Transcript The Psychopathology of the “dieting disorders”

The Psychopathology of the
Eating Disorders
Chris Thornton
Chris Thornton & Associates
Wahroonga, Ashfield, Eastwood,
Greenwich.
Ph: 0413154679
email:[email protected]
Anorexia Nervosa: Overview

90% female
 Mainly effects adolescents and young
women. Age of onsets 13-14 and 17-18.

Anorexia Nervosa is a chronic illness.
 Average length of illness is 5 – 7 years.
2
Anorexia Nervosa: The most
serious disorder of
adolescence.

Point prevalence of AN in females 15-19:
0.5%.
– Lifetime risk of schizophrenia is 1%.

Third most common chronic illness.

10 times more common than IDDM.
3
Anorexia Nervosa: Mortality

20% after 20 years.
 5 times higher than general population
matched for age.
 Death from “natural cause” 4x higher
 Death from unnatural causes 11X higher
 Death from suicide is 32 x higher than
expected (20 x in major depression).
4
Diagnosis of Anorexia
Nervosa
A.
Refusal to maintain body weight at or
above a minimally normal weight for age
and height (e.g. weight loss leading to
maintenance of body weight less than 85%
of that expected; or failure to make
expected weight gain during periods of
growth, leading to body weight less than
85% of that expected).
5
Diagnosis of Anorexia
Nervosa.
6
Calculating Body Mass Index

Weight (kgs)/ Height x Height (m)

Adult Measure
17.5
20 – 25
25+
30+
Anorexia Nervosa
Normal Weight Range
Overweight
Obesity
Asian Norms Available.
Children – Tanner charts.
7
Diagnosis of Anorexia
Nervosa
B. Intense fear of gaining weight or becoming fat,
even though underweight.
C. Disturbance in the way in which one’s body
weight or shape is experienced, undue influence of
body weight or shape on self evaluation, or the
denial of the seriousness of the current low body
weight.
8
Diagnosis of Anorexia
Nervosa
D. In postmenarcheal females, amenorrhea,
i.e. the absence of at least three consecutive
cycles. (A woman is considered to have
amenorrhea if her periods occur only
following hormone, e.g., oestrogen,
administration.
9
Diagnosis of Anorexia
Nervosa Subtypes
1.
Restricting Type: during the current episode of
anorexia nervosa, the person has not regularly
engaged in binge-eating or purging behaviour
(i.e., self induced vomiting or the misuse of
laxatives, diuretics, or enemas).
2.
Binge Eating/Purging Type: during the current
episode of anorexia nervosa, the person has
regularly engaged in binge eating or purging
behaviour (i.e., self induced vomiting or the
misuse of laxatives, diuretics, or enemas).
10
Bulimia Nervosa
Predominantly Female – Male Bulimics
rarely present.
 1% of all women.
 Onset 18 – 20.
 Dieting precedes bingeing and bingeing
usually precedes vomiting by about a year.

11
Diagnosis of Bulimia Nervosa
A.
Recurrent episodes of binge eating. An episode
of binge eating is characterised by both the
following:
i) eating, in a discrete period of time (e.g. within
any two hour period), an amount of food that is
definitely larger than most people would eat
during a similar period of time and similar
circumstances.
ii) a sense of lack of control over eating (e.g. a
feeling that one cannot stop eating or control
what or how much one is eating).
12
Diagnosis of Bulimia Nervosa
B. Recurrent inappropriate compensatory behaviours
in order to prevent weight gain, such as self
induced vomiting; misuse of laxatives, diuretics,
enemas, or other medications; fasting; or
excessive exercise.
C. The binge eating and inappropriate compensatory
behaviour both occurs on average, at least twice a
week for 3 months.
13
Diagnosis of Bulimia Nervosa
D. Self-evaluation is unduly influenced by
body shape and weight.
E. The disturbance does not occur exclusively
during episodes of Anorexia Nervosa.
14
Diagnosis of Bulimia Nervosa
- Subtypes
1.
Purging type: during the current episode of
bulimia nervosa, the person has regularly
engaged in self-induced vomiting or the misuse
of laxatives, diuretics, or enemas.
2.
Nonpurging type: during the current episode of
bulimia nervosa, the person has used other
inappropriate compensatory behaviours, such as
fasting or excessive exercise, but has not
regularly engaged in self-induced vomiting or
the misuse of laxatives, diuretics, or enemas.
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EDNOS = SUBCLINICAL ED (30% - 40%
of Patients)
1.
2.
3.
All the criteria for Anorexia Nervosa are met
except that, despite significant weight loss, the
individuals current weight is in the normal
range.
All of the criteria for Bulimia Nervosa are met
except that the binge eating or compensatory
mechanisms occur at a frequency of less than
twice a week, or for a duration of less than three
months.
The regular use of inappropriate compensatory
behaviour by an individual of normal body
weight after eating small amounts of food (e.g.
self induced vomiting after the consumption of16
two cookies).
EDNOS …cont.)
4.
Repeatedly chewing and spitting out, but not
swallowing, large amounts of food.
5.
Binge Eating Disorder.
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Binge Eating Disorder
A.
B.
C.
D.
E.
Recurrent episodes of Binge Eating (as in BN)
Binge eating episode is associated with 3+ of the following: Eating
more rapidly than normal; eating until feeling uncomfortable full;
eating large amounts of food when not feeling physically hungry;
eating alone because of how embarrassed about the amount of food;
feeling disgusted with oneself, depressed or very guilty after
overeating.
Marked distress over binge eating is present.
The binge eating occurs on average 2 days a week for at least 6
months.
The binge eating is not associated with the regular use of
compensatory behaviours and does not occur exclusively in the
course of AN or BN.
18
Points to remember about
diagnosis.

Only a diagnosis.
 More similarities than differences.
Diagnosis focuses n the differences.
 The primary presenting feature is pursuit of
thinness (it is a dieting rather than an eating
disorder). The behavioural features of
bulimia nervosa are secondary to the pursuit
of thinness.
19
Differential Diagnosis
1.
Bulimia & Anorexia .

2.
Weight
Medical Conditions.




ED associated with drive for thinness.
Weight loss is valued (egosyntonic)
Vomiting is associated with weight loss & control
and is self induced.
Weight & shape central in self construct.
20
Differential Diagnosis
3.
OCD/Psychosis.



4.
Body Dysmorphic Disorder.


5.
Must be non food related obsessions for OCD.
OCD/Psychosis has no fear of weight gain or pursuit of
thinness.
OCD may have insight into irrationality of thoughts.
Typically not present in anorexia nervosa.
BDD focuses on a specific feature.
BDD less worried about weight or thinness.
Borderline Personality Disorder


BPD has more impulsive features.
Function of Binge/purge differs.
21
Comorbidity in Anorexia
Nervosa.
Major Depression:
Dysthymia:
OCD:
Agoraphobia:
Sex Dysfn:
GAD
Social Phobia:
Panic
OAD
SAD:
40%
32%
30%
15%
45%
31%
27%
20%
37%
17%
22
Comorbidity in Bulimia
Nervosa
Major Depression:
Dysthymia:
OCD:
Social Phobia:
Alcohol:
Drug Dependence:
PTSD:
68%
36%
24%
25%
32%
39%
30%
23
Comorbidity on Axis II

BN:
 AN – R:
 AN – BP:
0% - 85%
31% - 87%
70% – 97%
24
Comorbidity on Axis II
1)
2)
3)
4)
5)
Bingeing & Purging is associated with Cluster B – BPD
Restricting associated with Cluster C – OCPD.
Remain after recovery from Axis I ED (Matsunaga et al
2000)
In BPD women – EDNOS 33%. (Marino & Zanarini
(2001).
In a Non Clinical Sample BPD (questionnaire) and
Bulimic Thoughts and behaviours were perfectly
mediated by Defectiveness-Shame Schema (Meyer et al,
2001)
25
Predispositional or Setting
Condition Models of an Eating
Disorder.
26
Individual Personality Factors
Premorbid Features of Anorexia & Bulimia: The
“Setting Conditions for Eating Disorders”
(Slade, 1992; Fairburn, Cooper, Doll & Welch,
1998).
Low Self Esteem (Sense of Ineffectiveness or
General Dissatisfaction with Life).
(2) Perfectionism & Obsessionality (A need for
control over events).
(1)
27
Eating Disorders & Personality.

Lilenfeld et al (2006) Eating Disorders and
personality: A methodological and
empirical review. Clinical Psychology
Review.
28
Predispositional Models
Data from Prospective, recovered, retrospective and family studies indicate that:
Prospective
Recovered
Retrospective
Family
 Negative
Negative
Negative Self
Emotionality
Emotionality
Evaluation
 Poor
Poor
Interoceptive
Interoceptive
Awareness
Awareness
 Perfectionism
Perfectionism
Perfectionism
Perfectionism
 Ineffectiveness
Harm Avoidance Cluster C
Ineffectiveness
 Drive for
Conformity
Thinness
 Obsessive
Obsessive
Obsessive
Compulsive TraitsCompulsive Traits Compulsive Traits
(childhood)
30
Perfectionism in Anorexia






Anxiety disorders are common comorbid and
premorbid.
OCD common in 30% of AN patients
Primary OCD symptoms surround a need for
exactness, symmetry and perfectionism.
These remain after recovery from anorexia
nervosa.
OCPD is a common comorbid Axis II condition.
Family Aggregation studies indicate a shared
transmission of ED and OCPD.
31
Ineffectiveness in Childhood
Martin, Wertheim, Prior, Smart, Sanson &
Oberklaid (2000)
 Followed 600 girls from infancy to 11-12.
 High Negative Emotionality from 3-4 years
correlated with Drive for Thinness.
 Current Body Dissatisfaction and Bulimia
was associated with Negative Emotionality.
32
Complications Model:
The Effect of Starvation
Keyes Study of Human Starvation

Pre-existing personality features are maintained by
starvation:
Depression
Obsessionality/Perfectionism
 Increased by starvation
Preoccupation with food, social withdrawal.
34
CCM: Family and Twin Studies
ED aggregate in families with increased by a factor
of 10.
Variance in heritability 33% - 84% in twin studies.
Family Studies: Support found for OCPD and
Restricting AN. Higher levels of OCPD in
relatives of RAN patients than in controls.
Both AN and obsessive traits linked to chromosome
1 (also 5HT abnormalities)
Twin Studies:
 Wade (2000) - Neuroticism and disturbed eating
(non shared environment).
 Klump et al (2002) Negative Emotionality and
disordered eating (genetic)
36
Conclusions: Eating Disorders
and Personality
PERSONALITY
STATE EFFECTS
Negative
Emotionality
Ineffectiveness
Perfectionism
Obsessive
Compulsive
Traits
Drive for
Thinness
Poor Interoceptive
Awareness
Increased
Neg. Emotionality
Increased Rigidity
& Obsessionality
ED
OCPD (for RAN)
Neuroticism/Neg
Emotionality
37
38
Cognitive and Behavioural
Models of the Maintenance
of the Eating Disorders
39
The Cognitive Behavioural
Formulation of Bulimia Nervosa
(Fairburn)
Negative Self Evaluation/Perfectionism (Low SE)
Shape and Weight dominate Self-concept
Intense Dieting
+
Negative Affect
Binge Eating
Compensatory Behaviours
40
Dietary Restraint Model


Polivy and Herman (1985)
A reliance on the cognitive control over eating,
rather than physiological cues, leaves dieters to
uncontrolled eating when these cognitive
processes are disrupted are disrupted or when
dietary rules are violated.
 Experimental trial have produced mixed support.
 Data from Obese patients does not provide
support.
 ? Meaning of the diet or success of the diet.
41
Extreme Concern with Weight
& Shape
Cognitive Behavioural Model: Garner &
Bemis 1982, 1985. Garner, Vitousek &
Pike 1997.
 Dieting is maintained by idiosyncratic
cognitions regarding the overvaluation of
weight and thinness in terms of self
concept.
42
The Cognitive Behavioural Model of Anorexia nervosa
Fairburn, Shafran & Cooper (1999)
Low Self Worth
Extreme need for
Self control.
Increased
Self worth & control
Trigger
Sociocultural
Factors
Dietary Restriction
Slowing of wgt loss
Eating Control
= Self worth & control
Weight Loss/Starvation
Hunger
Impaired Concentration
narrowing of interests
Threaten control
over eating
Hypervigilant
Body Checking
Avoidance of BC
Perceived failure of control over eating
43
“Transdiagnostic” Applications of
CBT for Eating Disorders
Fairburn, Cooper, Shafran (2003)
Behaviour Research and Therapy, 41,
509-528.
A Transdiagnostic
Perspective.

AN & BN are different behaviourally, but few differences in cognition
at various levels.

AN, BN share the same common psychopathology.

Diagnosis changes cross sectionally (e.g. 25% of BN patients have a
previous history of AN.

EDNOS is a common outcome for AN and BN.

In AN the “starvation syndrome” is an additional maintaining factor.
45
CBT BN 2003
1.
Clinical Perfectionism
The wider system of dysfunctional self evaluation of which
Drive for Thinness is one aspect.
Unrelenting Schema
Compensatory Schema
2.
Core Low Self Esteem
Defectiveness/Shame Schema
Core Schema
Mutual reinforcement between core and compensatory schema
Induces hopelessness about capacity to change (e.g. Long term
patients)
46
CBT BN 2003
4.
Mood Intolerance
Inability to cope appropriately with emotional states
leads to “dysfunctional mood modulatory behaviour”
Behaviour reduces awareness of the affect and
cognitions (i.e. Schema Avoidance (Waller);
Cognitive Narrowing Heatherton and Beumaster) and
neutralises it.
Multi-impulsive Bulimia (Lacey)
5.
Interpersonal Difficulties
Need to include an IP perspective due to effectiveness
of IPT.
Disturbed IP functioning predicts poor response to
treatment (Agras et al, 2000)
47
Dysfunctional Scheme for Self Evaluation
Over-eval. of control
of eating weight/shape
Perfectionism
CORE LOW SELF ESTEEM
Strict Dieting and other
weight control br.
Achieving in
other domains.
Binge Eating
Low Weight
Compensatory
Purging
Starvation Syndrome
Mood Intolerance
Interpersonal Life.
48
Cooper, M.J., Wells, A., & Todd, G. (2004)
A cognitive model of bulimia nervosa. British
Journal of Clinical Psychology, 43, 1-16.
Includes ‘developmental factors’
Negative or traumatic childhood experiences
give rise to “negative self beliefs”.
(i.e. Core Beliefs – particularly
defectiveness/shame)
49
St. George’s Hospital Medical School, University of London
Eating Disorders Service
Schema-focused CBT
in the eating disorders
Glenn Waller
St. George’s Hospital Medical School
University of London
[email protected]
General schema-focused formulation
Early
experiences
Internal or
external
trigger
Core beliefs


Core beliefs laid down as
the result of consistent
early experiences
Can be healthy or
unhealthy, depending on:
– nature of experience
– capacity to process and
‘Hot’
cognitions
Affect/behaviour
attribute

Can result in
vulnerability or resilience
to triggers
– diathesis-stress interaction
51
A hypothesised structure of core beliefs
in the eating disorders

Core Schema is the central pathology (the ‘hurt’)
– e.g., defectiveness/shame (“I am completely
worthless”)
– emotional deprivation (“My needs can never be met”)

No difference between AN and BN patients.
Therefore a need to look at schema processes.
52
Schema processes

Schema maintenance (where information is sought and
generated to preserve the existence of the current belief)
– seeking out evidence for our beliefs
– rejecting contradictory evidence
– Cognitive Distortions

Schema compensation
– primary avoidance of affect
– (where you don’t want to feel the affect generated by activation of
the core belief).
– use of an alternative (relatively acceptable) schema to reduce
activation of an intolerable one
– Functional relationship between schemas (e.g. defectivenessshame & Unrelenting standards).
53
Schema Compensation
Restrictive eating is a specific form of schema
compensation.
(i.e. Unrelenting Standard)
Reflected in beliefs such as:
If I lose weight I will be more successful/more
popular
&
If I gain weight I am a failure and unpopular.
54
Schema-focused formulation of restrictive
behaviours

Early experiences
Unhealthy core beliefs
- defectiveness/shame
- mistrust/abuse
- emotional deprivation
–
Trigger

‘Hot’ cognitions
-
again, a role for emotional
inhibition core beliefs
Activation of alternative
schemas to avoid emotional
activation (schema
compensation)
Unrelenting Standards
Emotional Inhibition
Subjugation
+
Threat of aversive &
intolerable
emotional states
Triggers risk the activation of
aversive emotions

Primary avoidance as the
central process
–
repressive style
Activation of
compensatory schemata
- unrelenting standards
- subjugation
55
Schema avoidance
– secondary avoidance of affect.
– (Where you feel the affect generated by the
core belief and attempt to block it to reduce
awareness of it).
– intentional or automatic avoidance of
processing
– behavioural, somatic, cognitive, emotional
56
Schema-focused formulation of bulimic
behaviours
Early experiences

Unhealthy core beliefs
- defectiveness/shame
- mistrust/abuse
- emotional deprivation
Trigger

‘Hot’ cognitions
+
+
-
Triggers activate of
aversive emotions
Affect seen as intolerable
due to nature of early
experiences
– role for emotional inhibition
core beliefs
Aversive & intolerable
emotional states

‘Escape’/blocking
behaviours

- binging and/or purging
- alcohol misuse
- self-harm
Triggers
Secondary avoidance as
the central process
(Schema Avoidance)
– dissociative style
57
Levels of Cognitions, Schemas and Symptoms
(Hughes et al, 2006 – Eating Behaviours)
ED beliefs have a causal role in BMI and Vomiting behaviour but only in the presence
of negative self beliefs. (Moderator Model)
Disorder-specific cognitions
Weight Concerns
Restraint
Eating Concerns
BMI
VOMITING
Core Beliefs
Emotional Deprivation
Abandonment
Self Sacrifice
Emotional Deprivation
58
Levels of Cognitions, Schemas and Symptoms
(Hughes et al, 2006 – Eating Behaviours)
Both levels of cognition have an independent
relationship with objective binge eating.
Restraint
Weight Concerns
Objective Binge
Eating Frequency
Emotional
Deprivation
59
Clinical Features of The Eating
Disorders.
60
Lasegue (1873; p. 496.)
“Not only does she not sigh for recovery, but she
is not ill-pleased with her condition . . . . Here we
have . . . an inexhaustible optimism against which
supplications and menaces are alike of no avail . .
. . The whole disease is summed up in this
intellectual perversion. Suppress this, and you
have an ordinary affection which at last yields to
the classic procedures of treatment”.
61
Bruch 1978

“on principle, anorexic patients resist
treatment. They feel that in extreme
thinness they have found the perfect
solution to their problems… They do not
complain about their condition- on the
contrary they glory in it.”
62
Some reasons for not
Changing (from a schema
perspective).
63
PROTECTION FROM SELF
AWARENESS (e.g from a
defectiveness schema)
“Without my anorexia I would have to accept who
and what I am”
 “I am my eating disorder”


“ED is a mask. ED means I don’t have to know
who I am and possibly find out I don’t like myself.

“It is a distraction from horrible thoughts and
feelings.
64
Unrelenting Standard

Weight control is all I can do as well as I
want. It is what I’m best at.”
and

“It allows me the excuse not to achieve in
any other area because I’m sick”.
65
Communication of Affect
(Emotional Inhibition)

This is the only way I can let people know
that I am not OK
66
Affect Regulation

Bingeing just numbs me out.
67
The Psychopathology of the
Eating Disorders
Chris Thornton
Chris Thornton & Associates
Wahroonga, Ashfield, Eastwood,
Kogarah, Greenwich.
Ph: 0413154679
email:[email protected]