[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health or ACAMH for short. And this is ACAMH Learn. Well, first of all, I just would like to say that it's a huge honour to host Professor Janet Treasure. Professor Janet Treasure is professor of adult psychiatry at King's College London. And she dedicated her academic research career to researching eating disorders. And she has done groundbreaking research in helping us all to better understand etiological models of eating disorders and how we can best shape treatments and interventions to help patients living with this sort of disorders. And today, we are going to talk to her about her latest research findings. It's a huge pleasure to have you here, Professor. Really, thank you for giving us a bit of your time. Thank you very much for inviting me. It's wonderful to be here. So we would like to start by asking. In the aftermath of the COVID pandemic, services all over England reported a significant increase in the number of referrals for eating disorders. And there was a significant spike in the number of urgent referrals as well. And we also observed this trend in a few other Western countries, such as the US. And you and your team, do you have any hypothesis of why this might have happened, this rise in the incidence of eating disorder cases? Well, you're right, it's really interesting to know to have this big change that suggests that there might be risk factors that are relevant to eating disorders. And perhaps the most important one is isolation because a wonderful lived experience story, in fact, by a doctor who had had anorexia when she was younger said isolation was the core aspect of the eating disorder. And the loneliness of it kept it going and shut people away. But it wasn't just that. There was a general threat, which increased anxiety. And we think that general stress is important. Also, there are issues related to eating and weight gain. They were saying COVID-15, that people perhaps gained 15 pounds. And then there was worries about on ITU if you're more overweight, things were more difficult. So there were lots of things that are particularly relevant to eating disorder. And you're right. It wasn't just two countries. It was worldwide showing this big spike. Could you speak a bit more about your research? You and your group have published substantial research regarding genome-wide association studies of anorexia nervosa, including that the groundbreaking GWAS study that was published in Nature Genetics back in 2019. And considering your findings, could you tell us a bit more about the role of metabolic dysregulation in anorexia nervosa? Yes. Well, getting into genetics was something I did very early on with twin studies. And I remember that that was very novel. But why I was driven to look at the genes was people with lived experience, carers were really interested in this. And so it's really wonderful that we've been able to do these large studies in which we've been able to get some genes that seem to be linked. But we still need more. You need about tenfold more than we've got already to fully pinpoint the genes. And so we haven't got an exact, this gene does that. And probably, that won't be with all of psychiatry. It's a mixture of genes. But the very interesting thing is we found that there are genes that are similar to psychiatric disorders. And the most strong one is for obsessive compulsive disorder. And that's not surprising because we do see obsessive compulsive traits before the onset of anorexia nervosa. So that's been well recognised that a lot of personality traits like those are shared. But the surprising thing was that there were links with metabolic factors. And although, of course, weight and food and eating is very metabolic, I think people tended to have a black and white, it's either all psychological or it's all metabolic. But this showed that there were some features that were related to weight, insulin, and other metabolic factors, so showing that there's these two aspects, metabolic and psychiatric, a sort of very much a psychosomatic illness. So that's very, very interesting. And since you mentioned the twin studies you did in the beginning of your work, and also still on the topic of genetics, do you think that the neuropsychological impairments that sometimes are described in anorexia, such as set shifting abnormalities that you found in the study you did with not twins but with siblings, could be considered an eating disorder endophenotype? Yes. Well, that's what we're really interested to look at, and a lot of people have been, to see, what are the traits that make people vulnerable? So then they are called endophenotypes. And we did find that some of these neuropsychological aspects were very much endophenotypes. So as you said, set shifting and perfectionism does seem to be there. But also, we're finding out more and more that these metabolic things are endophenotypes too. So the insulin sensitivity is an endophenotype, for example. So this is really interesting. It accentuates what the GWAS studies show. Still on the topic of endophenotypes and neuropsychological impairments, could you discuss a bit more about the attentional bias to food we sometimes see in eating disorders and how that influences illness trajectories? For example, in clinical practise, it's very common that we sometimes see patients shifting from very restrictive behaviours to later on presenting severe bingeing. And it would be great if you could [INAUDIBLE]. Yes. So that is an interesting thing to examine. And because we've been using virtual reality, we can watch what people are doing in the virtual reality. And what we do find is that the eye gaze to food in anorexia does seem to be a way not so much to food. And of course, they don't touch food very much the more severe the anorexia is-- virtually touching. Also, could you talk a bit more about your research with virtual reality and eating disorders? What do you think is the role of virtual reality in eating disorders research looking for the future? Well, it's a really useful method because it's-- exposure treatment and meal support is one of the keystones of treatment. But that can be quite hard to set up. You might have to keep bringing different foods. And of course, you can't expose yourself to it and expose to the eating and imagining the effects as easily without virtual reality, where virtual reality can really bring that to life. So some virtual reality has people changing shape more quicker than it would happen in real life. So you can do all sorts of very interesting experiments like that. And we've been doing different experiments with looking to see what sort of support in a kitchen is helpful and finding that having a pet with you, a pink elephant, in fact-- and this is something that people with lived experience thought might be helpful. And indeed, it was. It reduced the anxiety level. So having somebody who keeps you company and, fact, doesn't talk, but just is there with you did seem to help with managing the extreme anxiety and difficulty eating. Now, focusing a little bit on your studies with neuroimaging, we know that eating disorders disproportionately affect adolescents, particularly females. Could you discuss a little about the impact of eating disorders, especially anorexia, which has been more the focus of your work, on the adolescent brain based on your work with ED and [INAUDIBLE]? Well, we've been very lucky because there's been some great work going on internationally. As we've talked with genetic studies, you need large samples. Similarly, with brain scans, you need large samples. And the ENIGMA Consortium has made sure that there are lots of people involved in the scanning. And that's been done very nicely in a German lab, Stefan Ehrlich, looking at the adolescent brain and finding really interesting findings and concerning findings in that the brain substance is smaller when people have lost weight. So about 6% of the brain matter is lost. On the other hand, as soon as people start gaining weight, it returns. But that level is in dementia. You get 12% loss. In anorexia nervosa, it's 6%. And in schizophrenia or depression, it's 2%. So it's quite a substantial aspect. And also, people have been looking at the neurons and the connections and what happens. And it does seem to be that it's sort of connecting nodes that are particularly impacted. And you can imagine that they've got long distances to connect one bit of the brain with the other. And of course, that might fit with this sort of rigidity and difficulty set shifting that we do see as a symptom. And of course, we do see a wide array of neuropsychiatric problems. So we talked about some maybe traits that are there early on in life. But also, what we know is that these get exaggerated with the starvation that comes with anorexia nervosa. So the organ that needs to help you get out of the illness is very damaged by the illness. And we think that that's why people get stuck for so long. And it, of course, happens at such a critical time of brain development because the adolescent brain is forming new synapses being pruned and growing and developing and forming a new identity. And of course, that is put on hold. Yes. And you mentioned about the reduction in the brain matter. And we also know there are other impairment impairments in the anorexia nervosa brain, such as a reduction in hippocampal volume. And I was wondering if, in your opinion, considering patients that have treatment-resistant anorexia, do you believe that those impairments, they can be reverted with treatment? Or sometimes we see those impairments in hippocampal volume and other sorts of impairments, do they persist sometimes as chronic alterations in brain function? Well, what we really know is in the adolescents, because they often have an early phase of illness-- and we know we get better outcomes in adolescents. So they recover quicker and better. It does recover. We haven't got the data on brain scans in those with a more severe enduring. But on the other hand, clinically, we know that once people do recover, they can really get involved in life and have amazing careers and are very productive people and can have a really normal life. So we do think most things can be restored. There are some areas of development that-- if it occurs early, perhaps growth is stunted a little bit. But most things, once all the hormones and normal developmental things are put right, we can get full recovery. So that's great to know. And also, speaking a bit about treatment now, considering all those exciting new research that we are seeing that your group is conducting on virtual reality and considering all the complexity of eating disorders, in your expert opinion, what would be the best intervention strategy to adopt thinking about preventing poor outcomes of eating disorders in youth? Well, the most important is early intervention. And that's not easy because eating symptoms are hard. Eating disorders symptoms, especially anorexia nervosa, are hard to recognise. The individual themselves doesn't feel unwell. A classical symptom was, I do not suffer. Therefore, I'm well. That was somebody 200 years ago was recorded saying that. So that's one problem. But even for family members, the signs may be subtle and hidden. So it's hard to recognise. Getting to a GP can be difficult because of this. So all of this delays the time before people get treatment. And often, the symptoms are puzzling for GPs. And what we find when we look back is that there may have been treated for gut sort of problems, as if it's a problem in that system, rather than recognising that it's an eating disorder. So we know that often it's about two years before people come to treatment after the first signs. And often, family members are the key ones to ensure that people come for treatment. But that's a hard job for them because of this not recognising that there's a problem, because anorexia can seem quite a solution to people when they develop it. And still on the topic of treatment, as you said, treating eating disorders is very complex as they are multifactorial. And recently, there has been some new treatment developments, such as the use of ketamine in treating eating disorders. And could you talk a little bit more about those innovative treatment approaches that you and your group have been using, such as the virtual reality use and also ketamine? And yeah, what do you think are the perspectives for these new treatment approaches? Well, the mainstay of treatment and for early intervention has been family treatment, which when I first started in this area about 40 years ago, the research studies were going on. And we know that with people with the short illness, family-based treatments work. However, what we don't know so much is what about those where we aren't able to get in early and it's gone on for a longer time. And so that's more of a puzzle. We do know some of the features that make it more difficult. And that's if people have got obsessive compulsive traits as well, if they've got depression as well, and if they've got autism spectrum traits additionally. So all of those combined to make it harder. So that's made us look at other treatments that go on in these other disorders. And of course, for depression, there has been recognition that we need to help people who don't respond to the traditional antidepressants. And that's where ketamine and psilocybin, which is being tried at the moment-- and so that has led us to think that we should try these new-- well, they're not so new. They've been around for quite a while. But it's repurposing them for anorexia nervosa and recognising that depression and rigidity, which is something that can be specifically targeted by these sort of medications, can be helpful. And digging a little bit into the puzzle you mentioned because-- yes, your work with family therapy was groundbreaking. And the Maudsley family therapy randomised clinical trial had some very interesting findings, such as the one you mentioned that if the illness had persisted for longer than three years, the five-year recovery rate was very low. And I know this is still a puzzle. And it is still an area of research. But in your opinion, considering all the research that has been done ever since the Maudsley trials were published, which treatment strategy do you think is more suitable for those young people that have treatment-resistant anorexia nervosa? Well, when it's treatment resistant, we don't fully know. I do think no matter what, involving carers can be incredibly important. And they work extremely hard and contribute a huge amount to the management of people with eating disorder. So that's in addition to everything else. But I think these newer treatments are really very interesting. And probably, we're still very early on. The trials are only just starting. And so we don't know. But there's also interesting results from my colleague, [INAUDIBLE], looking at TMS, which is stimulating the brain in certain areas that has been found, again, to reduce depression. And then later on, it seems to allow people to change their eating patterns and gain weight too. So it's really exciting times. And also, in Germany, they're interested in the hormone leptin and seeing some patients having good results with that. But again, all of these things are right at the cusp and need to be studied in more detail. There has been a growth in genome wide association studies in all areas of psychiatry. And the findings on eating disorders, as we've discussed, are particularly interesting. And do you think that in the future, those findings regarding the [INAUDIBLE] that are implied in metabolic dysfunction for eating disorders could have an implication for treatment? What do you think are the future implications for treatment regarding those new genetic discoveries that are being done now? Yes, it's a bit difficult to know because there seem to be more many genes with small effects. But I guess the thing I was telling you about the leptin sort of fits with this metabolic aspect. And so that is very much a direct link. We really don't know. But also, what we do know is that we talked about the sad case of those where it's gone on for five years and either hasn't had any treatment because of difficulties getting into treatment or treatment that has not been effective. And what we do know, that all these maintaining factors-- so the brain suffering and the hippocampus shrinking and the new learning. And the ability to even conceptualise a recovery identity is just so impaired because we know that the creative aspects of the brain that is needed for that and the memory just isn't there in top function. And as every year goes by, the brain sort of is stuck or even deteriorates a little bit each year. So I think that that's our main trouble, is that the longer it goes on, rather like a snowball going down a hill, I think-- somebody with lived experience, Elise Pacquette who's done so many wonderful drawings about it-- but she talked about this factor. It's just like a snowball. And you get more rituals, more habits, and more stuck into the eating disorder as it goes on. And I think that's a really wonderful image-- well, terrifying image. But that is what happens. So unsticking it can be difficult. But it can be done. And as we've said, people can flourish and have post-traumatic growth once they recover from an eating disorder. And I think that's one of the things I've been most pleased about in my career, is that I've been able to work with people with lived experience. And that's, of course, becoming very fashionable, as it should be, in psychiatry. And we've been extremely lucky. As I said, carers have sponsored research when there was no research money elsewhere and told us what to look at. And they were right that those things they told us were the ones that proved benefits, looking at the brain and the genes. And similarly, people with lived experience either help write books for others and use a lot of their creative talents to help. And of course, so many become trained as doctors, psychologists, or whatever way that might add to their being able to help in some way in the future. That's really inspiring to hear. Because as you said, currently, public and patient involvement is very fashionable. It's even a requirement for applying for a grant in NIHR. But I wonder, 30 years ago, it wasn't. And you really pioneered that. And it's really nice to see how people with lived experience were right and how you've involved them in your research. I think that's our-- I call it our superpower because they certainly do have us-- Walter Kaye says something rather nice. Well, it's a sort of-- he says that the trouble with eating disorders, they have traits which are aligned to the bad, to the anorexia. But once those traits are aligned to the good, they're wonderful. So traits of being conscientious rather perfectionistic can, in the right environment, be absolutely wonderful traits. And similarly, being aware of risk and a bit more sensitive to danger, that's a really useful trait when you're developing new things to see those problems. So everything that can be negative can be switched to the positive. So I think that that's a really nice little motto I rather like. That's a really lovely way to end the interview-- switch the negatives to the positives. Thank you so much for that. All right, bye-bye then. Thank you. Thank you so much. [MUSIC PLAYING]