Eating Disorders
Professor Janet
Guys Medical School
[email protected]
Talk map
Historical Framing
An over view of causal factors
A clinical case- a personal account of
interactions with the environment
• Looking at causes in more depth
Historical Framing Of Eating Disorders
Psychiatric Illness?
Spectrum of EDs
Increasing tendency to fatness
Gull 1873
Lasegue 1873
Russell 1979
Volkow 2007
Anorexia nervosa lifetime prevalence 0.5-2%
Bulimia nervosa lifetime prevalence 2-4%
Eating disorder not otherwise specified 2-10%
(Hudson et al 2007, Jacobi et al 2001, Hay et
al 2008)
Lifetime prevalence of BN
in 3 cohorts of twins
↑ >1950 Cohorts
(Kendler 1991, Jacobi et al 2004,
Wittchen et al 2005, Hudson et al
2007, Hay et al 2008).
BN: Urban> rural (9:1) (Van Sohn et
al 2006)
BN: ↑ Westernised cultures (Keel &
Klump 2003)
Kendler et al 1991 Am J Psych 148:16271637
Time Trends in the Incidence of AN and BN
in Primary Care in the UK
Incidence rates per 100,000 females aged 10-39
Bulimia Nervosa
Anorexia Nervosa
Turnbull et al., 1996; Currin et al., 2004
Epidemiological questions?
• What has caused the emergence and
rapid increase in bulimia nervosa and
binge eating disorders in cohorts born
since 1950?
• Why Western cultures?
• Why urban/rural risk?
The Fiji Experience
•Introduction of television
and Western media
imagery was followed by
an increase in weight
concerns & disturbed
eating: (Becker et al.,
Candidate cultural risk factors
Size 0 culture & promotion of dieting.
Vomiting/purging as a method of
weight loss
Easy access to high palatable food
disembedded from social eating
However – what about AN?
• This culture change model does not
explain AN
• Other factors play a role
My Story
Melissa Wolfe
Eating Disorders and the Size Zero Phenomenon : My Story
• Size 0 and the media: not a cause – but a contributor
• Size 0 and the media: helping the illness to last
• Size 0 and the media: complicating recovery
Size 0 and the media: not a cause – but a contributor
• 1993 and the social context
• The causes of my eating disorder
• The wrong media message?
Size 0 and the media: not a cause – but a contributor
“No obsessing about models (Beryl the Peril was no Kate
“Size zero hadn’t even made it over the Atlantic when I got
The causes of my eating disorder
No one cause but a complicated mixture of:
• Emotional factors
• My personality
• Social pressures
• Getting addicted
The wrong media message
• Glamorising anorexia
• Hiding the real cause
Size 0 and the media: helping the illness to last
• An enabling factor: arming the anorexic
• An enabling factor: arming the anorexia
• Behind size 0
An enabling factor
“Ammunition. It’s a double whammy – it arms both the
anorexia and the anorexic.”
Arming the anorexic
“Size Zero normalises the abnormal. It helps you dismiss
the concern”
Arming the anorexia
“Anorexia preys on insecurity – size zero gives you an idea
when you’re not sure where you’re heading..”
“It thrives on perfectionism - size zero is a great
example of a physical standard that you’ve failed to attain.”
Behind Size Zero
“A dangerous mirage that makes anorexia all about
vanity and fashion and superficial surface level things
– when really it goes far deeper than that”
“feeling belittled – ‘it’s all about vanity’ – just makes you
want to shout even louder”
"It means that people are looking at the wrong cause – and
therefore providing the wrong treatment.”
Size 0 and the media: complicating recovery
• The reality of size 0
• Fighting against the tide
• False Ideals
The reality of size 0
“It’s the loneliness that will get you.
Not the hunger, or the worrying, or the rituals, or the paranoia.
Not even the fear of getting fat.
It’s the loneliness that’s the real killer.
The longer you’re ill, the worse it is.”
The reality of size 0
“Osteoporosis. More common in the elderly. Diagnosed at
Hair growth. Like a gorilla. Cheeks, back, arms and
Skin. Dry, grey, bleeds easily in cold weather. As do the lips.
Internal organs. Wasted. They give way. You can’t control it”.
Fighting against the tide
“A little taunt at every step of the way...”
False ideals
“airbrushing is lying to a whole generation….
and they’re not likely to live up to it.”
• My eating disorder was not caused by the media
• Size 0 and the media helped maintain my illness
• Size 0 made it difficult to view recovery as a positive
“my self esteem plummeted for 16 years and only began to reemerge as I finally saw the eating disorder for what it was.
And me for what I am.”
[email protected]
Translational Treatments
• Understanding the underlying
• How does the environment interact with
• Developing treatments that target factors
that perpetuate illness
Bullet: Predisposing Factors
Stress pregnancy/birth.
Values re shape, eating.
Teasing, bullying especially shape weight.
Competition, comparison, expectations.
Low self esteem
Enjoy structure, plans, rules and detail.
Events During Pregnancy
 Life events and
– Shoebridge et al.,2000,
– Favaro et al., Arch Gen
Psychiatry 2006
– Hormones
 Male- female twins
(Culbert et al 2008)
•Teasing & critical
comments about weight &
shape & eating (Jacobi 2004,
Fairburn 1997, Stice 2002, Taylor et al
The role of Fathers
The role of Fathers
• ED -paternal maladaptive behaviour (dose
response relationship) mediated by low
paternal identification. (Johnson et al 2002)
• Fathers who highly value thinness can
transmit this to daughters (Agras et al., 2007).
• Paternal teasing increase risk bulimia and
was predictive of (male) sibling teasing
(Keery et al., 2005).
Culture: Easy access to palatable food, loss of social eating,
idealisation thinness.
Family, peers, responsible adults
Food &/or weight salience
Teasing, criticism-re body or eating
The Biological Matrix
Personal Attributes
Negative Affect, Inhibition.
Stress sensitivity
Rigidity, perfectionism
High weight concerns
Internalisation of thin ideal
Life events
•Weight loss.
•Extreme oscillations in food
intake or energy expenditure.
•Chronic stress & negative
•Values relating to
Risk x Environment: Perpetuating Factors
Positive aspects.
• Values weight/shape.
• Family & other reactions.
Negative Aspects
•Damage to brain-general
& specific eg reward &
appetite centres.
• Damage to body
• Damage to relationships
with social isolation.
Schmidt U, Treasure J. Anorexia Nervosa: Valued and Visible.
A Cognitive-Interpersonal Maintenance Model and its Implications for Research and Practice.
Br.J.Clin.Psychol. 2006;45:1-25.
A focus on perpetuating factors is helpful
for treatment as they remain in action and
can be remediated.
The most effective forms of psychotherapy,
CBT and motivational interviewing, family
work focus on perpetuating factors.
Damage to the brain
Schmidt U, Treasure J. Anorexia Nervosa: Valued and Visible.
A Cognitive-Interpersonal Maintenance Model and its Implications for Research and Practice
. Br.J.Clin.Psychol. 2006;45:1-25.
The Brain Needs 500 Kcal /day
for running costs
To facilitate plasticity and new learning.
To develop new connections.
To strengthen synaptic links.
To develop long myelinated connections.
. Nutritionally
deprived brain at
critical phase of
Lenroot and Giedd, 2006. Neurosci Biobehav Reviews 30:718-726
Starvation impairs complex reflective tasks:
•Social cognition.
•Emotional recognition and regulation.
•The ability to see the bigger picture.
•Decision making.
Olsson A. The role of social cognition in emotion Trends in Cognitive Sciences 12 feb2008
Social problems: The Vicious Circle of
impaired social cognition
Poor nutrition impairs
aspects of social cognition
Unhelpful behaviours
Dysregulated emotion
↓ Reading emotion
Worsen how they feel
AN only friend
↓ Emotional Attunement
Create or worsen problems
↓ intimacy
↓ quality of relationships
Social problems: The Vicious Circle of
expressed emotion
Person with AN observes
anxiety and anger in others
Worsen how they feel
Because of
dysregulated emotional
Unhelpful behaviours
Person with AN mirrors
anxiety and anger
Create or worsen problems
Person with AN has poor
Emotion regulation skill
Because starvation damages
this area.
Reward Reactivity
Food reward centres
become disrupted by
intermittent oscillations
of food intake on a
deprived background
Animals models of binge eating
• A period of under nutrition.
• Divert food stomach
• Intermittent availability of
highly palatable food
• Stress.
• Breeding
(Rada et al 2005, Lewis et al 2005,
Avena et al 2005, Corwin 2006,
Corwin & Hajnal 2005, Boggiano et al
2005; Avena & Hoebel 2003, Avena
& Hoebel 2007, Boggiano et al 2007).
Animals models of binge eating
(these animals also become addicted to other
substances eg amphetamine)
• A period of under nutrition.
• Divert food stomach
• Intermittent availability of
highly palatable food
• Stress.
• Breeding
(Rada et al 2005, Lewis et al 2005,
Avena et al 2005, Corwin 2006,
Corwin & Hajnal 2005, Boggiano et al
2005; Avena & Hoebel 2003, Avena
& Hoebel 2007, Boggiano et al 2007).
Human models of binge eating
• A period of under nutrition
(Size 0 culture & promotion of dieting).
• Divert food stomach
(Vomiting as compensatory method)
• Intermittent availability of highly
palatable food
(Easy access to food disembedded
from social eating)
Offspring of
ED mothers
High Weight
and shape
• A spectrum of eating disorders now exist.
• The risk of binge eating disorders has increased
for cohorts born after 1950.
• Cognitive, emotional and physical factors can
impact on vocational functioning.
• Engagement into treatment can be difficult for
• Guided self care is a useful first step.
• Good results for psychotherapy BN –majority AN
now manage out of hospital.
Help Required
• We are always needing to have people
with and without an eating disorder history
to help with our research into
understanding causes of eating disorder
and how to treat them please get in touch
if you can help.
[email protected]
• At present there seems to be a lot of media and research
interest in the deleterious effects of (airbrushed) media
images of thin women on girls' self esteem and the
possible development of EDs (as based upon the
hypothesis that these images cause body dissatisfaction
and disordered eating or full blown EDs) - however
(unless I looked in the wrong place...) I could find little
published research about the dangers of constant
bombardment of children with messages about 'healthy
eating/exercise'. I, for one, have never felt affected by
media images of thin women and my AN was not caused
by body shape dissatisfaction, but I was very vulnerable
to media/educational messages about 'healthy living' and
• A big part of my AN was about seeking control, routine
and meaning in a chaotic and confusing world where I
felt I didn't fit socially. I used anorexic behaviours to
regulate my world - even create my own, personal,
comprehensible world. As a child I took media messages
about healthy eating and exercise (which were just
emerging in the early 1980s) too literally and operated
on the basis of 'more is better' and engaged in a lot of
categorising foods by their calorie, fat, protein,
carbohydrate and fibre content. I made lists of 'good' and
'bad' foods. I made lists of everything I would eat every
day at certain times and ticked the food off the list when I
had consumed it. This provided me with an illusory
sense of control in my life and reduced my anxiety.

PowerPoint presentation for the lecture