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

2. Ideas for understanding anorexia nervosa

3. 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

4. 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

5. 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

6. 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

7. Anorexic Self v Feared Self continuum

8. 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

9. modes

10. 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

11. Vulnerable mode in AN

12. 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

13. 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

14. Maintenance cycles
Blocks to change

15. ‘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

16. ‘The Dictator’

17. ‘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

18. ‘Dam Builder’

19. Therapy tips

20. 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

21. 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

22. Thanks to all my colleagues in Edinburgh, Adelaide, Melbourne & Cape Town for their invaluable contributions to this work
Thanks for listening!