Transcript: Researching the causes of eating disorders: the case of decision-making skills

00:00:02 Female voiceover 

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00:00:14 Dr Amy Harrison 

Welcome to the podcast Psyched about Education. This series celebrates the academic excellence of the work carried out at the Department of Psychology and Human Development and the impact this work has on policy and practice. In other words, how can psychology make a difference?

I'm Dr Amy Harrison, an associate professor in psychology and clinical psychologist, and I'm joined here today by Chloe, who has a diagnosis of anorexia nervosa and is receiving treatment, and our other guest, Dr Marta Francesconi, a lecturer in psychology and psychologist. In this podcast, we're going to be focusing on the relationship between decision making and the development of eating disorder symptoms. 

So, welcome, Chloe and Marta. Thank you so much for joining me in this podcast. I hope that we'll be able to bring together our research experience and the findings that we've been working on and personal lived experience of an eating disorder. We've been using data from the Millennium Cohort Study; this is a longitudinal study that followed people up, a cohort of people born in 2000-2001, throughout childhood and adolescence, and we've been using data from 11,303 boys and girls in that study. 

We've been interested in thinking about the presence of symptoms of eating disorders. Eating disorders are quite a diverse group of symptoms, which can involve things like under eating or maybe overeating and losing control over eating and maybe using behaviors like exercise to influence your shape and weight. These things cause a lot of distress to people and can really impact people's lives, so they are very important and significant mental health difficulties. And eating disorders can last a really long time. So we've been really curious about whether we can understand and spot some of the things that might be associated with eating disorders and being able to predict their presence later on, and also some of the factors that might be important in helping to protect against the development of eating disorder symptoms.

One of the things that we thought might be interesting to research was decision making. So, Marta, could you help us to understand what we mean by decision making? 

00:02:55 Dr Marta Francesconi 

Of course. First of all, thanks for inviting me to join you in this podcast, and thanks to Chloe for agreeing to be part of it too. So, by decision making skills we refer to the ability of selecting between two or more alternatives to reach the best outcome in the shortest time. So, we should think that when we make a choice, we are basically defining our position in any given situation. And we should think of a decision-making process as a thought process where we weigh the pros and cons of each alternative and we forecast the outcome of each option based on the information that we have available. I think it's clear how this skill may have a huge influence on our personnel and professional lives. 

00:03:59 Dr Amy Harrison 

Absolutely, just in our daily lives we have to make so many decisions, don't we, from what we're going to wear that day, what we're going to have for our breakfast, and who we're going to meet and how we're going to tackle different tasks that we come across. 

Chloe, I was wondering if you could give us perhaps an example of how decision-making has been difficult for you, as a person with experience of anorexia nervosa. 

00:04:24 Chloe 

Sure, thank you, Amy, and thank you for having me on this podcast, I feel absolutely honored and privileged to be here. For me when it comes to decision making, I've never really been able to make decisions for myself. I never really developed a sense of my own preferences. That can even go down to, what is my favorite color? What is my favourite flavour of ice cream? Even now to this day I still couldn't give you the answer to those questions. I am very passive and let others make a decision on where to go or what to do, because, as I say, I don't really have a preference either way. On the other hand, I can be incredibly inflexible and controlling. I can make plans, particularly on going on a trip abroad, and I'm just unable to divert from those plans or be spontaneous. So, I think it's had quite a big effect on my decision-making both historically growing up, in adolescence, through to adulthood. 

00:05:29 Dr Amy Harrison 

It sounds like it's played a really, really big part, actually, in your day-to-day functioning and your life. Marta, I was wondering if you could tell us a bit more, or summarize for us, some of the key findings that we obtained from our research using the Millennium Cohort Study data. 

00:05:45 Dr Marta Francesconi 

In our study, we explored the relationship between scores on a gambling task, which measures decision making under conditions of risk, in people at age 11 and 14 years and eating disorder symptoms that were measured at age 14 and 17. We found that less advantageous decision making at ages 11 and 14 was predictive of eating disorders symptoms at ages 14 and 17. We also found that those whose decision-making skills developed less than their peers between 11 and 14-years-old were more likely to have eating disorder symptoms at age of 14. And we finally saw that decision-making ability at 11 and 14-years-old helped to explain the relationship that exists between emotional dysregulation experienced during very early childhood – so, at ages three, five and seven – and eating disorder symptoms at ages 14 and 17. So what we basically found is that the cognitive and emotional skills developing throughout childhood and adolescence are involved in the eating disorder symptoms, in the development and in the experience of eating disorder symptoms, during adolescence. 

00:07:24 Dr Amy Harrison 

Thank you so much. Ijust wanted to add that the eating disorder symptoms that we were able to look at in the Millennium Cohort Study where things like people intending to lose weight or to reduce their dietary intake; people actually doing that, and acting on that intention and restricting their nutritional intake; people feeling dissatisfied about their body and thinking that it was too large; and also people using exercise in order to influence their weight and shape. 

It's interesting when you use secondary data, data that have already been collected, and use that to address new questions in your research, because you don't always have control over some of the things that were asked. We acknowledge that some of the symptoms of eating disorders are perhaps missing there. But I think this really gives us an interesting insight into a cognitive factor that might be involved in the later presence of eating disorders. And it very much mirrors your experiences, Chloe, you were explaining that decision making has always been quite challenging, and I think that's something that we're also seeing in in our research, that there are this group of people for whom decision making is developing a bit differently and is a bit more challenging, and that those are the people that are a bit more vulnerable to eating disorders. 

Marta maybe you might like to ask Chloe a little bit more about her experiences. 

00:08:57 Dr Marta Francesconi 

Yes, I'd like to ask to Chloe: as someone who has experienced an eating disorder, if she thinks that it might have been useful to have any kind of support with this skill, with the decision-making skill – if she thinks that having had this support earlier, it might have helped her with avoiding some of the difficulties that she experienced going through an eating disorder. 

00:09:32 Chloe 

Yes, I'd say so. I've had to relearn some basic skills which weren't made available through my childhood and adolescence. I feel like I would have had a better sense of self, which I can imagine would mean that I think more of myself than just a number on a scale or how my body is perceived by both myself and others. 

00:09:53 Dr Marta Francesconi 

Also, can I ask you, what do you think that people with eating disorders need to learn to make better decision? What would you suggest, what do you think could be useful? 

00:10:07 Chloe 

I think some guidance and support from both family and school. I think school plays quite a large role in particularly younger children on understanding how bodies, on how everyone has a different body and it's not one size fits all. But I find also from my personal experience, the [issue of] consistency versus chaos. What I mean by that is having a consistent home life and home environment versus a chaotic home environment. It's very difficult to make good decisions when there is chaos there. So there's a numbing effect to escape from that chaos; what feels like self-soothing behaviors, like restriction, give a perceived sense of control, but these behaviors are actually quite impulsive and are actually incredibly self-destructive. I find that without support, routine and a consistent home environment, it just doesn't allow for a developed set of emotional regulation techniques or resilience. 

00:11:13 Dr Marta Francesconi 

Thank you for sharing, this, it’s very interesting. Amy, would you like to discuss some of our ideas about where we’ll take the research next? 

00:11:29 Dr Amy Harrison 

Yes, thank you, thanks Chloe, that's very thought provoking. Because eating disorders have so many different symptoms – as you've pointed out, sometimes people can be over controlled in their behaviors, sometimes people can be more impulsive and under controlled, and there's lots of different challenges involved in eating disorders and associated with them – something like decision making might help us to explain the diversity of symptoms. Because when we're having to choose how to act in a given situation, we're having to make a decision and we're trying to use information from that situation to respond in an advantageous way. I really like your ideas about getting some coaching and some more support and some training, at school but also support from loved ones, to really develop this skill. One of the things I've learned in terms of my decision-making skills is I've observed people that seem to do it well, and I've taken on board some of their strategies, and I really think that can be really helpful. 

That's how we want to take this research forward. We'd like to develop a game, actually. We're interested in the idea of gamification and serious games. This is an approach where you produce a game that's fun and engaging and interactive, but it's not just for the sake of playing the game, it's about teaching a skill. It's been used in lots of different ways – for example, in teaching medics how to make good decisions in a hospital setting. I think we'd like to have a go at making a game like this that could be played in an app and offering it to children. Our research indicates that we need to offer it to children in primary school because we know that's when things like decision making are starting to really develop. And we would hope to then follow them up and see whether those who had access to the game and played this game and use the characters to learn some new decision-making skills enhance that ability and might be more protected against the later onset of eating disorders as they grow older. We'd obviously compare that with a group of people who just carry on as normal and don't have access to this game in this app. 

That's a really exciting application of this research, because we might be able to do something to help people to develop skills that are protective against difficulties like eating disorders – but also mental health difficulties more broadly, because there is this idea that psychological disorders, depression and anxiety, and so on, may be underpinned, may be related to decision making processes. 

00:14:34 Dr Marta Francesconi 

So, let me ask you one final question: how has your work or psychology research in this area made a contribution to policy or practice? 

00:14:45 Dr Amy Harrison 

Specifically, this research really shows policymakers in the education field how important it is to spend time on supporting the development of key cognitive skills, and I think that's really corroborated by Chloe’s personal experiences. Because this is a skill, this is a cognitive skill, decision making, that not only helps with learning, but it could also be protective against difficulties with mental health. So I think that's the key contribution that we've made. I think we've also contributed to an understanding of how eating disorders develop and we've added to the science on the cognitive factors that are involved. That's really important, because sometimes people misunderstand how eating disorders develop. They think that maybe people choose to have them or it's a fad or a phase that will go away. But the reality is quite different. Eating disorders can last a long time and are a serious mental illness. They're not a lifestyle choice that perhaps some people might sometimes think they are if they don't understand them very well. 

00:15:58 Chloe 

I'd just like to say that I completely agree. And I think it's so important that it is better widely known that having an eating disorder is not a choice. Initially it can start off as a means of control, but very quickly it becomes, it controls you, and I just think it's really important to know that. I really want to hone in on that, what you just said, Amy. So, thank you for saying that. 

00:16:27 Dr Amy Harrison 

Yes, I'm wishing you the very best in your recovery, Chloe. 

00:16:31 Chloe 

Thank you. 

00:16:32 Dr Amy Harrison 

That's it from us today. You've been listening to Psyched about Education. For further details, please see the links at the end of this podcast. Thank you. 

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