ED Patient: Innocent or complicitous victim?

1. ED Patient: Innocent or complicitous victim? An exploration of self-protective strategies in ED PM Crittenden & SR Wilkinson

2. Four Parts of Presentation • Overview of attachment (DMM) 2. Discussion of appearance & reality in ED 3. Three ED examples 4. Closing discussion Crittenden & Wilkinson

3. Three Aspects of Attachment • Inter-personal: Strategies for eliciting protection and comfort • Intra-personal: Information processing • Familial: Array of interacting strategies Crittenden & Wilkinson

4. Central concepts in the Dynamic Maturational Modelof 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 child’s mind. Crittenden & Wilkinson

5. Central Concepts in the DMM, con’t 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). Crittenden & Wilkinson

6. Attachment Models • Ainsworth: A B C • Main & Solomon: A B C D (disorganized) • In practice: Secure (B) versus Insecure • Dynamic-Maturational Model (DMM, Crittenden) Crittenden & Wilkinson

7. Ainsworth Patterns of Infant Attachment Integration Predictability Negative Affect Crittenden & Wilkinson

8. Ainsworth Patterns of Infant Attachment Plus Main & Solomon’s Disorganized Integration Predictability Negative Affect Secure ↑ ← Disorganized → ↓ Crittenden & Wilkinson

9. DMM: Transforming Information • Serves a self-protective function • Becomes more sophisticated with maturation of brain • Appearance ≠ reality Crittenden & Wilkinson

10. B3 Comfortable B1-2 B4-5 Reserved Reactive A1-2 C1-2 Avoidant Resistant/ Passive A+ C+ pre- compulsive pre- coercive A/C DMM in Infancy Integrated True Information True Cognition True Negative Affect Balanced Crittenden & Wilkinson

11. Psychological Advances • Implicit (non-verbal) causality • Implicit affective states • Being together: - in temporal contingency and - affective attunement Crittenden & Wilkinson

12. B3 Comfortable B1-2 B4-5 Reserved Reactive A1-2 C1-2 Threatening/Disarming Socially Facile/ Inhibited A3-4 C3-4 A/C Compulsively Caregiving/ Compliant Aggressive/ Feigned Helpless 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 Crittenden & Wilkinson

13. Psychological Advances • Verbal statements of what causes what • Words for feeling states • Construction of interpersonal episodes • Or the absence of these Crittenden & Wilkinson

14. B3 Comfortable B1-2 B4-5 Reserved Reactive C1-2 A1-2 Threatening/Disarming Socially Facile/ Inhibited A3-4 C3-4 A/C Compulsively Caregiving/ Compliant Aggressive/ Feigned Helpless C5-6 Punitive/ Seductive 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 Crittenden & Wilkinson

15. Psychological Advances • Why did you do that – when you knew you weren’t supposed to?!! • Understanding the causes of one’s own behavior – Which DR regulated action? Crittenden & Wilkinson

16. B3 Comfortable B1-2 B4-5 Reserved Reactive A1-2 C1-2 Threatening/Disarming Socially Facile/ Inhibited A3-4 C3-4 A/C Compulsively Caregiving/ Compliant Aggressive/ Feigned Helpless A5-6 C5-6 Compulsively Promiscuous/ Self-Reliant Punitive/ Seductive 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 Crittenden & Wilkinson

17. Psychological Advances • Wordless communication: • Type A: Borrowed words & ideas • Type C: Sullen wordlessness, behavioral communication Crittenden & Wilkinson

18. B3 Comfortable B1-2 B4-5 Reserved Reactive A1-2 C1-2 Threatening/Disarming Socially Facile/ Inhibited A3-4 C3-4 A/C Compulsively Caregiving/ Compliant Aggressive/ Feigned Helpless A5-6 C5-6 Compulsively Promiscuous/ Self-Reliant Punitive/ Seductive A7-8 C7-8 Delusional Idealization/ Externally Assembled Self Menacing/ Paranoid AC Psychopathy 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 Crittenden & Wilkinson

19. Strategies for Dangerous Caregivers Type A: • Do the right thing from the perspective of others. • Inhibit displays of negative affect. Crittenden & Wilkinson

20. 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.) Crittenden & Wilkinson

21. B3 Comfortable B1-2 B4-5 Reserved Reactive A1-2 C1-2 Threatening/Disarming Socially Facile/ Inhibited A3-4 C3-4 A/C Compulsively Caregiving/ Compliant Aggressive/ Feigned Helpless A5-6 C5-6 Compulsively Promiscuous/ Self-Reliant Punitive/ Seductive A7-8 C7-8 Delusional Idealization/ Externally Assembled Self Menacing/ Paranoid AC Psychopathy DMM in Adulthood No psychopathology Apparently not clinical, sometimes somatic Inexplicable & troubling psychopathology Very severe pathology Very severe pathology Extreme pathology Crittenden & Wilkinson

22. 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. Crittenden & Wilkinson

23. 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. Crittenden & Wilkinson

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

25. Parallel processing yields: • Many different DRs; • Each processed differently by the brain; • Multiple solutions to each problem. Crittenden & Wilkinson

26. 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. Crittenden & Wilkinson

27. 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. Crittenden & Wilkinson

28. 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. Crittenden & Wilkinson

29. Safety in the face of danger requires a fast response at the cost accuracy of response. Hence, exposure to danger reduces integration. Crittenden & Wilkinson

30. Peter Cook and Dudley Moore Dud: So would you say you’ve learned from your mistakes? Pete: Oh yes, I’m sure I could repeat them exactly. Crittenden & Wilkinson

31. Defining Crazy Doing again what failed every time before - and expecting a different outcome this time. Crittenden & Wilkinson

32. Three hypotheses: • ED girls are trying to protect themselves. • Parents of ED girls are trying to protect the girls. • Appearance does not equal reality. Crittenden & Wilkinson

33. Three Examples of Appearance/Reality Discrepancy • Ringer & Crittenden findings with DMM • Case study from in-patient treatment • Case study of family process & politics: Crittenden & Wilkinson

34. Adult Attachment Interview • DMM classifications & method • Assess strategy & information processing • Multiple DRs assessed • Strategy, trauma, modifiers Crittenden & Wilkinson

35. 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 Crittenden & Wilkinson

36. 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? Crittenden & Wilkinson

37. Ringer Sample • 19 Anorectics (restricting) • 26 Bulimics • 17 Anorectics (binging) Crittenden & Wilkinson

38. 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 Crittenden & Wilkinson

39. Common DMM strategies for ED • C5-6 • C3-4 (bulimic) • A1/C5-6 • [A] C5-6 (false A1) • A3-4 (Ringer & Crittenden) Crittenden & Wilkinson

40. Ringer & Crittenden Results, Con’t • Few Utr; most imagined (erroneous causation) • Almost no modifiers – very strategic (not Dp) Crittenden & Wilkinson

41. Transformations • Exaggerated affect • Non-verbal communication • Strategy employed without regard to outcomes • Strategy can be used self-destructively without regard to results Crittenden & Wilkinson

42. Psychological & Strategic Effects: Deception • Adol and family both focus on what can be said or talked about (displacement of problems). • This misleads everyone. It isn’t “lying”, but it deceives the self and others. Crittenden & Wilkinson

43. Why use deception? Parents’ perspective: • To protect the child from bad stuff; • To protect the parent from bad stuff; • Because they don’t know how to fix the bad stuff. Crittenden & Wilkinson

44. Why use deception? Adolescents’ perspective: • To avoid losing contact with a protective parent; • To communicate with the skills that one has. Crittenden & Wilkinson

45. Deception Scale • Lie • Intentional deception • Self-deception • Involving self-deception • Reciprocal & involving self-deception • Reciprocal, involving, & intentional self- and other-deception Crittenden & Wilkinson

46. Familial Processes Two cases of ED adolescents & parents: - Exploration of AAIs - In-patient clinical experience. Crittenden & Wilkinson

47. 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. Crittenden & Wilkinson

48. A Developmental Perspective on “Truth” • Truth about the past is not predictive truth. • The brain is evolved to use information to predict the future. Crittenden & Wilkinson

49. The only information that we have is information about the pastwhereasThe only information that we need is information about the future. Crittenden & Wilkinson

50. Consequently, information from the past must be transformed to maximally predict danger in the future. Crittenden & Wilkinson