New ways of thinking about anorexia nervosa

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Guest blog post by Janet Treasure, PhD FRCP FRCPsych and Ulrike Schmidt, Dr Med PhD FRCPsych, authors of the latest review on the cognitive-interpersonal model of anorexia nervosa published in the Journal of Eating Disorders.

Anorexia nervosa (AN) has a lifetime prevalence of 1% in females with a 10-20% lifetime fatality rate. Although early family intervention can prevent AN from becoming entrenched a subgroup have a persistent illness or develop the illness later when the family intervention is less effective. Thus in adults with AN (i.e. those with a more chronic illness) outcomes are poor and treatment drop-out is high. The evidence-base for psychological treatment of adults with AN is extremely limited with only a handful of trials to date and a call for new approaches has been made.

Family based treatment which is useful as an early intervention is not linked to any theory. However in order to develop interventions that are of benefit for those with a more severe and enduring form of illness it may be helpful to understand and target the factors that maintain the illness. It was with this in mind that Schmidt and Treasure developed a theoretical structure, a cognitive and interpersonal “Valued and Visible” model – to explain the factors that interacted to cause anorexia nervosa to persist.

This paper revisits the model and synthesizes the new evidence related to the four postulated components of the model.  It is now clearly established that obsessive compulsive traits and problems with social/emotional processing are causal and maintaining factors and contribute to the secondary interpersonal factors (familial and peer) that  lead the individual to become isolated within the illness. Also the secondary effects of both starvation and irregular nutritional patterns on the brain as well as on the body are more clearly understood.

It is hoped that with this more clearly defined specificity within the model that new approaches to treatment can be defined. This will encompass the traditional top down approach of talking treatments that use processes such as cognitive control to introduce a flexible change in behaviours, thoughts, attention and perception.  In addition there may be more direct ways of targeting these processes within the model. For example it may be possible to modify negative biases in attention or directly stimulate in efficient circuits.

In addition to eating disordered behaviors, people with anorexia nervosa have problems in social and emotional functioning which are thought to be causal and maintaining factors (Treasure et al., 2012b). Research has identified enhanced sensitivity to punishment as one of these vulnerabilities (Harrison et al., 2011), with both food and social stimuli experienced as threatening (Treasure et al., 2012a, Treasure et al., 2012b) in a transactional pattern (Soussignan et al., 2010). In addition, insecure attachment and early adverse social experiences have been found to produce a learned  vigilance to social judgment  (Cardi et al., 2012)  and  difficulties  engaging with positive social cues (Treasure et al., 2012b), increasing susceptibility to “fat talk”, teasing about weight and shape, and  learned  negative reactions to food, weight, and shape dominate behaviors (Treasure et al., 2012a).  These findings suggest that social emotional factors relating to attachment, competition/cooperation, and self-representation should be a key part of treatment. Up to a point current talking treatments do this but a large proportion of people with eating disorders fail to respond. This suggests that psychotherapy may be strengthened by the addition of more brain-directed treatments which target the primary processes.

Cardi, V., Matteo, R. D., Corfield, F. & Treasure, J. (2012). Social reward and rejection sensitivity in eating disorders: An investigation of attentional bias and early experiences. World J Biol Psychiatry. [PubMed]

Harrison, A., Treasure, J. & Smillie, L. D. (2011). Approach and avoidance motivation in eating disorders. Psychiatry Res 188, 396-401. [PubMed]

Soussignan, R., Jiang, T., Rigaud, D., Royet, J. P. & Schaal, B. (2010). Subliminal fear priming potentiates negative facial reactions to food pictures in women with anorexia nervosa. Psychol Med 40, 503-14. [PubMed]

Treasure, J., Cardi, V. & Kan, C. (2012a). Eating in eating disorders. Eur Eat Disord Rev 20, e42-9. [PubMed]

Treasure, J., Corfield, F. & Cardi, V. (2012b). A Three-phase Model of the Social Emotional Functioning in Eating Disorders. Eur Eat Disord Rev. [PubMed]

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