prevent obesity

what is the prevalence of obesity in the UK

• since 1993, proportion of obese population has risen from 14.9 → 28%

• almost ¾ of people aged 45-74 are overweight or obese

this number is significant due to other health issues that accompany obesity e.g. hypertension → increased risk of stroke/heart attack

why is NIHCE (2017) a good guideline to use for treatments

does best-practice systematic reviews + guideline panels that target multiple avenues e.g. representatives of patients, clinicians, academics etc. to implement interventions

• collects evidence from different avenues to find most effective interventions

• these guidelines tend to informs other recommendations internationally due to robust research process

• drives commissioning advice for the NHS

what are 2 factors to take into account when recommending treatments

• adults vs children/adolescents

• underweight vs non-underweight patients

what are 3 effective treatments for anorexia nervosa in adults + what do these have a similar level of effectiveness as

• 40 sessions of individual CBT for eating disorders (CBT-ED) → longer scheme than most other mental health conditions, highlighting the amount needed for positive change

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

• 20-30 sessions of specialist supportive clinical management (SSCM) → uses case-management approach to increase food intake + reduce problematic behaviour

these have similar level of effectiveness to behavioural therapy

what are 2 effective treatments for anorexia nervosa in children/adolescents

• AN-focused family therapy = most effective

• CBT-ED or adolescent-focused psychotherapy

what 4 features/stages of AN-focused family therapy make it an effective intervention

families are often in difficult interpersonal situations, so resetting the family dynamic reduces stress + can reduce need to resort to safety behaviours. features:

• non-blaming

• preventing accommodating patterns occurring → starts by taking control of the child’s eating

• eventually gives control back to the child

• finishes with relapse prevention to ensure change is maintained

what is the most effective treatment for adults or adolescents with binge eating disorder

16-20 sessions of group or individual CBT-ED

what are the most effective treatments for adults or adolescents with bulimia nervosa

• children/adolescents → family therapy for BN

• adults → 16-20 sessions of individual CBT-ED, but can try guided self-help CBT-ED first

what is the most effective treatment for adults or adolescents with OSFED

recommendation is the use the therapy recommended for the most similar full syndrome, e.g. use CBT-ED for atypical AN

what recommendations are made for treating ARFID + why are conclusions limited

disorder not addressed by NIHCE (2017) due to its recency → doesn’t have enough evidential basis to draw strong conclusions as research on mental health disorders = slow developing

• Thomas et al. (2021) performed small open trial for CBT-avoidant/restrictive with positive results, but no control group/randomised design means evidence is limited

what 4 pieces of recent research on EDs has corrected myths in the field

• briefer therapies can be as effective for non-underweight eating disorders (Waller et al., 2018) → found 10-session CBT-ED delivered by non-specialist therapists performed at comparable level to versions twice as long

• early symptom reduction enhances therapeutic alliance + treatment outcomes, but requires specific attention for younger patients + those receiving non-behaviourally oriented treatments (Graves et al., 2017)

• most robust predictor of efficacy was greater symptom change during early stages of treatments (Vall + Wade, 2015) → early change = critical

• no evidence that severity or duration of ED reduces effectiveness of treatment (Raykos et al., 2018)

what is the common element of what works in ED treatments

start with food as key element of treatment → issues mostly rooted in disordered food consumption, so changing diet/exposure to foods establishes a more positive relationship with it

• this has physical, cognitive, emotional + social benefits

• this is potentially the only necessary step in underweight ED cases, whether non-underweight cases experience extra value in psychological element of therapy

what is the need for case/risk management + what is a main example

monitors + manages risks in severe cases of EDs → as ED has the highest mortality rate of any mental health condition, intensive treatments e.g. in-patient care may be necessary

• use varies across cultures → rare in UK, but common in Germany

• this can be good for management + weight restoration in high-risk cases, e.g. establishing meal plans/slowly increasing dietary intake

• may also improve cognitive function, which may have been lost if body weight = low enough

what are limitations of in-patient care for EDs + what is its best use

• there is almost no evidence of it establishing recovery + there is a risk of creating patient dependence on the treatment

• very expensive to run

therefore is best used in stage 1 of anorexia nervosa treatment (if severe enough), prior to outpatient evidence-based therapies

what two kinds of medication have recommended to treat EDs + what are limitations

medications can be useful short-term, but do not have lasting positive effects (e.g. on cognitive patterns) once they cease, as well as having side-effects

• SSRIs at high doses for BN → enhances functional serotonin + reduces binges for some people taking it in short-term

• novel antipsychotics for AN → may reduce anxiety but increase weight gain due to metabolic slowing (not useful obviously)

what is an example of therapy that was recommended for EDs in the past

NIHCE previously recommended dialectical BT → developed for those with complex emotional needs/personality disorders to reduce suicidality + in order to manage emotions

• had good evidence due to reducing impulsive behaviours, but resulted in little change in core pathology → since overtaken by stronger evidence (e.g. of family therapy/CBT-ED)

what 3 other psychological therapies have some (weaker) evidence

• interpersonal therapy (IPT) focuses on relational dynamics in friends + family to improve eating behaviours → works for BN, but requires greater number of sessions + generally less effective than CBT

• focused psychodynamic approaches (FIT) focuses on psyche conflict based on Freud’s theories → effective for AN in Germany, but results not replicated

• integrative cognitive-affective therapy → less effective than CBT

what are 4 examples of psychological therapies with little evidence of efficacy

• mentalisation-based therapy enhances ability to attribute internal states to oneself + how you respond to them (based on psychoanalytic approaches) → mainly used for personality disorders/complex emotional needs, but less effective than CBT for EDs + takes longer to be effective (18 months)

• acceptance + commitment therapy (ACT) → originally used for physical health problems; evidence has only resulted from poorly-designed studies

• mindfulness-based approaches

• family therapies not food/eating focused

what did Hansen et al. (2002) find the mean effectiveness of evidence-based therapies for psychological disorders was generally

• 50% recovery

• 25% improvement

• 20% unchanged

• 5% deterioration

this has been reproduced in clinical settings if therapy is delivered correctly

did Fairburn (2009; 2013) find the same recovery rate for eating disorders

50% recovery rate can still be achieved in non-underweight cases, but it is lower (30%) for underweight cases

where do ED therapies have their impact

based on formulation of EDs used, different therapies will target different areas

• e.g. both CBT-ED + family therapies will target factors e.g. low self-esteem + restriction

• CBT-ED also targets perfectionism + fear of loss of control, while FTs target the sense of control resulting from starvation

how is homeostasis related to ED therapy

large goal of ED therapy is to restore homeostasis to reestablish healthy eating patterns by addressing diet, cognition + emotions

• encourages person to overcome reasons for not eating healthily + supports person to eat in response to biological need, rather than toxic environment or psychological concerns

what 4 positive effects does addressing eating + nutrition have

• reduces psychological symptoms e.g. anxiety, depression + impulse/compulsivity by increasing serotonin levels

• reduces co-occurring issues with substances due to mood stability + reducing negative effects from decreased starvation

• enhances cognitive flexibility + social skills

• normalises + stabilises weight

these all work to increase quality of life generally

what have outcomes been for psychological therapies treating obesity (Cooper et al., 2010)

they can support weight loss in the short term, but regardless of therapy type are poor at maintaining lower weight

• devised a new CBT for obesity + find in 3 conditions offered, weight gain actually increased after treatment → suggests long-term weight management is necessary

why does Brownell (2010) propose treating obesity is so difficult

suggests poor treatment + maintenance outcomes can be attributed to strong biological + environmental forces that oppose weightloss/foster regain → our evolutionary biology in combination with the toxic environment makes obesity difficult to achieve

• though even 5-10% weight loss can have major health benefits

what are 4 possible interventions of support for obesity

• political changes e.g. substantial sugar tax → has positive impacts on encouraging healthy eating, but has risk of fat shaming

• lifestyle coaching e.g. exercise programmes for overweight patients

• longer styles of therapy → relatively limited benefits

• continuing care models → found to be most likely to work

what is another style of effective obesity intervention + why does it still require psychological support

long-term maintenance of weight loss through bariatric surgery → reduces amount of food that can fill the stomach, meaning one feels full sooner

• psychological interventions = still necessary with this for adapting to lifestyle changes + developing preparation/maintenance strategies

what 3 symptom-based therapies does Waller (2016) suggest to address elements of ED pathology

these are not expected to produce remission/recovery:

• nutritional work → restores nutritional balance to improve cognition

• cognitive remediation therapy → addressive cognitive inflexibility associated with AN

• support or carers