Feature: Bringing order to chaos - Professor Chris Fairburn
28 September 2011
Sandwiched between advice on recognising "the roaming male" and an interview with Barry Norman, a short article on the Health Reports page of the April 1980 issue of 'Cosmopolitan' alerted readers to a "new and bizarre eating disorder affecting young women". Readers with experience of self-induced, secretive vomiting were asked to write in to receive a questionnaire.
Six months later, stimulated by the huge response to the 'Cosmopolitan' piece, BBC's 'Horizon' featured a man and woman with the same disorder, and once again people with personal experience of it were asked to write in. "For three days I had my own personal post van in Oxford," says Professor Chris Fairburn, the psychiatrist behind both requests, and now a Wellcome Trust Governor and Principal Research Fellow. "The hospital switchboard was blocked with phone calls."
The problem ruling these people's lives - bulimia nervosa - was little known in the early 1970s, even among health professionals. Today, it is widely recognised - and it is estimated that around 2 per cent of young women suffer from the disorder. For the last 25 years, Chris has led the field in developing ways to categorise, diagnose, assess and treat bulimia nervosa and the other eating disorders, and is about to start an ambitious new project to transform the way that therapists are trained.
He saw his first case of bulimia nervosa in 1976 during psychiatry training at the University of Edinburgh. Asked to see a woman referred by her GP for an eating disorder, Chris entered the room and was surprised to see someone who looked completely normal - the patients referred had invariably been extremely thin. He took a history, which was consistent with anorexia nervosa, yet her weight was fine. Sheepishly, he went to see his professor, who told him he must have got her weight wrong. "When the professor discovered I was right, he told me to see her again and find out what was really going on - and to tell him the next week."
The patient was dieting, vomiting, exercising and taking laxatives, but her weight was normal - how could this be? In the pre-Google world of 1976, Chris went to the library to investigate, but in vain. "I tried to read the world literature on this, but there wasn't one," he says. After several more appointments, he decided to ask the patient directly why her weight was normal. "With considerable embarrassment, she told me that she kept losing control over eating and was having repeated episodes of extreme overeating. She was very ashamed of this. She'd been very open in general, but she hadn't told me about this part. Her weight now made sense."
This sent Chris on a different literature search, but he found just a handful of mentions of cases in books and an obscure feminist journal. His professor dismissed the case as an oddity. Just a matter of weeks later, though, another similar patient appeared.
"The two women were in exactly the same situation," Chris says. "Both were in their early to mid-20s, had had the condition for around five years, had kept it secret successfully and were physically unwell." Over the following year, he saw more cases. He also asked colleagues to pass on similar patients, and he had soon amassed a relatively large group.
Well treated
Having gained experience of psychological treatment research as a medical student in Oxford, Chris knew something of cognitive behaviour therapy (CBT). This talking therapy helps people to recognise and alter their dysfunctional ways of thinking and behaving. "The more I understood these patients, the more I was convinced that CBT would be a good way of helping them."
People with eating disorders think differently to those without these conditions. "They judge themselves exclusively in terms of their shape and weight - nothing else much matters in their lives," Chris says. "They are dominated by their concerns about their shape and weight - eating disorders are par excellence 'cognitive' disorders."
To control their shape and weight, people with bulimia nervosa diet, but in an extreme and rigid way that can leave them prone to episodes of loss of control over eating, nowadays called binges. These binges can last for more than an hour and typically involve eating several thousand calories. Those affected binge on so-called 'forbidden foods' that they are trying to avoid, such as ice cream, cakes, biscuits and bread. Afterwards, they try to compensate for the binges, either by dieting more or by vomiting and/or taking laxatives to purge. "The trouble is that the resulting dieting makes them yet more prone to binge, and so they get stuck in a vicious cycle that is difficult to escape from," Chris says.
With "quite a lot of trial and error", he developed a cognitive behavioural theory concerning the processes that maintain the disorder and, on this basis, a new treatment. The first patient he treated got better in nine months. He applied what he had learned to his other patients and, within a couple of years, had pinned down how to treat most cases. Chris applied to the Medical Research Council (MRC) for funding to study the then-nameless condition. "I wish I'd kept the letter I got back," he says. "It said something like, 'fascinating, really nice design but we've never heard of the disorder you are treating'."
He returned to Oxford in 1979. In August of that year, the condition finally got a name: bulimia nervosa, coined by the world-leading figure on eating disorders, Professor Gerald Russell. In his paper (1), Russell described bulimia nervosa as "an ominous variant of anorexia nervosa". He presented 30 cases, warning that these patients were extremely difficult to treat. "That put me in a very interesting situation of having more cases than him and also being able to treat the disorder," says Chris.
The condition now had a name, but there was still the question of how common it was - something research funders needed to know. Chris suspected that it might be common, but hidden - after all, these patients looked normal and were highly secretive. This is when he had the idea to try to reach people with the condition using a women's magazine. The 'Cosmopolitan' piece was written and - combined with the response to 'Horizon' - resulted in over a thousand new cases being detected, most of whom thought they were the only one with the problem (2).
In 1981, Chris received MRC funding for the first randomised controlled trial of a psychological treatment for bulimia nervosa. The study confirmed that the new form of CBT had a sustained, positive effect, but Chris was surprised to find that another therapeutic approach, with the same amount of personal contact with the therapist but without cognitive or behavioural aspects, was also quite beneficial.
Chris was made a Wellcome Trust Senior Lecturer in 1984 and used this award to compare interpersonal therapy (IPT, which focuses only on patients' relationships) to behavioural therapy and CBT. "I wanted to dismantle CBT to see if focusing just on the patient's behaviour had the same effects," Chris says. The patients were treated for 18 weeks and, as before, over half made a full and lasting response to CBT. Interpersonal therapy was also quite effective, but it took far longer to work than CBT. By contrast, the dismantled version of CBT that was missing the cognitive elements had only a transitory effect (3).
In 1994, with support from the US National Institute of Mental Health, Chris began a collaborative study of 220 patients recruited from Stanford and Columbia to see whether the Oxford findings could be replicated. They were, almost exactly. The study, published in 2000, concluded: "Cognitive-behavioral therapy was significantly more rapid in engendering improvement in patients with bulimia nervosa than IPT. This suggests that CBT should be considered the preferred psychotherapeutic treatment for bulimia nervosa."
Just four years later, the National Institute for Health and Clinical Excellence (NICE), the UK body that advises on what treatments the NHS should provide, published guidelines strongly recommending CBT for bulimia nervosa. This was the first psychological treatment recommended by NICE.
A hidden problem
If you were to ask people in the street about eating disorders, the majority of people would probably be aware of anorexia nervosa and some would be aware of bulimia nervosa. However, Chris's work and that of others has recently shown most people diagnosed with an eating disorder have neither. Although some 10 per cent have anorexia nervosa and 30 per cent bulimia nervosa, the majority fall into a residual category termed 'eating disorder not otherwise specified', a type of eating disorder that is just as severe but has barely been studied.
"Although not much remarked upon," Chris says, "there are notable similarities between the eating disorders. They have very similar clinical characteristics, and patients commonly move between the diagnoses." This led to Chris having an 'aha' moment in the late 1990s. "I thought, given these similarities and links, there are likely to be common processes maintaining the eating disorders. Therefore, if we are capable of addressing these processes in one condition, bulimia nervosa, we ought be able to do the same in the other eating disorders." This so-called transdiagnostic way of thinking was highly contentious, and many in the field were sceptical about its 'one-size-fits-all' nature. Still, in 2000, Chris was awarded funding from the Wellcome Trust for a trial that would test whether CBT works for any eating disorder.
Results from the first part of this trial are promising. Looking at the patients who were not significantly underweight (i.e. the 80 per cent of patients with bulimia nervosa or 'eating disorder not otherwise specified'), the team found that the new version of CBT, designed for any eating disorder, worked for two-thirds of the patients, regardless of their original diagnosis (4) - a finding that has subsequently been replicated. Most recently, Chris has reported the results from the remaining patients, those with anorexia nervosa, and they too respond to the new treatment.
Researchers are applying the transdiagnostic way of thinking to other mental health disorders, and clinicians now have a single treatment that can be used across the eating disorders. Not surprisingly, the demand for training in the new treatment is immense, and this topic - how to train therapists on a large scale - is the focus of Chris's latest line of work.
"The way people learn psychological therapies today is ad hoc, and not dissimilar to the time of Freud," Chris says. Typically, trainee therapists attend an initial one- or two-day training event held by an expert, followed by some form of case supervision for six to nine months. "This method is all very well but it results in very few people being trained. Moreover, there is a major shortcoming - most therapists never see the therapy being implemented. If you needed cardiac surgery, would you like a surgeon who'd never seen the procedure being done? this is stunning to me, but is totally accepted by our field."
To investigate new ways of training that are suitable for use on a large scale, Chris has been awarded a Wellcome Trust Strategic Award. He plans to create web-based forms of training that will provide trainees with the opportunity to view entire (simulated) treatments online, made up from amalgams of real past treatments but with any personal identifiers removed. Chris plans to test these new web-based approaches against more conventional training methods. To do this, however, he and his international group of collaborators need to develop new means of measuring therapist competence, something that he says will be both challenging and controversial.
This may all seem a long way from negotiating with the editor of a women's magazine to include information on an unknown illness, but Chris's passion today is just as strong. "People with eating disorders and other mental health problems wait for years before seeking help, if they ever do," he says, "but we have treatments that can work in just months. My job now is to develop cost-effective, large-scale ways of training therapists across the world how to implement them."
This feature also appears in issue 68 of ‘Wellcome News’, where it includes a visual timeline of Professor Fairburn’s career highlights.
Image: Chris Fairburn in the garden of his department in Oxford. Credit: Wellcome Images.
References
1. Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med 1979;9:429-48.
2. Fairburn CG, Cooper PJ. Self-induced vomiting and bulimia nervosa: an undetected problem. BMJ 1982; 284:1153-5.
3. Fairburn CG et al. Psychotherapy and bulimia nervosa: the longer-term effects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy. Arch Gen Psychiatry 1993;50:419-28.
4. Fairburn CG et al. Transdiagnostic cognitive behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Am J Psychiatry 2009;166:311-9.
