A schema-mode model for anorexia nervosa A brief introduction Dr Calum Munro, Consultant Psychiatrist in Psychotherapy, Anorexia Nervosa Intensive Treatment Team, Edinburgh, Scotland.

Ideas for understanding anorexia nervosa

1. Core Needs in Anorexia Nervosa Active self-deprivation is a key feature of AN Involves both psychological & physical core needs in AN physical needs often need prioritisation for safety reasons So, we developed an adapted core needs framework Ref’s Maslow 1962 ; Tay & Diener 2011

Core Need Framework for AN PSYCHOLOGICAL CORE NEEDS PHYSICAL CORE NEEDS EMOTIONAL SAFETY The need to feel secure and safe enough CONTROL & COMPETENCE The need to feel ‘in control’ enough, with a sense of autonomy & confidence NURTURANCE The need to feel loved and cared for enough by others & by the self ACCEPTANCE The need to feel accepted enough by others & by the self for your strengths & fallability PHYSICAL SAFETY The need for enough warmth, shelter & protection from physical harm ACTIVITY The need for enough movement & activity NUTRITION The need for enough food & fluids REST The need for enough rest & sleep

2. Shame about Vulnerable Self An excess of vulnerable feelings Vulnerable psychological feelings: e.g. anxious, down, angry Vulnerable physical feelings: e.g. hungry, cold, tense, big Secondary shame about vulnerable feelings develops from an early age Toxic self-critical core beliefs I am unacceptable; I am too needy; I am lazy & greedy My feelings are unacceptable; My body is unacceptable

3. Anorexic Self v Feared Self Toxic core beliefs about unacceptability and neediness generate potent fears: ‘I’m not a good enough person’ or ‘I’ll not be a good enough person without my anorexia’ We call this the Feared Self and conceptualise it on a continuum with the Anorexic Self to discuss with patients

Anorexic Self v Feared Self continuum

4. Attachment to their ‘eating disorder’ People with AN universally have insecure attachment Ref. Ringer & Crittenden, 2007 Attachment to their ‘eating disorder’ feels safer than relying on interpersonal relationships with others ‘Anorexia’ viewed as a reliable friend & guide often as their only true identity

modes

Vulnerable mode in AN State of experiencing vulnerable feelings, reflecting unmet needs, with a sense of child-like helplessness People with AN want out of this mode, at any cost ashamed of feeling vulnerable and having needs wanting to control or detach Often drop ‘child’ label initially

Vulnerable mode in AN

Striving for control or perfection Self-Critical Mode (SCM) Equivalent of Demanding Parent Mode (Bernstein) Function in AN is to motivate to be a ‘better’ person, through self-criticism Over-Controller Mode (OCM) (as Bernstein) Function is to generate obsessively over-controlled, over- detailed behaviour to avoid ‘mistakes’, to make themselves a ‘better’ person Many guises re- control of self, others, the world

Cut-off or Hide Compliant-Surrenderer Mode (CSM) (as Bernstein) Detached Mode (DPM & DSS) (as Bernstein) Function in AN is to cut-off & numb; or to soothe vulnerable feelings through repetitive behaviours Self-soothing overlaps with OCM - repetitive routines can generate detached states Compliant-Surrenderer Mode (CSM) (as Bernstein) Function is to avoid the shame of their vulnerability and fallibility being recognised by others and risk criticism Putting others needs ahead of their own, self-sacrificing ‘Mask’ to appear OK and hide feelings

Maintenance cycles Blocks to change

‘The Dictator’ Maintenance Cycle SCM & OCM dominate escalating efforts to gain control of unacceptable vulnerability: tougher rules (SCM) and more obsessional routines (OCM) Increasing time taken up on controlling weight and vulnerable feelings – squeezing out the rest of life worsening mood and slide into a submissive depressive state of hopeless resignation (HRM) Analogy of a Dictatorship

‘The Dictator’

‘Dam Builder’ Maintenance Cycle OCM, DM & CSM dominate Extreme efforts to control and protect oneself from vulnerable feelings and problems (OCM) Strenuous physical or mental routines as a way of detaching from vulnerable feelings (DM) With other people, try hard to appear OK on the outside, so no-one is concerned and no-one interferes (CSM) We have used analogy of building a dam or a wall to hide and hold back vulnerability

‘Dam Builder’

Therapy tips

Therapy Tips for ST with AN Patience – sloooww process to build trust Acknowledge and validate the value of AN Illness is highly valued & ego-syntonic (ref Schmidt & Treasure 2006) Beware ‘functional’ detached protector Denial & detachment, ‘I’m fine’ = difficult to reach Resistance to formal technique use, so integrate subtly Therapist needs to feel secure about medical input to manage physical risks

Assessing Readiness to change ‘Loyal Anorexic’: determined commitment to the value of AN ‘Desperate Defector’: so desperate and scared that consider change ‘The Ambivalent Conscript’: a weak healthy mode, with intellectual understanding of their illness and what keeps them stuck ‘The Freedom Fighter’: enough of a healthy mode that they commit to recovery & ‘freedom’ from illness, yet, the semi-automatic nature of the maladaptive modes pulls them back frequently ‘The Free Woman/Man’: committed to recovery & beginning to reap the rewards of trusting themselves & being free from extreme self-criticism & self-control

Thanks to all my colleagues in Edinburgh, Adelaide, Melbourne & Cape Town for their invaluable contributions to this work Calum.Munro@nhslothian.scot.nhs.uk Thanks for listening!