An experimental exploration of social problem solving and its associated processes in anorexia nervosa
Introduction
Anorexia nervosa (AN) is a serious psychiatric illness which is characterised by self-starvation, hyperactivity and being physically underweight, alongside extreme concerns about weight, shape, or eating (American Psychiatric Association, 2000). AN has the highest mortality rate of all psychiatric disorders (Hoek, 2006). Only 50–75% of those diagnosed with AN make a full recovery and around 20% become chronically ill (Steinhausen, 2009, Keel and Brown, 2010). Patients report feeling isolated and problems in the interpersonal domain are now thought central to the development and maintenance of AN (e.g. Schmidt and Treasure, 2006, Rieger et al., 2010).
Social problem solving is the process by which a person attempts to identify effective or adaptive ways of coping with everyday life problems and is an important aspect of social competence (D'Zurilla and Chang, 1995). Social problem solving is underpinned by cognitive/executive processes, such as the ability to access and manipulate prior knowledge relevant to the problem situation in working memory, the generation of appropriate strategies, inhibition of inappropriate responses and monitoring and judging the effectiveness of solutions. It is also underpinned by social/emotional skills such as empathising, taking others' perspectives and responding to feedback during decision-making (Channon, 2004). All in all, effective social problem solving requires an intricate interplay of cognitive, emotional and behavioural skills (D'Zurilla and Nezu, 1982).
Recent research suggests that people with AN have characteristic neurocognitive impairments with poor cognitive flexibility, difficulties with global processing and integrating information into context and impaired decision making (Roberts et al., 2007, Lopez et al., 2008). They also have difficulties in the social cognitive domain, including impaired emotion recognition, impaired theory of mind (which refers to one's ability to make inferences about another person's beliefs, desires and intentions) and poor regulation of emotions (e.g. Oldershaw et al., 2010). Furthermore, a recent systematic review shows preliminary evidence for the persistence of a number of these social-cognitive impairments following recovery, such as attentional biases (towards or avoiding) threatening (social) stimuli and difficulty in facial emotion recognition (Oldershaw et al., 2011a). Taken together these findings suggest that impairments in social problem solving should be a likely consequence of these neurocognitive and socio-emotional impairments in AN sufferers. Indeed, there is preliminary evidence from self-report studies suggesting that people with AN are impaired in social problem solving (Paterson et al., 2007, Paterson et al., 2010, SwansonPlease provide all the authors names in Ref. (Swanson et al., 2010) et al., 2010). However, these studies explore social problem-solving processes, rather than outcomes and as yet no experimental paradigms have been employed to explore the latter.
One other factor that will be further explored in the current study is cognitive avoidance, which refers to cognitive strategies employed to avoid negative experiences and emotions. High cognitive avoidance is thought to play a role in the development and maintenance of AN (Troop and Treasure, 1997, Schmidt and Treasure, 2006). People with AN have been shown to find the experience of having negative thoughts and feelings aversive, are fearful of revealing these to others and try to avoid distressing thoughts and feelings. Higher levels of maladaptive beliefs about the experience and expression of thoughts and feelings are associated with a greater degree of eating disorder symptomatology in AN (Hambrook et al., 2011). Moreover, high cognitive avoidance has previously been found to relate to poor social problem-solving processes in Eating Disorders (ED) (Troop et al., 1994, Troop et al., 2003, Ghaderi and Scott, 2000, Bloks et al., 2004, Paterson et al., 2010, SwansonPlease provide all the authors names in Ref. (Swanson et al., 2010) et al., 2010).
Channon and Crawford (1999) developed an experimental task investigating social problem solving in which participants are asked to generate effective solutions to real-life, socially awkward scenarios (Social Problem Resolution Task, SPRT; Channon and Crawford, 1999, Channon and Crawford, 2010, Channon et al., 2001). The SPRT consists of a series of short scenarios of social everyday situations for which participants have to generate a course of action for the main character in the story (optimal solution), as well as identify their intended course of action (personal solution). The SPRT has demonstrated impaired social problem solving in people with acquired brain injury and neurodevelopmental disorders, such as Asperger's and Tourette's Syndrome (Channon and Crawford, 1999, Channon et al., 2001, Channon, 2004).
The aims of the present study were firstly to explore social problem solving in people with AN compared to that of healthy people using the SPRT, and secondly, to study the relationship between social problem solving and cognitive avoidance.
Our main hypothesis was that individuals with AN would generate both less effective optimal and less effective personal solutions than healthy controls (HC) as measured with the SPRT. Our subsidiary hypotheses were that individuals with AN would have higher levels of cognitive avoidance compared to HCs and that cognitive avoidance would correlate with poor social problem-solving ability in the AN group.
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Participants and procedure
Thirty-one female participants with AN and 39 female healthy control (HC) participants took part in this study. Participants from the AN group were recruited from the Eating Disorders in- and out-patient departments of the South London and Maudsley Hospital NHS Foundation Trust and the Barnet, Enfield & Haringey Mental Health NHS Trust. An AN diagnosis (following DSM-IV criteria) was confirmed by the patient's clinical team and by administering the Eating Disorder Examination version 16 (
Demographics
There were no overall group differences for age (AN: M=25.8, S.D.=8.6; HC: M=25.6, S.D.=10.8) t(70)=0.23, p=0.816 and IQ as measured by the NART (AN: M=114.3, S.D.=8.5; HC: M=116.7, S.D.=5.7) t(59)=1.35, p=0.182. AN participants had significantly lower BMI than those from the HC group (AN: M=16.4, S.D.=1.3; HC: M=21.5, S.D.=2.1) t(72)=12.36, p<0.001. BMI was not associated with any of the outcome variables in this study.
Clinical characteristics
As measured by EDE-Q global score, the AN group had higher levels of eating
Discussion
This is the first study to explore social problem-solving outcomes and associated processes in people with AN using an experimental study design. Our main hypothesis was partially confirmed as whilst people with AN did not differ from HCs in the quality of their optimal solutions, they did differ in terms of personal problem solving solutions.
Moreover, whilst in healthy controls there was little difference between the quality of their optimal and personal solutions, people with AN performed
Acknowledgements
This work was supported by a National Institute of Health Research (NIHR) Programme Grant for Applied Research (Reference number RP-PG-0606-1043). Ulrike Schmidt receives salary support from the NIHR [Mental Health Biomedical Research Centre] at South London and Maudsley NHS Foundation Trust and King's College London. The views expressed herein are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health. Lot Sternheim was a Local Scholar in the Marie Curie
References (42)
- et al.
Problem-solving in real-life-type situations: the effects of anterior and posterior lesions on performance
Neuropsychologia
(1999) Frontal lobe dysfunction and everyday problem-solving: social and non-social contributions
Acta Psychologica
(2004)- et al.
Social problem solving in adults
- et al.
The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the BeckDepression and Anxiety Inventories
Behaviour Research and Therapy
(1995) - et al.
Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples
Behaviour Research and Therapy
(2004) - et al.
The socio-emotional processing stream in anorexia nervosa
Neuroscience & Biobehavioral Reviews
(2011) - et al.
An eating disorder-specific model of interpersonal psychotherapy (IPT-ED): causal pathways and treatment implications
Clinical Psychology Review
(2010) - et al.
The Cognitive Avoidance Questionnaire: validation of the English translation
Journal of Anxiety Disorders
(2008) Outcome of Eating Disorders
Child and Adolescent Psychiatric Clinics of North America
(2009)The psychometric tradition—developing the Wechsler Adult Intelligence Scale
Contemporary Educational Psychology
(1981)
Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR
Convergence of scores on the interview and questionnaire versions of the Eating Disorder Examination: a meta-analytic review
Psychological Assessment
Coping strategies and recovery in patients with a severe eating disorder
Eating Disorders
Real-life-type problem-solving in Asperger's syndrome
Journal of Autism and Developmental Disorders
Mentalising and social problem-solving after brain injury
Neuropsychological Rehabilitation
Statistical Power Analysis for the Behavioral Sciences
Poor social comparison and the tendency to submissive behavior in anorexia nervosa
International Journal of Eating Disorders
Dissociation between performance on abstract tests of executive function and problem solving in real-life-type situations in normal aging
Aging & Mental Health
The relations between social problem solving and coping
Cognitive Therapy and Research
The eating disorder examination
Assessment of eating disorders: interview or self-report questionnaire?
International Journal of Eating Disorders
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