prof. janet treasure [email protected] gulls legacy
TRANSCRIPT
Prof. Janet TreasureProf. Janet [email protected]@iop.kcl.ac.uk
www.eatingresearch.co
m
Gulls Legacy
Questions to be discussed
• What sort of illness is it?• Anorexia or not? What does it tell us about
appetite control• What is the underlying psychopathology. • Why is it difficult to treat?• What are the factors that cause the illness to
persist? • The role of maintaining factors• New treatments
Sir William Gull•Queen’s Doctor•Define Illness •Name Anorexia Nervosa vs Apepsia hysterica•WW Gull (1868 Lancet ii 171-176)
What did clinicians observe then?
• a multitude of Cares and passions . . . From which time her appetite began to abate (Richard Morton (1694))
• “young girls who at the period of puberty become subject to inappetancy carried to the utmost limits . . . these patients arrive at the delirious conviction that they cannot or ought not to eat ... All attempts made to constrain them to adopt a sufficient regimen are opposed with infinite strategies and unconquerable resistance.” (Marcé, (1860))
• . “ . . . gradually she reduces her food further and further, and furnishes pretexts for so doing . . . the abstinence tends to increase the aptitude for movement.” ( Lasegue (1873))
There was an old person from DeanWho dined on one pea and a bean
He said “more than that Would make me quite fat”
That bombylious old person of Dean
Edward Lear 1862
Poetic Licence
What do clinicians observe now?
• Current diagnostic criteria of both AN and BN focus on weight and shape concerns as the central psychopathology
What do clinicians say now?
• Is it a form of anorexia?
• Arguments that because hunger is present then it is not anorexia .
What are the basics of appetite control?
Self regulation systemSelf regulation systemEmbeds eating into social context & Embeds eating into social context & individual valuesindividual values
Hedonic centreReward from food (limbic system
Homeostatic centreHomeostatic centreRegulates input and output of Regulates input and output of energy supplyenergy supply
What elements of appetite control may be involved in AN
Self regulation systemSelf regulation systemExecutive function- rigidity Executive function- rigidity
and inhibition and inhibition Personality traits: OCPDPersonality traits: OCPD
•“I cannot cook my food in an oven in which sausages have been cooked as their calories may contaminate my food; •I need to carry, store and prepare my food separately from the food of other people in order to prevent calorie contagion; •I will seal my room with masking tape to prevent cooking smells from entering” •Eye detail, magical thinking.
“; “if I see a piece of chicken that looks fried, then I will not eat it; if I have to eat more than my allotted allowance, then I will run for 50 minutes”. Implementation interventions
•Ritualised counting applied to cutting, biting and chewing of food is common. •Distraction
Cognitive strategies to avoid food
A summary of functional activation studies
Reduced activation in areas involved in the regulation of affect, motivation, reward & core basal function (ie core-SELF the subcortical, cortical midline structures Panksepp & Northoff 2008)
Increased activation in cortical control areasDorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex, pre-supplementary motor cortex and anterior insular cortex
What is the form of psychopathology
Fear about food or cognitive representations of food in the form of weight and shape. Triggers- traumatic experiences or a process of cognitive conditioning though verbal information (threatening information about food, weight and health) and/or vicarious learning (observing close others with food fears).
Why is treatment difficult?
• Is there a focus on food? • Poor nutrition impairs brain function.• Iatrogenic factor – coercive feeding may
consolidate fear memories. • Cognitive conditioning is difficult to reverse
and involves new learning which counteracts emotional memories (Batsell et al 2002, Quirk et al 2008,Bentz 2010) .
• Extinction learning is context dependent.
Why is treatment difficult?
• Is there a focus on food? • Poor nutrition impairs brain function.• Iatrogenic factor – coercive feeding may
consolidate fear memories. • Cognitive conditioning is difficult to reverse
and involves new learning which counteracts emotional memories (Batsell et al 2002, Quirk et al 2008,Bentz 2010) .
• Extinction learning is context dependent.
The Maudsley Method
• F.E.A.S.T., Families Empowered and Supporting Treatment for Eating Disorders) www.feast-ed.org. “Some in the eating disorders community are shocked and even offended by the emphasis on nutrition and behaviours instead of insight and motivation
• “Put simply, the Maudsley Approach sees the parents of the ill person as the best ally for recovery
The Essence of the Maudsley Method (Dare, Eisler, Russell)
• The three phases of treatment are* Parents take control of decisions of what, when, and how much the ill patient eats.
• * After weight restoration is nearly achieved, control is carefully given back to the patient.* Finally, the therapist and family work to restore normal and age-appropriate lifestyle and relations between family members.
Why is treatment difficult?
• Is there a focus on food? • Poor nutrition impairs brain function.• Iatrogenic factor – coercive feeding may
consolidate fear memories. • Cognitive conditioning is difficult to reverse
and involves new learning which counteracts emotional memories (Batsell et al 2002, Quirk et al 2008,Bentz 2010) .
• Extinction learning is context dependent.
Organ needed for recovery is damaged by symptoms
The Brain Needs 500 Kcal /day
• for running costs
• To facilitate plasticity and new learning.
• To develop new connections.
• To strengthen synaptic links.
• To develop long myelinated connections.
Brain shrinkage in anorexia nervosaBrain shrinkage in anorexia nervosa
↓ brain size especially grey matter (Castro-Fornieles et al, 2008 ) )↓ hippocampus (Connan et al 2006) ↓ Dorsal ACC (Muhlau et al 2007; McCormick et al 2008)
Lenroot and Giedd, 2006. Neurosci Biobehav Reviews 30:718-726
. Nutritionally deprived brain at critical phase of development
Self regulation and sophisticated aspects of brain function most sensitive to starvation and stress
Less adaptive more primitive coping:•Avoidance •Suppression•Rule bound •Reduced theory mind•Poor emotional regulation
Thinking styleDetail vs global
Rigid
Emotional style
AnxiousPoor emotional
regulation
Interpersonal Style
Expressed Emotion
Accommodatingenabling
Pro Anorexia
Striving & mastery
A cognitive-interpersonal maintenance modelSchmidt, U, Treasure, J (2006).
•.Difficulty in changing cognitive set.•Once a rule is learned it is difficult to shift. •Mastery at adhering to laws of thermodynamics.•Linked to childhood OCPD features•Worsened by starvation
Tchanturia et al 2005, 2006Roberts et al 2007
Rigidity
2. I want to keep and maintain a specific weight and in order to do that I know there are rules…I have to control my intake
3. It’ s as if you have a calculator in your head
totting up the intake and output. You are scientific about these
laws of thermodynamics what things go in your rule
system.
•4. Well there is the amount of exercise I do but that gets addictive more and more.•Walking at right angles rather than curves• The amount I sleep, I try to keep it short as you use fewer calories.•I would restrict the amount of tooth paste because fear of extra calories.•Avoid smelling food, if you can smell it there must be something there in your body you could absorb •If I cut my hair I would weigh that for my calculations•If my watch broke I would have to put something heavy on my wrist to compensate•If I lost a nose stud- I would have to have a replacement
•
1. What is the worry about food?
The therapist explores how detail
of the AN rules impacts on
eating
•Inability to see bigger picture i.e. Not seeing the wood for the trees.
• Heightened perceptual awareness.
•Analytical, detailed focus.
•Difficulty extracting gist.
•Global is impaired with weigh loss
Lopez et al 2008a, 2008b, 2008c, 2008d
Detail vs. Global Imbalance
Does your attention to detail have a negative side? For example are you hyper-sensitive to slight errors or mistakes eg music off key,
flavours discordant, details off in some way?
So everyone has their own cereal, everyone likes different cereals, so we have so many, and um we all like different cereals, and at the moment I like wheetabix and because everyone has two wheetabix’s and they are even because there are 24 wheetabix in the thing, because it is supposed to be even, because everyone is supposed to have two and that’s what’s normal, which I am trying to be normal.
And, things that annoy me, it got down to the end one day and there was one left, I took two and I was like ‘why is there one left?’ because I had two, because I am the only one that eats this. And then I said to mum, obviously someone else has had some wheetabix and I was like but that means they have only had one and
that’s not normal and so she was like maybe they had one wheetabix and some of their cereal… She was trying to make me relax…. dad he sort of brought it up a
few days later, he goes, well I am worried that you start counting things………
The vicious circle of cognitive style
AN mode:Starved
Perseverative
Fragmented
Increased rigidity
Inability to see big picture
Mastery over laws
ThermodynamicsSuccess over
detail rule- energy in and out
Worsens cognitive Problems
Trapped in AN habits
OCPD traitsRigidDetail>global
↑ Avoidance system. Anxiety, Harm avoidance Behavioural
inhibition system (BIS) (Dawe & Loxton, 2004; Loxton & Dawe, 2001, 2006, 2007, Claes et al., 2006; Harrison et al 2010)
Increased Sensitivity to Punishment
↓ emotional regulation (Systematic review-Aldao et al 2010 Nock et al 2008; Gilboa-Schechtman 2006, Harrison et al 2008, Holliday et al 2006, )
↑Maladaptive Regulation: Avoidance, Rumination, Suppression.
Improves with recovery (Harrison et al 2010)
Poor Emotional Regulation
The vicious circle of isolation
AN mode:Starved
Poor effortful control
Poor emotional regulation
Maladaptive strategies
Avoidance, suppression, rumination
Increase attention to punishment
Increase Increase punishment punishment sensitivity sensitivity
Impaired Reading Mind OthersOldershaw et al. (2010.)
OK
Moderate effects which improve after recovery
Increasing Isolation
• “I was recently asked to sum up my experience of anorexia nervosa in one sentence—actually, I can do it in just one word—isolation” (McKnight 2009)
• It’s the loneliness that will get you. Not the hunger, or the worrying, or the rituals, or the paranoia. Not even the fear of getting fat.It’s the loneliness that’s the real killer. The longer you’re ill, the worse it is.” Melissa
Unhelpful behavioursAvoids social contact
Worsen how they feel↑avoidance, rumination,
Suppression, ED behaviours
Create or worsen problemsNo opportunity to develop adaptive strategies over Thoughts and emotions
Person with AN has difficulty reading
others
The vicious circle of isolation
Why is treatment difficult?
• Is there a focus on food? • Poor nutrition impairs brain function.• Iatrogenic factor – coercive feeding
may consolidate fear memories. • Cognitive conditioning is difficult to reverse
and involves new learning which counteracts emotional memories (Batsell et al 2002, Quirk et al 2008,Bentz 2010) .
• Extinction learning is context dependent.
The visible aspect of ANThe reaction of others
KangarooOver protective,InfantilisingSuffocates growth
Expressed Emotion: Overprotection
43% ED vs 3% controls (Blair et al 1995)60% ED (n=165) vs 3% controls (n=93) (Kyriacou et al 2008)
Associated with carers anxiety(Kyriacou et al 2008)
Carers inhibit Emotional Regulation
Giving reassurance
Supporting Avoidance
Righting reflex
Rhinoceros Controlling.Giving advice, arguments. Charging into coercive circles Provokes AN defence
Expressed Emotion: Criticism & Hostility
47% ED (n=165) vs 15% Control (n=93) (Kyriacou et al 2008)
Associated with difficult behaviours by patients(Kyriacou et al 2008)
Terrier
Nagging.Giving advice, arguments.
Expressed Emotion: Criticism
Working at the wrong stage of change
If you argue for change
Other will argue
against change
Coercive strategies
consolidate food fears(Batsell et al
2002)
Understanding how people can change
behaviours (Prochaska & DiClemente 1984)
Precontemplation – daughter/son fails to see problem Contemplation
Action –
Maintenance
ImportanceImportanceConfidenceConfidence
Balance of warmth & direction
Too much sympathy & micro-management
Too much Control &direction
Just enoughSubtle direction
Motivational Interviewing
•I think she quite likes the fact that I’m…I’m understanding a bit more I find I talk to her differently. let her talk. I listen more…I think…than I used to …um and don’t sort of interpose my own ideas. I kinda of …I nudge…I do the nudging bit
“I had to keep calmer and husband had to stop being so logical, because he has a logical mind and anorexia has nothing to do with logic”
•“ I mean, you can give your sibling or your daughter the warning that you’re not going to solve it and that you are going to walk away to calm down and that you will talk about it in an hour when the adrenaline’s gone and that was a revolution”
•“What does this mean? Don’t be too emotional, don’t be too rational. But by working through the family work I sorta understood what they were saying, and although you can’t always do it, by having certain ground rules or principle that you go back to I just found that useful”
Improving Communication in family
Carers reaction to ED behaviours
Jellyfish
Emotional Response transparent
Overtly distressed, depressed, anxious,
irritable & angry
Ostrich Avoiding seeing,
thinking & dealing With problem
Unhelpful behavioursAN mirrors
anxiety and anger
Worsen how they feel↑ anxiety, anger in AN
Create or worsen problemsAN unable to regulate
Due in part starvation damage
Person with AN observes anxiety and anger in others
An emotional vicious circle
Bullied by ED voice
Families accept:•Food & meal rituals.•Safety behaviours (exercise etc) .•OCD behaviours with reassurance. •Calibration and competition with other family members.
I will not eatI would prefer to die
Edi sometimes comes down in the morning and says she dreamed about eating a chocolate mousse. She will then keep asking throughout the day- I did not eat a mousse did I? She goes on and on.
I have to have different crockery for preparing and cooking my meals. They are kept separately.
Edi will ask me a hundred times a day whether she ate too much at her last meal.
“She stands over me when I am cooking to ask whether I have put oil in the food and checks throughout the meal. I am the only one who can cook for her.
Families: OCD Accommodating
She will only drink from a new bottle of water. The fridge is stocked with her water.
No one can go in the kitchen when she is there.
She often buys cream cakes etc that she makes me eat even when I do not want them.
Edi has to see me eat every night before she will eat anything and judges what she eats by the type of food and amount I have eaten that night.
Every time I go up/down any stairs she then has to go up/down them
twice as many .
She does not like it when I buy healthy foods for me to eat.
Families: calibration and competition
BehavioursAppeasing
Organise family life Around invalid
Martyr self or family
Positive attention & respect for Edi keeps it going
ConsequencesEd feels special
Ed dominates the house & routines
AntecedantsYou are distressed by your
child’s pain Anxious to not upset her more
Protecting the invalid
The ABC of Accommodating: Bullied by Ed
Enabling ED. Avoidance & modify routine
Covering up for: •Plumbing toilet problems•Stealing (food and money)•Mess•Social & family
•Her car was out of action, so I drove her to the supermarket at 11.0 pm. I did not want her to go locally as it is expensive and people know us.
“If I go down to the kitchen and find that she has finished off all the cereal I have to go off and drive to the supermarket so that the others can have breakfast
•I have to clean up the toilets; it’s not nice for the rest of the family.•“I know that money has gone
from my purse so I take more care to hide it but my husband does not take as much care- so I am sure she is taking his money.
Family enabling bulimic behaviours
BehavioursMop up after Ed
to make things betterIgnore turn blind eye to
Ed behaviours
Later Consequences Ed behaviour continues
Consequences Protected from learning
about consequences of actions
Antecedants The consequences of Ed
Behaviours are impossibleFor you, or family or Ed to tolerate
The ABC of Enabling Ed behaviours
The interpersonal perpetuating cycle
Distressing EDSymptoms
And Behaviours
Carers concernedAnd anxious at ED
symptoms
Carers respond:Expressed emotion
AccommodateEnable
•(Zabala et al, Eur Eat Rev 2009)
Kyriacou et a 2008Sepulveda et al 2009
Why is treatment difficult?
• Is there a focus on food? • Poor nutrition impairs brain function.• Iatrogenic factor – coercive feeding may
consolidate fear memories. • Cognitive conditioning is difficult to reverse
and involves new learning which counteracts emotional memories (Batsell et al 2002, Quirk et al 2008,Bentz 2010) .
• Extinction learning is context dependent.
New Treatments Translations and Technology
New treatments focused on learning safety with foodNew technologies – vodcasts, virtual reality
What happens after Recovery in AN (Uher et al 2003)
Recovered vs Acute Recovered vs Acute & Control& ControlApical prefrontalApical prefrontal
Recovered =Control>ANRecovered =Control>ANLateral prefrontalLateral prefrontal
Recovered =Acute>ControlsRecovered =Acute>ControlsOFCOFC
Acknowledgements
Nina Jackson (RIED), NIHR, BRC