Control and perceived criticism in eating disorders


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Oral Presentation, European Council of Eating Disorders, ECED, Florence, 2011

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  • Presentiamo il frutto di molti anni di un gruppo ricerca, con dati psicopatologici e i dati preliminari di un trial randomizzato
  • La resistenza al cambiamento
  • The need to control eating and weight having the sensation of controlling life shows a perception general linsufficient control
  • Associazione tra criticismo e perfezionismo
  • Tuttavia, si sa poco sulla esatta natura di questa associazione: come interagiscono?
  • Cauta inferenza sul criticismo come fattore iniziale dell ’anoressia restrittiva
  • Implicazioni cliniche
  • Il trial
  • At baselina tha two groups did not show differences
  • Results in our protocol group
  • Domanda perché c’è una autostima più bassa all’inizio nel nostro gruppo e alla fine è migliore del gruppo di fairburn?
  • Ma nel nostro gruppo c’è anche l’intervento sul perfezionismo dato che diamo fairburn, perché se aggiungi controllo, perfezionismo diminiuisce nel nostro gruppo
  • Control and perceived criticism in eating disorders

    1. 1. Control and perceived criticism in eating disorders: their psychopathological role and significance for treatment Sandra Sassaroli+, Giovanni M. Ruggiero°   + Studi Cognitivi, Post-graduate cognitive psychotherapy school, Foro Buonaparte 57, 20121 Milano; ° Psicoterapia Cognitiva e Ricerca, Post-graduate cognitive psychotherapy school, Foro Buonaparte 57, 20121 Milano;
    2. 2. Clinical background <ul><li>Our research on control in ED began with the observation of anorexic clients who clearly became ill after a period of emotional stress </li></ul><ul><li>The symptom appeared to us as an attempt to retrieve control and a general feeling of self confidence on their lifes </li></ul>
    3. 3. Clinical underground <ul><li>This attitude was fundamental in resisting to change proposed by the psychotherapist </li></ul><ul><li>The clients considered the clinical relationship as a threat against their feelings of control and self esteem </li></ul><ul><li>This negatively influenced the motivation to treatment </li></ul>
    4. 4. Control in eating disorders <ul><li>In our opinion, the clinical concept of anxious perception of lack of control is applicable to eating disorders (ED). </li></ul><ul><li>In fact, the need of subjects with ED to feel in control of life, which gets displaced to controlling eating, weight, and body shape, implies a pervasive perception of insufficient control. </li></ul>
    5. 5. Control in eating disorders <ul><li>Subjects with ED often look for control (Bruch, 1973; Button, 1985). </li></ul><ul><li>Dietary restrictions enhance the subjective sense of being in control (Slade, 1982). </li></ul><ul><li>In the case of ED, the sense of control is often obtained by continuous monitoring of eating and body weight and shape (Fairburn & Harrison, 2003). </li></ul>
    6. 6. Control in eating disorders <ul><li>Hence, ED could be described as disorders of the sense of self-esteem combined with a illusory compensation (i.e., a need to feel in control of life), which gets displaced onto controlling eating (Fairburn, Shafran, & Cooper, 1999). </li></ul>
    7. 7. Control in eating disorders <ul><li>However, this popular theory did not generate empirical research on the role of the need for control in ED. </li></ul>
    8. 8. Criticism in eating disorders <ul><li>The second variable which attracted our clinical attention was perceived criticism </li></ul><ul><li>In our opinion, perceived criticism is a factor predisposing to maladaptive perfectionism , which in turn is a main risk factor for ED </li></ul><ul><li>Episodes of perceived criticism related to harsh parenting styles are probably experienced during childhood or adolescence and should temporally precede the emergence of perfectionism in an adult individual. </li></ul><ul><li>Kawamura, Frost, and Harmatz (2001) have reported evidence in support of this hypothesis. </li></ul>
    9. 9. Criticism in eating disorders <ul><li>In fact, maladaptive perfectionism includes an intense self-critical attitude ( Frost, Marten, Lahart, & Rosenblate, 1990 ). </li></ul><ul><li>Perfectionism strongly interacts with and is dependent upon perceived criticism ( Brewin, Firth-Cozens, Furnham, & McManus, 1992; Vieth & Trull, 1999; Kawamura, Frost, & Harmatz, 2001; Huprich, 2003; Irons, Gilbert, Baldwin, Baccus, & Palmer, 2006 ). </li></ul>
    10. 10. Criticism in eating disorders <ul><li>The association between perceived criticism and maladaptive perfectionism in individuals with ED is a well-established finding (Hewitt & Flett, 1991; Dunkley, Blankstein, Masheb, & Grilo, 2006). </li></ul><ul><li>However, it is not clear how these two factors would interact with each other . </li></ul><ul><li>We aimed at assessing the nature of this interaction. </li></ul>
    11. 11. Control and criticism <ul><li>During past years, we developed empirical research aimed at testing the roles of control and criticism and how control and criticism participated to the psychological process of ED (Sassaroli et al., 2003, 2005, 2008; Ruggiero et al., 2003) </li></ul><ul><li>Given that other reserches privileged the study of perfectionism, our research team aimed at exploring how control and criticism interact with perfectionism </li></ul>
    12. 12. Our studies: interaction between control, criticism and perfectionism <ul><li>We tested how control and perceived criticism predicted drive for thinness, bulimia, and body dissatisfaction when interacting with perfectionism </li></ul><ul><li>We tested both mediatonal and moderational models (Sassaroli et al., 2003, 2005, 2008; Ruggiero et al., 2003) </li></ul><ul><li>We used clinical and non clinical samples and self report questionnaires </li></ul>
    13. 13. More frequently used instruments in our studies <ul><li>Drive for thinness , bulimia , and body dissatisfaction subscales of the Eating Disorders Inventory-version 3 (EDI-3, Garner, 2004) to measure ED. </li></ul><ul><li>The Multidimensional Perfectionism Scale (MPS; Frost, Marten, Lahart, & Rosenblate, 1990) measures six dimensions of perfectionism, including concern over mistakes </li></ul><ul><li>The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) assesses global self-esteem and sense of self-worth </li></ul><ul><li>The Anxiety Control Questionnaire (ACQ; Rapee, Craske, Brown, & Barlow, 1996) assesses perceived control over emotional reactions and external threats. </li></ul>
    14. 14. Results <ul><li>Perfectionism mediates between criticism and ED, while control moderate the influence of perfectionism on ED </li></ul><ul><li>In addition we replicated the well known finding about the role of self esteem </li></ul>
    15. 15. Visual summary of results of our correlational studies (Sassaroli et al., 2003, 2005, 2008; Ruggiero 2005)
    16. 16. Control: discussion <ul><li>Our results suggest that ED psychopathology reflects not only cognitive constructs of perfectionism and low self-esteem but also imply beliefs about maintaining psychological stability and well being with rigid and controlling attitudes and behaviors . </li></ul>
    17. 17. Treating control <ul><li>Concerning the treatment of issues of control, the therapist should develop a strategy that challenges the belief that the degree of control exerted by the patient is insufficient ( appraisal of control as insufficient ) and the belief that only absolute control is acceptable ( desire for and compulsion to control ). </li></ul><ul><li>Our clinical team developed and published (Sassaroli & Ruggiero, 2008) the treatment protocol for the biased perception of control. </li></ul>
    18. 18. Treating control <ul><li>The final aim of a treatment focused on control is to encourage the patient: </li></ul><ul><li>To disconnect the rigid link between control on eating and the feeling of general control of life and interpersonal relationships </li></ul><ul><li>To accept a smaller degree of exerted control and to develop the ability to judge a partial degree of control as being sufficient. </li></ul>
    19. 19. Criticism: discussion <ul><li>In addition, results suggest that restrictive dieting would be related to a process in which perceived criticism is the initial factor which facilitates the arising of perfectionism </li></ul><ul><li>From our results it might be cautiously inferred that maladaptive perfectionism is a sort of reaction to painful experiences of perceived criticism , which in turn generates the ED when the person focuses his or her perfectionism on the narrow domain of body aspect, weight and fat. </li></ul>
    20. 20. Treating criticism <ul><li>Concerning criticism, the intervention should be aimed at assessing suffering related to the conflicting relationship and helping the patient to recognize that he or she would use perfectionism to cope with the emotional pain generated by criticizing relationships. </li></ul>
    21. 21. Sandra Sassaroli, M.D. 1 , Roberta Fiscaletti, Psy.D. 1 , Francesca Fiore, Ph.D. 1 , Sara Bertelli, M.D. 3 , Silvio Scarone, M.D. 3 , Giovanni Maria Ruggiero, M.D. 2 1 Studi Cognitivi, Cognitive Psychotherapy School, Milano, 2 Psicoterapia Cognitiva e Ricerca, Cognitive Psychotherapy School, Milano, Italy 3 Eating Disorders Unit, Ospedale San Paolo Milano The control focused treatment of eating disorders (CFT-ED): a randomized trial
    22. 22. Introduction <ul><li>The Control Focused Treatment of Eating Disorders (CFT-ED) applies our research results to clinical practice </li></ul><ul><li>CFT-ED is a variant of the standard cognitive-behavioural treatment for eating disorders (Fairburn ’ s CBT-ED) that assumes that the assessment and the treatment of the belief of control will increase the understanding of the psychopathology of ED and the efficacy of cognitive treatment </li></ul><ul><li>At the present moment, we have not introduced criticism in the clinical protocol yet </li></ul>
    23. 23. CFT-ED <ul><li>CFT-ED adds interest about the cognitive belief of control to Fairburn ’ s clinical protocol and comprises three steps: </li></ul><ul><li>1) assessing and recognizing control as a conscious cognitive belief; </li></ul><ul><li>2) assessing the connection between control of eating, weight, and food and the perception of general control of life; </li></ul><ul><li>3) reframing the patient ’ s attitude about the belief of insufficient control and reframing the compulsion for absolute control. </li></ul>
    24. 24. Method: Instruments <ul><li>30 patients who receive treatment in Ospedale San Paolo di Milano, Cà Granda, with Bulimia Nervosa completed a number of self-reported instruments on clinical and cognitive aspects of ED: </li></ul><ul><ul><li>Eating Disorders Inventory (EDI-3; Garner, 2004); </li></ul></ul><ul><ul><li>Anxiety Control Questionnaire (ACQ; Rapee, Craske, Brown, & Barlow, 1996); </li></ul></ul><ul><ul><li>Multidimensional Perfectionism Scale (MPS; Frost, Marten, Lahart, & Rosenblate, 1990); </li></ul></ul><ul><ul><li>Rosenberg Self-Esteem Scale (RSE; Rosenberg 1965); </li></ul></ul><ul><ul><li>General Satisfaction Questionnaire (GSQ, Huxley P., Mohamad H.,1991 ; Conti L., 2000). </li></ul></ul>
    25. 25. Method: Participants <ul><li>30 Subjects divided in two groups: </li></ul><ul><ul><li>CFT-ED group (CFT, Sassaroli & Ruggiero, 2010) </li></ul></ul><ul><ul><li>Fairburn ‘ s (enhanced) E-CBT-ED group (Fairburn, Cooper, Shafran, 2003) </li></ul></ul><ul><li>85% Females (Age 31,5; SD=5,76), and 15 % Males (Age 30,2; SD=4,23). </li></ul><ul><li>Randomized allocation  to one of the two groups </li></ul><ul><li>Each participant provided written informed consent. The Ethical Committee of the “ Studi Cognitivi ” cognitive psychotherapy school of Milan approved the study. </li></ul>
    26. 26. Method: Therapy and therapists <ul><li>12 sessions of Fairburn ’s CBT-ED and 12 sessions of CFT-ED were delivered to patients by 6 CBT therapists trained in “Studi Cognitivi” (officially recognized cognitive psychotherapy school in Italy) </li></ul><ul><li>3 therapists implemented CBT-ED according to Fairburn ’s protocol; they were forbidden to ever introduce to the patient the cognitive belief of control or encourage (or discourage) the patient to speak about control when the patient spontaneously introduced the topic; </li></ul><ul><li>3 therapists implemented CFT-ED according to Sassaroli ’s CFT-ED published protocol (Sassaroli, Ruggiero, 2008) </li></ul>
    27. 27. Baseline <ul><li>The data were analyzed by a series of multivariate analysis; </li></ul><ul><li>Comparison between the two groups at Time 0 does not show statistical differences. Hence samples were clinically and cognitively matched </li></ul>
    28. 28. Results: CFT-ED group from T0 (beginning) to T1 (12 sessions) Clinical variables improved: bulimia, body dissatisfaction, interoceptive awareness, asceticism, Cognitive variables improved: concern over mistakes (pathological perfectionism), Worsened : self-esteem
    29. 29. Results: Fairburn’s CBT-ED group from T0 (beginning) to T1 (12 sessions) Clinical variables improved: bulimia
    30. 30. Comparison between CFT-ED and Fairburn’ s CBT-ED at T1 (12 sessions) Concern over mistakes lower (= better) in Fairburn CBT group; Control higher (= better) in CFT group
    31. 31. Comparison between CFT-ED and Fairburn ’s E-CBT-ED at T2 (6 months follow-up) No difference regarding Concern over mistakes; Control, life satisfaction and self-esteem higher (= better) in CFT group
    32. 32. Summing up <ul><li>At the 12th session : </li></ul><ul><ul><li>Fairburn ’s CBT-ED group clinically improved </li></ul></ul><ul><ul><li>CFT-ED group clinically and cognitively improved </li></ul></ul><ul><ul><li>Perfectionism better in Fairburn E-CBT-ED group </li></ul></ul><ul><ul><li>Control better in CFT-ED group </li></ul></ul><ul><li>Follow-up 6 months </li></ul><ul><ul><li>Clinical improvement equal in both group </li></ul></ul><ul><ul><li>Perfectionism lowered (= improved) in both groups (no difference) </li></ul></ul><ul><ul><li>Sense of control higher (= improved) in CFT group </li></ul></ul><ul><ul><li>Life satisfaction higher in CFT group </li></ul></ul><ul><ul><li>Self-esteem higher in CFT group </li></ul></ul>
    33. 33. Discussion <ul><li>From a clinical viewpoint: both Fairburn’ s CBT-ED and CFT-ED interventions show a significant improvement </li></ul><ul><li>The treatment of control could generate a temporary lowering of self esteem. However at follow up, self esteem is higher in our CFT-ED group than in Fairburn’s CBT-ED group. </li></ul>
    34. 34. Discussion <ul><li>From a cognitive viewpoint, results confirm cognitive targets: Fairburn ’s E-CBT-ED influences mainly perfectionism and CFT influences mainly control. However at follow up perfectionism in our CFT-ED group is as improved as in Fairburn’s CBT-ED group </li></ul><ul><li>Follow up: CFT-ED patients seem to show higher well-being (higher life satisfaction and self-esteem) </li></ul>
    35. 35. Clinical implications <ul><li>In conclusion, a treatment more focused on control could add a degree of psychological well-being to clinical improvement afforded by standard CBT ? </li></ul><ul><li>A cognitive intervention more attuned to the psychological complexity of the disorder could add a sense of wellbeing to the client? </li></ul><ul><li>The clients feel a better understanding of their suffering ? </li></ul>
    36. 36. Limitations <ul><li>Increasing the number of patients per group </li></ul><ul><li>Exploring the mediators/moderators of change: is clinical improvement due to either control or perfectionism? Or to both? </li></ul>
    37. 37. <ul><li>Thank you very much! </li></ul><ul><li>Email: [email_address] [email_address] </li></ul>