Anorexia Nervosa and Bulimia Nervosa

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Anorexia Nervosa and Bulimia Nervosa

• Dr A. Eivors and Dr S. Nesbitt
• 29th November 2005

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Plan for today

• Introductions/expectations
• What an eating disorder means to you
• Clinical definitions
• Models of development
• Case study exercise
• BREAK

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Plan for today

• Overview of recommended treatments
• Ideas for future research
• Clients perspectives
• Case study
• What we see as important aspects of this work

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Prevalence of Eating Disorders

• A.N. affects about 1 in 250 females and 1 in 2000
  males
• Five times that number have B.N. (0.5-1 of young
  women)
• Other eating disorders are even more common
  (EDNOS)
• Usually start in adolescence or young adult life
  (but can occur in childhood and later life).

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Anorexia Nervosa

• Maintenance of low weight
• BMI lt 17.5 or failure to gain weight in children
• Avoidance of food /- exercise /purging
• Poor nutrition leads to disruption in menstrual
  cycle
• Associated with social withdrawal and
  obessionality

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Anorexia Nervosa

• Leads to difficulties with education, work and
  medical complications (secondary problems)
• Co-morbidity depression, anxiety, OCD and
  hyperactivity
• Starvation effects brain, bone, heart, ovaries,
  impaired growth.

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Outcome in A.N.

• 46.9 recover
• 33.5 improve
• 20.8 chronic illness
• Mortality in 10 cohort studies ranges from
  1.36-17.8
• (Steinhausen 2002)

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Bulimia Nervosa

• Recurrent episodes of binge eating accompanied by
  a sense of loss of control
• Compensatory behaviour -purgingexercising
• Above behaviours both occur, on average, at least
  twice a week for 3 months
• Undue emphasis on body weight and shape

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Bulimia Nervosa - Outcome

• 50 fully recover
• 30 partially recover
• 20 continue to be symptomatic
• (Hay Bacaltchuck, 2002)

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Physiological Effects

• Mortality 10
• Extreme tiredness and feeling weak
• Feeling shivery, cold and dizzy
• Constipation, diarrhoea, and bladder problems
• Impact on fertility
• Swollen ankles and hands, cold hands and feet

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Physiological Effects

• Symptoms you cant see
• Vomiting food
• Effects on the way you look
• Taking laxatives

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Aetiological Factors in A.N.

• Genetic (heritability 58 - but what exactly is
  being inherited?)
• Early environmental
• Adverse life events
• Family factors
• Socio-cultural
• Perfectionism
• Impulsivity

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Aetiology in A.N.

• Need to avoid dichotomous thinking
• Mulitfactorial no single factor in isolation
  can account for the development of the illness
• Development of illness depends on combination of
  individual vulnerabilities and protective
  factors, biopsychosocial, family and cultural

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Bulimia Nervosa Aetiology

• Genetic (heritability 58)
• History of pre-morbid obesity (18-40)
• Adverse life events
• Family factors
• Socio-cultural factors
• Perfectionism
• Impulsivity

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Issues of Race and Culture

• Eating disorders are no longer the province of
  the white academically able middle class girls in
  the west
• Western medical models of anorexia nervosa does
  not promote the meaning of self-stravation

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Countries reporting Eating Disorders (Gordon 2001)

• Argentina Hungary Portugal
• Australia India Singapore
• Belgium Iran South Africa
• Brazil Israel South Korea
• Canada Italy Soviet Union
• Chile Japan Sweden
• China Mexico Switzerland
• Czech Republic Netherlands Turkey
• Denmark New Zealand Arab Emirates
• Egypt Nigeria UK
• France Norway US
• Germany Poland Hong Kong

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• The 3 Ps model
• Predisposing factors (what might have made
  someone vulnerable)
• Precipitating factors (what triggered)
• Perpetuating factors (what maintains)

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Predisposing factors

• Family (Minuchin et al 1978, Palazzoli, 1978)
• Genes
• Environment (Herzog, 1984)
• Personality

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Precipitating factors

• Puberty (Crisp, 1997)
• Trauma
• Neurological changes

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Perpetuating factors

• Environment
• Starvation
• Family

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The weight course in A.N.
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The weight course in A.N.

• 1. This is a diagram illustrating weight
  history. It represents the natural process of
  weight gain into adolescence
• 3. In addition to the obvious physical changes
  that occur as a young person reaches puberty
  there are also changes in thinking and overall
  experiences that occur with starting periods and
  puberty.
• 5. Entering adolescence can produce new
  challenges and problems period of adjustment
  for all.
• 7. The weight loss of the magnitude seen in AN
  causes changes in physical appearance, hormonal
  functioning and general experience that turn back
  the developmental clock in some ways. Discomfort
  and conflicts associated with the move to
  adulthood no longer seem relevant and are
  replaced by feelings of control and confidence

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The weight course in A.N.

• 8. Achieving a sub pubertal weight and shape
  appears to resolve a range of potential
  developmental concerns.
• 9. Some do poorly. There is further weight loss
  and possible death. They are unable to overcome
  the anxiety surrounding the initiation of weight
  gain.
• 10. Some recovery . This does not simply mean
  gaining weight. It requires addressing the
  issues at point 5 that made weight loss so
  attractive. Weight gain and changed eating
  behaviours are placed within the context of
  achieving other personal goals such as happiness
  and good relationships with family and friends

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Case Study

• Rachel (14 years old)
• Oldest of 3 children, parents both professional
  (Mother had a mild eating disorder herself in
  adolescence)
• Described as always looking after others.
  Conscientious student and many hobbies.
• Grandmother died when she was 13. She began her
  periods shortly afterwards and the following
  month began exercising and restricting diet.

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NICE Guidelines 2004

• NICE 2004 review three main areas
• 1) Physical Management
• 2) Psychological Therapies
• 3) Service Development Issues
• Focus Psychological Interventions

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Effective Treatment for A.N.

• The extra value of in-patient treatment over
  out-patient management needs further
  investigation
• Admission may cause harm as well as benefit
  anorexia nervosa
• Gains achieved in hospital are frequently
  reversed by longer-term follow-up
• (Gowers et al 2000)

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Effective Treatment in A.N.

• The decision to hospitalise may give an
  unrealistic expectation to the patient and family
  that this is a condition that can be overcome by
  professionals doing something to the patient
  rather than supporting him or her in the decision
  to change.
• (Gowers et al 2000)

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Psychological Therapies

• Type of therapy
• Some form of psychotherapy is essential, and is
  more effective than non-specific supportive
  management by either a psychiatrist or dietician
  (Palmer Treasure, 1999).
• Psychotherapy needs to address a range of
  issues- self-image, self-esteem, developmental
  issues, interpersonal and systemic issues and the
  acquisition of healthier coping strategies (Bell
  et al., 2000).

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Psychological Intervention for A.N.

• Cognitive Analytic Therapy (CAT)
• Cognitive Behaviour Therapy (CBT)
• Interpersonal Therapy (IPT)
• Family Interventions focused specifically on the
  eating disorder
• Motivational Enhancement Therapy (MET)

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Psychological Intervention for B.N

• Evidence based self help programme
• Cognitive Behaviour Therapy for Bulimia Nervosa
  (CBT-BN)
• Interpersonal Therapy (IPT)

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Further research

• Motivational work
• Outpatient based treatments
• Further studies to evaluate the merits of
  individual, family or combination treatments
• Further research to identify most effective
  intervention to challenge primary cognitive
  distortion

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The Clients perspective

• What is important to our clients?
• Psycho-education
• A supportive environment
• Challenging dysfunctional beliefs
• Behavioural strategies
• Collaboration

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Qualitative research

• Eivors et al 2003 study to investigate reasons
  for drop-out from treatment
• Treatment context often recreates feelings of
  loss of control which initially precipitated
  condition
• I dont feel I had any control over
  anything..they were just putting the weight on me
  and they werent solving anything
• theyve got to recognise that anorexia is part
  of a symptom of whats going on in a persons
  life. Sort out what the real problem is, get to
  the bottom of it and then sort out the eating
  disorder

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Clients experiences

• Sesan (1994) Hospitalisation dis-empowers client
  and repeat patterns of oppression. She argues
  that our attempts to control the symptoms of
  eating disorders may inadvertantly silence these
  women.
• Newton et al. (1993) Many patients had been
  successfully helped outside of medical contexts
  with less structured approaches.

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Skills Required for Therapeutic Work

• Balancing Physical aspects of this work (e.g
  monitoring of weight) with psychological therapy
• Pace/timing/nature of intervention
• Consistency
• Boundaries
• Being mindful of ones own relationship with food

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