The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors

Abstract

Aim: To describe the evidence base relating to the Cognitive-Interpersonal Maintenance Model for anorexia nervosa (AN).

Background: A Cognitive-Interpersonal Maintenance Model maintenance model for anorexia nervosa was described in 2006. This model proposed that cognitive, socio-emotional and interpersonal elements acted together to both cause and maintain eating disorders.

Method: A review of the empirical literature relating to the key constructs of the model (cognitive, socio-emotional, interpersonal) risk and maintaining factors for anorexia nervosa was conducted.

Results: Set shifting and weak central coherence (associated with obsessive compulsive traits) have been widely studied. There is some evidence to suggest that a strong eye for detail and weak set shifting are inherited vulnerabilities to AN. Set shifting and global integration are impaired in the ill state and contribute to weak central coherence. In addition, there are wide-ranging impairments in socio-emotional processing including: an automatic bias in attention towards critical and domineering faces and away from compassionate faces; impaired signalling of, interpretation and regulation of emotions. Difficulties in social cognition may in part be a consequence of starvation but inherited vulnerabilities may also contribute to these traits. The shared familial traits may accentuate family members' tendency to react to the frustrating and frightening symptoms of AN with high expressed emotion (criticism, hostility, overprotection), and inadvertently perpetuate the problem.

Conclusion: The cognitive interpersonal model is supported by accumulating evidence. The model is complex in that cognitive and socio-emotional factors both predispose to the illness and are exaggerated in the ill state. Furthermore, some of the traits are inherited vulnerabilities and are present in family members. The clinical formulations from the model are described as are new possibilities for targeted treatment.

Keywords: Anorexia nervosa; Complex intervention; Eating disorder; Model.

Figure 1

Obsessive compulsive personality traits. Legend A diagrammatic representation of traits related to obsessive compulsive personality disorder (OCPD) in eating disorders . Those that are mainly present in the acute, starved state are shown in italics.

Figure 2

A diagrammatic formulation of obsessive compulsive personality disorder (OCPD) traits. Legend. A diagrammatic formulation of obsessive compulsive personality disorder (OCPD) traits showing how they predispose to, and increase, the vulnerability to precipitating factors and also perpetuate the disorder. The grey box indicates how shared familial traits may contribute to the perpetuation of the problem.

Figure 3

Social processing traits. Legend. A diagrammatic representation of social processing traits in eating disorders. Those that are mainly present in the acute starved state are shown in italics.

Figure 4

A diagrammatic formulation of social processing traits. Legend. A diagrammatic formulation of social processing traits showing how they predispose to and increase the vulnerability to precipitating factors and also perpetuate the disorder. The grey box indicates how shared familial traits may contribute to the perpetuation of the problem.

Figure 5

A diagrammatic formulation of carers involvement within the maintenance of an eating disorder. Legend. A diagrammatic formulation of how carers own vulnerabilities, insecure attachment, anxiety and OCPD traits predispose to more difficulties coping with the eating disorder leading to anxiety and distress which in turn are associated with high expressed emotion, or accommodation to eating disorder symptoms which act to maintain the disorder.