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Anorexia Nervosa as a Passion Louis C. Charland Ph.D. Professor Departments of Philosophy and Psychiatry & School of Health Studies University of Western Ontario London Ontario Canada N6A 3K7 Email: charland@uwo.ca Slide 2 Hypothesis Anorexia Nervosa is a Passion (A Theoretical Empirical Hypothesis) Slide 3 Oxford Circa 2008 Collaborative Insights Tony Hope, Psychiatrist Ribots concept of passion fits Tan & Hope et al. Anorexia study data very nicely. Louis C. Charland, Philosopher Ribots concept of passion helps understand predominance of affectivity in Tan & Hope et al. study data, especially the manner in which emotions and feelings are organized. Slide 4 Collaboration Louis C. Charland PhD Professor, Departments of Philosophy and Psychiatry & School of Health Studies, University of Western Ontario, London, Ontario, Canada Tony Hope MD Professor of Medical Ethics and Honorary Consultant Psychiatrist, The Ethox Centre, Department of Public Health, University of Oxford Anne Stewart MD Consultant Psychiatrist, Oxford City CAMHS and Honorary Senior Clinical Lecturer, University of Oxford Jacinta Tan MD Senior Research Fellow and Honorary Consultant Psychiatrist, College of Health and Human Sciences, Swansea University Slide 5 Study Twenty-nine patients with anorexia nervosa were recruited from four different centers across the south of England. Sixteen of the participants were under the age of 18 years. The patients ages ranged from 15 to 26 years. At the time of interview patients were at various stages and levels of anorexia. The Body Mass Index (BMI) of all but six participants was below 20 (the generally accepted lower limit of the normal range) with a mode of 17 and the lowest value of 12. Tony Hope, Jacinta Tan, Anne Stewart, Ray Fitzpatrick. Anorexia Nervosa and the Language of Authenticity. Hastings Center Report, Volume 41, Number 6, November-December 2011, 19-29 Slide 6 Hypothesis Anorexia Nervosa is a Passion (A Theoretical Empirical Hypothesis) Slide 7 Clinical Features Diagnosis ICD 10: an intrusive dread of fatness DSM IV: intense fear of gaining weight or becoming fat Weight 85% less than normal and BMI 17.5 kg/m2 Course Progressive worsening with gradual loss of control. Relentless pursuit of thinness, often to the point of starvation Observations Patients often secretive, deny their symptoms, and resist treatment Patients typically lack a sense of autonomy and selfhood Kaplan Benjamin, J. & Sadock Virginia A. Synopsis of Psychiatry (9th Ed.). Philadelphia: Lippincott, Williams & Wilkins, 2003, 739-741. Weight Criteria for Diagnosis of Anorexia Nervosa Hebebrand, Johannes, Wehemeier, Peter M. & Helmut Remschmidt, Am J Psychiatry 2000;157:1024-1024. 10.1176/appi.ajp.157.6.1024 Slide 8 Terminology Phthisiologia, Richard Morton 1689 Apepsia Hysterica, William Gull 1868 Anorexia Histerique, Charles Lasgue 1873 Anorexia Hysterica, William Gull 1873 Anorexia Nervosa, Wiliam Gull 1873 Self-Starvation, Vandereycken & Van Deth 2001 Slide 9 Passion to be Thin (Mild Lifestyle Form) IMPORTANT: This is NOT a pro-ana or pro-mia site. http://thinspiration-pictures.blogspot.ca/ Slide 10 http://www.documentingreality.com/forum/f149/extreme-anorexia-collection-51048 / Passion to be Thin (Extreme Lifestyle Form) Slide 11 http://2.bp.blogspot.com/-6Aiq9ERuXI4/Tgl8qbvwdvI/AAAAAAAABEE/BRy_Agf9QvQ/s1600/Anorexia_case-1900- Nouvelle_icononographie_de_la_Salpetriere.jpg http://www.documentingreality.com/forum/f149/extreme-anorexia-collection-51048 / Passion to be Thin (Morbid Form) Slide 12 Passion to be Thin (Severe Morbid Form) Kaplan Benjamin, J. & Sadock Virginia A. Synopsis of Psychiatry (9 th Ed.). Philadelphia: Lippincott, Williams & Wilkins, 2003, 742. Slide 13 Presentation Today IWhat is a Passion? IIWhy Anorexia Nervosa is a passion IIIImplications Slide 14 What is a Passion? Slide 15 Reinstating the Passions: Arguments from the History of Psychopathology Charland, Louis C. (2010). Reinstating the Passions: Arguments from the History of Psychopathology. In Peter Goldie (Ed.) The Oxford Handbook of Philosophy of Emotion (Oxford: Oxford University Press), 237-259. Slide 16 Affectivity: Today Emotions Moods Feelings Slide 17 Affectivity: History Passions Affections Slide 18 From Passions to Emotions Amlie Oskenberg Rorty (1982) Thomas Dixon (2003) From Passions to Emotions and Sentiments Philosophy, Vol. 57, No. 220 (April), 159-172 From Passions to Emotions: The Creation of a Secular Psychological Category. Cambridge University Press. Slide 19 1649 Aprs avoir considr en quoi les passions de lame diffrent de toutes les autres penses, il me semble quon peut gnralement les dfinir des perceptions, ou des sentiments, ou des motions de lame, quon rapporte particulirement elle, et qui sont causes, entretenues, et fortifies par quelque mouvement des esprits. Rene Descartes, Les Passions de l Ame. Paris: Librairie Gnrale Franaise, 1649/1990. Article 27, p.57 Slide 20 Thodule Armand Ribot Dec 8, 1839 - Dec 18, 1916 cole Normale Suprieure 1875 Psychologie exprimentale Sorbonne 1885 Chaire de psychologie exprimentale et compare, Collge de France 1888 Slide 21 Achievements Agrg de philosophie, cole normale suprieure 1965 Appointed to College de France 1888 First Chair of Experimental and Comparative Psychology Champion of psychologie physiologique Reviews of British and German psychology. Books on memory, personality, attention, will, unconscious Several books on affectivity and la vie affective Introduced mthode pathologique Known for Ribots Law; Anhedonia Founder of International Congress of Psychology, Paris 1889. [Congrs International de Psychologie Physiologique] Founder of Revue philosophique de la France et de l'tranger Slide 22 Essai Sur Les Passions 1907 Slide 23 Examples Jealousy Guilt Ambition Drunkenness Collecting Note:Not all names of passions are names of emotions. Slide 24 Why Anorexia Nervosa is a Passion Slide 25 Criteria for a Passion Slide 26 1. Long-Term Orientation the illness is so consuming you cant see past it, it IS everything you think about all the time. Its how you make every single decision, its how you get up each morning and go to bed each night, it is everything. And you cant see past that to a life beyond it at all, it becomes who you are completely and you get quite delusional almost, that thats just the way you are and there isnt anything else! Slide 27 2. Fixed Ideational Focus it [losing weight] was the most important thing in my life at the time. Ive always, apart from the obvious things like my family and my friends, Ive always thought my work and doing well at school is the most important thing, but for that, I mean even now my works gone back to being my most important thing, but at that point losing weight was the most important thing . the illness is so consuming you cant see past it, it IS everything you think about all the time. Its how you make every single decision, its how you get up each morning and go to bed each night, it is everything So - it really runs things. Slide 28 3. Motivating Power I still can see facts as they are. What Ive lost is the ability to apply them for myself because emotions have taken over, but I dont think my rational side is being destroyed, or anything. I think its still there, its just a question of accessing it.... once we had pizza and I hadnt had pizza in like at least a year and it was like, it was just so I couldnt even bite, I couldnt even like cut it I was just so like, they couldnt believe how traumatised I was about a pizza! And so I think its quite funny now, but it was really, I was crying at the table, I was, I couldnt look at it, I just felt sick and I just didnt want to touch it, it made me feel horrid. Slide 29 4. Organizes Emotions I love the feeling I get when I can feel my bones sticking out. I love feeling empty. I love knowing I went the whole day without eating. I love losing weight. I love people telling me 'you're too skinny!' I hate being this so-called normal weight. I feel like a fat, blubbery, nasty lardbag. (But why these particular feelings and emotions and related affective dispositions in these circumstances?) Hellmich, Nanci. 2011. On the Web: Thinness Worship. USA Today, Health & Science, 07/24/2001 - Updated 10:07 PM ET. http://www.usatoday.com/news/health/2001-07-24-anorexia-sites.htm accessed 09/02/2012 1:58pm Slide 30 5. Integrated with Cognition if youre anorexic then you think that you need to lose weight and so if you think that you need to lose weight your next logical step is how am I going to lose weight, so then your thought process is ok Im going to eat less or Im going to, like, do more like work out more. Slide 31 6. Progressive Course I think it was just something that I slipped in to and I did without realising. And it was almost like because I had, that became I suppose a level of achievement for me, it was a goal, I wasnt aiming to LOSE weight but then realising that I could do it spurred me on I think losing the weight just becomes SO compulsive that - almost you dont think about things, you dont think there was an active decision to give things up, it was more that it, the drive, the pull towards the anorexia was so strong that I almost didnt, it almost wasnt a conscious decision. Slide 32 7. Morbidity because you cant see how thin you are or how ill you are because you are just constantly concentrating on how thin you could be. So even if youre just down to your bones youd just be like, oh look Ive still got some more on there, and I think that striving to be thinner prevents people from being able to say wait, stop and say, wait actually I am too thin and I do need help and I think thats why people are unable to make proper decisions. Well I always THOUGHT that I could, like before I tried it I thought all the time well I could easily eat more and stop this if I wanted. But when I came to try to do that I couldnt. Slide 33 Anorexia as a Passion Intellectual Component Ide fixe: central law in anorexic schema Affective Component Specific feelings and emotions at specific times Motivational Component Strong tendency to act according to above Slide 34 Anorexic Passion Slide 35 Implications Slide 36 An Affective Disorder I wouldnt say anorexia is a thought as such. I dont think I, its more of a feeling I, I WANT to do it and I guess in a way its almost an EMOTION, anorexia. And everyone says well you know youve got to think of your heart, what do you really want in your heart? Well its like I want anorexia but I know in my HEAD that I shouldnt, because you know I know thats why I sort of know about all the sort of risks and everything. So its sort of like at what point, which, where does the choice come from as well?..... Because, theres this little emotion that seems to accompany being thin, and I cant it, I cant really, I dont really have the language to explain it, Not an affective disorder of mood Not an affective disorder of emotion Not an affective disorder of feeling An affective disorder of passion Slide 37 Addictive Grip Interviewer: And are there any things that you wish people whove never had anorexia nervosa should understand? Participant: That youre not doing it because you want to. Youre not doing it because you want some form of attention.... youre not doing it because youre selfish and you want everybodys lives to revolve around you. And that you dont WANT it. Its not something that youve chosen to have, you havent gone out and said well Im gonna be an anorexic. Its something thats, thats captured you not the other way round. Slide 38 Loss of Control For a long time I thought it was, there was nothing wrong with me, it was, there was nothing wrong with me, it was just other people thought there was, something wrong with them not me, but um over the summer I did feel that I really wasnt in control of what I was doing and its sort of before then I never really tried to get better, Id always been forced to or, kind of, gone along with it to keep other people happy and I thought that as soon as I decided I did want to get better Id be able to, but now I realise it doesnt quite work like that and so thats kind of made me see it as a bit more of an illness, something you dont have complete control over. Slide 39 Decisional Capacity It is not clear that a person driven by a passion is acting autonomously. The behavior and decisions (including to refuse treatment) are not the result of careful and rational reflection on life- goals (that is the paradigm of autonomous behavior). The decisions (e.g. to refuse treatment) may be rationalized in ways that meet the standard criteria for capacity, but be made as a result of the affective motivating power of the passion. In order to help the person to be free from the grip of the passion, and attain a greater degree of autonomy over her life, it may be necessary to impose upon her a routine that has a chance of breaking down the self-destructive patterns of behavior that is both part of, and helps maintain, the passion that is anorexia nervosa. Slide 40 Treatment Early Intervention Essential Limits of Cognitive-Behavioral Therapy Ribot, How the Passions End (1907) Jackson, Passions in Psychological Healing (1990) Contraria Contratiis Curanator Jackson, Stanley, W. The Use of the Passions in Psychological Healing The Journal of the History of Medicine and the Allied Sciences Vol. 45, 1990, 150-175. Slide 41 Thank you Louis C. Charland Ph.D. Professor Departments of Philosophy and Psychiatry & School of Health Studies University of Western Ontario London Ontario Canada N6A 3K7 Email: charland@uwo.ca Slide 42 Treatment Decision-Making in Anorexia Nervosa an Empirical Project The empirical ethics project on treatment decision-making in anorexia nervosa had its inception in the early 1990s in Oxford, United Kingdom, when Professor Tony Hope, a medical ethicist who is also a psychiatrist by background, and Dr Anne Stewart, a child and adolescent psychiatrist with a special interest in eating disorders, first formed the idea of investigating capacity to refuse treatment in anorexia nervosa. Tony and Anne were joined by Dr Jacinta Tan, then a junior doctor in training to be a psychiatrist, and together they began to develop an empirical method to conduct ethics research and began exploratory fieldwork in this area. In 2002, Jacinta completed her specialist training and embarked on a large scale qualitative research project of patients and parents views on this subject as well as a survey of psychiatrists attitudes, funded by a Wellcome Trust Health Services Research Training Fellowship. Professor Ray Fitzpatrick, Professor of Public Health at the University of Oxford and an eminent medical sociologist, joined the team to provide expertise on research methods. The data collection was completed in 2006 and followed up with a project, again funded by the Wellcome Trust, developing methods of validating the results through workshops with research participants, other patients and parents, and health professionals. This culminated in the production of a report for laypeople which is available in the public domain at http://www.psychiatricethics.org.uk/ANwebreport/report.pdf. Although initially developed to investigate capacity in people with anorexia nervosa, the qualitative data has highlighted many different aspects of the patient experience of anorexia nervosa and its treatment. After publishing several widely- quoted results papers, the implications of the rich data set are still being explored, in particular how it sheds light on the concept of capacity in general as well as broad experiences of patients with anorexia nervosa. Slide 43 Interviews Semi-structured interviews began with the interviewer asking about what the participant felt and thought about anorexia nervosa. The interviewer encouraged each participant to enlarge on her initial responses. The interviewer proceeded to ask about the following general areas: understanding of anorexia nervosa; views about compulsory treatment and the role of the family; beliefs about shape and weight and around risks from being low in weight; experiences of treatment; views about the impact of anorexia nervosa on decision-making; views and values about the future, and the impact of anorexia nervosa on these.