EATING DISORDERS Christopher G Fairburn University of Oxford credo-oxford.com
EATING DISORDERS Definition The EDs are states in which there is a persistent and severe disturbance of eating that significantly affects psychosocial functioning or physical health, or both, and that is not accounted for by another disorder Mainstream EDs have distinctive clinical features and positive diagnostic criteria Classification Anorexia nervosa Bulimia nervosa Other similar eating disorders (subthreshold AN or BN, and mixed states) Binge eating disorder Avoidant/restrictive food intake disorder (ARFID)
EATING DISORDERS - Adolescents Anorexia nervosa Bulimia nervosa Other eating disorders (OEDs) Binge eating disorder ARFID OEDs BED BN AN
EATING DISORDERS - Adults Anorexia nervosa Bulimia nervosa Other eating disorders (OEDs) Binge eating disorder [ARFID] OEDs BED AN BN
EATING DISORDERS Anorexia nervosa Bulimia nervosa Other eating disorders (OEDs) Binge eating disorder ARFID Anorexia Nervosa Sustained and selective under-eating Low weight Driven by extreme concerns about shape and weight Mainly young women OEDs BED AN BN
EATING DISORDERS Anorexia nervosa Bulimia nervosa Other eating disorders (OEDs) Binge eating disorder ARFID Bulimia Nervosa Sustained and selective under-eating Punctuated by repeated binge eating Same extreme concerns about shape and weight Unremarkable weight Mainly young women OEDs BED AN BN
EATING DISORDERS Anorexia nervosa Bulimia nervosa Other eating disorders (OEDs) Binge eating disorder ARFID Other Eating Disorders Mainly subthreshold or mixed states Same psychopathology as AN and BN Unremarkable weight Mainly young women OEDs BED AN BN
EATING DISORDERS Anorexia nervosa Bulimia nervosa Other eating disorders (OEDs) Binge eating disorder ARFID Binge Eating Disorder Recurrent binge eating General tendency to overeat Often co-occurs with obesity Broad age range; one third male OEDs BED AN BN
EATING DISORDERS Anorexia nervosa Bulimia nervosa Other eating disorders (OEDs) Binge eating disorder ARFID ARFID Persistent selective eating Not well characterised Mainly children OEDs BED AN BN
EATING DISORDERS Mainstream Eating Disorders Anorexia nervosa Bulimia nervosa Other similar eating disorders (subthreshold and mixed states) Other States Binge eating disorder ARFID OEDs BED AN BN
AN OEDs BN
Shared Psychopathology AN OEDs BN
COURSE Anorexia Nervosa Starts in adolescence; often self-limiting or easily treated If persists, frequently evolves into BN or an OED Minority remain as AN and the disorder may become life-long and life-threatening Bulimia Nervosa Starts in late adolescence or early adulthood Commonly preceded by AN or an AN-like state May persist as BN or evolve into an OED Other Eating Disorders Course not well characterised Starts in adolescence or early adulthood Often preceded by AN or BN
Shared Psychopathology AN OEDs BN
Diagnostic Migration AN OEDs BN
The Transdiagnostic Perspective
DISTRIBUTION General Points Distribution not stable. Secular changes: Emergence of BN in the 1970s in Northern Europe and North America; and subsequent spread to other countries Emergence of EDs in Asian countries since 1990s Uneven global distribution
DISTRIBUTION Anorexia Nervosa Bulimia Nervosa Worldwide distribution Western societies Western societies Ethnicity Mainly Caucasian Mainly Caucasian Sex Female >> male Female >> male Age Adolescents Young adults Prevalence rate 0.1-0.5% 1.0-2.0% Secular changes Possible increase Probable increase
DISTRIBUTION Anorexia nervosa Bulimia nervosa BED Worldwide distribution Western societies Western societies Not known Ethnicity Mainly Caucasian Mainly Caucasian Even distribution? Sex Female >> male Female >> male Female > male Age Adolescents Young adults Middle aged Prevalence rate 0.1-0.5% 1.0-2.0% Not known Secular changes Possible increase Probable increase Not known
DETERMINANTS General Points Ill-understood Methodological challenges i. EDs are not common ii. EDs are difficult to detect iii. Clinical samples are unrepresentative iv. EDs are difficult to diagnose; inconsistent definitions used v. Not obvious what phenotypes to study e.g., AN or persistent AN v. Issue of comorbidity Largely ignored, yet there appears to be a relationship between EDs and depression
DETERMINANTS General Points (cont) Undoubtedly familial Ten-fold increase in risk among first degree relatives Cross-transmission between the mainstream EDs Twin studies suggest an important genetic contribution Additive genetic factors contribute 40% to 60% of liability Two GWAS studies of AN Negative findings (due to small sample sizes?; Ns = 1,000 and 3,000) New one underway (goal N = 25,000) Secular changes suggests social processes contribute Some well established risk factors
RISK FACTORS
PHARMACOLOGICAL TREATMENTS Anorexia Nervosa No pharmacological treatments Bulimia Nervosa Antidepressant medication has a short-term effect on the frequency of binge eating Other Eating Disorders No studies Binge Eating Disorder Lisdexamphetamine has a short-term effect on the frequency of binge eating
PSYCHOLOGICAL TREATMENTS (until recently) Anorexia Nervosa Adolescents Eating disorder-focused family therapy (Maudsley method; FBT) Adults No specific evidence-based psychological treatment; SSCM Bulimia Nervosa CBT-BN Other Eating Disorders No treatment studies Binge Eating Disorder CBT-BN; IPT; Guided CBT self-help
CBT-E OUTCOME STUDIES All eating disorder patients Anorexia nervosa, Bulimia nervosa & ED-NOS Byrne et al, 2010 Non-underweight patients Bulimia nervosa & ED-NOS Fairburn et al, 2009 Knott et al, 2014 Fairburn et al, 2015 Dalle Grave et al, 2015 - adol Underweight patients Anorexia nervosa Fairburn et al, 2013 Dalle Grave et al, 2013 - adol Dalle Grave et al, 2013 inpt Dalle Grave et al, 2014 - adol ip Byrne et al, in preparation Bulimia nervosa only Poulsen et al, 2014
credo THE OXFORD TRIALS (Fairburn et al, 2009, 2015) Design Patients with any ED (BMI 17.5 40.0) Consecutive adult referrals - N=154; N=130 Trial 1 - Randomised to focused or broad forms of CBT-E, or waitlist Trial 2 - Randomised to focused CBT-E or Interpersonal Psychotherapy (IPT) In both trials: Treatment involved 20 sessions over 20 weeks Closed 60-week follow-up Blind assessments Baseline, end of treatment, and after 20, 40 and 60 weeks
credo THE OXFORD TRIALS (Fairburn et al, 2009, 2015) Trial One Main Findings CBT-E rated as highly acceptable 78% completed all 20 sessions of treatment Good response to both forms of CBT-E Two-thirds made a full and sustained response DSM diagnosis was not predictive of response
credo THE OXFORD TRIALS (Fairburn et al, 2009, 2015) Trial Two Main Findings CBT-E rated as highly acceptable 78% completed all 20 sessions of treatment Good response to both forms of CBT-E Two-thirds made a full and sustained response DSM diagnosis was not predictive of response
credo Response rate (%)) CBT-E study 2 CBT-E study 1 IPT
EVIDENCE-BASED TREATMENT 2016 Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Other Eating Disorders Adults CBT-E** SSCM** CBT-E*** IPT** CBT-E*** GSH*** IPT** CBT-E*** IPT* Adolescents FBT*** CBT-E* FBT** CBT-E* CBT-E* CBT-E*
EMPIRICAL STATUS OF CBT-E Main Findings CBT-E can be used... Across all ED diagnoses With adolescents and adults CBT-E is more effective than all the treatments with which it has been compared IPT; PPT; MANTRA; SSCM Routine clinical services are reporting results similar to those from the RCTs
THE SCALABILITY PROBLEM Psychological Treatments are Difficult to Scale Up The challenge is how to get effective treatments, like CBT-E, to all those who would benefit from them
We are here AVAILABILITY OF A TREATMENT
etraining in CBT-E Three Studies (N=960 therapists) A Country Trained all eligible therapists across Ireland (supported training) A Continent RCT comparing independent and supported training Eligible therapists across North America The World Global cohort study of independent training
AVAILABILITY OF A TREATMENT We are here etraining
AVAILABILITY OF A TREATMENT We are here etraining CBTe