ED Patient: Innocent or complicitous victim

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ED Patient Innocent or complicitous victim?

• An exploration of
• self-protective strategies in ED
• PM Crittenden SR Wilkinson

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Four Parts of Presentation

• Overview of attachment (DMM)
• 2. Discussion of appearance reality in ED
• 3. Three ED examples
• 4. Closing discussion

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Three Aspects of Attachment

• Inter-personal Strategies for eliciting
  protection and comfort
• Intra-personal Information processing
• Familial Array of interacting strategies

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Central concepts in the Dynamic Maturational
Model of Attachment (DMM)

• Attachment refers to self-protective processes
  used in the face of threat or danger.
• Attachment is about HOW to protect oneself, not
  how strong the bond is.
• Its form depends on the information available to
  the childs mind.

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Central Concepts in the DMM, cont

• 2. Attachment behaviour organizes into strategies
  for elicting protection and comfort (9-11 mo.)
• 3. The array of possible strategies increases as
  the brain matures making new information and
  new actions possible (1 year-old age).

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Attachment Models

• Ainsworth A B C
• Main Solomon A B C D (disorganized)
• In practice Secure (B) versus Insecure
• Dynamic-Maturational Model (DMM, Crittenden)

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Ainsworth Patterns of Infant Attachment
Integration
Predictability
Negative Affect
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Ainsworth Patterns of Infant Attachment Plus Main
Solomons Disorganized
Integration
Predictability
Negative Affect
Secure
? ? Disorganized ?
?
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DMM Transforming Information

• Serves a self-protective function
• Becomes more sophisticated with maturation of
  brain
• Appearance ? reality

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DMM in Infancy
Integrated True Information
True Cognition
True Negative Affect
Balanced
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Psychological Advances

• Implicit (non-verbal) causality
• Implicit affective states
• Being together
• - in temporal contingency and
• - affective attunement

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DMM in the Preschool Years
Integrated True Information
True Cognition
True Negative Affect
Distorted Cognition Omitted Neg. Affect
Distorted Neg. Affect Omitted Cognition
False Positive Affect
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Psychological Advances

• Verbal statements of what causes what
• Words for feeling states
• Construction of interpersonal episodes
• Or the absence of these

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DMM in the School Years
Integrated True Information
True Cognition
True Negative Affect
Distorted Cognition Omitted Neg. Affect
Distorted Neg. Affect Omitted Cognition
False Positive Affect
False Cognition
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Psychological Advances

• Why did you do that when you knew you werent
  supposed to?!!
• Understanding the causes of ones own behavior
  Which DR regulated action?

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DMM in Adolescence
Integrated True Information
True Cognition
True Negative Affect
Distorted Cognition Omitted Neg. Affect
Distorted Neg. Affect Omitted Cognition
Sexual desire
False Positive Affect
False Cognition
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Psychological Advances

• Wordless communication
• Type A Borrowed words ideas
• Type C Sullen wordlessness, behavioral
  communication

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DMM in Adulthood
Integration of True Information
Cognition
Negative Affect
Distorted Cognition Omitted Neg. Affect
Distorted Neg. Affect Omitted Cognition
False Positive Affect
False Cognition
Integration of False Information
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Strategies for Dangerous Caregivers

• Type A
• Do the right thing from the perspective of
  others.
• Inhibit displays of negative affect.

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Strategies for Non-contingent Parents

• Type C
• Stick to your own feelings bribe threaten.
• Demand what you feel you need now!
• (The future is unpredictable.)

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DMM in Adulthood
No psychopathology
Apparently not clinical, sometimes somatic
Inexplicable troubling psychopathology
Very severe pathology
Very severe pathology
Extreme pathology
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Strategies Representations

• The construct of internal working models has
  been used to describe the mental component of the
  strategies employed to protect the self.
• Dispositional representations (DRs) are a more
  accurate way of describing the interface between
  psychological functioning and behavior.

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Dispositional Representations (DRs)

• Network of firing neurons representing the state
  of
• - self now
• - context now
• - associations with self and context in past
• (Perception is 90 memory - Gregory)
• DRs function to dispose self to act.

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• No model is stored.
• DRs are always generated anew in the present.
• The presence, and probability of firing, of
  synapses reflects past experience.

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• Parallel processing yields
• Many different DRs
• Each processed differently by the brain
• Multiple solutions to each problem.

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Types of information guiding self-protective
strategies

• 1. Predictable consequences (Type A)
• Understanding of causation
• Low slow arousal ? little somatic awareness
• Inhibition of negative affect display of false
  positive affect (fear smile)
• Therefore temporal order of events guides DRs.

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• 2. Unpredictable consequences (Type C)
• Lack of understanding of causation
• High fast arousal
• Use of displays of affect to elicit protection
  comfort
• Therefore feelings guide DRs.

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Integration

• Integration corrects error, selects the best DR,
  constructs new and more comprehensive DRs.
• Integration is slow.
• Integration consumes brain resources, i.e., it
  reduces scanning for danger.
• Integration is dangerous if danger is near.

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Safety in the face of danger requires a fast
response at the cost accuracy of response.
Hence, exposure to danger reduces integration.
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Peter Cook and Dudley Moore

• Dud So would you say youve learned from your
  mistakes?
• Pete Oh yes, Im sure I could repeat them
  exactly.

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Defining Crazy

• Doing again what failed every time before -
• and expecting a different outcome this time.

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• Three hypotheses
• ED girls are trying to protect themselves.
• Parents of ED girls are trying to protect the
  girls.
• Appearance does not equal reality.

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Three Examples of Appearance/Reality Discrepancy

• Ringer Crittenden findings with DMM
• Case study from in-patient treatment
• Case study of family process politics

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Adult Attachment Interview

• DMM classifications method
• Assess strategy information processing
• Multiple DRs assessed
• Strategy, trauma, modifiers

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Failure of Strategies

• Localized, topic-specific failure of strategic
  functioning Unresolved trauma
• Generalized, pervasive failure of strategic
  functioning Depression Disorientation
• Punctuated, generalized pervasive failure of
  strategy with imaginary intrusions
  Disorganization

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Questions

• Are ED patients strategic?
• What strategies do they use?
• What transformations of information are needed
  and why?
• Do different symptoms presentations differ by
  strategy transformation?

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Ringer Sample

• 19 Anorectics (restricting)
• 26 Bulimics
• 17 Anorectics (binging)

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Ringer Crittenden Results

• Limited engagement with interviewer, few episodes
• Several strategies used by EDs
• No difference by type of ED
• Strategies not unique to ED

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Common DMM strategies for ED

• C5-6
• C3-4 (bulimic)
• A1/C5-6
• A C5-6 (false A1)
• A3-4
• (Ringer Crittenden)

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Ringer Crittenden Results, Cont

• Few Utr most imagined (erroneous causation)
• Almost no modifiers very strategic (not Dp)

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Transformations

• Exaggerated affect
• Non-verbal communication
• Strategy employed without regard to outcomes
• Strategy can be used self-destructively without
  regard to results

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Psychological Strategic Effects Deception

• Adol and family both focus on what can be said or
  talked about (displacement of problems).
• This misleads everyone. It isnt lying, but it
  deceives the self and others.

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Why use deception?

• Parents perspective
• To protect the child from bad stuff
• To protect the parent from bad stuff
• Because they dont know how to fix the bad stuff.

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Why use deception?

• Adolescents perspective
• To avoid losing contact with a protective parent
• To communicate with the skills that one has.

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Deception Scale

• Lie
• Intentional deception
• Self-deception
• Involving self-deception
• Reciprocal involving self-deception
• Reciprocal, involving, intentional self- and
  other-deception

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Familial Processes
Two cases of ED adolescents parents -
Exploration of AAIs - In-patient clinical
experience.
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Truth in ED Families

• Parents have past dangers with current traumatic
  effects.
• Parents have current problems (e.g., marital
  discord).
• Parents try to protect their children from these
  by hiding them.

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A Developmental Perspective on Truth

• Truth about the past is not predictive truth.
• The brain is evolved to use information to
  predict the future.

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The only information that we have is information
about the pastwhereasThe only information
that we need is information about the future.
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Consequently, information from the past must be
transformed to maximally predict danger in the
future.
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Five Transformations of Information

• Truly predictive (things are as they appear).
• Erroneous (things have no meaning, but they
  appear to, trust them)
• Omitted (important things appear irrelevant,
  forget them)
• Distorted (things appear, but must be minimized
  or exaggerated to fit the future)
• Falsely predictive (things mean the opposite of
  what they appear to mean).

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Discovery of truth by pre-ED baby

• Infancy
• M is caring baby wants her.
• M is sometimes unavailable or upset B gets
  anxiously upset.
• M gets more upset when B gets upset.
• Outcomes B wants M, cant predict Ms behavior,
  inhibits angry feelings but is aroused.

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Psychological Strategic Effects

• Causal information is omitted.
• Affect is exaggerated.
• Child is Type C2-4 and maybe also idealizing of M
  (A1/C2-4)

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Discovery of truth by pre-ED child

• Preschool
• M is caring child wants her.
• M is sometimes unavailable or upset child tries
  to talk about it, but M wont tell this story.
• M is most comforting when child needs help.
• Outcomes Child wants M, doesnt understand
  causation, doesnt learn language of feeling,
  cant tell episodes of difficulties, learns to
  appear helpless.

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Psychological Strategic Effects

• Language does not replace affect for
  communication so information is not explicit.
• Angry feelings are hidden from view so anger is
  not experienced or expressed explicitly.
• Child becomes excessively dependent on M for
  comfort and well-being.

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Discovery of truth by pre-ED child

• School-age
• M is caring child wants her- so child hides her
  anger.
• Child feels bad acts different from peers, has
  few friends, but cant explain why.
• Child finds erroneous causal explanations.
• Outcomes Child wants M, is angry but acts meek,
  creates erroneous explanations, cant use
  language to solve problems. M tries harder to
  help, worries, but cant talk about bad stuff.

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Psychological Strategic Effects

• Lacking words, episodes, and a dialogue, child
  does not learn to reflect integratively on self,
  feelings, and behavior
• False explanations and distorted feelings are
  generated by child and accepted with relief by
  parents.
• Everyone thinks life is hunky-dory. It is not.

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Discovery of truth by ED adolescent

• Secondary school
• M is worried Adolescent uses passive aggression
• Adolescent feels hopeless, becomes sullen (if
  words dont function, why use them?)
• Adolescent cant become independent, doesnt want
  to leave, but cant stay
• M doesnt understand, tries to help, makes it
  worse
• Outcomes Adolescent becomes symptomatic, hides
  symptoms, misunderstands causal relations.

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Psychological Strategic EffectsIgnorance and
Incompetence

• Adolescent is in an internal struggle lacks the
  mental skills to resolve it.
• Adolescent is in an interpersonal struggle and
  lacks the social communicative skills to
  resolve it.
• Adolescent does not know and cannot tell about
  the true issues nor can the family.

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Psychological Strategic Effects Deception

• Adolescent and family both focus on what can be
  said or talked about (displacement of problems).
• This misleads everyone. It isnt lying, but it
  deceives the self and others.

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Macro-system processesTerri Schiavo case

• Adolescent bulimia, quick marriage
• Black hole of desperation (family follows her to
  FL)
• Triangulated struggle between Terri, husband, her
  family (as if she had a lover!)
• Recurrence of bulimia, heart attack, brain
  damage

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Terri Sciavo, cont

• Imagined processes (right to life)
• Obscured issues (family struggle Terris
  adulthood)
• Unexpected outcomes at all levels (government
  becomes part of family mental illness and
  displaced struggle)
• Unexpected effects of media attention to ED
  increase prevalence of this symptom display in
  troubled youth?

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Psychological Strategic EffectsThe Breaking
Point

• By adolescence, everything is at stake
• - self-identity
• - understanding causality feelings
• - personal independence
• - future family reproduction.
• The struggle to survive the struggles becomes
  itself a death struggle with phantom problems.

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In the eating disorders, the struggle to survive
the obscured family struggles becomes itself a
death struggle around phantom problems.
Appearance no longer resembles reality.
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Treatment

• Therapist (T) needs a mental model of ED.
• T needs to discover the specifics of the ED
  patient her parents.
• T needs to know own strategy (usually Utr, often
  A3, sometimes C3-6, some earned B).
• As and Cs usually need different intervention
  strategies

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Treatment, cont

• Establish safety patient, parents, staff.
• Be open explicit, not entrapped.
• In parallel,
• (1) increase skills of ED patient and family
• (2) open family secrets to view safely.
• Avoid moral judgment this is about safety
  comfort.

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Three central ideas

• Patients and parents use protective strategies.
• That have unexpected outcomes.
• That lack and verbal integrating processes.
• A C require different approaches.
• Trauma is not central.
• Developmental pathways and dispositional
  representations are.

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To contact us

• pmcrittenden_at_att.net or www.patcrittenden.com
• simonroger.wilkinson_at_uus.no