Exploring mechanisms underlying compulsive behaviour in anorexia

nervosa: implications for treatment

Caitlin Lloyd1, Dr Anne Haase1 & Dr Ian Frampton2

1 University of Bristol, UK 2 University of Exeter, UK

Overview

• Presentation of a novel model of the development and maintenance of anorexia nervosa (AN)

• Exploration of how the model may inform prevention interventions

• Group activity: How can the model inform current treatment?

Anorexia nervosa as a compulsive disorder

• Compulsive behaviour is repeated persistently despite maladaptive outcomes (Gillan & Robbins, 2014).

-experienced with a conscious urge (Everitt & Robbins, 2016).

• Persistent dietary restriction central to AN.-maladaptive to limit caloric intake at severely low weight.-AN sufferers report urges to engage in behaviour conducive to dietary restriction (Godier & Park, 2014a; 2014b).

Compulsive behaviour

Imbalance between habit system (dorsal striatum) and goal-directed system (prefrontal cortex and ventral striatum) dominance of habit system

Dominance of the habit system

Dietary restriction: a habit in AN

Foerde, Steinglass, Shohamy & Walsh (2016)

• In binary choice task individuals with AN and healthy women indicated preferences for a snack they would be required to eat.

• Selections correlated with caloric intake at buffet meal the following day.

• Individuals with AN less likely to choose high calorie foods and displayed enhanced caudate activation during selections.

• Caudate hyperactivity related to reliance on behavioural habits (Gillan et al., 2015).

The development of compulsive behaviour in AN

• Model presented by Park, Godier & Cowdrey (2014) and Godier & Park (2015) suggests goal-directed system weakness and strength of starvation habits responsible for development of compulsive starvation in AN.

• Habits develop and strengthen with behavioural repetition-proposed starvation is more rewarding for individuals with AN (Park et al., 2014).

-leading to continued engagement to the point it becomes a strong habit (Steinglass & Walsh, 2006; Walsh, 2013; Steinglass & Walsh, 2016).

Unanswered questions

• How does goal-directed system dysfunction develop?

• Why is starvation more reinforcing for certain individuals?

The role of anxiety in goal-directed system dysfunction

•Stress implicated in goal-directed system dysfunction, and related to reliance on habit system for learning and behavioural control (Soareset al., 2012).

•Changes in structure and function of goal-directed and habit system regions result from stress (Luksys & Sandi, 2011; Schwabe & Wolf, 2010; Soares et al., 2012).

• Individuals with anxiety disorders rely on habit system for learning (Alvares et al., 2014).

Anxiety and reinforcement

•Anxiolytic effects are negatively reinforcing.

•Anxiety is easier to reduce, and reductions are more beneficial, when baseline levels of anxiety are higher (Hadjistavropoulos et al., 2016; Hedman et al., 2015).

•Addictive substances are more reinforcing when one is in an aversive emotional state (Hogarth et al., 2015;

Owens et al., 2015; Rosseau et al., 2011).

Dietary restriction is negatively reinforcing

•Serotonin (5-HT) and noradrenalin (NA) systems mediate anxiety. Activity of these systems reduces when caloric intake is limited due to lower consumption of neurotransmitter precursors (Brockmeyer et al., 2012; Kaye et al., 2003).

Anxiety and AN

• Suggested anxiety increases the reinforcing effects of starvation, leading to excessive engagement in dietary restriction via development of AN drives, fears and preoccupations (O’Hara, Campbell & Schmidt, 2015).

• The excessive repetition of behaviour conducive to starvation, combined with a tendency to rely on the habit system for learning and control of behaviour, causes starvation to become compulsive.

Anxiety and AN

• Prolonged starvation upregulation of 5-HT and NA receptors.

• Anxiety relief evoked by starvation is temporary (Kaye et al., 2003).

• Starvation becomes necessary to maintain an acceptable emotional state.

• Anxiety is able to trigger restrictive behaviour.

Relationship between anxiety and AN is well supported

• Higher rates of anxiety disorders in AN populations, and individuals with AN display enhanced trait anxiety (Guarda et al., 2015).

• Anxiety present prior to AN onset (Kaye et al., 2004).

• Greater childhood anxiety related to lower BMI (Dellava et al., 2010).

Anxiety and dietary restriction in AN

•Ecological momentary assessment studies show anxiety is related to, and seems to actually precede, starvation behaviour in individuals with AN (Lavender et al.,

2013).

•Greater pre-meal anxiety predicted lower calorie intake at meal for individuals with AN (Steinglass et al., 2010).

Considering how anxiety operates gives rise to a novel model of AN development/maintenance

Activity: Model Walkthrough

Implications for prevention interventions

• Parallel cognitive dissonance programmes for body image and dieting (e.g. Healthy Living, Body Project)

• Management through emotion regulation training and anxiety reduction interventions (dieting)

• Aim to reduce need for habitual or repetitive behaviours

Small Group Work

• In small groups develop a novel intervention (standalone or adjunctive) that is based on the presented model.

• After 20 minutes be ready to feedback to the group outlining:

-the targets of your intervention.-how the treatment addresses these targets.-particular considerations that should be made when delivering/evaluating the intervention. -expected costs of the intervention.

Group Feedback

The task: In small groups develop a novel intervention that is based on the presented model.

Presentations should outline:

-Intervention targets.-How the treatment addresses these targets.-Particular considerations that should be made when delivering/evaluating the intervention. -Expected costs of the intervention.

for your attention

Thank you

Dr Joanna Steinglass

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