Lecture 10

Question 1

what are the first set of “feeding and eating” disorders in the DSM-5 and ICD-11

Answer 1

pica

rumination disorder (called rumination-regurgitation disorder in ICD-11)

avoidant-restrictive food intake disorder

Question 2

what are the third-sixth “feeding and eating” disorders in DSM-5 and ICD-11

Answer 2

anorexia nervosa

bulimia nervosa

binge eating disorder

Question 3

what are the two last categories in the “feeding and eating” disorders in the DSM-5 and ICD-11

Answer 3

other specified feeding or eating disorder (OSFED - previously known as “eating disorder not otherwise specified or EDNOS, changed 2013”)

unspecified feeding or eating disorder

Question 4

how many categories of “feeding and eating disorders” are there?

Answer 4

8

Question 5

what is anorexia nervosa

Answer 5

weight loss/low body weight (due to dietary restriction, BMI<18.5, rapid weight loss (ICD-11 only >20% in 6 months, children/adolescent s fail to make expected weight gain)

intense fear of weight gain/avoidance of weight gain even if underweight

disturbance in the way weight and shape is experienced/excessive preoccupation with shape/weight ie over-evaluation of shape/weight and too highly valued in determining self-worth

can’t recognise they are underweight

Question 6

what are the subtypes of anorexia nervosa

Answer 6

binge eating/purging (recurrent episodes of binge eating and purging=self-induced vomiting, misusing laxatives, diuretics)

restricting (no bingeing/purging- in DSM-5, this is only in the last 3 months)

Question 7

what is bulimia nervosa

Answer 7

frequent episodes of binge eating

recurrent (inappropriate) compensatory behaviours

over-evaluation of shape and weight

in DSM-5, this binge eating has to be once a week for 3 months

in ICD-11, this has to be once a week for 1 month

Question 8

what is the binge eating disorder classification in DSM-5

Answer 8

recurrent binge eating
3 of the following:
eating more rapidly than usual
eating until uncomfortably full
eating large amounts when not physically hungry
eating alone due to being embarrassed about the amount being eaten
feeling disgusted with oneself, depressed or very guilty afterwards

must be once a week for 3 months

also:
distress about binge eating

no compensatory behaviour

Question 9

what is the binge eating disorder classification in ICD-11

Answer 9

recurrent binge eating symptoms:
binge eating occurs over a discreet period of time (ie 2 hours)
eating notably more or differently than usual
sense of loss of control over eating (feeling you cant stop)

must be at least once a week for three months

ALSO distress about binge eating

and

no compensatory behaviour

Question 10

what did fairburn, copper and shafran 2003 identify about ED diagnosis

Answer 10

overlap of features across EDs:
over-evaluation of shape and weight

overeating vs undereating

compensatory behaviours

attempts to control eating, shape and weight

monitoring weight/shape/eating OR avoidance

common for patients to cross-over between different diagnosis

Question 11

how common are EDs

Answer 11

1.25 million individuals in UK (BEAT 2018)

DAHLGREN ET AL., 2017= systematic review of interview studies found rates in young females in EU/US:
AN=nearly 1-2 ppl out of 100 lifetime prevalence
BN= 2 ppl out of 100 lifetime prev
BED=3 ppl out of 100 lifetime prev
OSFED=1 person out of 20 OR 1 person out of 10 lifetime prev (5-11% lifetime prev!!)

QIAN ET AL., 2022- meta analysis, lifetime prev rates of AN, BN and BED were 0.16%, 0.63%, and 1.53% BUT now likely to be higher

Question 12

what is the ED prevalence in diff genders

Answer 12

AN and BN more common in women (10:1)

for BED, 2:1 women to men

BUT prevalence of AN among men is increasing globally as more focus on being muscular or lean, excess protein consumption, steroid misuse etc

roughly 90% cases women

Question 13

how does ED prevalence vary across cultures

Answer 13

AN in all cultures BUT instead of fear of weight gain, the focus may be on gastrointestinal discomfort or cultural or religious motives AND greater incidence in higher-income countries/those affected by globalisation

purging methods vary cross-culturally ie herbal purgatives for ‘medicinal’ or other reasons

For BED levels of body dissatisfaction and BED varies

LGBTQ community may vary as well!!!

Question 14

what are physical consequences of EDs

Answer 14

malnutrition (ie cardiac problems, bone deterioration, poor growth)

binge eating (physical damage, obesity and associated risks)

purging (ie dental health, if using self-induced vomiting, and electrolyte imbalance)

AN has the highest mortality rate of all psychiatric disorders due to physical complications and suicide (9X more likely to die than someone without it)

Question 15

what are impacts of EDs

Answer 15

mortality risks/physical consequences

cognitive (poor concentration)

emotional (anxiety/shame)

social (isolation)

developmental (onset occurs at a time of physical, social and interpersonal)

Question 16

when do EDs typically start

Answer 16

adolescence

Volpe et al., 2016= 75% occur before the age of 22

Question 17

what is the typical age of ppl with EDs

Answer 17

of 24,300 ED-related hospital admissions in England in 2020-23, almost half were under 25 years

Question 18

what are recovery rates of EDs like

Answer 18

modest

early intervention is best (within first 3 years of onset)

see Schmidt et al., 2016, FREED

Question 19

how did COVID-19 impact EDs

Answer 19

Taquet et al 2022, Touyz et al., 2020, Brown et al, 2021=increased EDs due to social isolation and changes to people’s routine and structure

Question 20

how many people did 2019 Health Survey for England find had a positive ED

Answer 20

16% of surveyed adults screened positive for a possible ED

Question 21

who was Averil Hart

Answer 21

history of severe AN

inpatient in a specialist hospital in Cambridge

went to uni 6 weeks later in a diff country and she was immediately transferred to Norwich team with no robust discharge or crisis plan

it took one month to allocate her a care co-ordinator, and the allocated one was inexperienced and miscalculated her weight

no physical health monitoring in her new team

she was gravely ill 3 months after starting uni and passed away in hospital

see “Ignoring the alarms: how NHS earing disorder services are failing patients”

Question 22

what are the 5 key recommendations for ED treatment

Answer 22

training=train doctors and medical professionals!

parity=achieve parity in the quality and availability of adult services, including better transition from CAMHS

co-ordination=improve multi-service communication, NICE asked to include coordination in its Quality Standard

workforce=address training gaps, Health Education England to review capacity and training to increase availability of ED specialists

investigation=serious-incident learning and data capture need to improve. thoroughly investigate deaths

Question 23

how can MEED improve how clinical care functions

Answer 23

Managing Medical Emergencies in Eating Disorders (MEED)

Royal College of Psychiatrists (2022)

traffic light system for identifying patients’ risk to life

guidance for all ages and all EDs

updated guidance on physical and psychiatric management

Question 24

what significant failings did the all party parliamentary group 2025 identify that people with EDs are facing

Answer 24

barriers to treatment access

insufficient healthcare provider training

fragmented care pathways

lack of standardised data around EDs

postcode lottery in service provision

patients are being discharged from services with dangerously low BMIs

Question 25

what is the All Party Parliamentary Group 2025's proposed plan for improving ED treatment

Answer 25

calls the Government to: develop a national strategy for EDs provide additional funding for ED services that targets adult and children services launch a confidential inquiry into all ED deaths increase research funding for EDs to enhance treatment outcomes and discover a cure ensure non-executive director oversight for adult and children's ED services, which is implemented in ALL NHS TRUSTS AND HEALTH BOARDS in the UK

Question 26

what did Guarda et al., 2022 and others report about terminal anorexia nervosa

Answer 26

people with AN could qualify for assisted death

Question 27

what are Guadiani et al., 2022's proposed characteristics for 'terminal' anorexia

Answer 27

AN diagnosis older than 30 previous participation in high quality care patient is fully capable of making decisions but concludes further treatment won't be beneficial

Question 28

how did Asaria, 2023 critique Guadiani et al., 2022's proposed characteristics for 'terminal' anorexia

Answer 28

AN is reversible you can recover at any age and it takes time, don't have to be 30+ who decides what is 'high quality care'? starvation can limit capacity to make decisions some people are ambivalent towards life even if they think additional treatment isn't beneficial

Question 29

what is 'atypical anorexia nervosa'?

Answer 29

Walsh et al., 2023: exhibiting many signs and symptoms characteristic of AN but substantially more severe ED-related cognitive disturbances than typical AN more non ED specific psychopathology (ie depression, anxiety, self-esteem, functional impairment) than typical AN too

Question 30

what did Eddy et al., 2017 find about how chronic EDs are

Answer 30

followed people with AN and BN up to 25 years after initial presentation half those who hadn't recovered in the first 9 years did so by the 22-year follow up brief stretches of weight restoration or symptom remission (even just 3 months) were strong predictors of long-term recovery in AN people with BN improve within first decade and early change predicts long term outcomes in BN, recovery is less likely as time goes on but it's still possible 1/3 still struggle some who recover, then relapse, so ongoing support is necessary

Question 31

what does the cognitive behavioural model say about EDs

Answer 31

core ED psychopathology model: at first, over-evaluation of shape and weight and their control this leads to strict dieting and other controlling behaviours this then can lead to binge eating or significantly low weight or both if binge eating, this influences, and is influenced by, compensatory behaviours like self-induced vomiting events and associated mood changes all influence these other maintaining processes of the cycle are: core low self-esteem perfectionism interpersonal problems mood intolerance (BUT this is now conceptualised as part of events and associated mood change)

Question 32

who made the cognitive behavioural model of EDs

Answer 32

fairburn, copper and shafran 2003

Question 33

what is the interpersonal model for EDs

Answer 33

longstanding interpersonal difficulties is the cause for the strict dieting/controlling behaviours that lead to binge eating and/or significantly low weight day-to-day interpersonal problems mediate the cycle

Question 34

who proposed the interpersonal model for EDs

Answer 34

murphy et al., 2012

Question 35

what is the cycle of maladaptive coping in BED from an emotional dysregulation perspective

Answer 35

triggering event (can be internal or external) leads to a positive of negative emotion in need of regulation this leads to a deficit in helpful emotion coping skills this leads to low expectation for mood regulation which then leads to increased anxiety, fear and overwhelm this causes an urgency to stop emotional escalation which then causes over learnt, impulsive, maladaptive mood regulation behaviour ie self-harm this causes even more decreased self-esteem, guilt, shame and isolation which reinforces one's low expectation for mood regulation the maladaptive mood behaviour can also cause avoidance of any more adaptive regulation strategy and decrease distress temporarily

Question 36

who is the cycle of maladaptive coping in BED from an emotional dysregulation perspective adapted from

Answer 36

Saler et al., 2008

Question 37

what did McIntosh et al., 2005 conclude about AN treatments

Answer 37

trialled three psychotherapies for AN non-specific supportive clinical management was superior to more specialised psychotherapies, opposite to the primary hypothesis

Question 38

what is the Christchurch AN Treatment study

Answer 38

McIntosh et al 2005 56 ppts, all women aged 17-40, 14.5

Question 39

is there one treatment for EDs that is broadly accepted as more effective than the others

Answer 39

NO! mixed results

Question 40

what is SSCM

Answer 40

focuses on weight restoration, normalised eating, symptom reduction and psycho-education it's patient driven, takes a supportive/therapist and strength focused stance it's flexible, holistic and focuses on termination

Question 41

what does NICE 2017 recommend for treatment of EDs for children and young people

Answer 41

family-focused therapy (both joint family and individual sessions) family supports patient to take responsibility emphasises weight restoration and regular eating if not helpful, also use CBT-ED and AFP-ED and specialist/medical admission

Question 42

what does NICE 2017 recommend for treatment of EDS in adults

Answer 42

outpatient individual therapy: -CBT/MANTRA/SSCM for AN -CBT for BN and BED weight monitoring for AN and BN weight restoration focus and encourage healthy diet stepped care model- day care and inpatient options if deterioration

Question 43

what does the specialist supportive clinical management for EDs identify as the most common risk factors for EDs

Answer 43

family, society and personal

Question 44

why is there a need for early intervention?

Answer 44

for AN, duration of treatment is associated with illness outcome EDs are associated with changes in brain structure and development age of onset is typically when the prefrontal brain is developing (this is responsible for self-regulation) neuroimaging and cognitive neuroscience data suggests that the illness state becomes more entrenched and difficult to change as time passes see FREED

Question 45

what are the key interventions for therapeutic care

Answer 45

address stigma (reflect on our own and others' biases and use a non-judgemental approach) foster trust through communication collaborate with patient and their family, promote empowerment and choice where possible consider psychological support needs and triggering times and make an action plan education and explanations around symptoms can be helpful be mindful of co-existing risks to self (ie self-harm, suicide)

Question 46

what are good signposts for individuals and families

Answer 46

keeping safe programme (NHS self help programme) FREED resources for patients and carers (psycho-education for young adults) PEACE pathway (for those with autism and EDs) Center for Clinicial Interventions - Disordered Eating Workbook (online self-help) Support and Empathy in EDs (SEED charity)