The Empirical Status of Current Psychological Treatments for Eating Disorders


– [Lauren] Welcome to the Deakin Alumni
and School of Psychology webinar with Dr. Jake Linardon. Dr. Jake Linardon is a
lecturer and a research fellow at Deakin University.
He has published numerous peer-reviewed journal articles in the field of eating
disorders and their treatment and is particularly interested in not only
understanding which psychological treatments for eating disorders are
effective but also how, for whom, and under what set of circumstances these
treatments work. Thank you so much for joining us today, Jake.
I’ll now pass it over to you to begin your presentation. – [Dr. Linardon] Thanks for that lovely
introduction, Lauren. And it’s an honor to present this webinar
today. So, I’ll get started into it straight away. So, I just like to present
an overview of what I’m going to be touching on throughout the next 45 minutes
to an hour. So, I’ll just talk about a brief overview of what eating disorders
are and the specific eating disorder subtypes. Then I’m gonna be
talking about a specific form of treatment called cognitive-behavior therapy,
and in particular, focusing on the underlying theory, treatment,
and the evidence supporting this CBT-based approach. Then I’m gonna move on
talking about the third wave or the third generation of cognitive-behavior
therapies. I’m looking at the current evidence-base for those particular
treatments. And then finally, I’m going to propose three directions
moving forward to advance the field of eating disorder treatments,
in particular, focusing on mediators and mechanisms of change,
looking at predictors/moderators of response, and also considering the role
of technology in treating eating disorders. So just a brief overview
of what eating disorders are. So, we can usefully distinguish between a
few different subtypes of eating disorders.
And the three most common ones I have presented here are one, Anorexia Nervosa,
which is characterized by chronic restriction of food or energy intake,
which usually leads to dangerously low body weight and accompanied by various
body image distortions. Most typically, an intense fear of weight gain.
Bulimia Nervosa, on the other hand, is characterized by recurring episodes of
binge eating in combination with various inappropriate compensatory behaviors.
Plus there’s also a core feature of body image disturbance there as well.
And finally, Binge-eating Disorder is characterized by recurring episodes of
binge eating but without the inappropriate compensatory behaviors. So useful,
not only does the compensatory behaviors distinguish bulimia nervosa from
binge-eating disorder, but usually, what we see in these two subtypes is that
people with binge-eating disorder are usually overweight or obese because they
don’t engage in those compensatory behaviors. So,
why is studying these particular eating disorders, not only these but the
other ones? And so, why is it important? So there are a couple of reasons.
One is that they’re highly prevalent conditions. So,
they’re becoming more and more common globally across the world and of all
demographic backgrounds. So what we used to, kind of,
believe was that eating disorders affected younger women of western cultures.
We know that this isn’t true now. It affects women from all ages,
all demographic, ethnic backgrounds, and it’s also increasingly affecting men
as well. So for instance, in Australia, it’s estimated that more than 1 million
people are diagnosed with some form of eating disorder. But we also know that
there are significantly more people in Australia that have eating disorder
symptoms but do not necessarily meet diagnostic criteria. So,
people that binge-eat irregularly, people that use unhealthy weight control
behaviors, and things like that. We also know that eating disorders are
associated with mortality and morbidity. So for example, anorexia nervosa has the
highest mortality rate of any psychiatric disorder.
That even includes depression and anxiety, and most deaths resulting from anorexia
nervosa either from suicide or the medical complications that are experienced.
Bulimia nervosa and binge-eating disorder, as well, are associated with mortality but
to a lesser extent. But they’re also associated with various crime morbidities
like depression and anxiety, low self-esteem. And finally,
eating disorders are very expensive. So, the health system expenditure for
eating disorders in 2012 in Australia was estimated at $100 billion. So hopefully,
this underscores the importance of developing effective psychological
treatments for eating disorders. And in this slide is a very brief slide
outlining what the more commonly used psychological treatments are and the ones
that have been tested or studied in research designs.
So they include cognitive-behavioral therapy,
which I’ll touch on in a lot more detail in a second, which is essentially a
treatment that helps patients or people change their unhealthful thinking
patterns, behaviors, and their efforts. Family-based therapy is typically used for
younger people, so adolescence and, in some cases, children,
and it rests on the assumption that changing things within the family
environment are important for reducing eating disorder symptoms.
Interpersonal psychotherapy rests on the assumption that interpersonal conflict or
problems are a major contributor or cause to eating disorder symptoms. So,
IPT essentially helps people develop more effective interpersonal relationships or
ways in which people can deal with the social settings with the assumption that
that will, therefore, help people reduce some core symptoms.
Dialectical behavior therapy is another common approach which views emotion
dysregulation as the core problem. So, things like binge eating behaviors,
purging behaviors are understood to result from helping people regulate painful
emotional states. So as a result, DBT teaches people a broad repertoire of
skills to help replace these dysfunctional behaviors. And finally,
acceptance and commitment therapy essentially attempts to help people
increase their acceptance of painful emotional experiences without the need to
act on those experiences, but rather living in a way that is
consistent with one’s values. So I’d like to primarily focus on
cognitive-behavioral therapy now because, as I’ll mention in a little bit,
this is the treatment that has the most empirical support at the moment for eating
disorders, in particularly the subtypes I mentioned earlier. So,
I’ll just present this kind of schematic representation of the theory behind the
treatment. So, this theory essentially underpins what we do in treatment,
how we treat people with eating disorders. So, a couple of things to consider with
this theory that we have here is that CBT is concerned with the mechanisms that are
maintaining the eating disorder. So, the things that are keeping the eating
disorder going. This means it doesn’t really… CBT is not really
concerned about what caused the eating disorder, it’s more so focus on the
here and now. What are the things that are keeping it going? And the idea is that if
we can knock out or disrupt the things that are keeping it going,
then that should have a flow and effect to the core symptoms that we observe.
And also, another thing is that this theory and this treatment are
transdiagnostic. Meaning that it can be applicable to all the eating disorders
subtypes that I mentioned earlier. So CBT is a transdiagnostic approach that
can treat all eating disorders that we typically observe. So,
as we can see in this model that I’ve presented here, at the core,
at the very top of the diagram is what we call an over-evaluation of weight, shape,
and eating. So this basically means that whereas most people without any eating
disorder, evaluate their self-worth on a variety of domains, so things like,
you know, their interpersonal relationships,
their work performance, their sporting achievements,
people with eating disorders, on the other hand, primarily evaluate
their self-worth on their ability to control their weight, shape,
and eating. So basically, their self-worth is equated with how they
look and how much they weigh. This is problematic because what we know
is that it leads to or encourages strict dieting. So strict dieting can come
in many forms. So things like people fast quite often. They go for long periods of
time without eating anything. So like, essentially starve themselves.
Or it also includes the strict dietary rules that we typically see. So,
the rules that dictate or govern what people eat, when people eat,
and how much people eat. And we know that these rules are so
difficult to sustain. So imagine trying to restrict
carbohydrates from your diet for the rest of your life. That is incredibly
difficult. So, a consequence of that is that those rules will generally be broken.
They generally can’t be sustained. And once those rules are broken,
then that is assumed or hypothesized to encourage binge-eating behavior.
But it’s important to note that there are very small subset of cases that are
successful in their dietary restraint, and that’s usually the anorexia nervosa
restricting subtype. So those people maintain their set of
starvation symptoms and dangerously low body weight. Whereas most of the other
eating disorder cases go on to binge eat in response to essentially that breakdown
of dietary restraint, which then known as binge eating.
People feel really guilty about that, so they’ve been compensated via vomiting,
laxative misuse, and whatnot. And it’s also important to note that there
are other, kind of, triggers to binge eating as well. So things like sudden
changes in mood. So, when people feel pretty down about
themselves, people then resort to comfort, comfort foods, eating,
because it makes them feel better very temporarily. But we know as well that
that can be a bit of an issue because that just fuels the cycle as well.
So essentially, this is the theory behind the treatment of CBT. So,
what we want to do is we want to knock out these maintaining mechanism.
So we want to knock out that over-evaluation of weight and shape.
We want to target that strict dietary restraint. And we also want to
help people deal better with sudden mood changes. So now I present the
cognitive-behavioral treatment, which is directly based on that theory
that I talked about. And that image there is the manualized
version of the treatment that we use as therapists. So as I said,
it’s a treatment that’s transdiagnostic in scope. So, this book here or this
manual can be used for any eating disorder subtype. And again,
it targets those factors that are keeping the eating disorder going with little
emphasis on what caused the disorder. It’s a manualized treatment that lasts
around 16 to 19 sessions, give or take, kind of, case by case basis.
But it’s also important to note that there are self-help versions available as well.
So, the developers, Christopher Fairburn, he has written an abbreviated version of
this book which is a self-help book. And it’s used for people that don’t have
access to standard treatment, and I’ll talk about that in a little bit
later. And the main kind of therapeutic strategies or components or modules in
this book include self-monitoring. So when people record their eating
behaviors, and the idea is that people who record their behaviors really get a great
insight toward the nature of their problem. So what are the things
that are kind of triggering or maintaining their disturbed eating patterns?
There’s also an induction of regular eating where we typically instruct
patients to eat three meals and three snacks a day, no more than three hours
apart. The idea is that if we introduce a pattern of regular eating,
we can knock out that dietary restraints, or more specifically,
the fasting and restrictive behaviors that we usually see. We’ve got weekly weighing
where the therapist meets with the client once a week to weigh the client.
And the idea is that the therapist helps the client interpret any fluctuations in
body weight. So, interpret in a more balanced view which essentially aims to
target that overconcern that I was talking about earlier. We’ve got exposure
techniques which helps reintroduce foods into one’s diet. So we know that people
with eating disorders usually have a list of forbidden foods that they dare not eat,
because if they eat, that’s a cause of anxiety,
and it’s a real trigger food for binge-eating. So the therapist here
helps the client reintroduce those foods into diet without that catastrophic
consequence. Then we’ve also got problem-solving which helps deal with the
emotion dysregulation difficulties that we usually see. And then we finally got
cognitive restructuring which is a broad collection of techniques that help clients
essentially change or modify the way that they think about their body and about
eating. So what’s the evidence for CBT at the moment? So first up, essentially,
this type of treatment approach is the front running treatment for binge eating
disorder subtype. So, disorders of binge eating like bulimia
nervosa, binge eating disorder, and your other specified feeding and
eating disorders. And clinical guidelines all over the world recommend CBT as the
first step in treatment. So that’s what we should be giving to
people with eating disorders as a first step. That’s what the recommendation
is, and that’s based off a series of meta-analyses and systematic reviews
that have been published. I’ve been lucky enough to publish quite a
few meta-analyses on CBT within the past couple of years.
And here are the findings from the meta-analyses that I’ve led on the
effectiveness of CBT. So one, we know that CBT outperforms
pharmacotherapy. So typically, anti-depressant medications as well as
specific other evidence-based psychotherapy.
So things like interpersonal psychotherapy and even non-directive supportive
counseling. So CBT is better than those other treatment approaches.
We know that CBT is the most effective when it’s based entirely off that
transdiagnostic book that I talked about. So there are other different CBT protocols
or approaches that are available as well that are based on slightly different
theories and slightly different techniques,
but we have observed that the effects are strongest when it’s based on that book
that I presented earlier and that model that I presented earlier.
For bulimia nervosa, we know that 43% of people who receive CBT
completely stop binge eating and purging, so, it’s only 43%. And I’m going to touch
on a little bit more about that in a couple of slides to come.
For binge eating disorder, it’s a little bit better.
So we observed 58% are expected to completely abstain from binge eating.
Remember that binge eating disorder is not characterized by purging. So,
in 58% of the cases, we can completely stop binge eating.
And importantly, I think another important thing to demonstrate is that there are
broader effects of CBT than merely symptom reduction. So we published a
couple of meta-analyses showing that CBT has a very positive impact on quality of
life. So people’s well-being and their quality of life significantly improved
after they received CBT independent of the reduction of symptoms.
And we also know that depression is very symptomatic of eating disorders.
It co-occurs with eating disorders to a great extent. And we’ve shown that
delivering CBT also has a very positive impact on reducing any co-occurring
depressive symptoms in people with bulimia nervosa and binge-eating disorder.
So what does this means? So what are the implications of this?
I think the biggest implication of this is that given that CBT outperforms other
specific psychological treatments, it’s kind of suggesting that it’s likely
that it isn’t the factors that are common across all psychological treatments that
are making CBT works. So things like the therapeutic alliance,
you know, showing empathic concern, it’s more so likely that what makes CBT
effective is the specific ingredients that underpin CBT. So those techniques that I
was talking about earlier. That’s not to say that the therapeutic
alliance and other common factors are not important, it just means that they’re
necessary but they’re not sufficient in order to produce the best kind of
outcomes. So that was the evidence for CBT. And that CBT that I was talking
about there is typically referred to as the second wave of CBT. So now,
I want to talk and move towards the third wave of the CBT approaches which is
gaining heaps and heaps of momentum and attention and, kind of,
research attention as well. So, CBT, as I talked about, it’s not a panacea.
It doesn’t work for everyone, and what we know is that a lot of people
stop CBT. They don’t like it, they drop out, they discontinue. So,
it’s estimated that around 25% of people, so a quarter of people that receive CBT
drop out early. We also know that some people who received CBT do not respond at
all. So they show no improvements. And in some cases, they actually get
worse. And then finally, we know that people who improved or
recovered, it’s very common for them to go on to relapse later on down at follow up
periods as well. So it’s not the best. Sorry, it’s not the be-all and end-all.
More progress needs to be done. So it’s been suggested that one,
we need a broader range of effective eating disorder treatment.
So we need more, kind of, options to help people with.
And the third wave cognitive-behavioral therapies are tattered as a possible
solution to this. So what are they? So the principles and the techniques of
these third-wave cognitive-behavioral therapies are quite different to the
second-wave approaches that I was talking about. For instance,
rather than trying to change the content or the validity of cognitive or emotional
processes, as is documented in the second-wave, third-wave…sorry,
as is mentioned in the second-wave approaches,
the third-wave treatments aim to target the function or the awareness of these
cognitive or emotional processes. So really trying to change the
relationship someone has with their cognitions and their emotions.
So in saying that, the third-wave approaches primarily use response-focused
emotion and cognitive regulation strategies which are, essentially,
strategies that help people deal with their responses after the cognition
or the emotion has occurred. That’s a little bit different to the
second-wave approach that I talked about earlier which tries to prevent those
emotions and cognitions from occurring in the first place. The third-wave is a
little bit different, it allows them to happen but it’s what we
do after it that is the key difference there. So common techniques
using these third-wave CBTs are acceptance, mindfulness,
metacognition, and psychological flexibility.
So I was quite interested in the third-wave of the cognitive-behavioral
therapies. I’m looking at what we know about them in the context of eating
disorders. So, we published a systematic review shown in this slide here.
In quarter procedures journal looking at the empirical status of all of the
different third-wave therapies. And what we just essentially wanted to do
was just look at the current evidence-based forum across each eating
disorder subtype. And what our primary aim of this paper was to determine whether or
not each third-wave treatments are considered empirically supported.
So we used some established APA criteria for determining whether or not the
treatment was an empirically supported one for each eating disorder.
So we can usefully distinguish between a couple of different types of empirically
supported treatments. One is that it’s an empirically supported
treatment that is specific in its mechanisms. So all that means is
that a treatment outperforms a pill or another evidence-based treatment in
multiple randomized control trials by many different research groups.
The second criteria is that it’s an empirically supported treatment.
So that essentially means that the treatment outperforms no treatment in
multiple randomized control trials conducted by more than one research group.
So the more than one research group is a really important point to consider because
we need independent groups to replicate our finding because if multiple studies
show that one treatment works but the researchers have a really strong
allegiance to a particular treatment, then it’s probably not the best
representation that we have because people that have a strong allegiance to a
particular treatment expect their treatment to work. So we need people to
replicate these findings that don’t have such a strong allegiance to their
treatment because it’s a more kind of balanced appraisal of the evidence for
a particular type. And then we really can also talk about a possible empirically
supported treatment. So that essentially means that a
particular therapy is better than nothing or better than no treatment in one study
or by more than one study by the same research group. So that’s just the
criteria we used. I’m just providing a bit of background to the criteria that we used
to determine whether each third-wave therapy was empirically supported or not.
So, this brings us to the findings of this particular paper that I talked about. So,
in this paper, we identified 27 studies that looked at the effects of a particular
third-wave treatment. And the third-wave treatment is listed on
that table there. Only 13 of these were randomized controlled trials,
and we need randomized control trials because they allow us to determine a cause
and effect relationship. So what we found was it was quite
promising in that each of the treatments that are listed there produced very large
improvements in symptoms. So, that effects, as I presented there,
is a G of point H. That essentially means that there are quite big improvements in
symptoms. However, there’s a caveat to this in that they were based on
uncontrolled studies. So, it’s impossible to determine whether
improvements were a result or were caused by treatment or were, kind of,
caused by other naturally occurring factors. So,
whether or not people just got better over time, or regression to the main,
or things like that. So essentially, all I’m trying to say is that findings
based on uncontrolled studies cannot tell us whether or not it was the treatment
that produced that improvement. So, what we wanted to do was then look
specifically at the randomized controlled trials that allow us to determine that
cause and effect relationship. And we wanted to just simply state whether
or not each of the third-wave treatments were empirically supported.
And in this table here, we’ve got kind of what we found.
And this is a similar table that we’ve got in the paper. So, for anorexia nervosa,
the outlook is pretty dire in that none of the third-wave therapies are
empirically supported at all, and that’s largely because these
treatments haven’t been tested yet in RCTs. The only exception is there’s
been one trial, to my knowledge, of acceptance and commitment therapy,
and unfortunately, ACT didn’t even outperform a whitelist control in that
study. So, it was no better than receiving nothing which is quite surprising
actually. So, there’s no empirically supported treatments for anorexia nervosa.
It’s a little bit different for the other two disorders, so bulimia nervosa and
binge-eating disorder, in that we have a few that are possibly
empirically supported treatments. And that’s because…they’re possibly
empirically supported because that’s only one RCT has been done on them and it’s
been showing quite a bit of promise in that all of those treatments have
outperformed no treatment, but we need more research to, kind of,
demonstrate that they are empirically supported. So essentially,
what we concluded in this paper was that CBT, though the second-wave CBT,
needs to retain its status as the treatment of choice for these particular
eating disorders and, at the moment, these third-wave treatments can only be
considered experimental until much more research needs to be done to, kind of,
look at their evidence base. So, it’s quite tentative at the moment.
So, what do we got so far is a summary of the treatment. So,
I think it’s important to know that over the past 20 years,
huge progress has been made in developing this kind of treatment approaches and
showing that they have a lot of promise, that they’re helping a lot of people.
But there are still a lot of issues that still remain across literature and one is
that a huge number of people do not fully respond to, even now,
best available treatments. So earlier I said that more than half of
people with bulimia nervosa that received CBT did not fully recover.
That’s not to say that they don’t improve a little bit, but they don’t fully recover
or they don’t fully respond. Also, we’re not able to kind of determine
who is and who is not going to benefit, and I’ll talk about why that’s a problem
in a second. Third, we have very little understanding towards how, why,
and through what mechanisms a particular treatment works. So really understanding
what is it about the treatment that’s making it work, why is it doing it this
way. Again, we have very little understanding of that. And again,
I’m going to talk about why that’s a problem in a second.
Fourth is that…I briefly mentioned earlier that there’s quite a lot of people
that just drop out from treatment early. And we know that people who drop out are
likely to fare much worse than people who complete treatment. So people who drop out
are still likely to be very symptomatic over the course of their life compared to
if people remained in treatment. So we need to kind of understand ways in
which we can prevent drop out, minimize drop out, or anything that kind
of, yeah, minimizes or prevents drop out. And we’ve published a meta-analysis
estimating the prevalence of drop out from CBT, and we’ve found that 25% of
the people with eating disorders tend to drop out early from treatment,
and these are the ones that really do poorly later on in life.
So we need some strategies to kind of overcome this. And now, I think,
probably the biggest issue that we’re facing at the moment across the literature
is that fewer than 25% of people in need of help actually receive treatment.
So that’s 75% with an eating disorder or symptoms that are close to meeting
criteria for an eating disorder either don’t seek treatment or they can’t access
at all in some way. And I’m gonna in a little bit about the reasons as to why
that’s happening and how we can potentially overcome that. So overall,
what it says is that yes, we’ve made a lot of progress,
but there are still heaps more to be done to essentially improve this population
group. And what I think, based on, kind of, my work in this area at the
moment, I think that there are three very important future directions that can,
kind of, help this go forward to some extent. I’m going to talk about
each of these future directions now. And the first one is we need to identify
the mediators of change. So what that means? So what a mediator is
in the context of psychological treatments?
They’re essentially variables that explain how, why, or through what
mechanisms a particular treatment works. So, as I talked about earlier,
at the moment we know that CBT works for some people. We know that it’s
effective, you know, for around half of the people that receive
it. But a crucial point to note is that we don’t know how it works or what components
of CBT are responsible for making it work. Say for instance, is it that regular
eating strategy that I talked about earlier? Is that the thing that’s
driving the reduction in symptoms? Or is it the weekly weighing strategy that
I talked about? Or is it the problem solving, the self-monitoring
strategy? The issue is that we don’t know these, and it’s because when we test
these particular treatments, we test them as a package,
we test them all combined into one package and we deliver that package to a sample of
people with eating disorders. And then if we document that it’s
effective relative to no treatment or another treatment, we just assume that all
of these components are effective. But that’s not the case.
It’s likely that some are effective and that some aren’t. So that’s when mediators
come into it. They tell us specifically what those active ingredients are,
what those components are that are making people get better. And also,
what are those components that are not making people get better at all?
So what are those redundant components? But then the issue is, so, who cares?
Like, why do we need to know what the components are? If it’s working,
why do we need to worry about that? Well, there are a few reasons for this.
So, if we know what components or aspects of a particular treatment are effective,
then there are a couple of things that we can, kind of, ensure.
And one is that we can really emphasize them in treatment. So we can spread the
word to all clinicians around the world delivering CBT and say, “Hey,
you need to make sure you really emphasize this particular component in your
treatment in order for maximal outcome.” So we can kind of anticipate that people
will have a better outcome if they’re emphasizing that particular component of
treatment. The second one is that if we know which components of the treatment are
effective, then we can develop and even refine those components to make them even
more powerful than what they already are. Because we know we’ve got a starting point
and we can expand on them and make them even more potent, and as a result,
improve people even more so. And third, if we know what components aren’t
effective, so what are the mediators that aren’t actually working,
then we can just remove them from the treatment. We can get rid of them
because they’re not doing anything. And the benefit of that is it’s going to
use up less resources because it would mean that we need less sessions with our
therapists, and as a result, we can make the treatment more efficient,
more cost-effective, and essentially save people’s time and
money without giving them something that isn’t going to work for them in the first
place. So theoretically, if we take that all together,
it means that if we understand what the mediators or mechanisms of change are,
then treatment would theoretically be more effective, more efficient,
and at a lower cost. The second important future direction I
think is looking at predictors or moderators of response. So,
when I’m talking about predictors, I’m simply talking about variables that
correlate with an outcome or improvements regardless of the type of treatment
delivered. That’s a little bit different to a moderator, which is a variable that
interacts with the treatment to predict an outcome. So in other words,
it’s a variable that correlates with an outcome only for a specific of
treatment but it doesn’t work for another treatment,
it doesn’t correlate with the outcome for another treatment.
And I’ll go through an example in a second of what I actually mean. So,
these types of variables, predictors, and moderators, are very important for,
kind of, understanding who is and who is not going to respond to a particular type
of treatment. And we published a systematic review a few years ago looking
at the evidence-based for predictors and moderators of response.
And we found the same conclusion is that we have no idea yet who is likely going to
benefit from the treatment. So it’s almost like clinicians are going
in with a blind eye and have no idea whether or not they can anticipate this
client will get better or this client will not get better, which is a big problem.
And I’ll talk about why that’s a problem in one second. So, again,
why do we need to bother studying predictors or moderators? And hopefully,
it will make sense. So there are two main reasons why we need to study them and why
it’s important. The first one is that it’s important for treatment matching.
And what I mean is, if we know what a moderator variable is,
we can decide what type of treatment a patient will receive based on their
demographic or their clinical profile. So if I use a typical example,
let’s just say that we’ve identified that low self-esteem, so people with low
self-esteem, to begin with, do very poorly with CBT,
but they actually do quite well with IPT. So that’s what we call moderator.
Self-esteem, in that case, is a moderator. So, if we know that,
if we know that self-esteem is a moderator, then what a clinician could
do is if they get a new case with an eating disorder and they’re trying
to decide what treatment there is, if they kind of gauge their levels of
self-esteem and they identified that this particular person that they’re dealing
with at the moment has a very negative view of themself, it would not make any
sense at all to give them CBT, because that is likely going to determine
that they’re going to have a poor outcome. Therefore, the clinician might decide that
IPT would be the best approach for that particular person. So that’s what we call
treatment matching. We’re matching a particular treatment to a person based on
their kind of profile. And we can also tailor interventions as
well based on predictors. So for instance, if we identified that age is a variable
that correlates with the outcome, regardless of the type of treatment a
person receives. So let’s just say younger people do worse than older people in
eating disorder treatments. So in that case, age is a predictor of
outcome. So, what we could do then is that if we know this, we might be able to
tailor our interventions accordingly. So if a clinician comes in to treat
someone with an eating disorder and they’re of younger age,
and we know through evidence that younger people do worse than older people, well,
what can we do about that? Well, there are a couple of things we can
do about that. We can tailor our intervention in a couple of ways. One,
we might be more intensive. So we might say to the younger person,
“Hey, I want you to come in two times a week instead of that one time a week.
I want to be able to monitor you a little bit more.” Or alternatively,
you could provide more frequent and longer sessions to the younger person. So there,
all I’m trying to say is that there are a bunch of ways in which we might be able to
beat the trend essentially and try to prevent younger people from having a
poor outcome by just giving them more support. So ultimately,
those two things, treatment matching, and tailored interventions will stem from
if we identify predictors and moderators. And the big, kind of,
outcome of this is that people will get better. The improvements in outcomes
will occur theoretically if this happens, so it should be a very important priority
for future work. And the final future direction that I think is very important
is to capitalize on technology. And the reason for this is that we know,
there’s been some research that’s been done to show that less than a quarter of
the people who are suffering from an eating disorder have access to or
seek treatment. And there are many, many reasons as to why this happens.
So the big pool of people the, 75% of people who are still suffering by
themselves without any help at all, the reasons for why this is occurring is
that one, there are too few trained therapists out there. So,
there aren’t enough therapist to accommodate the massive pool of people
that are suffering from an eating disorder.
And as [inaudible 00:36:08], what some work to time showing that even
tripling the number of trained therapists worldwide will have essentially no impact
on this. So, what are we going to do about that? And I’ll talk about that just
in a second. The second reason is that it’s too expensive treatment. So,
at the moment in Australia, Medicare covers us 10 sessions of
psychological treatments. And as I talked about,
for CBT to work at the moment, we need about 16 to 20 sessions.
So Medicare covers half of that. It just doesn’t really make sense. So,
it’s too expensive for people to kind of afford. The third one is that there are
huge geographical constraints. So, particularly people living in really
rural areas cannot access treatment. There’s no center, there’s no treatment
center available to them at all. So, how are they going to be able to
access these evidence-based treatments? And the final reason why people don’t get
treatment is because of the stigma associated with mental illness. So,
many people with eating disorders, not only eating disorders but other things
like depression and anxiety, they’re ashamed of their condition.
They don’t want to speak out about it because they’re embarrassed of it.
So what we need to do is we need to kind of overcome these barriers.
We need to find ways in which we reduce this huge gap we’re observing in the
treatment sphere. And one very, very important way to reduce this huge gap
is by capitalizing on technology. So capitalizing on the internet,
using smartphones. And why is that? We know that most people around the world
have access to a smartphone, have access to a computer, and internet,
and things like that. So what we can do is we can translate the
components of evidence-based treatments from that manual that I was talking about
and try to embed them within the internet, the computer, or a smartphone.
So people have something that they can use by themselves. And if we can do that,
then it will reach an enormous amount of people for little to no cost at all.
So it just may be that this low-intensity intervention of smartphones will do the
trick. It may help some people. It might not be beneficial for other
people but if it helps people, if it helps more people than otherwise
would if we didn’t give the smartphones, then I think that’s a win.
And what we can do is use a particular step to care approach which is that
everyone who has a particular condition, start off with this minimal intensity
intervention. So, download an app that helps them with their eating disorder,
use an internet-based treatment. But if they don’t respond,
then they may go on to the more, kind of, intensive psychological treatment.
So we’re kind of saving the resources for the people who are more severe.
And there’s good evidence showing that it’s a very promising approach for other
disorders like depression, anxiety, even stress, and things like that. So,
it’s showing a lot of promise, but in the field of eating disorders,
essentially, very little is learned. There’s a couple of trials that’s looked
at computerized treatments for eating disorders and it’s showing promise,
it’s showing that people are benefiting from it. But in terms of smartphones and
apps, there’s essentially no trials being done on that. So, that’s where it,
kind of, I think I’m hoping to step in in terms of really capitalizing on
technology and trying to translate the CBT based on that approach,
towards an app so that people worldwide can have access to some form of care and
essentially improve the quality of their life and reduce their symptoms. So,
they are the three…in my opinion, they are the three important future
directions that are needed to advance the field of eating disorder treatment and to
essentially help many more people, billions and billions of people worldwide,
get access to some sort of care. And that’s where I end off.
Thank you very much for listening to my presentation. And I’ll pass it on to
Lauren now. – Thanks so much for that presentation,
Jake. It was really, really insightful and did go through a lot
in 45 minutes. So, listeners, it’s now time for our Q&A session. So,
if you have any questions at all, please feel free to type them into the
question box. And we have a listener here who’s wondering if what the name of the
book was that you mentioned. – Yep. So, the name of the book is just
called “Cognitive Behavioral Therapy and Eating Disorders” and it’s by Christopher
Fairburn. So you can buy that book online. It’s more of a clinician book.
So it’s primarily used for clinicians for their patients. But what I would
recommend if anyone was interested in, kind of, implementing the strategies by
themselves, there is actually self-help books out that are based on that approach.
So, the same author has written an abbreviated version of that book and
the idea is that people can use the steps by themselves. And that book is called
“Overcoming Binge-eating.” It’s essentially the same thing as that
other book that I showed you in that slide, it’s just a shorter
version. It’s got the same techniques and principles, but it’s called here,
“Overcoming Binge Eating” by Christopher Fairburn.
And you can buy that also online, or I think it even might be in the shops.
But I highly recommend it. It’s such an easy to read book and it’s
got great steps to follow. – We have another question.
It’s what are the current recommendations for treatment of anorexia nervosa? – Yes. So, anorexia nervosa is a little
bit tricky. To be honest, it’s not so much my area of expertise.
I focus more on bulimia nervosa and binge-eating disorder,
but what we do know in anorexia nervosa is that family-based treatment, particularly,
for younger, kind of, younger, I guess, populations, is generally the recommended
treatment approach for younger people with anorexia nervosa.
There’s also a treatment approach that is also based on family-based principles
called the Maudsley approach, and that was developed in the U.K.
and that’s also has been shown to be quite effective for people with anorexia nervosa
of all ages. But the issue is that with anorexia nervosa,
we haven’t yet to determine what the most superior treatment is.
So when we’ve compared many different treatment approaches to anorexia nervosa,
we typically find that both produce equivalent effects, so as a result,
we don’t know what the best one is just yet. There are some recommendations
that CBT and family therapy are the way to go. They’re, kind of,
should be your first, kind of, line of treatment, but we’ve got no idea,
not no idea, but we’re just a bit unclear of what’s the most superior one.
It’s a little bit different to bulimia and binge eating disorder where CBT is a clear
favorite at the moment. So, it’s clearly the most effective one.
Good question. – And Julia asked, what are the current
recommendations for treatment of anorexia? Oh, I’m sorry, I’ve already read that one,
I’m sorry. Nicole asks, wondering if there is any research about
the efficacy of the 12-step models in this area? – To be honest, because I’ve done a lot of
systematic reviews on psychological treatments for eating disorders,
and I haven’t come across any of the 12-step models for eating disorders.
My understanding is the 12-step is kind of taking an addiction-based approach.
There is some work on food addiction, but there’s certainly hasn’t been,
kind of, any leeway into conducting studies on the 12-step approaches in
people with eating disorders. I guess it could be a future direction
given that the increased interest in food addiction, but yeah,
at the moment, it would only be theoretical. So, we don’t know just
yet. – Question from Sandra is,
thinking of the use of technology, how much supervision/monitoring would be
required to evaluate the outcome and who would be responsible for it? – That is an excellent question. So,
we’ve just actually published a meta-analysis on technology-based
interventions for mental health problems, so not just eating disorders,
we looked at everything, depression, anxiety, stress. And what we consistently
found was that any degree of supervision was beneficial. So, what we found that any
degree, whether that be, you know, a clinician who is just sending
encouraging text messages, whether they were calling them,
just checking how they’re going, you know, they need any help, anything like that
produces much better outcomes compared to if people are left alone to do them.
But the dose or the exact or precise amount of support needed is a bit unclear.
We’re not sure what the optimal dose is for…the optimal dose of, I guess,
support needed is at the moment. I guess it’s a really important thing to
think about in the future. But what we do know at the moment is that
something is better than nothing. The next step is to then talk about, okay,
then what is that something? How much of that something is needed?
Good question. – Berna has asked, would any of these
techniques and principles be useful for addressing obesity? – Absolutely. So, we usually say that
binge eating disorder is highly comorbid with obesity. The reason,
as I mentioned earlier, is that it’s because people with binge
eating disorder eat a lot of food but they don’t compensate for it like anorexia
nervosa, so as a result, obesity is quite common,
and the same principles can be applied. So, we know that people with obesity,
generally speaking, have a relatively negative view of their bodies. So,
a lot of the body image components can be applicable to them. But what if we want to
help people control their consistent overeating or grazing or binge-eating?
We can also use the same approaches too. So, we can also use that regular eating
that I was talking about. So really making sure that people eat
regular intervals, because in what we see a lot with people with obesity is that
they may go for quite a bit periods without eating, and then they’ll just
succumb to the temptation of or the, kind of, the deprivation of not eating for
a while, and then, that’s when kind of all hell breaks loose. And then they go on to
bingeing. So we can definitely use the same principles for people with obesity,
and it’s been shown to be quite effective in this group as well. – We have a question from Geda asking if,
any other IN treatments with established efficacy for adults? – Yep. So, as I mentioned a bit earlier,
as I was talking, CBT’s one of them, and probably, the other one is the
Maudsley Approach to treatment, which is based on, kind of,
family-based principles too. And there’s also another one called
Specialist Supportive Clinical Management. So that’s just basically getting in a
multi-disciplinary team consisting of psychiatrist, nutritionists, JPs,
and really kind of taking on a case by case basis of what can actually be
done. There’s actually a manual published on Specialists Supportive Clinical
Management. And interestingly, this type of approach has been shown to be
equally effective to CBT and the Maudsley Approach as well. So that’s another way in
which we can treat them. Again, there’s no clear standout to what
treatment is the best but we know that we have a few options available.
That’s why we need to look at moderators. So, what particular person will benefit
from what particular treatment? – Another question from our listener,
is comorbidity affected at impacts outcome in CBT for eating disorders? – Yeah, that’s also a great question. So,
we did a review paper in 2017 that looked at all of the variables that are being
studied as predictors of outcome. So that’s kind of the same thing as
impacting the outcome, and we looked at a bunch of different
comorbidities. So, like depression, anxiety, substance abuse,
all of the mental health, and other co-occurring mental health
conditions that have been looked at as determinants of outcome and what we
found is that no, there’s no available evidence to suggest that those things have
a detrimental impact on outcome, which is good because it means that we can
go in not worrying too much about those other signs and symptoms and just really
focus on the eating disorder as well. It’s not to say we shouldn’t pay attention
to them, we should, but we can be confident at the moment that they’re not
going to be too detrimental to a person’s outcomes later on. – Riley asked, twin studies,
identical twins with anorexia nervosa recovery outcomes if ED commence at an
early age, 8 to 10 years old, and is still current at age 19 to 20
years. – I’m not entirely sure of the question
but I wouldn’t be capable of answering that question because I don’t have any
expertise and knowledge in twin studies. I’m sorry about that. – Stephanie asked, would you work in
conjunction with a dietitian for any of these? – Absolutely, yes, you certainly would.
I think in the manual in CBT usually recommends a team approach that consists
of a therapist who’s working in conjunction with JPs, dieticians,
and things like that. So that just forms part of the components
of treatment that we need to make sure that we’re doing for those,
and that is the same with all the other treatments that I talked about earlier.
So, yes, they’re certainly very important aspects to the treatment team. – And luckily, this is the last question.
What’s the current evidence for self-help treatment? – It’s a…that’s a good
question. So, the self-help treatment or the “Overcoming Binge-eating” book that I
spoke about a little bit earlier. So, we know that guided self-help is when,
you know, someone is helping someone along the guided program. So,
whether that be a clinician, whether that be a…it could even be a
research assistant, we know that that produces quite important outcomes in terms
of that it works, but the thing is it only works for people with binge eating
disorder. At the moment, there’s no evidence to suggest that
self-help is effective for bulimia nervosa.
There have been a couple of trials on it documenting that it’s not even better than
simple whitelist controls. But for binge-eating disorder,
it is quite good. It’s the, kind of, first step in treatment that’s
recommended. And the reasons aren’t entirely clear, but we’ve shown in our
work that binge-eating disorder is easier to treat than bulimia nervosa.
And it’s another, kind of…there will be another webinar in of itself to explain
why that would be the case, so I probably won’t go into the details
there. – Thank you all so much for listening in
to today’s presentation with Dr. Jake Linardon. If you have any follow up
questions, please feel free to contact him directly. His details are on the
screen. And thank you so much for your time today, Jake. Thank you to our
listeners for tuning in and participating in today’s webinar. We hope you can join
us again next time. – Thank you.

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