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

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. 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 Poetic Licence

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. “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 Cognitive strategies to avoid food

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

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 motivationwww.feast- ed.org “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. Lenroot and Giedd, 2006. Neurosci Biobehav Reviews 30:718-726. Nutritionally deprived brain at critical phase of development

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

28. . 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 Rigidity

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

30. 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 Detail vs. Global Imbalance

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 Increased rigidity Inability to see big picture Mastery over laws Thermodynamics Success over detail rule- energy in and out Worsens cognitive Problems Trapped in AN habits OCPD traits Rigid Detail>global

33. ↑ A voidance system. Anxiety, Harm avoidance Behavioural inhibition system (BIS) (Dawe & Loxton, 2004; Loxton & Dawe, 2001, 2006, 2007, Claes et al., 2006; Harrison et al 2010) Increased Sensitivity to Punishment

34. ↓ 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) Poor Emotional Regulation

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

36. Impaired Reading Mind Others Oldershaw et al. (2010.) 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. 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 Person with AN has difficulty reading others The vicious circle of isolation

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

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

45. 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)

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

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

48. 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 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 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” Improving Communication in family

49. Carers reaction to ED behaviours

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

51. Ostrich Avoiding seeing, thinking & dealing With problem

52. 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 Person with AN observes anxiety and anger in others An emotional vicious circle

53. 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

54. 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. I have to have different crockery for preparing and cooking my meals. They are kept separately. 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. Families: OCD Accommodating She will only drink from a new bottle of water. The fridge is stocked with her water. No one can go in the kitchen when she is there.

55. She often buys cream cakes etc that she makes me eat even when I do not want them. 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. 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. Families: calibration and competition

56. 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 Antecedants You are distressed by your child’s pain Anxious to not upset her more Protecting the invalid The ABC of Accommodating: Bullied by Ed

57. Enabling ED. Avoidance & modify routine Covering up for: Plumbing toilet problems Stealing (food and money) Mess Social & family

58. 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. “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 have to clean up the toilets; it’s 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. Family enabling bulimic behaviours

59. 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 Antecedants The consequences of Ed Behaviours are impossible For you, or family or Ed to tolerate The ABC of Enabling Ed behaviours

60. The interpersonal perpetuating cycle (Zabala et al, Eur Eat Rev 2009) Kyriacou et a 2008 Sepulveda et al 2009

61. 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.

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

63. What happens after Recovery in AN ( Uher et al 2003) Recovered vs Acute & Control Apical prefrontal Recovered =Control>AN Lateral prefrontal Recovered =Acute>Controls OFC

64. Acknowledgements Nina Jackson (RIED), NIHR, BRC