Prof. Janet Treasure j.treasure@iop.kcl.ac.uk eatingresearch

1. Gulls Legacy Prof. Janet Treasure j.treasure@iop.kcl.ac.uk www.eatingresearch.com

2. 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

3. Sir William Gull • Queen’s Doctor • Define Illness • Name Anorexia Nervosa vs Apepsia hysterica • WW Gull (1868 Lancet ii 171-176)

4. 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))

5. Poetic Licence There was an old person from DeanWho dined on one pea and a beanHe said “more than that Would make me quite fat”That bombylious old person of DeanEdward Lear 1862

6. What do clinicians observe now? • Current diagnostic criteria of both AN and BN focus on weight and shape concerns as the central psychopathology

7. What do clinicians say now? • Is it a form of anorexia? • Arguments that because hunger is present then it is not anorexia .

9. What are the basics of appetite control?

10. Self regulation system Embeds eating into social context & individual values Hedonic centre Reward from food (limbic system Homeostatic centre Regulates input and output of energy supply

11. What elements of appetite control may be involved in AN

12. Self regulation system Executive function- rigidity and inhibition Personality traits: OCPD

13. Cognitive strategies to avoid food • “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

14. A summary of functional activation studies Increased activation in cortical control areas Dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex, pre-supplementary motor cortex and anterior insular cortex 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)

15. 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).

16. 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.

17. 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.

18. 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

19. 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.

20. 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.

22. Organ needed for recovery is damaged by symptoms

23. 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.

24. Brain 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)

25. . Nutritionally deprived brain at critical phase of development Lenroot and Giedd, 2006. Neurosci Biobehav Reviews 30:718-726

26. 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

27. A cognitive-interpersonal maintenance model Schmidt, U, Treasure, J (2006). Thinking style Detail vs global Rigid Emotional style Anxious Poor emotional regulation Interpersonal Style Expressed Emotion Accommodating enabling Pro Anorexia Striving & mastery

28. Rigidity • .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, 2006 Roberts et al 2007

29. 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 1. What is the worry about food? 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 The therapist explores how detail of the AN rules impacts on eating

30. Detail vs. Global Imbalance • 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

31. 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………

32. The vicious circle of cognitive style AN mode: Starved Perseverative Fragmented Worsens cognitive Problems Trapped in AN habits Increased rigidity Inability to see big picture Mastery over laws Thermodynamics Success over detail rule- energy in and out OCPD traits Rigid Detail>global

33. Increased Sensitivity to Punishment ↑ 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)

34. Poor Emotional Regulation ↓ 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)

35. The vicious circle of isolation AN mode: Starved Poor effortful control Increase attention to punishment Poor emotional regulation Maladaptive strategies Avoidance, suppression, rumination Increase punishment sensitivity

36. Impaired Reading Mind OthersOldershaw et al. (2010.) Reading the Mind In EYES Reading the Mind in VOICE Reading the Mind in FILMS Reading Emotion in MUSIC OK Moderate effects which improve after recovery

37. 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

38. The vicious circle of isolation Person with AN has difficulty reading others Unhelpful behaviours Avoids social contact Worsen how they feel ↑avoidance, rumination, Suppression, ED behaviours Create or worsen problems No opportunity to develop adaptive strategies over Thoughts and emotions

39. 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.

40. The visible aspect of AN The reaction of others

41. 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)

42. Carers inhibit Emotional Regulation Giving reassurance Supporting Avoidance Righting reflex

43. Expressed Emotion: Criticism & Hostility 47% ED (n=165) vs 15% Control (n=93) (Kyriacou et al 2008) Rhinoceros Controlling. Giving advice, arguments. Charging into coercive circles Provokes AN defence Associated with difficult behaviours by patients (Kyriacou et al 2008)

44. Expressed Emotion: Criticism Terrier Nagging. Giving advice, arguments.

45. Working at the wrong stage of change Other will argue against change If you argue for change Coercive strategies consolidate food fears (Batsell et al 2002)

46. Understanding how people can change behaviours(Prochaska & DiClemente 1984) Precontemplation – daughter/son fails to see problem Contemplation Importance Confidence Maintenance Action –

47. Balance of warmth & direction Too much sympathy & micro-management Too much Control & direction Just enough Subtle direction Motivational Interviewing

48. Improving Communication in family “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 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 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”

49. Carers reaction to ED behaviours

50. Jellyfish Emotional Response transparent Overtly distressed, depressed, anxious, irritable & angry