Prof. Janet Treasure

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Gulls Legacy
Prof. Janet Treasure j.treasure_at_iop.kcl.ac.uk
www.eatingresearch.com
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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

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• Sir William Gull
• Queens Doctor
• Define Illness
• Name Anorexia Nervosa vs Apepsia hysterica
• WW Gull (1868 Lancet ii 171-176)

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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))

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There was an old person from DeanWho dined on
one pea and a beanHe said more than that Would
make me quite fatThat bombylious old person of
DeanEdward Lear 1862
Poetic Licence
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What do clinicians observe now?

• Current diagnostic criteria of both AN and BN
  focus on weight and shape concerns as the central
  psychopathology

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What do clinicians say now?

• Is it a form of anorexia?
• Arguments that because hunger is present then it
  is not anorexia .

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What are the basics of appetite control?
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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
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What elements of appetite control may be involved
in AN
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Self regulation system Executive function-
rigidity and inhibition Personality traits OCPD
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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

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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)
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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).
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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.

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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.

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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

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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.

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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.

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Organ needed for recovery is damaged by symptoms
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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.

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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)
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. Nutritionally deprived brain at critical phase
of development
Lenroot and Giedd, 2006. Neurosci Biobehav
Reviews 30718-726
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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

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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 Accommodat
ing enabling
Pro Anorexia Striving mastery
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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
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2. I want to keep and maintain a specific weight
and in order to do that I know there are rulesI
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
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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
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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
wheetabixs 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 thats whats 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
thats 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
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OCPD traits Rigid Detailgtglobal
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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)
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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)
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Increase punishment sensitivity
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Impaired Reading Mind OthersOldershaw et al.
(2010.)
OK
Moderate effects which improve after recovery
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Increasing Isolation

• I was recently asked to sum up my experience of
  anorexia nervosa in one sentenceactually, I can
  do it in just one wordisolation (McKnight 2009)
• Its 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.Its
  the loneliness thats the real killer. The longer
  youre ill, the worse it is. Melissa

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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
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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.

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The visible aspect of AN The reaction of others
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KangarooOver protective,InfantilisingSuffocates
growth
Expressed Emotion Overprotection 43 ED vs
3 controls (Blair et al 1995) 60 ED (n165)
vs 3 controls (n93) (Kyriacou et al 2008)
Associated with carers anxiety (Kyriacou et al
2008)
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Carers inhibit Emotional Regulation
Giving reassurance
Supporting Avoidance
Righting reflex
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Expressed Emotion Criticism Hostility 47 ED
(n165) vs 15 Control (n93) (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)
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Expressed Emotion Criticism
Terrier Nagging. Giving advice, arguments.
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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)
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Understanding how people can change behaviours
(Prochaska DiClemente 1984)
Precontemplation daughter/son fails to see
problem
Contemplation
Importance Confidence
Maintenance
Action
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Balance of warmth direction
Too much sympathy micro-management
Too much Control direction
Just enough Subtle direction
Motivational Interviewing
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Improving Communication in family

• I think she quite likes the fact that ImIm
  understanding a bit more I find I talk to her
  differently. let her talk. I listen moreI
  thinkthan I used to um and dont sort of
  interpose my own ideas. I kinda of I nudgeI 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 youre 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 adrenalines gone and that was a
  revolution

• What does this mean? Dont be too emotional,
  dont be too rational. But by working through the
  family work I sorta understood what they were
  saying, and although you cant always do it, by
  having certain ground rules or principle that you
  go back to I just found that useful

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Carers reaction to ED behaviours
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Jellyfish Emotional Response transparent
Overtly distressed, depressed, anxious,
irritable angry
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Ostrich Avoiding seeing, thinking dealing
With problem
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An emotional vicious circle
Person with AN observes anxiety and anger in
others
Unhelpful behaviours AN mirrors anxiety and
anger
Worsen how they feel ? anxiety, anger in AN
Create or worsen problems AN unable to regulate
Due in part starvation damage
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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 eat I would prefer to die
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Families OCD Accommodating
I have to have different crockery for preparing
and cooking my meals. They are kept separately.

• 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.

• 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.

No one can go in the kitchen when she is there.
She will only drink from a new bottle of water.
The fridge is stocked with her water.
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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 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 .
She does not like it when I buy healthy foods for
me to eat.
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The ABC of Accommodating Bullied by Ed
Antecedants You are distressed by your childs
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
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Enabling ED. Avoidance modify routine

• Covering up for
• Plumbing toilet problems
• Stealing (food and money)
• Mess
• Social family

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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

• 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 its 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.

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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
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The interpersonal perpetuating cycle
Kyriacou et a 2008 Sepulveda et al 2009

• (Zabala et al, Eur Eat Rev 2009)

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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.

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New Treatments Translations and Technology
New treatments focused on learning safety with
food New technologies vodcasts, virtual reality

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What happens after Recovery in AN (Uher et al
2003)

• Recovered ControlgtAN
• Lateral prefrontal

Recovered vs Acute Control Apical prefrontal

Recovered AcutegtControls OFC
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Acknowledgements
Nina Jackson (RIED), NIHR, BRC