Cognitive model of AN: A model of the cognitive contributors to anorexia nervosa.
An integrated theoretical model
A useful model would be one that accounts for the various clinical and experimental observations that have been documented (such as a preponderance of females being afflicted; the adolescent onset; the comorbid anxiety, perfectionism and obsessionality; and certain neurocognitive traits). A helpful integrated model would also guide treatments that work. This is immediately problematic because the treatment outcome studies for adults have produced a range of treatments that all have some moderate support. In bulimia nervosa, cognitive-behavior therapy (CBT), or its enhanced version (Fairburn, 2008) remains the treatment of choice, while interpersonal psychotherapy (IPT) has been shown to have slightly better outcomes after more than one year follow-up after a slower initial response compared with CBT (Agras, Walsh, Fairburn, Wilson & Kraemer, 2000; Tannofsky-Kraff & Wilfley, 2010). Various treatments have been found to have some degree of effectiveness for AN: specialist supportive clinical management has emerged as an effective treatment (McIntosh et al., 2005; McIntosh, Jordan & Bulik, 2010; Touyz et al., 2013), as has focal, brief psychodynamic therapy (Zipfel et al., 2014), but CBT has had mixed results (Pike, Carter, & Olmstead, 2010). The fact that a variety of therapies have equivalent outcomes suggests that no one approach is “right,” but there are some common factors that get addressed through therapeutic engagement with a professional who knows about EDs and offers caring treatment.
In each effort to provide a comprehensive model of the EDs, the common thread is that EDs are egosyntonic conditions that confer powerful adaptive functions for the affected individual. Here is where the commonality lies – in providing a sensitive formulation of the initial vulnerability factors and triggers and then the maintaining factors that are relevant for each individual. Such a formulation must necessarily welcome psychodynamic input (vulnerabilities such as an enmeshed maternal relationship, or fears of sexual maturation), neurocognitive aspects (as a predisposing factor and then as a maintaining factor with weight loss), beliefs and attitudes about one’s self worth and the reliance on thinness to feel adequate, as well as reinforcement issues once the dieting starts.
Some notable efforts have already been made to incorporate cognitive-behavioral and psychodynamic perspectives into the one treatment-oriented formulation. Garner and Bemis (1982), Garner et al. (1997), Schmidt and Treasure (2006), and Vitousek, Watson, and Wilson (1998) have each outlined how CBT is effective when each patient is understood in terms of their underlying personal and interpersonal needs and how the ED serves an adaptive function to meet that need. Guidano and Liotti (1983, 1985) have made an important contribution to the cognitive model of psychopathology by highlighting the role of early development and especially attachment in infancy. One’s schemas, or tacit rules, about the world are formed as one relates to others and one’s basic fabric of self-knowledge is constructed from early patterns of caregiving. Thereafter, “any information about the outside world always and inevitably corresponds to information about the self” (Guidano & Liotti, 1985, p. 108). Thus attachment influences fundamental tacit self-knowledge which, in turn, drives how we filter all future experiences. They argue that specific attachment experiences and schemas make a person vulnerable to specific conditions later in life, and these include eating disorders (Guidano & Liotti, 1983). Ward, Ramsay, and Treasure (2000) have summarized some of the research into attachment issues as they impact on eating disorders. Hardit and Hannum (2012) also had a focus on attachment when examining the tripartite influence model, finding that anxious attachment was a significant moderator of the effects of sociocultural attitudes on one’s body dissatisfaction.
We emphasize the need for a thorough and longitudinal assessment of every patient, with a careful developmental, family, genetic, personal, and social history. The sort of generic model presented in Figure 20.1 cannot readily be used in therapy, as each sketched formulation will necessarily be different for each client. For instance, what makes weight loss so incredibly reinforcing for one person will be different for another, and their personal self-discrepancies will also differ and may (or may not) be very relevant in the start or maintenance of their ED. What makes the weight loss so reinforcing may be a sociocultural factor (being involved in a certain subculture, such as dance), or may relate to early trauma and a damaged self (e.g. from a punitive and critical but enmeshed parent). Beyond undertaking a thorough assessment of each person, several other treatment implications arise from the literature reviewed above.
Treatment implications
Work with the egosyntonicity
As has been highlighted throughout this chapter, the EDs (especially AN but also binge-eating disorders such as BN) are egosyntonic. That is, the affected person finds that the symptoms and consequences of the disorder serve powerfully helpful functions in their life that feel valued and “right” to them. This has long been understood by clinicians when confronted by the difficulties that their patients encounter as they engage in recovery. Bruch (1973, 1978) highlighted the need for and the exalted valuing of their symptoms, as has Vitousek (Garner & Bemis, 1982; Garner et al., 1997; Vitousek et al., 1998). This can only be done if a thorough and curious assessment of each patient is undertaken by a clinician who is aware of the common adaptive functions that EDs often embody.
The principles and practices of motivational interviewing have been advocated as a means to work with the egosyntonicity of EDs (Garner et al., 1997; Schmidt & Treasure, 2006; Treasure & Schmidt, 2008; Vitousek et al., 1998). The common recommendations that these various authors make include: voicing an understanding of how the ED has indeed been adaptive for that person; timing interventions with regard for the person’s readiness for change; using respectful questions about costs, benefits, and whether the ED is truly adaptive; and engaging in a close collaborative relationship in which alternative, healthier ways to meet emotional needs can be taught and experimented with.
Be willing to work deeply
The therapist needs to take time to peel back layers of self-awareness. Some clients are aware of the underlying seed from which the ED grew (such as a fear of developing sexuality or an impossibly enmeshed relationship with an emotionally powerful parent) but will not share that in therapy (e.g., until they trust the therapist to deal with it sensitively or until their assumed hopelessness for a healthy resolution has been assuaged). Other patients do not have conscious access to older psychological issues that help explain the onset and then maintenance of their condition. In such cases, it takes time to explore that together. This exploration is helped if the therapist is aware of the common adaptive functions that EDs can serve. It is often advised that therapy can take well over a year and the chronicity of illness correlates strongly with required duration of treatment (Touyz et al., 2013). However, working “deeply” does not mean very long-term therapy with no requirement to change. A lot of work on self-deficiencies and underlying motivation can be done relatively briefly when the therapy is focused. Fairburn (2008) advocates for 20 sessions for bulimia and 40 for AN when using CBT-E. Zipfel et al. (2014) compared CBT-E to focused psychodynamic therapy over 10 months, finding roughly equivalent results. Waller (2012) points out that engagement and motivation increase when early behavioral changes are emphasized and achieved in therapy.
Use “non-negotiables”
The form of therapy advocated above can take some time and the therapist must tolerate anxiety-provoking behaviors in their patient (vomiting and weight loss are objectively dangerous and EDs have a high mortality rate). This necessitates clear non-negotiables for the therapy. Geller has outlined a clinically useful guide in this regard (Geller & Srikameswaran, 2006). The therapist must be clear about when treatment would pause – perhaps for an inpatient admission, or to address some comorbidity. The involvement of medical practitioners who will monitor and treat any biological disturbances and communicate with the therapist is also advised. Having non-negotiables not only establishes a safe way to proceed, but also helps access core schemas of undeservedness or worthlessness in the client and can repair past experiences of neglect (Geller & Srikameswaran, 2006). Their therapist’s actions affirm to the client that they are indeed worth looking after well, and they may then learn how to care for themselves.
Use the parallel-track approach to target the core over-valuing of weight and shape
Addressing the overemphasis on weight and shape in self-evaluation is an almost universal recommendation by clinicians (Garner & Bemis, 1982; Fairburn, 2008; Fairburn et al., 2003; Waller et al., 2007). If the approach was purely psychological (addressing emotional needs and cognitive processes) then one could devote all the therapy time to issues such as self-evaluation, reinforcing a broader base of identity (or ego-strength), meeting the client’s interpersonal needs, or managing their emotional deficits. However, when this is done to the exclusion of attending to weight restoration and the normalizing of eating behaviors, then less progress is made (Garner et al., 1997; Waller et al., 2007). The person with an ED often pleadingly requests just to work on their affective distress or self-esteem or identity issues first – which will then enable them to eat more easily. This rarely works and fails to address the medical morbidity. The alternative is to do both roughly at the same time, as the vehicle of therapy moves down two “parallel tracks” (Garner et al., 1997). One cannot repair unhealthy or diminished self-evaluation while hanging on to a single dominant method of feeling adequate or safe (dieting). Furthermore, while the various reinforcing effects of dietary restriction and weight loss are present and while the neurocognitive effects of the same are having sway, then the capacity for and likelihood of therapeutic change is very low.
Identify and modify neurocognitive style
The findings of cognitive rigidity and difficulty in shifting set or seeing a bigger picture appear to be reliable. The importance lies in helping the individual to see how automatic cognitive processes have led them to form and become attached to certain “rules.” Cognitive remediation therapy (CRT) has been manualized by the developers of this approach (Tchanturia & Hambrook, 2010). It may not be possible to significantly change how a person’s brain processes tasks and information; however, respectfully raising insight into a person’s strengths and weaknesses in their cognitive style of information processing and into their capacity for cognitive flexibility may enable them to engage better in recovery.
Cognitive-behavioral therapy
Once this is all done, CBT can work remarkably effectively. There is certainly a role for classic behavioral and cognitive interventions even when the illness was triggered and then maintained by early dynamic processes. Once a patient is able to see objectively the early causal and maintaining factors, then they are better able to consider meeting their needs in healthier ways than through ED symptoms. Even then, they may still lack the insight or skills required to change all the habitual, forceful thoughts, rules, and urges that are the residue of years of ED. This is when the core interventions outlined by many, notably including Fairburn (2008), Garner et al. (1997) and Waller et al. (2007), can be most helpful. These strategies include self-monitoring of eating and its relationship with thoughts and feelings, using a collaborative case-formulation approach, and using goal-setting, hypothesis-testing, thought-challenging, and cognitive defusion. For many patients it is necessary to identify and work with the core beliefs around worth, defectiveness, and likelihood of rejection (Garner et al. 1997; Guidano & Liotti, 1983).
Conclusion
When it is said that EDs are disorders of the self, it means that the disorder reflects the nature of distress that the individual experiences and is manifest in their efforts to change or perfect those aspects of the self. Furthermore, aspects of the self change as the ED becomes more severe and chronic, and these changes reinforce the disorder, making it harder for the affected person to see the need for or benefit of recovery. If one abandons allegiances to any one model, then the psychodynamic and cognitive models can be integrated in clinical application. This integration is centered on the crucial observation that EDs come to serve functions in the person’s life that are sometimes desperately needed and at other times valued and prized. These functions can be unconscious needs emerging from early attachment failures, or deficits in coping or emotional damage. They could equally be conscious avoidance of an aversive state (such as sexual maturation) or pursuit of a positive state (such as competitive sense of achievement or moral superiority). Clinical observations require us to accept that there are broad psychodynamic and cognitive-behavioral factors in the development of an ED; and that these factors are present in various combinations and in varying intensities in each patient. As a result, the therapy must be individually tailored in its planning and execution and must offer sensitivity to the psychological needs of the individual, while providing a safe, knowledgeable, and structured pathway to recovery. The emerging success of Specialist Supportive Clinical Management (McIntosh et al., 2010) even for those with longstanding AN (Touyz et al., 2013) is an example of this in action. We all eagerly await the pending results of new large studies that will shed more light on what works for whom.
The Self in Understanding and Treating Psychological Disorders, ed. Michael Kyrios, Richard Moulding, Guy Doron, Sunil S. Bhar, Maja Nedeljkovic, and Mario Mikulincer. Published by Cambridge University Press. © Cambridge University Press, 2016.
References
Related posts:
The self in bipolar disorder
The self in schema therapy
The self in posttraumatic stress disorder
The self in the obsessive–compulsive-related disorders: hoarding disorder, body dysmorphic disorder, and trichotillomania
Painful incoherence: the self in borderline personality disorder
Future directions in examining the self in psychological disorders
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