E97 - Novel Treatments for Eating Disorders (with Prof. Ulrike Schmidt)

Prof. Ulrike Schmidt is a Professor of Eating Disorders and Director of the Centre for Research on Eating and Weight Disorders at King’s College London. She is also a Consultant Psychiatrist at the South London and Maudsley NHS Foundation Trust. 

Ulrike works to understand fundamental biology and psychological determinants of eating and weight disorders, including obesity. Her research includes multiple trials of new treatments and led to the development of MANTRA, a NICE-recommended psychotherapy for people with anorexia nervosa.

She has also led the development and research on FREED, First Episode Rapid Early Intervention for Eating Disorders a multi-award winning early intervention programme for young people with eating disorders, initially trialled in a few locations in the UK which was so successful it has now been rolled out nationally in England.

Today we discuss:

• The most important distinctions between different eating disorders such as anorexia, bulimia and binge eating disorders.
• The most important biological, psychological, social and cultural risk factors for developing such a disorder.
• What the path to recovery looks like.
• The FREED the treatment pathway professor Schmidt has done a lot of work on
• Potential novel treatments for eating disorders such as neuromodulation treatments and psychedelic treatments. 

To find out more about FREED:
www.inspirethemind.org/post/early-intervention-for-eating-disorders-grounds-to-celebrate

To find out more about MANTRA:
https://mantraweb.co.uk/

Interviewed by Dr. Alex Curmi, consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to enquire about an online psychotherapy appointment with Dr. Alex, you can email - alexcurmitherapy@gmail.com.

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Transcript

Welcome back to the podcast. My name is Alex. I'm a consultant psychiatrist. Today we're going to be talking about eating disorders. A group of common mental health conditions, thought to be affecting up to 1.25 million people in the UK. With us to discuss this topic is Professor Ulrich Schmidt. Professor Schmidt is the professor of eating disorders and director of the center for Research on Eating Disorders at King's College London. She's also a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust. Professor Schmidt works to understand fundamental biological and psychological determinants of eating and weight disorders, including obesity. Her research includes multiple trials of new treatments and led to the development of mantra, a nice recommended psychotherapy for people with anorexia nervosa. She has also led the development and research on Friede, which stands for first episode Rapid Early Intervention for Eating Disorders. A multi award winning early intervention programme for young people with eating disorders. Initially piloted in a few locations in the UK which was so successful it has now been rolled out nationally in England. Today we discuss the most important distinctions between different eating disorders such as anorexia, bulimia and binge eating disorder. The most important biological, psychological, social and cultural risk factors for developing such a disorder. What the path to recovery looks like. We talk about freed the treatment pathway. Professor Schmidt has done a lot of work on potential new treatments on the horizon for eating disorders like transcranial magnetic stimulation, psychedelics, and much more. This is the Thinking Minds podcast, a podcast all about psychiatry, psychology, psychotherapy and related topics. If you like it and want to support it, check out the links in the description. You can also follow us on social media. Do like, follow subscribe on whatever platform you're listening on, share it with a friend and if you have the time, leave us a review because that really helps new people to find us. Thanks for listening. And now here is today's conversation with Professor Ulrich Schmidt. Thank you so much for joining me today. I'm delighted to be here. What do you think makes the treatment of eating disorders so challenging? It's challenging and it isn't. We have a number of really good treatments, and also we have quite a few people who respond to our first line treatments. Um, but what we also have is a subgroup of patients who have gone through our usual treatments, which are psychological, um, therapies mainly, and nutritional treatments, um, and who still have a persistent eating disorder. And this sort of 30% of our patients, where all the things that we usually try and effective and who still have an eating disorders, those are the ones who are really challenging to help. Another thing that contributes to making some of the work we do challenging is that, of course, for anorexia nervosa, the medical risk can be extremely high. The families are often extremely alarmed and concerned, and worry that their loved 1st May die from the illness, and it's often the case that people with anorexia in particular, may not fully recognize how unwell they are, and may, um, feel that somehow they have to try harder to, um, become even thinner and are, um, seeing a value in their, um, suffering and in their eating disorder and are quite disconnected from the medical risks. So those things together, um, that the person themselves might not recognise how unwell they are, the pressure coming from the families and then us having certain treatments, but not a great deal yet in routine practice and of of novel treatments, um, that makes some of our patients challenging. And for the uninitiated, what are the differences between some of the most common eating disorders we see, like anorexia and bulimia. Binge eating disorder. What are some of the main differences between those? One can think about eating disorders as occurring on the spectrum from severe, persistent under eating, which is the hallmark of anorexia nervosa and a real drive for thinness. And then in the middle of bulimia nervosa, where there is alternating under eating and overeating, often very distressing episodes of binge eating. Um, and at the other end of the spectrum, binge eating disorder, where people have distressing episodes of overeating but they don't make up for them in the same way as people with bulimia do who use starving themselves, but also purging to counteract the effects of overeating and across the whole spectrum of eating disorders. What drives these behaviors is that people often, um, have a strong desire to, um, be. Sooner or healthier, um, that they have concerns about their weight, shape and eating. And these concerns become very intense, all consuming, um, very, um, overwhelming for some people so that it's really not much space for other things in their lives. Um, and in addition, often what drives the eating disorder is unhappiness in the person's life of stresses caused by life stresses. Um, so do you think that's almost part of the function of the disorder? If you like, that the focus on food becomes so all consuming. It's almost a simplification of one's life that, uh, the complexities of life can be so overwhelming that focusing just on food and weight are almost a relief from dealing with all the other complications a young person might have to deal with. That's hypothesis. One can can put forward that to simplify life in this way and to take control over your life in this way. Um, is quite central for, for for many young people with eating disorders. And of course, we live in a culture where, um, being slim is highly valued, is associated with seeing, uh, seemingly being seemingly successful in control, um, and where overeating, being binge is, um, stigmatized, really stigmatized. Um, and are there are we seeing differences in how eating disorders can present because of cultural shifts? So, for example, nowadays, particularly in men, there's a stronger, uh, cultural trend towards being not only lean but also very muscular. And my understanding is we're seeing more men who are obsessed with not having a physique that's lean, but also very muscular. Is that something that we're seeing clinically, this more men presenting with eating disorders, with the strong desire to be would for more muscularity. Absolutely. We know from epidemiological studies that a lot of the men with eating disorders do have muscularity concerns. And as clinicians, we are often not as good as we should be in asking about this. What we also know is that in the community, um, when you do epidemiological studies, about a third of the cases of eating disorders are male. There is a bit across the different disorders, but broadly speaking a third are male. But in clinic we see only 5 to 10% of our patients who were male. And that means that probably that is also an issue, that it's much harder for males to come forward, that some of them might think, I couldn't possibly have an eating disorder, or I couldn't possibly seek help for this because it's a it's a women's disorder, and that 30% is higher than I remember in medical school. So has it grown? Is there a trend that men are increasingly suffering from eating disorders? I don't think it's fully known because we don't have these epidemiological studies that have been done at different time intervals, um, that have included men. Um, nowadays men are included. I'm happy to say, and there is a real drive to make sure that services are also much more inclusive. It'd be good to talk about the risk factors and the vulnerabilities towards developing a disorder like that. And we can take it biologically, psychologically, socially, biologically. What are some of the risk factors that predispose a person to developing an eating disorder? Like most psychiatric disorders, eating disorders have multifactorial causes. Um, that includes the whole spectrum biological, psychological and social. It's very clear from twin studies and also from large, um, genetic studies involving thousands and thousands of um patients, that there is a strong genetic component, uh, to all eating disorders. And this genetic risk can be thought of as a risk for developing any psychiatric disorder. So there is an overlap between the risk for depression, anxiety disorders, um, and eating disorders for anorexia. There's also an overlap with the genetic risk for OCD. For people with binge eating, there is an overlap with the risk for impulsivity. So there is this broad psychiatric risk. But there is also a risk that has been termed metabolic risk, so that there are just some people who are genetically predisposed to being much less turned on by food and death, will find it easy to underrate and to be skinny and to be slim. And they find it really hard to get their weight up and others, they just have to look at food and they want to eat it. They find it much harder to resist food. They are prone to developing overweight and and obesity, and then also all the metabolic consequences that come with that. So the genetic risk is this dual risk for both psychiatric disorders. And then there is a sort of more metabolic physical component. Yeah. So but so biologically certainly we see a strong genetic predisposition as with a lot of mental health conditions. Would that overlap also include conditions like ADHD, which is known to be a highly heritable psychiatric condition, can include impulsivity. A lot of people with ADHD seem to present with binge eating and maybe bulimic type behaviors. That's correct. I guess the other important thing is to say is there is no anorexia gene or no bulimia gene, and that the genetic risk involves multiple, um, genes, all of which have a small effect and then work together to make someone more vulnerable. So that's also really, really important to hold in mind. Yes. And I suppose also the idea that genes don't exist in isolation, they of course, can be turned off or on by environmental triggers. We don't fully understand how this works, but we know broadly, having the genes, having the genetic risk isn't quite enough. So psychologically, what's the common makeup of someone with who might develop an eating disorder across the board? Um, these are often people who are quite anxious, who worry a lot, who may have a tendency also to mood disorders, depression. And when you come to developing Anorexia. It's often also people who have obsessive compulsive traits or even obsessive compulsive personality disorder, um, who are a bit on inflexible in their thinking and therefore find it really hard to follow. If I find it really easy to follow food rules. Um, and on the other side, on the binge eating end of the spectrum, it is people with more impulsive personalities who, um, go um, after quick rewards and who might find it really hard to resist a lovely piece of cake that's put in front of them. Um, that's being very simplistic, but those traits often go, um, with these different disorders. Um, have there been any studies, uh, looking at what are the big five personality traits that people with eating disorders commonly have? Because thinking about anorexia and I'm speculating, but I would imagine, uh, something like someone being high in conscientiousness. Uh, high in emotion sensitivity, lowering openness to experience might predispose to something like anorexia. Has this been looked at scientifically? Has been looked at. And you're absolutely correct in your guesses. And neuroticism is also high across eating disorders. Yeah. Yes. Okay. And now socially how important do you think social risk factors are for eating disorders. And what are the really common social risk factors. I think social risk factors are really important. And we do know, um, from transcultural research, that having a culture where there is a lot of emphasis on thinness with surrounded by thin role models, um, is really important. Um, we know this, for example, from the work of Anne Becker, who went to CDC on multiple occasions and really rural areas in Fiji. And about 30 years ago when she started this work as an anthropologist, eating disorders were virtually unknown. And then with the introduction of television and American teen television series, eating disorders suddenly started to appear there and preoccupation with thinness started to appear. So those sorts of things really make eating disorders much more common. Um, eating disorders have always been around. We know there are very good medical descriptions from the 19th century, before we had the cult of thinness. Um, there are also descriptions of medieval nuns who probably had anorexia. Um, but it was justified religiously. Um, they would, um, starve themselves for religious reasons. But what we know, and this is really well documented, um, for example, Saint Catherine of Siena, she had she went to confession on a regular basis, and her confessor reported to the Pope that she was taking starvation for religious reasons too far. He was concerned about her, and in the end she died very young from starvation. So eating disorders have always been around. But if you have a culture that actively encourages you to to lose weight, to be thin and wear, um, very delicious, highly palatable food is abundant. So if you can resist eating this, you get extra brownie points. So that's a culture where you're going to see more eating disorders out of curiosity. Because when you said cultures that promote, uh, thinness, I could only think really of Western culture. Are there any other cultures out of curiosity that promote thinness as an ideal? It's it's it's it's all Western industrialized. It's the weird countries, um, Western educated, industrialized. I can't remember what R and D stands for. Yeah. Yes. Okay. So we've talked a bit about broad, broad culture. What about family environment? Family dynamics? I was always thought, you know, when I was looking at this in training, family therapies, one of the gold standard treatments for eating disorders, which made me think family dynamics must be one of these causes. Is that true? Do we have we studied this? Yes. There's been a lot of work on this. And I think the main thing to say is families do not cause eating disorders. We see families very much as. Helping recovery efforts. Families can be driven to behaving unhelpfully. Um, but if you had a teenage child that isn't eating and where you're worried they're dying and you feel very helpless and you don't know what to do, you might end up shouting at them or trying to argue with logic or say, pull yourself together. We need to do something, and you might become engaged in all sorts of unhelpful behaviours. So we know that a lot of what seems like family dynamic is actually an expression of parents helplessness vis-a-vis a life threatening illness. And in family therapy, parents are very much seen as helpful partners in effecting recovery. Um, and that's really, really important. And originally, um, family therapy for eating disorders was developed for um, young teenagers under 18. Um, and it's recommended by the Nice guidelines as the treatment for anorexia in younger teens and also now for bulimia and younger teens. But. In adults too. I work with adults. We love to have families on board as supporting, um, the therapy of the person. We know that where you have the families on board. Half the battle is won. Because we are social beings, we rely on our families, we need them around and often we need to get a listen. Yes, that makes sense, but is there any truth to the notion that when family dynamics are suboptimal in some way, that could increase the risk by suboptimal? I mean, if the person doesn't feel comfortable expressing themselves emotionally, emotionally, or if there's a lot of conflict or there isn't a lot of trust in the family system, do you think that could have an effect? It could have an effect. But often this this might contribute to maintaining the disorder. And it's it's often just driven by by the helplessness of the family. There are some families that's a small number of families where there are very long standing issues, whether it's family trauma, family conflict, that's very long standing. Um, but those are the minority. And. Mhm. Mostly families are part of the solution. Yeah. Fair enough. That makes a lot of sense. How did you initially become interested in working with eating disorders? Well, I've always liked the idea of working with young people, and I also liked the idea of doing psychological therapy. So in my training, I, um, went for all the jobs where you could learn about psychological therapy. So I had a stint in behavior and cognitive behavioral therapy, working with people with anxiety disorders and, um, OCD. Then I worked and did some family therapy and systemic therapy and also did a stint in psychodynamic psychotherapy. And I did happen to do a research project as a trainee in bulimia. So I met Professor Gerald Russell, who was then, uh, who then led the eating disorders unit at the Maudsley. He was also the man who first described bulimia nervosa and he offered me a substantial substantive research job to do more work in bulimia. And it was in a large trial which combined antidepressant therapy with, um, uh, cognitive behavior treatment. And I really enjoyed this work. And what I particularly enjoyed was that when you work with people with eating disorders, often they're very unwell and very distressed when they first come into treatment and their lives have got gotten stuck through their disorder. But you can really help them to turn things around and to get on with their lives, to get back onto their developmental trajectory, to carry on with education, to have kids, have a family, do good work. And, um, that's really rewarding. Yes. So there's a huge ability to enact change, especially in young people. They might be in a really difficult position, uh, when they first start coming. And then there can be this huge amount of progress, which is very satisfying clinically. What what's your approach when you first sit down with someone, whether they have an eating disorder or not, using them from a psychiatric point of view. What's your approach clinically when when dealing with a new patient? Very much. Try to want to to to to hear why the person has come and also who whose idea it was for them to come. Um, that's very important in the eating disorders because very often we have people who haven't come on their own volition. They've come because someone in the family has been concerned. And you really then want to find out whether they themselves have any concerns or not, or what what they think about this whole encounter. And very often by going very gently at the beginning and hearing them out, hearing also about perhaps their reluctance to come, what that is rooted in, um, you can perhaps gradually win people over a bit to think, well, I thought I didn't have a reason to be concerned, but maybe I do have a bit of a reason to be concerned. And often also people are really frightened that some something is going to be sprung on them that they're going to be, I don't know, locked up in hospital or forced to do things that they don't want to do. And it's really helpful to hear of any fears or anxieties at the beginning that people may have about, um, meeting a psychiatrist, a person who they might see as someone in authority, especially if they are they're still very young. Yeah. It's one of the biggest problems in psychiatry in general is that often. There might be a certain sense of distrust, a certain sense of animosity, and people can lack insight so they people can be really unwell but not have a clear sense of that. And as you pointed out, that can be especially true in anorexia. And how do you how do you deal with that tension, and how do you begin the process of winning someone over, as it were, to try and, um, maybe get them to appreciate certain aspects of their condition, which you can see clearly, but maybe they can't. Technically, what we use is a skill that's called motivational interviewing, which was is is a conversation style that was originally developed for people with alcohol problems who often also find it really hard to own up to their difficulties, because often other they feel other people are accusing them of of of something. And part of this is that you are very reflective. You take it very slowly. You don't assume anything. Um, you don't offer your own opinions, but you try to elicit the views of the person. You don't try to persuade them. You don't try to threaten them or or say, um, things like, you're going to die or you better be careful. If you carry on like this, you just try to listen to them and give them this space to to talk about what what is is, um, what are their views about their the issues that brought and, and very often just by slowing things down in this way, by listening, but not assuming that you are the expert, but letting being very respectful to them as. The person in charge and the expert who will share as much or as little as they want to. They begin to trust you a little more, and they may say some things that may, um, be relevant as a concern. And sometimes also when when you can see this, um, you can then say can introduce other ideas. So we, for example, ask people about whether they have noticed any physical changes because we see this sometimes with patients might not apply to them. Is this something that is of concern to you? So we go very, very cautious really and very slowly. And then we open it up to psychological concerns, if anything happening in their social sphere that might be linked to the things that brought them. And you build up very gradually a picture of some things that perhaps aren't quite as the person would want them to. And then you can reflect this back to them and pause and get their views on this. And very often people say, oh yeah, I hadn't really thought about it in this way. And so by slowing it down, you also signal that you are not. Rushing towards action or quick conclusions about. Um. Um, we also ask people about the positives of their disorder, um, the benefits. And that's often also really, really helpful, something that people often haven't been asked about before. Um, and for people with anorexia, this is often that their anorexia is experienced like a friend, like something that makes them feel very safe, something that makes them feel very in control. Perhaps it helps them to manage emotions, because anorexia can often make you, um, feel very little. You need a positive, more negative emotions. And that, of course, contributes to you feeling in control a lot. Um, so people have a lot of positives. And also it means for some people that other people can see that something's not quite right, because they just take a look at them and see how thin the person is, but without the person having to explain what's wrong. Um, so and that's also really important. And then you can get people to, to tell you a bit more about that, um, and enter their world in some sense. Do you think that it's. Common for people with an eating disorder to actually be much more concerned about it than they let on, because often on at first glance in the clinic, people with such a disorder can appear very nonplussed, very unmotivated to change. But do you think, actually it's more that they don't necessarily trust the person they're talking to yet, or the clinician quite yet to reveal that they actually are more concerned about these behaviors than than they're willing to reveal. Some people that is the case, that they just want to keep it to themselves a bit and that that there is an issue of trust. Some people just really, really can't feel it. They can't see why others are so concerned. And these are often people who are very, very unwell, but they just can't see why, why their parents are going up the walls and their GP is really concerned and so on. Yeah. And it does sound like a lot like an addictive type process addiction like process. You mentioned how it's really important to, uh, highlight and cover the positive aspects of these behaviors. And just like with alcohol, if you're talking to someone with some kind of alcohol issue, it's really important to cover what are the benefits of drinking alcohol or using drugs with that person? Because that is a pathway to what kind of behaviors might be good to help them recover, because ultimately we all need to feel safe. We all need to deal with boredom. We all need to regulate our emotions. It's just that some ways of doing that are better than others. So it makes sense that you'd want to cover that in the case of an eating disorder as well. There are some parallels there. But for anorexia, the anorexia is often so highly valued that this almost goes beyond what you see in addictions, in the sense that someone who has alcohol problems doesn't value being addicted. Do you see what I mean? They need that drug, but they don't think it's. It's a good thing to have their addiction, whereas someone with anorexia may feel really that they value the anorexia, and that's a good distinction. So they're attached to the process, not just the outcome. Yeah. Um, tell us about Friede. So obviously you work in a service which is trying to provide the best possible treatments for eating disorders, early treatment, early intervention. Tell us about this program. So it's a program that we started ten years ago. Um, three it stands for first episode rapid Early intervention for Eating disorders. And when we started the work, um, it was a time when we had lots of people on a waiting list and we realized for our youngest patients, I worked with adults, the 18, 19 year olds, um, who'd come to us for the very first time. Um, we were just about to launch themselves into adulthood that waiting for treatment was really, really unhelpful. So six months of waiting is like a lifetime for someone at that age. And there's so many things going on in their lives educationally and socially and work wise that really you need to get in there quickly. We also know from what we know from the first descriptions of anorexia, the clinicians hundred 50 years ago said, get in there early. But we also know from neurobiological research that, um, when you look at brain scans of people with anorexia and how they make decisions about food, that habit circuitry in the brain is involved. And the more the longer your illness duration and the more eating disorder habits, bad habits you will develop. So there is a is an element where you you keep making unhelpful food choices, always going for low calorie, boring food that you don't really like. And and you really train yourself in this way. And so to really get away from this, people develop becoming the eating disorder, becoming very entrenched people, becoming very driven by unhelpful habits. We wanted to get in there really quickly through food. And food is not a treatment. It's a service model and care pathway. So it's a bit like early intervention services for psychosis. Um, only this is for eating disorders. And we try to call people as soon as we get a referral, we try to assess them within two weeks and start treatment as soon as we can thereafter again, ideally within another two weeks. So within a month we want people in treatment. And we really want to not just see people quickly, but we also have lots of adaptations to treatment to make them use friendly, make them very relaxed, make them very chatty, make them very welcoming, and also take account of the fact that what we are seeing early on. Is people who are either adolescents or emerging adults. So people who are at this a very interesting and difficult developmental stage where you are meant to find who you are in life. They have loads of transitions in this identity development phase. They may still depend a bit on their parents but want to be independent. There's a lot of drive for autonomy, and we have adapted our treatments accordingly to really make sure that we speak to this young population. And when we've done interviews with patients after treatment. They recognize that both the rapid treatment is helpful, but also the fact that we have made it very useful and very tailored to this developmental period of adolescence and emerging adulthood. The outcomes have been quite spectacular, and we have first tested, freed in our own service, um, and looked at a cohort of young people who had had treatments, who freed and then compared these with similar young people who had been seen in our service earlier. So similar illness duration, recent onset, young people aged 18 to 25. But the outcomes in freed were so much better. So in freed, 60% of the anorexia patients, um, were back to a healthy way at one year, compared to 20% of the patients who had had treatment as usual or had waited quite a while and then had. Some evidence based treatment, and we have done follow up studies at two years, and there's still a gap in terms of the recovery rates then between treatment as usual and to free patients. As a result, also the freed patients need much less hospital treatment. It is all done in outpatient, but sometimes sunlight does need to come in if they've if it doesn't work. So in free this was 6%. Whereas in treatment as usual it was 12%. And the cost savings that arise from that are important because they then can come back into the service. Um, and we've replicated this in their larger study across four services. And then on the strength of this free, it has been rolled out nationally all over England and is now available in all adult eating disorder services in England. Um, so that's that work was completed in 2023. And we're now thinking of how can we, um, introduce free to the other parts of the UK? And there are also people internationally who are interested in freed, and some people in Canada have, um, developed a free can for Canada. Uh, and people in Australia have been inspired by this and have developed a free like a service model. And in the Netherlands to. Wow. That's incredible. So essentially what's been demonstrated is. An intervention which is easy to access early and tailored to that individual, and perhaps tailored to that the stage of life they happen to be in. Are those the factors you think, that are exerting such a huge positive effect, or is there anything else? This combination, I think for me, um, seems to be what does it. Yeah. And I'm really curious, what are the adaptations to the treatment which make it more tailored to youth and that particular stage of life? They, we bring in families, which in adult services isn't something that until recently you you didn't routinely. So we we try very hard to involve families, um, in whatever way the old person lets us involve them. So that's really, really important to say because we know that they still rely on their families. A lot of them either live still at home, will have regular contact with their parents, and even the ones who say, no, no, no, I want to protect my parents from this. I don't want them. Actually. Usually it's a beneficial thing if the parents are involved. The other thing that we pay a lot of attention to is social media use, um, because social media can be used. Okay as a way to start off staying in touch with your friends, but it can also be used in the service of eating disorder. And we know that people do a lot of social comparison online with other people. Um, that can then be used in the service of the eating disorder. There can be people upload endless selfies, and those types of activities really can help you get stuck with your eating disorder and can maintain the eating disorder. So we want to get people to think about is your social media use mostly helpful or is it a hindrance? Um, could you think of reducing it or using it differently? So to play around with this. Um, so we do a lot of assessment and intervention around this. Um, other things that we are doing is we offer psychological therapies. Um, where there is a focus on identity development and finding your finding out who you want to be in life. Um, we have developed an outpatient therapy for anorexia called mantra, which has a whole module on identity in there. And we originally put it in there because some people develop an anorexia like identity, they can't think of what life without anorexia would be like. So we thought originally this identity module would be for people with very long standing anorexia. But as it turns out, the identity module is a is really the thing that our younger patients love the most. Because for them, finding their identity is a developmental task everyone is preoccupied with. Who do I want to be when I'm more a more fully formed adult? Yeah, and it's worth noting that our culture has lost a lot of the rituals, which we would have previously used to help people discover their identity, like rites of passage and things along those lines. And going back to social media briefly. Obviously, you talked about the dangers of comparison, which seems, you know, anyone could fall into that trap of comparing themselves to maybe their peers or others on the internet in terms of images. But my understanding is there are also issues in the past of, uh, aspects of the internet actually promoting eating disordered behavior, promoting anorexia. Is that still an issue as far as you're aware? Or have social media platforms like Facebook, TikTok, Instagram have? Have they done a good job at regulating this? Right. It's certainly there is less talk about pro anorexia pro eating disorder sites. Um, but as far as I'm aware, they also find different ways of, of labeling themselves. So some of them will have gone underground. I'm sure there is still a there's still a lot of websites where, um. Pro eating disorder practices are well publicized, so I think it's still out there. Um, but these other things, like comparing yourself against your peers and against celebrities, etc., that I think is also quite noxious. And, um, what's also quite clear from research that social media that are visually based. Tick tock, Instagram, etc., that they have much more potential for, um, doing harm to vulnerable people, not to everyone, but to people who are already, um, very tuned in to self comparison with other people and how do I look, etc. and making that the yardstick for for how they feel. So if we had to look at the treatment one can expect in a program like freed from a bird's eye view, what are the different aspects of treatment one can expect? We do use nice recommended, um, uh, psychological therapies like cognitive behavior therapy or family, um, treatments or mantra for anorexia as well. Um, and then we're using a lot of brief versions of this for, for people who may have milder eating disorders because we have put them earlier, um, so to speak. So. And then in addition to that, we make sure that all the therapists tweak the therapy according to their developmental stage. And but we also have additional, um, things that we offer, such as university starter groups, for example, because starting university is quite a tricky thing when you have an eating disorder. Um, I think with with any mental disorder, the issue is due to tell other people about it. But with eating disorders, because eating is so much part of what students do, you know, going out for a pizza or so, what do you do if that sort of thing is really hard for you? Um, how do you manage? It's, um, you know, the people you share a flat with, um, eat all hours of the day or every meal? There are never any regular meals. How do you, you know, how do you manage to say I actually need to eat three times a day because you are recovering from an eating disorder and you have worked very hard to re-establish an eating routine. You may think, this is not cool. What do I tell my friends? So we have university starter groups which look with people at those things. And how do you budget? How do you cook for yourselves? All those things will be considered. And then in terms of other aspects of the treatments we talked about psychologically. Uh, the university started groups and what else might comprise the treatment plan. We also try to get people to see our dieticians early on, um, because we really want to get across to people that the sooner they start working on re-establishing the healthy nutrition, um, the sooner they will be able to fully recover because, um, really to, to try to. Stopped eating this or that, becoming very entrenched. And we worked very hard with with our patients. We have very skilled, lovely dietitians who don't just dish out a meal plan, but do a lot of work with people who may still be sitting on the fence and and be unsure how much of this they want to do. Um, yeah. Yeah. And I'd love to learn more about, really, the nuances of how you work with someone from a dietary point of view, like what kind of foods one recommends, how you handle the calorie problem, how fast you gain weight, and maybe there's a dietitian on your team, perhaps that I could talk to in depth, but are there any like are there any major principles that you're aware of and how you tackle this? From a dietary point of view? A lot of it is common sense principles. Um, so where people are eating just one meal a day or eating very irregularly, we try to work very hard to establish a regular eating routine, because our whole digestive system, um, wants to know that there is food coming along at regular intervals. And our patients often feel very full when they when they've eaten. And it's, it's often because, um, gastric emptying, stomach emptying and also the passage through the bowels has slowed down because there is so little coming along. If you eat more regularly, you're not going to feel so full. Um, and if you start with little and often three meals and a couple of snacks, um, starting with foods that go down easily, milky foods, yogurts, those sorts of things, um, and building it up from there. We have a lot of patients who have big plates, but it's just. Lettuce leaves and and and low calorie stuff. So to eat more nutritious foods, to build in more nutritious foods in a way that's comfortable and that's regular, um, because one of the other problems we have is that, um, especially some young people who may be working in the corporate world, um, they get invited for meals out, and then they feel that they have to compensate for this before or after by eating little. And actually trying to get better from an eating disorder really involves is eating regularly, several times a day and building it up from there. Um. Mhm. Mhm. And I it would be really interesting to hear more about mantra. So how how old is mantra. Who designed it. And what are some of the main principles of mantra. Mantra is now a nice recommended um treatment for adults with anorexia. One of three. Um, so CBT is also recommended or uh, another um therapy that was developed in New Zealand, which was called um Specialist Supportive Clinical Management. We developed mantra at the Maudsley. And when I say we this is my colleague Janet, Trisha and myself, um, we started with this work in the early 2000 and we looked at, um, the literature on what we thought were the sort of key maintaining factors of anorexia. And we thought that, um, there were two psychological factors, one which is an anxious and avoidant relational style where you try to have as. Little interpersonal conflict or challenges as possible. The other one was a cognitive style that's characterized by cognitive inflexibility and an inability to see the bigger picture, to always be very detail focused. And there are lots and lots of neuropsychological studies that support this. And then we know that, and I've said this already. The families become very, very concerned and may inadvertently keep the anorexia going through becoming emotionally over involved in cooking all the special things. Let me go and buy you the very special yogurt that has five calories less than some other brand, and those sorts of things, all by getting very cross and getting very angry with the person. Um, and the fourth thing is that often together, um, some of these things then lead to, um, anorexia becoming very valued and the person developing beliefs about how the anorexia helps them in their lives, so helps them to be more in control, to manage emotions, to manage relationships. And and so we wanted to build a therapy that addresses all these four factors. Um, a therapy that meets patients where they're at. So it's very motivational, very gentle, um, and focuses really on helping people to get a bigger life, but also make changes to their nutrition and end up, if possible, either fully recovered or much better from their anorexia. And we we wrote a treatment book for patients with lots of case examples and lots of it's a workbook. So, um, lots of exercises that people can do between sessions. And that forms the backbone of this therapy. Um, so, um, we've tested it now in several trials. It's been internationally tested as well. It's not better than CBT. It's just the same in outcome. Similar and outcomes, but it gives people different options. And because CBT is not for everyone, nor is mantra for everyone. Um, so that's I think, very helpful. And when we looked at in one of our trials, we looked at acceptability. It was rated as more acceptable than the comparison treatment. And where you have a population that are a bit ambivalent about their treatment or want to run the other way. Susceptibility is really, really important. Um, and is the book, uh, publicly available? The workbook says, yes, it is now a published book that that's, um, can be bought with all the positives and negatives that that has because we are trying to develop it further. And so we have various research versions as well. Colleagues in Austria have developed the German version for younger adolescents, and it's worked really well in that context too. Um, other colleagues are using it for relapse prevention after inpatient treatment, um, of anorexia. So there are various other trials going on at the moment. And, um, it's been translated into Japanese and there's a Japanese trial going on, as well as the book called mantra. The book is called a Cognitive Interpersonal Workbook for Anorexia Nervosa. Amazing. And what you said, you know, published, for better or for worse, are positives. And negatives. What are some of the negatives of having a published? Do you think the negatives are there? Does it just suddenly becomes a bit fossilised that it's harder to make changes? Yeah, that makes sense. Are there any new treatments on the horizon emerging for eating disorders? I know you want to talk a little bit about neuro modulatory treatments. Well, could you tell us a little bit about that? We are exploring neuromodulation treatments and there are lots of different types, but two main types are repetitive transcranial magnetic stimulation. Um, where you um it's non-invasive. You have a figure of eight coil. You induce an electromagnetic field and via that and a current in underlying brain regions, and this can be stimulatory or um, um or inhibitory. And we have used this method in adults with anorexia with a very long standing illness. On average these people had 14 years of illness duration. They had had loads of previous treatments. And what we found was that with 20 sessions of this, um, repetitive transcranial magnetic stimulation, which was applied to the um, front of the brain, dorsolateral prefrontal cortex, um, that we improve people's moods, um, a lot initially. Sort of. And three months mood was markedly improved compared to a placebo treatment. Um, which patients couldn't distinguish from the real treatment. And what we also noticed at that point was people said I feel much more relaxed around eating. Um, but there wasn't much of a signal in terms of improvement in body weight. But then at 18 months, we found that the people who had had the real rtms did much, much better in terms of their physical recovery, in terms of their weight than than the other groups in the control group. So it's actually a really good news because we first make people feel better, and then they feel relaxed enough to do something about their eating. Whereas people always have this fear that someone is just going to fatten them up in inverted commas. And and we obviously don't want to do that. That would be very, very distressing to people. So we've done this very first trial. Um, there are other groups who are also interested, but we really were the first ones to do that. And we're now using a similar variant of repetitive transcranial magnetic stimulation in young people with persistent anorexia. Um, so we have to find these young people. We've said if they've had one course of treatment that hasn't allowed them to make a full recovery, then we're happy to to to do the TMS treatment with them, because I think when, when, when you're young and in school still or just starting at uni every month counts very much. Um, because it, it can set you back in terms of your developmental trajectory. So we're doing that work. And we have also used another form of brain stimulation. Which is called tDCS. Transcranial direct current stimulation, where you apply a very small surface current to the brain. Again, what we stimulate is the dorsolateral prefrontal cortex. This is an area of the brain that's very important in self-regulation. But also then in regulation of what you need, regulation of emotions. All of those things are matter for eating disorders and people. Subjective experience was I feel more relaxed around eating. And eating is the most fear inducing thing for these patients with anorexia. So and this had this was related to what happened to to their ability to eat and to tolerate a bit of weight gain. And the beauty of this tDCS treatment is that you can do cognitive training or psychological therapy in parallel, whilst you're doing the stimulation. So we have used this in people with binge eating disorder combined with, um, a food related cognitive training. So training people to look away from high calorie foods. And we found that this combination training is really effective in combination treatments or training. Plus the real tDCS is really effective. Um, more so than if you combine the training with a sham stimulation, or if you just do the cognitive training alone. So we are very excited by these findings or these findings are preliminary. None of this is available in routine practice yet, but it's going to come. And there are other people who are also doing trials. So there is a big push to make these things more widely available. And I should say that, um, eating disorders are coming relatively late to brain stimulation. Um, in the TMS and tDCS have been widely used for treatment of depression. Um, TMS is a recognised second line treatment for um treatment resistant depression in the UK and in the US, so that thousands of people have had it. It's a safe treatment. Um. If anything, it improves your cognitive functioning. So that's really important. And it's it's safe. And is there any possibility that the treatment can be delivered in a in a shorter, more intense way. Because I know at Stanford University for depression, people like Nolan Williams who have had on the podcast are experimenting with, uh, very short courses where they might spend an hour and a half a day for five days getting transcranial stimulation. Is there any evidence that that could similarly apply for eating disorders? It hasn't been done in eating disorders, but that's obviously the next step to do to to to go for these short and concentrated protocols. Because in our first anorexia trial, we've included 35 people, but we had over 300 people who wanted to be part. A lot of them, in the end, couldn't be part because they lived in Scotland or Ireland, northern Ireland, or a long way away in the north of England. And travelling for TMS would have been too difficult. So, and our protocol involved people having treatment for all months. So if you could do something that's more concentrated, that would really make it much more accessible. Um, are there any other novel treatments for eating disorders on the horizon? I know that everywhere you look nowadays in psychiatry, psychedelics seem to be emerging. Have psychedelics been looked at at all in the realm of eating disorder, like Alex are being looked at, um, in eating disorders and there are various, um, single case and small pilot series, both of psilocybin and ketamine. Um, our own center, my colleague who has been involved in this psilocybin trial here, uh, in the UK and um, also has funding for a ketamine trial. Um, so this is all, uh, forthcoming. So right now we don't have enough data to to know how effective these treatments are. That's correct. We don't fully know yet how effective they are in eating disorders. And of course, one of the issues with, um, psilocybin is that you are always able to guess whether you have had the real thing or a placebo. Um, so there is. Also likely to be a really, um, strong placebo effect or a really strong expectation effect. I would say not the placebo effect in those who who have had it. Um, because people who come really want to have it and then if they realize they have had it or they have not had it and either be very disappointed or very excited. I certainly agree with you. But having said that, we talked to a psychiatrist named Benji Waterhouse on the podcast a few months back, and he told us this fascinating story where he was involved in a psilocybin research trial. He was working with an old lady who had treatment resistant depression for a number of years. They gave her the medication, um, she put on the blindfold and she just totally spaced out for six hours. So it was really obvious that she was in the treatment arm and had depression went away. All of these symptoms she's had for so many years lifted. And even at follow up, six months on her depression symptoms had lifted. And then they all found out together which treatment arm she was in and she was, in fact, in the placebo. Um, so even though I think in general, you're probably right, it is very the placebo effect may indeed be more powerful than we think. At least there was a good outcome in this case. Um, yes. Well, I want to say I hope it works. It would be wonderful to have something that that really gives hope to some of the patients for whom all our more conventional treatments don't work so well, and to give them new options and different options, and that don't involve going over the same old ground in terms of psychological therapies. Again, I, um, as I said, I, I like delivering psychological therapies. I believe that they are very helpful for a lot of our patients. But there is a subgroup which where we we were not successful with psychological therapies. And to have something else there would be wonderful. Absolutely. To close, I would just ask if if a relative of someone who possibly has an eating disorder is listening, how would you recommend they approach that person? Obviously they would suggest, you know, seeking treatment, some form of treatment as soon as possible. But I mean, in terms of day to day interactions, how would you advise that person, uh, approach their relative who may be suffering from an eating disorder. It's quite hard to give a general recommendation. It would depend on the aids and the nature of the person on the nature of the eating disorder. On the medical risks or perceived risks involved. Um, but having said all that, I think a good thing is to talk to the person and to listen where they're coming from, and to not immediately jump in with giving advice, but to wait and really hear the person out. Perfect. Professor Schmidt, thank you so much for spending some time with me today. I really enjoyed hearing what you have to say and you provided such rich, such valuable information. We will provide links, so feel free to send me over anything about Friede, some interesting research papers and perhaps the link to your workbook as well if you would like. And we can put all those links in the description for people to access. Real pleasure to talk to you. Alex.