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Anorexia Nervosa as a Passion

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1 Anorexia Nervosa as a Passion
Louis C. Charland Ph.D. Professor Departments of Philosophy and Psychiatry & School of Health Studies University of Western Ontario London Ontario Canada N6A 3K7

2 Hypothesis Anorexia Nervosa is a Passion
(A Theoretical Empirical Hypothesis)

3 Collaborative Insights
Oxford Circa 2008 Collaborative Insights Tony Hope, Psychiatrist Ribot’s concept of passion ‘fits’ Tan & Hope et al. Anorexia study data very nicely. Louis C. Charland, Philosopher Ribot’s concept of passion helps understand predominance of affectivity in Tan & Hope et al. study data, especially the manner in which emotions and feelings are organized.

4 Collaboration Louis C. Charland PhD
Professor, Departments of Philosophy and Psychiatry & School of Health Studies, University of Western Ontario, London, Ontario, Canada Tony Hope MD Professor of Medical Ethics and Honorary Consultant Psychiatrist, The Ethox Centre, Department of Public Health, University of Oxford Anne Stewart MD Consultant Psychiatrist, Oxford City CAMHS and Honorary Senior Clinical Lecturer, University of Oxford Jacinta Tan MD Senior Research Fellow and Honorary Consultant Psychiatrist, College of Health and Human Sciences, Swansea University

5 Study Twenty-nine patients with anorexia nervosa were recruited from four different centers across the south of England. Sixteen of the participants were under the age of 18 years. The patients’ ages ranged from 15 to 26 years. At the time of interview patients were at various stages and levels of anorexia. The Body Mass Index (BMI) of all but six participants was below 20 (the generally accepted lower limit of the normal range) with a mode of 17 and the lowest value of 12. Tony Hope, Jacinta Tan, Anne Stewart, Ray Fitzpatrick. Anorexia Nervosa and the Language of Authenticity. Hastings Center Report, Volume 41, Number 6, November-December 2011, 19-29

6 Hypothesis Anorexia Nervosa is a Passion
(A Theoretical Empirical Hypothesis)

7 Clinical Features Diagnosis Course Observations
ICD 10: “an intrusive dread of fatness” DSM IV: “intense fear of gaining weight or becoming fat” Weight 85% less than ‘normal’ and BMI ≤ 17.5 kg/m2 Course Progressive worsening with gradual loss of control. ‘Relentless pursuit of thinness, often to the point of starvation’ Observations Patients ‘often secretive, deny their symptoms, and resist treatment’ Patients ‘typically lack a sense of autonomy and selfhood’ Kaplan Benjamin, J. & Sadock Virginia A. Synopsis of Psychiatry (9th Ed.) . Philadelphia: Lippincott, Williams & Wilkins, 2003, Weight Criteria for Diagnosis of Anorexia Nervosa Hebebrand, Johannes, Wehemeier, Peter M. & Helmut Remschmidt, Am J Psychiatry 2000;157: /appi.ajp

8 Terminology Phthisiologia, Richard Morton 1689
Apepsia Hysterica, William Gull 1868 Anorexia Histerique, Charles Lasègue 1873 Anorexia Hysterica, William Gull 1873 Anorexia Nervosa, Wiliam Gull 1873 Self-Starvation, Vandereycken & Van Deth 2001

9 Passion to be Thin (Mild Lifestyle Form)
IMPORTANT: This is NOT a pro-ana or pro-mia site.

10 Passion to be Thin (Extreme Lifestyle Form)

11 Passion to be Thin (Morbid Form)

12 Passion to be Thin (Severe Morbid Form)
Kaplan Benjamin, J. & Sadock Virginia A. Synopsis of Psychiatry (9th Ed.) . Philadelphia: Lippincott, Williams & Wilkins, 2003, 742.

13 Presentation Today I What is a Passion?
II Why Anorexia Nervosa is a passion III Implications

14 What is a Passion?

15 Reinstating the Passions:
Arguments from the History of Psychopathology Charland, Louis C. (2010). Reinstating the Passions: Arguments from the History of Psychopathology. In Peter Goldie (Ed.) The Oxford Handbook of Philosophy of Emotion (Oxford: Oxford University Press),

16 Affectivity: Today Emotions Moods Feelings

17 Affectivity: History Passions Affections

18 From Passions to Emotions
Amélie Oskenberg Rorty (1982) Thomas Dixon (2003) From Passions to Emotions and Sentiments Philosophy , Vol. 57, No. 220 (April), From Passions to Emotions: The Creation of a Secular Psychological Category. Cambridge University Press.

19 1649 Après avoir considéré en quoi les passions de l’ame diffèrent de toutes les autres pensées, il me semble qu’on peut généralement les définir des perceptions, ou des sentiments, ou des émotions de l’ame, qu’on rapporte particulièrement à elle, et qui sont causées, entretenues, et fortifiées par quelque mouvement des esprits. Renée Descartes, Les Passions de l ’Ame. Paris: Librairie Générale Française, 1649/1990. Article 27, p.57

20 Théodule Armand Ribot Dec 8, 1839 - Dec 18, 1916
École Normale Supérieure 1875 Psychologie expérimentale Sorbonne 1885 Chaire de psychologie expérimentale et comparée, Collège de France 1888

21 Achievements Agrégé de philosophie, École normale supérieure 1965
Appointed to College de France 1888 First Chair of Experimental and Comparative Psychology Champion of ‘psychologie physiologique’ Reviews of British and German psychology. Books on memory, personality, attention, will, unconscious Several books on affectivity and ‘la vie affective’ Introduced ‘méthode pathologique’ Known for “Ribot’s Law”; “Anhedonia” Founder of International Congress of Psychology, Paris [Congrès International de Psychologie Physiologique] Founder of Revue philosophique de la France et de l'étranger

22 Essai Sur Les Passions 1907

23 Examples Jealousy Guilt Ambition Drunkenness Collecting
Note: Not all names of passions are names of emotions.

24 Why Anorexia Nervosa is a Passion

25 Criteria for a Passion

26 1. Long-Term Orientation
… the illness is so consuming you can’t see past it, it IS everything you think about all the time. It’s how you make every single decision, it’s how you get up each morning and go to bed each night, it is everything. And you can’t see past that to a life beyond it at all, it becomes who you are completely and you get quite delusional almost, that that’s just the way you are and there isn’t anything else!

27 2. Fixed Ideational Focus
… it [losing weight] was the most important thing in my life at the time. I’ve always, apart from the obvious things like my family and my friends, I’ve always thought my work and doing well at school is the most important thing, but for that, I mean even now my work’s gone back to being my most important thing, but at that point losing weight was the most important thing …. … the illness is so consuming you can’t see past it, it IS everything you think about all the time. It’s how you make every single decision, it’s how you get up each morning and go to bed each night, it is everything … So - it really runs things.

28 3. Motivating Power I still can see facts as they are. What I’ve lost is the ability to apply them for myself because emotions have taken over, but I don’t think my rational side is being destroyed, or anything. I think it’s still there, it’s just a question of accessing it. ... once we had pizza and I hadn’t had pizza in like at least a year and it was like, it was just so …I couldn’t even bite, I couldn’t even like cut it I was just so like, they couldn’t believe how traumatised I was about a pizza! And so I think it’s quite funny now, but it was really, I was crying at the table, I was, I couldn’t look at it, I just felt sick and I just didn’t want to touch it, it made me feel horrid.

29 4. Organizes Emotions I love the feeling I get when I can feel my bones sticking out. I love feeling empty. I love knowing I went the whole day without eating. I love losing weight. I love people telling me 'you're too skinny!' I hate being this so-called normal weight. I feel like a fat, blubbery, nasty lardbag. (But why these particular feelings and emotions and related affective dispositions in these circumstances?) Hellmich, Nanci On the Web: Thinness Worship. USA Today, Health & Science, 07/24/ Updated 10:07 PM ET. accessed 09/02/2012 1:58pm

30 5. Integrated with Cognition
… if you’re anorexic then you think that you need to lose weight and so if you think that you need to lose weight your next logical step is “how am I going to lose weight”, so then your thought process is “ok I’m going to eat less or I’m going to, like, do more” like work out more.

31 6. Progressive Course I think it was just something that I slipped in to and I did without realising. And it was almost like because I had, that became I suppose a level of achievement for me, it was a goal, I wasn’t aiming to LOSE weight but then realising that I could do it spurred me on … I think losing the weight just becomes SO compulsive that - almost you don’t think about things, you don’t think there was an active decision to give things up, it was more that it, the drive, the pull towards the anorexia was so strong that I almost didn’t, it almost wasn’t a conscious decision.

32 7. Morbidity … because you can’t see how thin you are or how ill you are because you are just constantly concentrating on how thin you could be. So even if you’re just down to your bones you’d just be like, oh look I’ve still got some more on there, and I think that striving to be thinner prevents people from being able to say wait, stop and say, wait actually I am too thin and I do need help and I think that’s why people are unable to make proper decisions. Well I always THOUGHT that I could, like before I tried it I thought all the time well I could easily eat more and stop this if I wanted. But when I came to try to do that I couldn’t.

33 Anorexia as a Passion Intellectual Component
Ideé fixe: central ‘law’ in anorexic schema Affective Component Specific feelings and emotions at specific times Motivational Component Strong tendency to act according to above

34 Anorexic Passion Anorexic Fixed Idea ‘Obsession’ Anorexic Affectivity
(Belief that one must be thin; that one is too fat) Anorexic Affectivity (Fear and dread of being fat) Anorexic Motivation (Drive to lose weight)

35 Implications

36 An Affective Disorder I wouldn’t say anorexia is a thought as such. I don’t think I, it’s more of a feeling I, I WANT to do it and I guess in a way its almost an EMOTION, anorexia. And everyone says “well you know you’ve got to think of your heart, what do you really want in your heart?” Well it’s like I want anorexia but I know in my HEAD that I shouldn’t, because you know I know that’s why I sort of know about all the sort of risks and everything. So it’s sort of like at what point, which, where does the choice come from as well? Because, there’s this little emotion that seems to accompany being thin, and I can’t it, I can’t really, I don’t really have the language to explain it, … Not an affective disorder of ‘mood’ Not an affective disorder of ‘emotion’ Not an affective disorder of ‘feeling’ An affective disorder of passion

37 Addictive Grip Interviewer: And are there any things that you wish people who’ve never had anorexia nervosa should understand? Participant: That you’re not doing it because you want to. You’re not doing it because you want some form of attention you’re not doing it because you’re selfish and you want everybody’s lives to revolve around you. And that you don’t WANT it. It’s not something that you’ve chosen to have, you haven’t gone out and said “well I’m gonna be an anorexic.” It’s something that’s, that’s captured you not the other way round.

38 Loss of Control For a long time I thought it was, there was nothing wrong with me, it was, there was nothing wrong with me, it was just other people thought there was, something wrong with them not me, but um …over the summer I did feel that I really wasn’t in control of what I was doing and… it’s sort of …before then I never really tried to get better, I’d always been forced to or, kind of, gone along with it to keep other people happy and I thought that as soon as I decided I did want to get better I’d be able to, but now I realise it doesn’t quite work like that and so that’s kind of made me see it as a bit more of an illness, something you don’t have complete control over.

39 Decisional Capacity It is not clear that a person driven by a passion is acting autonomously. The behavior and decisions (including to refuse treatment) are not the result of careful and rational reflection on life-goals (that is the paradigm of autonomous behavior). The decisions (e.g. to refuse treatment) may be rationalized in ways that meet the standard criteria for capacity, but be made as a result of the affective motivating power of the passion. In order to help the person to be free from the grip of the passion, and attain a greater degree of autonomy over her life, it may be necessary to impose upon her a routine that has a chance of breaking down the self-destructive patterns of behavior that is both part of, and helps maintain, the passion that is anorexia nervosa.

40 Contraria Contratiis Curanator
Treatment Early Intervention Essential Limits of Cognitive-Behavioral Therapy Ribot, ‘How the Passions End’ (1907) Jackson, ‘Passions in Psychological Healing’ (1990) Contraria Contratiis Curanator Jackson, Stanley, W. The Use of the Passions in Psychological Healing The Journal of the History of Medicine and the Allied Sciences Vol. 45, 1990,

41 Thank you Louis C. Charland Ph.D. Professor
Departments of Philosophy and Psychiatry & School of Health Studies University of Western Ontario London Ontario Canada N6A 3K7

42 Treatment Decision-Making in Anorexia Nervosa – an Empirical Project
The empirical ethics project on treatment decision-making in anorexia nervosa had its inception in the early 1990s in Oxford, United Kingdom, when Professor Tony Hope, a medical ethicist who is also a psychiatrist by background, and Dr Anne Stewart, a child and adolescent psychiatrist with a special interest in eating disorders, first formed the idea of investigating capacity to refuse treatment in anorexia nervosa. Tony and Anne were joined by Dr Jacinta Tan, then a junior doctor in training to be a psychiatrist, and together they began to develop an empirical method to conduct ethics research and began exploratory fieldwork in this area. In 2002, Jacinta completed her specialist training and embarked on a large scale qualitative research project of patients and parents’ views on this subject as well as a survey of psychiatrists’ attitudes, funded by a Wellcome Trust Health Services Research Training Fellowship. Professor Ray Fitzpatrick, Professor of Public Health at the University of Oxford and an eminent medical sociologist, joined the team to provide expertise on research methods. The data collection was completed in 2006 and followed up with a project, again funded by the Wellcome Trust, developing methods of validating the results through workshops with research participants, other patients and parents, and health professionals. This culminated in the production of a report for laypeople which is available in the public domain at Although initially developed to investigate capacity in people with anorexia nervosa, the qualitative data has highlighted many different aspects of the patient experience of anorexia nervosa and its treatment. After publishing several widely-quoted results papers, the implications of the rich data set are still being explored, in particular how it sheds light on the concept of capacity in general as well as broad experiences of patients with anorexia nervosa.

43 Interviews Semi-structured interviews began with the interviewer asking about what the participant felt and thought about anorexia nervosa. The interviewer encouraged each participant to enlarge on her initial responses. The interviewer proceeded to ask about the following general areas: understanding of anorexia nervosa; views about compulsory treatment and the role of the family; beliefs about shape and weight and around risks from being low in weight; experiences of treatment; views about the impact of anorexia nervosa on decision-making; views and values about the future, and the impact of anorexia nervosa on these.

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