The Psychopathology of the Eating Disorders

1. The Psychopathology of the Eating Disorders Chris Thornton Chris Thornton & Associates Wahroonga, Ashfield, Eastwood, Greenwich. Ph: 0413154679email:ckthornton@bigpond.com

2. 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.

3. 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.

4. 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).

5. Diagnosis of Anorexia Nervosa • 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).

6. Diagnosis of Anorexia Nervosa.

7. Calculating Body Mass Index • Weight (kgs)/ Height x Height (m) • Adult Measure 17.5 Anorexia Nervosa 20 – 25 Normal Weight Range 25+ Overweight 30+ Obesity Asian Norms Available. Children – Tanner charts.

8. 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.

9. 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.

10. Diagnosis of Anorexia Nervosa Subtypes • 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). • 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).

11. 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.

12. Diagnosis of Bulimia Nervosa • 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).

13. 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.

14. 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.

15. Diagnosis of Bulimia Nervosa - Subtypes • 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. • 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.

16. EDNOS = SUBCLINICAL ED (30% - 40% of Patients) • 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 of two cookies).

17. EDNOS …cont.) • Repeatedly chewing and spitting out, but not swallowing, large amounts of food. • Binge Eating Disorder.

18. Binge Eating Disorder • 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.

19. 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.

20. Differential Diagnosis • Bulimia & Anorexia . • 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.

21. Differential Diagnosis • OCD/Psychosis. • 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. • Body Dysmorphic Disorder. • 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.

22. Comorbidity in Anorexia Nervosa. Major Depression: 40% Dysthymia: 32% OCD: 30% Agoraphobia: 15% Sex Dysfn: 45% GAD 31% Social Phobia: 27% Panic 20% OAD 37% SAD: 17%

23. Comorbidity in Bulimia Nervosa Major Depression: 68% Dysthymia: 36% OCD: 24% Social Phobia: 25% Alcohol: 32% Drug Dependence: 39% PTSD: 30%

24. Comorbidity on Axis II • BN: 0% - 85% • AN – R: 31% - 87% • AN – BP: 70% – 97%

25. Comorbidity on Axis II • 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)

26. Predispositional or Setting Condition Models of an Eating Disorder.

27. 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). • Perfectionism & Obsessionality (A need for control over events).

28. Eating Disorders & Personality. • Lilenfeld et al (2006) Eating Disorders and personality: A methodological and empirical review. Clinical Psychology Review.

29. 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 • IneffectivenessHarm AvoidanceCluster CIneffectiveness • Drive forConformity 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.

33. 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)

34. Conclusions: Eating Disorders and Personality PERSONALITY STATE EFFECTS Negative Increased Emotionality Neg. Emotionality Ineffectiveness Perfectionism Increased Rigidity Obsessive & Obsessionality Compulsive ED Traits Drive for Thinness Poor Interoceptive Awareness OCPD (for RAN) Neuroticism/Neg Emotionality

36. Cognitive and Behavioural Models of the Maintenance of the Eating Disorders

37. 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

38. 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.

39. 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.

40. The Cognitive Behavioural Model of Anorexia nervosaFairburn, Shafran & Cooper (1999) Low Self Worth Extreme need for Trigger Self control. Increased Sociocultural Self worth & control Factors Dietary Restriction Slowing of wgt loss Eating Control Weight Loss/Starvation = Self worth & control Hunger Threaten control Impaired Concentration over eating narrowing of interests Hypervigilant Body Checking Avoidance of BC Perceived failure of control over eating

41. “Transdiagnostic” Applications of CBT for Eating Disorders Fairburn, Cooper, Shafran (2003) Behaviour Research and Therapy, 41, 509-528.

42. 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.

43. CBT BN 2003 • Clinical Perfectionism • The wider system of dysfunctional self evaluation of which Drive for Thinness is one aspect. • Unrelenting Schema • Compensatory Schema • 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)

44. CBT BN 2003 • 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) • 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)

45. Dysfunctional Scheme for Self Evaluation Over-eval. of control Perfectionism of eating weight/shape CORE LOW SELF ESTEEM Strict Dieting and other weight control br. Achieving in other domains. Binge Eating Low Weight Compensatory Starvation Syndrome Purging Mood Intolerance Interpersonal Life.

46. 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)

47. St. George’s Hospital Medical School, University of London Schema-focused CBTin the eating disorders Eating Disorders Service Glenn Waller St. George’s Hospital Medical School University of London g.waller@sghms.ac.uk

48. General schema-focused formulation Early experiences • 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 attribute • Can result in vulnerability or resilience to triggers • diathesis-stress interaction Internal or external trigger Core beliefs ‘Hot’ cognitions Affect/behaviour

49. A hypothesised structure of core beliefsin 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.

50. 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. defectiveness-shame & Unrelenting standards).