Anorexia Nervosa: Striving for Control

Anorexia nervosa (AN) is an eating disorder characterized by severely low bodyweight, fear of weight-gain, and a subjective believe to be “fat”. An elevated need for control and fear of losing control are considered core aspects in the development and maintenance of AN and restricting food intake is thought to function as a means to gain feelings of control (Fairburn, Shafran, & Cooper, 1999; Schmidt & Treasure, 2006). Feelings of inefficiency (i.e. lack of control regarding personal goals) have been found to predict longer duration of treatment and worse treatment outcome, underlining the relevance of the need for control in AN (Olatunji, Levinson, & Calebs, 2018; Pinto, Heinberg, Coughlin, Fava, & Guarda, 2008; Surgenor, Maguire, Russell, & Touyz, 2007). The constant striving for control could lead to rumination and negative affect – two further important symptoms associated with AN. The Goal Progress Theory of rumination (GPT; Carver & Scheier, 1990; Martin & Tesser, 1996) proposes that perceived discrepancies between desired goals (in the case of AN e.g. goals regarding lowest possible calorie intake, weight, etc.) and the current state (in the case of AN e.g. the subjective conviction of having eaten or weighing too much) trigger ruminative thoughts, which subsequently lead to negative affect. Following this theory, it could be suggested that gaining feelings of goal-progress and control could lessen the burdening repetitive thoughts and negative affect and that individuals with AN try to achieve this by restricting food intake. This dietary restriction requires self-control. However, previous research has shown that patients with AN typically not only show such elevated self-control, but also display rigid habitual behaviours and routines, struggle with set-shifting, and often display comorbid obsessive-compulsive symptoms (Treasure & Schmidt, 2013; Halmi et al., 2003). This raises the question of whether food restriction in AN is indeed an act of self-control or rather a habit. Recent scientific development has challenged the traditional dichotomy between controlled and automatic processes (Shiffrin & Schneider, 1977), instead suggesting that they are intertwined in such a way that often self-control works via the establishment of goal-serving habits and routines (Gillebaart & de Ridder, 2015; Galla & Duckworth, 2015). These theoretical considerations can generally draw support from previous research, but have not been investigated explicitly in the context of AN. It was the main goal of this thesis to analyse associations between feelings of inefficiency, rumination and negative affect, controlled and habitual behaviour, and eating behaviour to establish an empirical foundation for the proposed relationships between these aspects of AN. Study 1 (Fürtjes, Seidel, et al., 2020) employed ecological momentary assessment (EMA; data collection several times a day over a period of several days in the natural environment of the participants) to investigate associations between feelings of inefficiency, rumination, and affect in a sample of individuals with a history of AN who had recovered from the disorder in terms of eating behaviour and bodyweight and age-matched healthy control participants (HC). AN participants displayed elevated rumination about bodyweight/figure (but not food) and negative affect compared to HC, suggesting that these cognitive-affective symptoms are persistent even after recovery. Analyses investigating associations with inefficiency showed that inefficiency was associated with heightened rumination and negative affect, which is in line with the GPT. Furthermore, AN participants showed higher levels of inefficiency than HC and stronger associations between rumination and negative affect. These findings indicate that feelings of lack of goal-progress and control are a central aspect of AN, likely contributing to maintenance of the disorder by triggering dysfunctional cognitive-affective processes. The fact that these associations were still present in a sample of recovered individuals underlines the persistence of these processes, suggesting that they might not only maintain the disorder but could also present a vulnerability factor or contribute to risk of relapse. Study 2 (Fürtjes et al., 2018) made use of EMA and leptin, an endocrinological marker of undernutrition, to further investigate associations between rumination and affect in a sample of patients with acute AN, once at the beginning of treatment and again after weight-restoration. In line with Study 1, results confirmed that rumination about bodyweight/figure and negative affect are closely linked in AN and that this association persists even after weight-gain. Thoughts about food on the other hand were associated with leptin levels, declined with weight-gain, and showed weaker associations with affect. This suggests that thoughts about food may reflect a physiological symptom of the disorder, connected to undernourishment, whereas thoughts about bodyweight/figure might present a cognitive-affective symptom which could be involved in maintenance of the disorder (as suggested by Study 1). To test supporting evidence for the interaction of self-control and habits in the regulation of eating behaviour, Study 3 (Fürtjes, King, et al., 2020) employed task-based measures of controlled and automatic processing as well as self-report measures of self-control, habitual behaviour, and eating behaviour in a large female sample representative of the general population through an online study design. Results obtained via structural equation modelling (SEM) revealed that eating behaviour appears to be largely guided by habits and automatic behavioural tendencies, whereas controlled aspects have an indirect influence via this association. These findings could be interpreted as support for the proposal that self-control might work via the establishment of goal-serving habits and routines, which outlines the possibility that the restrictive eating behaviour in AN might be achieved and maintained via a combination of self-control and rigid routines and habits. Taken together, the research presented in this thesis was able to demonstrate how striving for control as a core aspect of AN might play a role in triggering dysfunctional cognitive-affective processes, likely contributing to development and maintenance of the disorder, and that self-control and habitual behaviour interact inguiding human eating behaviour, carrying implications for the mechanisms behind restrictive eating in AN. Clinical implications that can be derived from this research include addressing need for control and feelings of inefficiency in therapy to enable improvement of dysfunctional cognitive-affective processes as well as eating behaviour

The Relationship Between Trauma, Attachment, Self-Compassion, and Emotion Regulation: A Structural Equation Model

Previous research has examined the relationship between trauma, attachment, selfcompassion, and emotion regulation, but never with an incarcerated population. Given the link between emotion regulation and illegal behaviors, it may be helpful to more fully understand this relationship in order to lay the groundwork for future intervention research. I gathered data from 378 participants. I then examined the relationships between these constructs on data from 204 participants, the number that remained after cleaning the data, by way of a structural equation model. Findings suggest that greater experiences of trauma may lead to insecure attachment styles, impacting individuals’ ability to trust and access supportive relationships, both of which lead to difficulties regulating emotions, which has been shown to be related to illegal behavior and incarceration. A lack of security in relationships and difficulties in regulating emotions are also connected to an individual’s self-report of self-compassion. This highlights the systemic impact of trauma and ways it may predispose those who have experienced trauma to be more likely to engage in illegal behavior and self-judgment. Research and practice implications are discussed

The Bifactor Model of Psychopathology: Methodological Issues and Clinical Applications

For decades, clinicians have debated whether psychiatric problems should be ‘lumped’ into broad dimensions or ‘split’ into discrete entities. The bifactor model provides a potential solution to this debate by including both a general dimension of psychopathological severity known as the p factor, and specific dimensions reflecting specific problem areas such as internalizing and externalizing. This thesis evaluates the methodological properties and clinical utility of the bifactor model. Chapter 3 is a reliability review of bifactor studies and demonstrates that while self-report measures capture both general and specific domains of psychopathology, the total and subscale scores derived mainly reflect a general p factor. Chapter 4 investigates whether the general and specific psychopathology factors are products of response biases (i.e. tendencies in the way people fill out questionnaires), rather than variation in people’s experiences of psychiatric problems. Less than 4% of the variance in the general and specific psychopathology factors was explained by response biases, demonstrating their substantive validity. Chapter 5 analyzes clinical outcomes assessed over a psychosocial intervention for antisocial youth with a bifactor model and demonstrates more nuanced changes in disorder-specific factors after accounting for changes in the p factor (e.g., antisociality declines but anxiety increases over time). Similarly, Chapter 6 demonstrates the prognostic value of specific personality disorders for predicting depression outcomes assessed over an inpatient intervention only after accounting for the prognostic effect of a general personality disorder factor (e.g., borderline personality disorder predicts slower recovery). These findings demonstrate the substantive nature of the general and specific psychopathology factors, but also the difficulties in reliably measuring specific domains beyond general psychopathology. They also support the bifactor model’s utility in untangling clinically relevant effects that are otherwise masked by the shared variance among psychiatric problems

Investigating Avatar Customization as a Motivational Design Strategy for Improving Engagement with Technology-Enabled Services for Health

Technology-enabled services for physical and mental health are a promising approach to improve healthcare globally. Unfortunately, the largest barrier for effective technology-based treatment is participants' gradually fading engagement with effective novel training applications, such as exercise apps or online mental health training programs. Engaging users through design presents an elegant solution to the problem; however, research on technology-enabled services is primarily focused on the efficacy of novel interventions and not on improving adherence through engaging interaction design. As a result, motivational design strategies to improve engagement---both in the moment of use and over time---are underutilized. Drawing from game-design, I investigate avatar customization as a game-based motivational design strategy in four studies. In Study 1, I examine the effect of avatar customization on experience and behaviour in an infinite runner game. In Study 2, I induce different levels of motivation to research the effects of financial rewards on self-reported motivation and performance in a gamified training task over 11 days. In Study 3, I apply avatar customization to investigate the effects of attrition in an intervention context using a breathing exercise over three weeks. In Study 4, I investigate the immediate effects of avatar customization on the efficacy of an anxiety reducing attentional retraining task. My results show that avatar customization increases motivation over time and in the moment of use, suggesting that avatar customization is a viable strategy to address the engagement barrier that thwarts the efficacy of technology-enabled services for health

Exploring the barriers to generating compassionate imagery in individuals diagnosed with a personality disorder: The role of adverse childhood experiences, self-compassion and current affect

This thesis is presented in three distinct sections: Part one consists of a systematic literature review that explores the relationship between self-compassion and the severity of post-trauma psychopathology. A total of 18 studies were examined and reviewed. The findings of this review demonstrated that lower self-compassion is associated with poorer post-traumatic outcomes which include higher levels of post-traumatic stress disorder symptoms, depression, anxiety, eating disorders, substance abuse and suicidality. This thesis was conducted as part of a joint project with another student who was also completing her clinical psychology doctorate at UCL (Naismith, 2016). Part two presents an empirical paper that explored whether adverse childhood experiences (ACEs), current affect and self-compassion were predictive of the ability to generate compassionate imagery in individuals diagnosed with a personality disorder. General imagery vividness, negative mood and the negative psychological impact of ACEs were related to difficulties with generating compassionate imagery. Levels of self-compassion improved after one-week of practising the imagery exercises. The distressing impact of childhood trauma may need to be addressed prior to engaging some individuals with a personality disorder in standard forms of compassion focussed therapies. Part three of this thesis consists of a critical appraisal of the work. It specifically highlights the importance of considering the emotional impact of this work on the researcher. The emotional reactions can be conceptualised as a catalyst that activates development of compassionate ways of working with stigmatised groups, specifically those that have received a diagnosis of a personality disorder

Social media mental health analysis framework through applied computational approaches

Studies have shown that mental illness burdens not only public health and productivity but also established market economies throughout the world. However, mental disorders are difficult to diagnose and monitor through traditional methods, which heavily rely on interviews, questionnaires and surveys, resulting in high under-diagnosis and under-treatment rates. The increasing use of online social media, such as Facebook and Twitter, is now a common part of people’s everyday life. The continuous and real-time user-generated content often reflects feelings, opinions, social status and behaviours of individuals, creating an unprecedented wealth of person-specific information. With advances in data science, social media has already been increasingly employed in population health monitoring and more recently mental health applications to understand mental disorders as well as to develop online screening and intervention tools. However, existing research efforts are still in their infancy, primarily aimed at highlighting the potential of employing social media in mental health research. The majority of work is developed on ad hoc datasets and lacks a systematic research pipeline. [Continues.]</div

The Influence of Neuroendocrine and Genetic Markers of Stress on Cognitive Processing and Intrusive Symptoms

This body of research investigated the influence of neuroendocrine and genetic elements of arousal on cognitive processes in the development of intrusive memories and flash-forward intrusions as related to Post-Traumatic Stress Disorder. Specifically, this thesis investigated various mechanisms that may underlie intrusive symptoms as postulated by prevalent theories of PTSD. Study 1 examined the distinctive relationship between peritraumatic dissociation and subsequent re-experiencing symptoms. Network analyses revealed strong positive edges between peritraumatic dissociation and subsequent amnesia, as well as the re-experiencing symptoms of physical reactivity to reminders, flashbacks, intrusions, and dreams, and to a lesser extent emotional numbness and hypervigilance. The finding that peritraumatic dissociation is related to subsequent re-experiencing symptoms is consistent with cognitive models that emphasize the role of dissociative experiences during a traumatic event in the etiology of PTSD re-experiencing symptoms. Study 2 aimed to determine whether peri-traumatic stress, as measured via salivary cortisol and salivary alpha-amylase, as well as pre-existing genetic polymorphisms on the FKBP5 gene increased dissociation and data-driven processing, and subsequently impacted intrusive memories related to a trauma film. The findings revealed that greater noradrenergic arousal predicted less intrusive memory distress in individuals who scored higher on data-driven processing and trait dissociation, and in FKBP5 low-risk carriers. For individuals who reported less data-driven processing and trait dissociation, and in FKBP5 high-risk carriers, as noradrenergic arousal increased, intrusive memory distress increased. This study also showed no association between data-driven processing with memory fragmentation, and fragmentation with intrusive memories. Whilst these findings support some aspect of cognitive models of PTSD as they indicate a role for data-driven processing and dissociation in intrusive symptoms, they highlight a threshold at which these variables stop moderating the relationship between arousal and intrusive memories and suggest that memory fragmentation is not related to intrusive memories. Study 3 examined the role of cognitive control in flash-forward intrusions in the context of an enduring stressor, the COVID-19 pandemic. In line with expectations, results showed that as cognitive control worsened, FKBP5 high-risk carriers reported more flash-forward distress, and low-risk carriers reported less distress. These findings are considered in the context of hippocampal changes and are consistent with emerging theories of PTSD. Lastly, study 4 sought to investigate the role of two neurological processes, pattern separation and pattern completion in intrusive memories in individuals with PTSD compared to trauma exposed controls. Consistent with existing literature, the data indicate that individuals with PTSD reported more data-driven processing, more intrusive symptoms, and demonstrated better behavioural pattern completion than trauma-exposed controls. These findings are in line with current cognitive models of PTSD, as they again indicate a role for data-driven processing in PTSD. However, study 4 found no support for the postulate that deficient pattern separation is a feature of PTSD and found an opposite effect for the role of pattern completion. Whilst these findings are inconsistent with theory, they are in line with existing experimental studies. Overall, the findings from this thesis provide insight into cognitive and biological models of PTSD and shed light on the mechanisms underlying the nature and development of intrusive symptoms

Design revolutions: IASDR 2019 Conference Proceedings. Volume 3: People

In September 2019 Manchester School of Art at Manchester Metropolitan University was honoured to host the bi-annual conference of the International Association of Societies of Design Research (IASDR) under the unifying theme of DESIGN REVOLUTIONS. This was the first time the conference had been held in the UK. Through key research themes across nine conference tracks – Change, Learning, Living, Making, People, Technology, Thinking, Value and Voices – the conference opened up compelling, meaningful and radical dialogue of the role of design in addressing societal and organisational challenges. This Volume 3 includes papers from People track of the conference

Development and psychometric properties of the Multidimensional Schizotypy Scale: a new measure for assessing positive, negative, and disorganized schizotypy

This dissertation reports on the development of a new self-report questionnaire measure of schizotypy – the Multidimensional Schizotypy Scale (MSS). Schizotypy offers a useful and unifying construct for understanding schizophrenia-spectrum psychopathology. Questionnaire measures have been widely used to assess schizotypy and have greatly informed our understanding of the construct; however, available measures suffer from a number of limitations, including lack of a clear conceptual framework, outdated wording, unclear factor structure, and psychometric shortcomings. The MSS is based on current conceptual models and taps positive, negative, and disorganized conceptual dimensions of schizotypy. The derivation sample included 6,265 participants sampled from four universities and Amazon Mechanical Turk. A separate cross-validation sample of 1,000 participants from these sources was used to examine the psychometric properties of the final subscales. Scale development employed classical test theory, item response theory, and differential item function methods. The positive schizotypy and negative schizotypy subscales contain 26 items each, and the disorganized schizotypy subscale contains 25 items. The psychometric properties were almost identical in the derivation and validation samples. All three subscales demonstrated good to excellent reliability, high item-scale correlations, and good item and test curve characteristics