Gulls Legacy
Prof. Janet Treasure
j.treasure@iop.kcl.ac.uk
www.eatingresearch.com
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))
Poetic Licence
There was an old person from Dean
Who 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
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 system
Embeds eating into social context &
individual values
Hedonic centre
Reward from food
(limbic system
Homeostatic centre
Regulates input and output of
energy supply
What elements of appetite control
may be involved in AN
Self regulation system
Executive function- rigidity
and inhibition
Personality traits: OCPD
Cognitive strategies to avoid food
“; “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
•“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.
A summary of functional activation studies
Increased activation in cortical
control areas
Dorsolateral prefrontal cortex (DLPFC),
anterior cingulate cortex, presupplementary motor cortex and anterior
insular cortex
Reduced activation in areas
involved in the regulation of
affect, motivation, reward &
core basal function (ie coreSELF the subcortical, cortical
midline structures Panksepp
& Northoff 2008)
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.feasted.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 nervosa
↓ brain size especially
grey matter (CastroFornieles et al, 2008 )
↓ hippocampus (Connan
et al 2006)
↓ Dorsal ACC (Muhlau et
al 2007; McCormick et al
2008)
. Nutritionally
deprived brain at
critical phase of
development
Lenroot and Giedd, 2006. Neurosci Biobehav Reviews 30:718-726
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
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
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
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.
The therapist
explores how detail
of the AN
rules impacts on
eating
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
•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
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
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
OCPD traits
Rigid
Detail>global
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
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)
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)
The vicious circle of isolation
Increase
punishment
sensitivity
AN mode:
Starved
Poor effortful
control
Increase
attention to
punishment
Poor emotional
regulation
Maladaptive
strategies
Avoidance,
suppression,
rumination
Impaired Reading Mind Others
Oldershaw et al. (2010.)
Reading the Mind
In
EYES
Reading the Mind
in
VOICE
Reading the Mind
in
FILMS
Reading Emotion
in
MUSIC
Moderate effects which improve after recovery
OK
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
The vicious circle of isolation
Person with AN has
difficulty reading
others
Worsen how they feel
↑avoidance, rumination,
Suppression, ED behaviours
Unhelpful behaviours
Create or worsen problems
No opportunity to develop
adaptive strategies over
Thoughts and emotions
Avoids social contact
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 AN
The reaction of others
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)
Kangaroo
Over protective,
Infantilising
Suffocates growth
Associated with carers anxiety
(Kyriacou et al 2008)
Carers inhibit Emotional Regulation
Giving reassurance
Supporting Avoidance
Righting reflex
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)
Expressed Emotion: Criticism
Terrier
Nagging.
Giving advice,
arguments.
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
Importance
Confidence
Maintenance
Action –
Contemplation
Balance of warmth & direction
Too much
Control &
direction
Just enough
Subtle direction
Motivational
Interviewing
Too much
sympathy &
micromanagement
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”
•“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”
•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”
Carers reaction to ED behaviours
Jellyfish
Emotional Response
transparent
Overtly distressed,
depressed, anxious,
irritable & angry
Ostrich
Avoiding seeing,
thinking & dealing
With problem
An emotional vicious circle
Person with AN observes
anxiety and anger in others
Worsen how they feel
Unhelpful behaviours
↑ anxiety, anger in AN
Create or worsen problems
AN unable to regulate
Due in part starvation damage
AN mirrors
anxiety and anger
Bullied by ED voice
Families accept:
I will not eat
I would
prefer to die
•Food & meal rituals.
•Safety behaviours (exercise
etc) .
•OCD behaviours with
reassurance.
•Calibration and competition
with other family members.
Families: OCD Accommodating
I have to have different
crockery for preparing and
cooking my meals. They
are kept separately.
“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.
She will only drink from a
new bottle of water. The
fridge is stocked with her
water.
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.
Edi will ask me a hundred times a
day whether she ate too much at her
last meal.
No one can go in the kitchen when
she is there.
Families: calibration and competition
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.
She does not like it when I buy
healthy foods for me to eat.
She often buys cream cakes etc that she
makes me eat even when I do not want
them.
Every time I go up/down any stairs
she then has to go up/down them
twice as many .
The ABC of Accommodating: Bullied by Ed
Antecedants
You are distressed by your
child’s pain
Anxious to not upset her more
Protecting the invalid
Behaviours
Appeasing
Organise family life
Around invalid
Martyr self or family
Positive attention &
respect for Edi
keeps it going
Consequences
Ed feels special
Ed dominates the house
& routines
Enabling ED. Avoidance & modify
routine
Covering up for:
•Plumbing toilet problems
•Stealing (food and money)
•Mess
•Social & family
Family enabling bulimic behaviours
“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 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.
•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.
•I have to clean up the toilets; it’s not
nice for the rest of the family.
The ABC of Enabling Ed behaviours
Antecedants
The consequences of Ed
Behaviours are impossible
For you, or family or Ed to tolerate
Behaviours
Mop up after Ed
to make things better
Ignore turn blind eye to
Ed behaviours
Later Consequences
Ed behaviour continues
Consequences
Protected from learning
about consequences
of actions
The interpersonal perpetuating cycle
Distressing ED
Symptoms
And
Behaviours
Carers respond:
Expressed emotion
Accommodate
Enable
Kyriacou et a 2008
Sepulveda et al 2009
Carers concerned
And anxious at ED
symptoms
•(Zabala et al, Eur Eat Rev 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 food
New technologies – vodcasts, virtual
reality
What happens after Recovery in
AN (Uher et al 2003)
Recovered =Control>AN
Lateral prefrontal
Recovered vs Acute
& Control
Apical prefrontal
Recovered =Acute>Controls
OFC
Acknowledgements
Nina Jackson (RIED), NIHR, BRC