L12 - Higher Order Cognition

Case study link: Graham Partridge with orthorexia nervosa

Cognitive content as a source of pathology is limiting - we should extend to functions of cognition (in a processing sense (not bio/lesion sense) -what brain is doing)

  • Look at transdiagnostic approaches to PP to move away from putting everything into one box but have some aspects of functioning that transcend this

Transdiagnostic Perspective and Classification Limitations

  • High comorbidity rates across psychiatric diagnoses (e.g., meeting criteria for one personality disorder typically confers a high probability of meeting criteria for four) indicate fundamental flaws in categorical classification systems.

  • Transdiagnostic approaches shift focus from disorder-specific cognitive content to generalized cognitive functions and processing mechanisms that operate across diagnostic boundaries.


Eating Disorders

  • Anorexia Nervosa:

    • Restriction of food

    • Intense fear of gaining weight

    • Perceptual biases in the way they see body weight and shape which affects self-worth

  • Bulimia Nervosa:

    • Recurrent binge eating episodes (eating a lot and lack of control during episode)

    • Inappropriate compensatory behaviours (exercise, purging) to make up for binge

    • Binge and compensatory behaviour occur at least once a weekf or 3 weeks

    • Self-evaluation is based on body shape and weight

    • Not exclusively happening during anorexia episodes

  • Orthorexia Nervosa: Righteous appetite, characterized by:

    • Extreme preoccupation with consuming healthy foods, and rigid, egosyntonic avoidance of foods perceived as toxic or unhealthy.

    • Belief of physical or spiritual purity through dietary adherence (for some)

    • Deriving self-worth, control, pride, or identity from adherence; failure triggers severe self-reproach, guilt, and punishing compensatory behaviors.

    • Substantial expenditure of time and financial resources, resulting in social/occupational impairment.

  • Core Shared Mechanisms: All three conditions share rigid self-evaluative belief systems and behavioral routines designed to ccognitive dissonance (the discomfort arising from discrepancies between internal beliefs and behaviors).

    • Shows shared features across diagnoses (leads to need for transdiagnostic approaches)


Beyond Cognitive Content

Psychological disorders may be better understood by cognitive processes/functions, rather than just specific thought content

  • Locus of pathology (where problem lies)

    • Behaviour theory: learning mechanisms are normal, what has been learned is abnormal

    • Beckian theory: schema activation process is normal, schema content (outcome) is not

  • Classification of disorders

    • Behaviour theory = transdiagnostic

      • The same learning principles can explain many disorders

      • Focuses on common processes across diagnoses

    • Beckian theory = schema content is disorder-specific

      • Can explain each disorder by having a particular behaviour of congitive content that accounts for it

        • Constrained approach


Metacognition: "Thinking about thinking" - critical for resource allocation towards thinking.

  • Meta-cognitive phenomena questionnaire where each fator is focused on some aspect of maladaptive meta-cognitive function

  • Assessed via five distinct domains:

    • Cognitive confidence (trust in one's own memory).

    • Positive beliefs about worry (perceived coping utility of worry).

    • Cognitive self-consciousness (habitual monitoring of thought processes).

    • Uncontrollability and danger of thoughts.

    • Need to control thoughts.


The Self-Regulatory Executive Function (SREF) Model

  • Doesn’t focus just on cognitive content - considers the cognitive process

  • Core features:

    • Normal and abnormal (what changes when there’s PP)

    • Content and process - now also considers:

      • Attention (the way attentional resources are allocated (automatic or controlled)

      • Memory

      • Meta-cognition

    • Instrumental transitory states

      • Called configurations (sometimes modes)

      • Temporary thinking state ppl enter bc they think it will achieve change/a goal (e.g. Worry to prepare for danger, worry to solve a problem)

      • When maladaptive: gets stuck in the configuration where it becomes persistent and unhelpful (no longer transient)


  • Formulated by Wells and Matthews, describing cognitive operations across three levels:

    • Low-Level Processing Units: Fast, automatic, resource-independent processing.

      • External, body, and cognitive info

    • Memory Systems (beliefs): Declarative self-beliefs (positive, negative or neutral) and beliefs about procedural plans/rules (how should I do this).

    • SREF Configuration: Controlled, resource-dependent processing responsible for executive control, and especially identification and resolution of discrepancy/cognitive dissonance

      • Processing continues until dissonance is solved and then SREF goes “offline”

  • SREF model proposal that PP disorders are maintained not by just the thought content - but by maladaptive self-regulation strategies that become activated when people perceive a discrepancy between their current state and their goals/beliefs


  • Memory and SREF configuration are at a controlled processing level (resource-dependent domain) and low-level processing units operate somewhat automatically (fast, crude output)


Maladaptive SREF Outcomes in Pathology:

  • When the SREF configuration fails to terminate, remaining perpetually active:

    • Belief elaboration breaks down bc they don’t expose selves to situations that show their belief was wrong

      • If they are exposed → discount that evidence

    • Attentional bias toward threat cues and chronic active worrying/rumination.

    • Intensification or suppression of activity (more worrying, avoidance, thought suppression etc)


SREF Summary:

  • Trigger → discrepancy detected → beliefs activated → coping strategy (worry/rumination/etc.) → attempt to resolve discrepancy → resolution

    • Or, if the strategy becomes persistent:

      • Attempt to resolve discrepancy → more monitoring of thoughts/body/threats → more coping strategy → distress maintained (PP)


Treatment Implications using SREF

  • Therapeutic Targets:

    • Disrupting Rumination: Teaching individuals to identify and interrupt perseverative worry loops without removing exposure to worry-activating situations

      • Avoidance doesn’t help correct maladaptive behaviour - need to step back in meta-cog sense and realise rumination

    • Detached Mindfulness: A distancing that facilitates meta-cognitive reflection on what’s happening

    • Belief Modification: Directly restructuring both core self-beliefs and metacognitive beliefs (e.g., challenging the belief that worry is protective or uncontrollable).

    • Response Plan Alteration: Establishing alternative, adaptive procedures to resolve distress and allow SREF deactivation.

    • Attention Training: Training conscious reallocation of attention away from self-monitoring and to something more adaptive.

    • Exposure to Activators: Exposing individuals directly to feared stimuli without permitting compensatory neutralizing behaviors to reduce avoidance.




Textbook Readings:

1. Relational Frame Theory & ACT (Bennett, pp. 66–72)

  • Relational Frame Theory (RFT):

    • Humans naturally link words, thoughts, and real-world events together (relational framing).

    • Cognitive Fusion: Treating thoughts as literal truths rather than temporary mental events (e.g., believing "I am a failure" instead of noticing "I am having the thought that I am a failure").

    • Experiential Avoidance: Trying to suppress or run away from uncomfortable thoughts and feelings, which causes psychological rigidity and makes distress worse over time.

  • Acceptance and Commitment Therapy (ACT):

    • Aim: To build psychological flexibility rather than fighting or eliminating thoughts.

    • Acceptance: Allowing feelings and thoughts to exist without trying to control them.

    • Cognitive Defusion: Stepping back and seeing thoughts merely as words or ideas.

    • Contact with the Present Moment: Being mindful of the "here and now" without judgment.

    • Values: Clarifying what truly matters most in life.

    • Committed Action: Taking practical steps aligned with personal values.

  • Overlap with the S-REF Model:

    • Both ACT and Wells' Self-Regulatory Executive Function (S-REF) model agree that psychopathology is maintained by rigid coping habits and avoidance, rather than just negative thought content alone.

2. Eating Disorders: Anorexia and Bulimia (Bennett, pp. 312–321)

  • Anorexia Nervosa:

    • Severely restricted food intake resulting in significantly low body weight.

    • Intense fear of weight gain and distorted evaluation of body shape and size.

    • Subtypes: Restricting type (dieting, fasting, exercise) and Binge-eating/purging type.

    • Highest mortality rate among psychiatric disorders, frequently linked to cardiac issues and suicide.

  • Bulimia Nervosa:

    • Repeated episodes of out-of-control binge eating (eating large amounts of food in short periods).

    • Followed by compensatory behaviors (purging, misuse of laxatives, fasting, or extreme exercise) at least once a week for 3 months.

    • Body weight is usually in the normal range, but self-esteem is excessively tied to weight and appearance.

  • Causes and Contributing Factors:

    • Biochemical & Gut Microbiome:

      • Dysregulation in the hypothalamus and neurotransmitters (dopamine alters reward and pleasure; serotonin influences satiety and mood).

      • Starvation in anorexia reduces serotonin, temporarily relieving anxiety.

      • Gut bacteria imbalances affect appetite hormones and neurotransmitter production.

    • Socio-Cultural & Family:

      • Societal pressures idealizing thinness.

      • Families with high conflict avoidance, over-protectiveness, rigid standards, or parental perfectionism.

    • Cognitive Factors (Fairburn):

      • Rigid rules around food and weight-related self-worth.

      • In bulimia, breaking an unrealistic dietary rule triggers "all-or-nothing" thinking, leading to a binge.

    • Psychological Autonomy (Bruch):

      • Early parenting that fails to respond to a child's internal cues leads to poor emotional awareness and a desperate need to control body shape.

3. Māori Mental Health Transformations (Durie, pp. 35–47)

  • Historical Transformations:

    • De-institutionalisation (1970s–1990s): Psychiatric asylums were closed in favor of community care, but poor planning led to "revolving-door" hospital admissions and homelessness.

    • Indigenisation: Addressing the post-1970s surge in Māori psychiatric admission rates by incorporating Treaty of Waitangi principles (partnership, participation, protection).

  • Key Models and Milestones:

    • Te Whare Tapa Whā (1982): A holistic health model based on four cornerstones:

      • Taha wairua (spiritual)

      • Taha hinengaro (mental/emotional)

      • Taha tinana (physical)

      • Taha whānau (family/social)

    • Whaiora Unit (1983) & Hui Whakaoranga (1984): Pioneered culturally grounded clinical units and established national health strategies led by and for Māori.

    • Workforce Growth: Training community health workers and funding Māori mental health professionals.

  • Practising at the Interface:

    • Integrating clinical science with indigenous knowledge (tikanga and mātauranga).

    • Ensuring culturally sensitive engagement and assessment (e.g., the Hua Oranga outcome measure that assesses all four dimensions of health across patient, whānau, and clinician perspectives).

  • The Next Frontier — Whānau Ora & Mauri Ora:

    • Shifting from reactive clinical treatment to addressing root social and environmental determinants (housing, education, poverty) through primary care.

    • Whānau Ora: Placing the family at the center of health solutions using navigators.

    • Mauri Ora (Flourishing): Moving beyond recovery from illness (mauri noho / languishing) toward holistic vitality, wellness, and self-determination (mauri ora / flourishing).