The “denial” (note those “”) of the illness in anorexia is well described. It is one of the most frustrating aspects of the illness for carers and clinicians alike. It contributes greatly to the expressed emotion (frustration, anger, criticism and patient blaming) that comes from clinicians and acts as a therapist driven therapy interfering behaviour. Therapist will describe their feelings that somehow the patient is willfully lying to them, because the patient “must” be aware of their illness. They are being that naughty anorexic patient who seems to seek out to disrupt therapy.
What if clinicians ask that question that we ask patients so often “Is there a different, more workable, way of thinking about this?” As always, the answer is yes.
Until I began reading the blogs of Laura Collins, I had never heard of anosognisia. This is apparently a common problem in several brain diseases which where the sufferer no insight or is unaware of the illness. It occurs in neurological diseases such as Alzheimer’s disease, Huntington’s disease and after strokes. It can also be a feature of schizophrenia and bipolar disorder.
Some FMRI pictures and more information can be found here.
Im not sure if it has ever been studied in anorexia nervosa. Im not sure if it would be preexisting and exacerbated by starvation, or caused by starvation.
It important though for us to hold information in a way that may help us see that anorexia nervosa is not a willful choice. Holding this stance is incredibly helpful for therapist (and hence their patients).
A recent post on the PsychCentral Blog reports on a study by Norman Farb, a PhD psychology student from the University of Toronto published in Biological Psychiatry.
"When previously depressed individuals enter mild states of sadness, their brain’s response can predict if they will sink into depression again, say researchers at the University of Toronto.
“Part of what makes depression such a devastating disease is the high rate of relapse,” says Norman Farb, a PhD psychology student and lead author of the study.
“However, the fact that some patients are able to fully maintain their recovery suggests the possibility that different responses to the type of emotional challenges encountered in everyday life could reduce the chance of relapse.”
For the study, researchers used functional magnetic resonance imaging (fMRI) to track the brain activity of 16 formerly depressed patients as they watched sad movie clips. Sixteen months later, after nine of the 16 patients had relapsed into depression, the team compared the brain activity of the relapsed patients against those who remained healthy as well as a control group who had never been depressed". .....Click here to read the full PsychCentral post
This has some interesting implications for psychological treatment of depression.
The article suggests that the neurological difference is related to rumination about sadness. This is where we get sad or worried about our own sadness, which of course keeps the cycle of depression going. Mindfulness Cognitive Behavioural Therapy (MBCT) teaches patients to develop what might be called an "observer self". This is where we develop the skill of "meta cognition" where we look at, rather than respond to our thoughts. We notice that they are thoughts which may or may not be helpful, rather than facts that must be followed as truth. Patients with depression are specifically taught in MBCT to be aware of their thoughts about sadness and to let them pass, rather than act on them. For example, "It's awful that I'm sad, I think I am getting depressed again. Why is this happening to me. This is awful" could be noticed, rather than ruminated on. Rumination is likely to focus your mind on all things negative, which begin to create a self fulfilling prophecy about becoming depressed.The UK National Institute of Clinical Excellence (NICE) has recently endorsed MBCT as an effective treatment for prevention of relapse in Depre. Research has shown that people who have been clinically depressed 3 or more times (sometimes for twenty years or more) find that taking the program and learning these skills helps to reduce considerably their chances that depression will return. The evidence from two randomized clinical trials of MBCT indicates that it reduces rates of relapse by 50% among patients who suffer from recurrent depression.
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