Final Report Summary - ET4AN (New technologies to support eating in Anorexia Nervosa: a neuroimaging study)
Summary of research programme undertaken
During the course of the 2-year Marie Curie Postdoctoral Fellowship I have achieved the following results:
• Timely completion of the proposed research project
- Recruitment and testing of 16 patients with severe and enduring Anorexia Nervosa (AN) and 21 healthy controls. The study I proposed was aimed at reducing food-related anxiety using gradual exposure to food stimuli in patients with severe and enduring AN. The testing sessions were conducted at the Eating Disorders Research Unit and the Centre for Neuroimaging Sciences at King’s College London. The baseline and follow-up testing procedures involved participants completing self-reports to measure eating disorders symptoms, mood symptoms, rituals and disturbing thoughts around food, and social functioning, and a brain scan to measure brain activations related to the visual presentation of photographs of foods.
- Development and delivery of 12 sessions of exposure-based therapy. After the completion of the baseline measures, patients with AN received 12 sessions of gradual exposure to food stimuli, during a 3-month period. The protocol for the intervention was developed under the supervision of Prof. Treasure. The first two sessions involved a clinical assessment of specific issues and worries about eating; and the development of a personalised hierarchy of threatening foods (ranging from the least to the most threatening). Sessions 3-12 involved gradual exposure to the food items listed in the hierarchy. During the exposure sessions patients were encouraged to confront, rather than avoid their anxiety, and to eat the food item chosen.
- Statistical analyses of self-report measures and brain imaging data. Statistical analyses were conducted on the self-report and brain imaging data obtained in the clinical and control groups. The statistical analyses for the brain imaging data were conducted in collaboration with Dr O’Daly, an expert in clinical neuroimaging.
- Identification of the study’s main clinical findings. The treatment sessions were associated with a significant increase in body mass index and self-reported confidence to change, and with a significant decrease in anxiety, negative affect, and eating disorders symptoms. Overall, these findings indicate that a brief intervention based on gradual exposure to food stimuli can effectively reduce food-related anxiety in a sample of patients with severe and enduring AN.
- Identification of neural substrates of clinical change. The neuroimaging data showed that the intervention was also associated with reduced activation in the brain regions associated with the processing of personally relevant phobic stimuli (i.e. precuneus) and with increased activation in the prefrontal cortex (i.e. a brain region involved in planning complex actions). Interestingly, a cross-sectional study on people fully recovered from AN also had shown increased activation to food stimuli in the same prefrontal cortex region (Uher et al., 2003). These findings highlight a potential neural signature for recovery in AN.
• Development and execution of brief testing sessions to measure cognitive processes associated with food-related anxiety in patients with eating disorders A brief research project was conducted to investigate patients’ perception of food stimuli. In particular, implicit vigilance to food pictures, and liking and wanting of high- and low-calorie foods were investigated. The findings from this study contributed to the understanding of the cognitive and affective processes underlying eating-related difficulties in patients with eating disorders (i.e. one of the aims of the proposed project).
• Timely completion of a wide training programme
My training programme included: 1) completion of training courses (e.g. neuroimaging data analyses, grant writing, compassion-focused therapy; N=6); 2) completion of the mentorship programme offered by my two supervisors (i.e. monthly meetings with Prof. Treasure; Prof. Campbell); 3) attendance of national and international conferences (N=7); and 4) research visits to international institutions (N=3).
• Broad and effective dissemination of science
This included: a) presenting my research findings at 4 national and international conferences; and 2 meetings with the Eating Disorders Research Unit team at King’s College London; 2) conducting two workshops for mental health professionals; 3) publishing the findings from my research on peer-reviewed international journals (N=11 published papers; N=4 papers under review; N=6 papers in preparation).
• Undertaking teaching activities
These included tutoring 3 Ph.D. students of the Eating Disorders Research Unit at King’s College London; 10 Masters’ students on the “Perspectives of Pain and Nervous System Disorders” Masters’ course of King’s College London; 1 third-year medical student; 4 European Masters’ students undertaking an internship at the Eating Disorders Research Unit at King’s College London; becoming the clinical placement supervisor of the Mental Health Studies Masters’ course at King’s College London; and a trainer employed on the Researcher Development Programme of King’s College London.
• Funding applications and development of the next phase of my career
During the 2-year Marie-Curie award, I have contributed to the preparation of 9 grant applications (of which 3 awarded and 1 submitted) and developed 3 fellowship applications.
Conclusions
The results of my research project demonstrate that patients with AN experience high levels of anxiety when exposed to food stimuli. The findings from the exposure-based intervention indicate that is possible to reduce these abnormal responses. Clinical change is underlined by changes in brain circuits which are associated with recovery from the severe and enduring subtype of the illness.
I believe these findings can be disseminated to provide hope, motivation and confidence to change to patients with severe and enduring AN, their carers and therapists. The next steps will be to pilot strategies to render this intervention widely accessible; and to train professionals and carers in facilitating the use of effective techniques to reduce food-related anxiety in patients with AN. These will allow ensuring that clinical change generalises to different contexts, and is sustained over time.
Socio-economic impact of the project
Anorexia Nervosa is a severe mental illness and has the highest rates of mortality amongst psychiatric disorders. Illness-associated costs are as high as £1.25 billion per year due to prolonged and repeated admissions. About the 25% of patients develop a severe and enduring form of the illness, which becomes resistant to treatment due to the neuroprogressive changes associated with prolonged starvation.
The 12-session intervention developed and tested during the award has the potential to produce significant clinical changes in patients with severe and enduring AN. We are currently developing ways in which this intervention can be disseminated globally. In particular, we are piloting the use of self-help materials to be delivered on mobile devices and developing protocols to train health professionals, carers, and peer mentors (i.e. ex service users) to provide non-expert guidance through a website.
We will use these findings to prepare a larger randomised controlled study testing the intervention developed during the award, with the overall purpose of facilitating recovery in patients with AN.
During the course of the 2-year Marie Curie Postdoctoral Fellowship I have achieved the following results:
• Timely completion of the proposed research project
- Recruitment and testing of 16 patients with severe and enduring Anorexia Nervosa (AN) and 21 healthy controls. The study I proposed was aimed at reducing food-related anxiety using gradual exposure to food stimuli in patients with severe and enduring AN. The testing sessions were conducted at the Eating Disorders Research Unit and the Centre for Neuroimaging Sciences at King’s College London. The baseline and follow-up testing procedures involved participants completing self-reports to measure eating disorders symptoms, mood symptoms, rituals and disturbing thoughts around food, and social functioning, and a brain scan to measure brain activations related to the visual presentation of photographs of foods.
- Development and delivery of 12 sessions of exposure-based therapy. After the completion of the baseline measures, patients with AN received 12 sessions of gradual exposure to food stimuli, during a 3-month period. The protocol for the intervention was developed under the supervision of Prof. Treasure. The first two sessions involved a clinical assessment of specific issues and worries about eating; and the development of a personalised hierarchy of threatening foods (ranging from the least to the most threatening). Sessions 3-12 involved gradual exposure to the food items listed in the hierarchy. During the exposure sessions patients were encouraged to confront, rather than avoid their anxiety, and to eat the food item chosen.
- Statistical analyses of self-report measures and brain imaging data. Statistical analyses were conducted on the self-report and brain imaging data obtained in the clinical and control groups. The statistical analyses for the brain imaging data were conducted in collaboration with Dr O’Daly, an expert in clinical neuroimaging.
- Identification of the study’s main clinical findings. The treatment sessions were associated with a significant increase in body mass index and self-reported confidence to change, and with a significant decrease in anxiety, negative affect, and eating disorders symptoms. Overall, these findings indicate that a brief intervention based on gradual exposure to food stimuli can effectively reduce food-related anxiety in a sample of patients with severe and enduring AN.
- Identification of neural substrates of clinical change. The neuroimaging data showed that the intervention was also associated with reduced activation in the brain regions associated with the processing of personally relevant phobic stimuli (i.e. precuneus) and with increased activation in the prefrontal cortex (i.e. a brain region involved in planning complex actions). Interestingly, a cross-sectional study on people fully recovered from AN also had shown increased activation to food stimuli in the same prefrontal cortex region (Uher et al., 2003). These findings highlight a potential neural signature for recovery in AN.
• Development and execution of brief testing sessions to measure cognitive processes associated with food-related anxiety in patients with eating disorders A brief research project was conducted to investigate patients’ perception of food stimuli. In particular, implicit vigilance to food pictures, and liking and wanting of high- and low-calorie foods were investigated. The findings from this study contributed to the understanding of the cognitive and affective processes underlying eating-related difficulties in patients with eating disorders (i.e. one of the aims of the proposed project).
• Timely completion of a wide training programme
My training programme included: 1) completion of training courses (e.g. neuroimaging data analyses, grant writing, compassion-focused therapy; N=6); 2) completion of the mentorship programme offered by my two supervisors (i.e. monthly meetings with Prof. Treasure; Prof. Campbell); 3) attendance of national and international conferences (N=7); and 4) research visits to international institutions (N=3).
• Broad and effective dissemination of science
This included: a) presenting my research findings at 4 national and international conferences; and 2 meetings with the Eating Disorders Research Unit team at King’s College London; 2) conducting two workshops for mental health professionals; 3) publishing the findings from my research on peer-reviewed international journals (N=11 published papers; N=4 papers under review; N=6 papers in preparation).
• Undertaking teaching activities
These included tutoring 3 Ph.D. students of the Eating Disorders Research Unit at King’s College London; 10 Masters’ students on the “Perspectives of Pain and Nervous System Disorders” Masters’ course of King’s College London; 1 third-year medical student; 4 European Masters’ students undertaking an internship at the Eating Disorders Research Unit at King’s College London; becoming the clinical placement supervisor of the Mental Health Studies Masters’ course at King’s College London; and a trainer employed on the Researcher Development Programme of King’s College London.
• Funding applications and development of the next phase of my career
During the 2-year Marie-Curie award, I have contributed to the preparation of 9 grant applications (of which 3 awarded and 1 submitted) and developed 3 fellowship applications.
Conclusions
The results of my research project demonstrate that patients with AN experience high levels of anxiety when exposed to food stimuli. The findings from the exposure-based intervention indicate that is possible to reduce these abnormal responses. Clinical change is underlined by changes in brain circuits which are associated with recovery from the severe and enduring subtype of the illness.
I believe these findings can be disseminated to provide hope, motivation and confidence to change to patients with severe and enduring AN, their carers and therapists. The next steps will be to pilot strategies to render this intervention widely accessible; and to train professionals and carers in facilitating the use of effective techniques to reduce food-related anxiety in patients with AN. These will allow ensuring that clinical change generalises to different contexts, and is sustained over time.
Socio-economic impact of the project
Anorexia Nervosa is a severe mental illness and has the highest rates of mortality amongst psychiatric disorders. Illness-associated costs are as high as £1.25 billion per year due to prolonged and repeated admissions. About the 25% of patients develop a severe and enduring form of the illness, which becomes resistant to treatment due to the neuroprogressive changes associated with prolonged starvation.
The 12-session intervention developed and tested during the award has the potential to produce significant clinical changes in patients with severe and enduring AN. We are currently developing ways in which this intervention can be disseminated globally. In particular, we are piloting the use of self-help materials to be delivered on mobile devices and developing protocols to train health professionals, carers, and peer mentors (i.e. ex service users) to provide non-expert guidance through a website.
We will use these findings to prepare a larger randomised controlled study testing the intervention developed during the award, with the overall purpose of facilitating recovery in patients with AN.