Enhancing motivation for change in treatment-resistant eating disorders

The role of depression and anxiety in impulsive and obsessive-compulsive behaviors among anorexic and bulimic patients

Eating disorders are believed to range across a spectrum of varying degrees of obsessive-compulsive and impulsive behavior. Sixty anorexic (mean age = 19.8; sd = 5.9) and 109 bulimic (mean age = 26.9; sd = 11.3) female patients completed self-report questionnaires assessing obsessive-compulsiveness, impulsivity, depression and anxiety, as well as two eating disorder scales. Results yielded significantly higher levels of impulsivity and negative body image in the bulimic compared to the anorexic group. Regression analysis predicting impulsivity showed that bulimia and negative body image were the main contributors. Regression analysis for predicting obsessive-compulsive behavior suggested that depression and anxiety obscure the link between anorexia and obsessive-compulsive behavior, and a high BMI intensifies the association between anxiety and obsessive-compulsive behavior. The high rates of both impulsivity and obsessive-compulsiveness found in both groups, and their association with the severity of the eating disorder, may suggest that impulsivity and obsessive-compulsiveness are not mutually exclusive and can both be found among anorexic and bulimic patients.

A consideration of developmental egocentrism in anorexia nervosa

Recent research has suggested that normal adolescent processes are important in understanding psychosis, and that young adult individuals with psychosis are often struggling to develop an individual and autonomous self (the "fundamental task" of adolescence). The current paper explores the utility of considering normative adolescent developmental processes in understanding anorexia nervosa. Data were collected from 31 female young-adults with symptoms of anorexia nervosa, 26 female comparison young-adults and 71 female adolescents on measures of adolescent egocentrism. A one-way ANOVA indicated that individuals with symptoms of anorexia nervosa scored more highly than both their peers and the adolescents on several dimensions of egocentric developmental beliefs. Correlations also showed that egocentrism was positively associated with eating concern in participants with symptoms of anorexia. The results suggest that young-adult women with symptoms of anorexia nervosa tended to feel physically invulnerable while also feeling both psychologically vulnerable to others and special or different. Together with the finding of excessive self-consciousness, this supports a notion that they may be experiencing exaggerated versions of normal self-developmental phenomena. Clinically, offering alternative ways of feeling unique other than dieting may be important in therapeutic approaches to anorexia nervosa. Similarly, strategies aimed at normalisation, such as facilitating healthy attachment to peers, may be useful for individuals with anorexia nervosa.

Identifikation von erfolgsrelevanten Veränderungen im Prozess einer Körperbildtherapie

Zusammenfassung. Theoretischer Hintergrund: Mehrere Studien belegen gute Ergebnisse für Interventionen zur Verbesserung des Körperbildes bei Patientinnen mit Essstörungen; jedoch fehlen Prozessanalysen der relevanten Wirkfaktoren. Fragestellung: Erfolgsrelevante Veränderungen von Klärungs- und Bewältigungserfahrungen sowie symptomspezifische Intrasession-Veränderungen werden im Verlauf einer standardisierten Körperbildtherapie untersucht. Methode: 54 Patientinnen mit Essstörungen füllten vor und nach jeder Gruppensitzung die Body Image States Scale zur Erfassung der State-Körperunzufriedenheit und am Sitzungsende den Stundenbeurteilungsbogen mit den Wirkfaktoren „Einsicht/Klärung” und „Problembewältigung” aus. Ergebnisse: Bei gleichen Eingangswerten zeigten sich erfolgsabhängige Verläufe für die Körperunzufriedenheit nach Sitzungsende und die erlebte Problembewältigung. Sowohl Klärungs- als auch Problembewältigungsprozesse sind mit der Intrasession-Verbesserung der Körperunzufriedenheit assoziiert. Schlussfolgerungen: Während beide Erfolgsgruppen profitieren, bedarf der differenziell günstigere Verlauf der erfolgreicheren Patienten weiterer und erweiterter Forschung.

Expanding the concept of motivation to change: the content of patients' wish to recover from anorexia nervosa

OBJECTIVE

Motivational approaches to anorexia nervosa (AN) have mainly concerned motivational quality and quantity. We investigated the content of patients' wish to recover.

METHOD

Eighteen women, aged 18-39, with AN were interviewed in depth using a phenomenological study design. Interviews were tape-recorded, transcribed, and analyzed using the QSR-N*Vivo software program.

RESULTS

Four motivational content areas characterized informants' wishes to recover: "Sense of vitality" (e.g., joy, concentration, spontaneity, energy); "Sense of autonomy" (e.g., choosing to recover, new methods of mastery, self-determination); "Sense of insight" (e.g., awareness, seeing nuances, limitation of goals, self-knowledge); and "Negative consequences" (e.g., loss of future, costs to own children, feeling sick or thin, social costs, physical costs).

CONCLUSION

Our sample of AN patients' motivation to recover may be described using three dimensions: content, quality, and quantity, and may also include motives with no behavioral intention. Sustained therapeutic success may rest upon the therapist's ability to identify and ally with the patient's motives to recover.

A pilot study exploring Machiavellianism in anorexia nervosa

Machiavellianism has not previously been systematically explored in the eating disorders. This personality dimension involves the social cognitive processes required to identify others' intentions and the use of strategies to deceive and manipulate others. Individuals suffering with Anorexia Nervosa (AN) often try to conceal their disorder through the use of deceptive strategies. In this study we explore Machiavellianism in 22 female AN patients and 41 female healthy controls (HCs). AN patients and HCs did not differ significantly in their self-reported Machiavellianism, but both groups did score highly in this domain. Possible explanations for these results are discussed.

Illness intrusiveness in anorexia nervosa

OBJECTIVE

"Illness intrusiveness" refers to illness-induced lifestyle disruptions. The primary aim of the current study was to compare the level of illness intrusiveness in anorexia nervosa (AN) to that reported in a variety of other chronic medical and psychiatric conditions. A secondary aim was to compare the two subtypes of AN (binge/purge vs. restricting) in terms of the nature and extent of illness intrusiveness. A final goal was to examine changes in the level of illness intrusiveness in AN following successful completion of specialized inpatient treatment.

METHODS

The participants were a consecutive series of 121 female inpatients with AN who were admitted to a specialized inpatient unit for treatment of the eating disorder. Assessments took place before and after inpatient treatment and at 3-month follow-up.

RESULTS

At baseline, illness intrusiveness scores for AN patients were significantly higher than those reported by women in the medical and psychiatric comparison groups. Overall, illness intrusiveness scores decreased (i.e., improved) significantly following successful completion of inpatient treatment. Among patients with the restricting subtype, scores continued to improve during follow-up, whereas this was not the case among patients with the binge-purge subtype of AN, whose scores did not change significantly during follow-up.

CONCLUSION

Despite being notoriously ambivalent about change, these findings suggest that AN patients perceive their illness to be highly disruptive to a variety of life domains, even more so than patients with other chronic medical and psychiatric conditions.

The Eating Disorder Recovery Self-Efficacy Questionnaire (EDRSQ): change with treatment and prediction of outcome

The purpose of this study was to examine the predictive validity of the Eating Disorder Recovery Self-Efficacy Questionnaire (EDRSQ), an empirically-derived self-report instrument that assesses confidence to eat without engaging in eating disordered behavior or experiencing undue emotional distress (Normative Eating Self-Efficacy) and confidence to maintain a realistic body image that is not dominated by pursuit of thinness (Body Image Self-Efficacy). Participants were 104 female inpatients with anorexia nervosa (AN), subthreshold AN, or underweight bulimia nervosa who were treated at a specialized eating disorder clinic and completed the EDRSQ and Eating Disorder Inventory-2 (EDI-2) Drive for Thinness (DT) and Body Dissatisfaction (BD) subscales upon admission. A subset of patients completed the EDRSQ (n=81) and EDI-2 subscales (n=70) following inpatient treatment. Self-efficacy increased significantly during treatment. EDRSQ scores at admission were inversely related to length of hospital stay and posttreatment DT and BD subscales and positively related to partial hospital weight gain rate. The EDRSQ significantly predicted length of hospital stay and posttreatment BD above and beyond clinical indicators and eating disorder psychopathology at inpatient admission. Findings support the validity of the EDRSQ and suggest it is a useful predictor of short-term hospital treatment outcome in underweight eating disorder patients.

Shared temperament risk factors for anorexia nervosa: a twin study

OBJECTIVE

To answer two questions about the nature of the relationship between anorexia nervosa (AN) and dimensional temperament traits: Which traits are comorbid with AN? Which traits share transmitted liabilities with AN?

METHODS

A community sample of 1002 same-gender female twins was selected with respect to participation in two earlier waves of data collection. Measures of eating disorder diagnoses and features were ascertained through interview and continuous measures of temperament were ascertained from self-report measures.

RESULTS

Four temperaments were comorbid with AN, namely, higher levels of perfectionism (concern over mistakes, personal standards, doubt about actions), and higher need for organization. Comparison between the female co-twins of AN probands and controls (who had never had an eating disorder) showed that the former group reported higher levels of personal standards, organization, and reward dependence. The association between personal standards and reward dependence remained when controlling for the temperament of the proband or control in monozygotic twins.

CONCLUSIONS

The evidence overall supports the suggestion that AN may represent the expression of a common underlying familial liability to a temperament style that reflects a striving for perfectionism, a need for order, and a sensitivity to praise and reward. The nature of the shared risk factors is likely to be, in part, genetic.

The patient's account of relapse and recovery in anorexia nervosa: a qualitative study

OBJECTIVE

The purpose of this study was to explore the subjective accounts of weight-recovered female patients, who met DSMIV criteria for anorexia nervosa (AN), regarding their views of their illness following weight restoration.

METHOD

Qualitative semi-structured interviews were administered to 15 participants to ascertain their perspective of the factors that either contributed to their maintaining a healthy weight, or the factors involved in their having relapsed over the follow-up period.

RESULTS

Qualitative analyses revealed six core categories: internal motivation to change, recovery as a work in progress, the perceived value of the treatment experience, developing supportive relationships, awareness and tolerance of negative emotion and self-validation.

DISCUSSION

This study provides valuable information about the way in which AN patients experience their illness and highlight the factors that help or hinder recovery. These findings may help enhance relapse prevention programs and potentially enhance our ability to identify and target those individuals at the greatest risk of relapsing.

The Individual Within a Condition: A Qualitative Study of Young People's Reflections on Being Treated for Anorexia Nervosa

BACKGROUND

Anorexia nervosa is a mental health problem that can seriously impede the physical, social, and psychological functioning of those who develop it. Unfortunately, outcome for this patient group, even after treatment, is not necessarily promising.

OBJECTIVE

To explore the views of young people about being treated for anorexia.

DESIGN

Qualitative interviews were conducted with 10 adolescents. All interviews were recorded with participants' written consent and transcribed verbatim. A thematic analysis was applied to these data.

RESULTS

Five themes were derived from the analysis: a) accessing appropriate care, b) balancing the physical and psychological, c) qualities required in professionals, d) help from nonprofessional routes, and e) perceived progress.

CONCLUSIONS

Participants were clear about needing to be motivated to change. Practitioners can help by challenging patients in a nonconfrontational manner, treating them as individuals rather than cases of anorexia, and considering their psychosocial and physical functioning. J Am Psychiatr Nurses Assoc, 2008; 13(6), 368.-375. DOI: 10.1177/1078390307309215.

Motivation to change in eating disorders: clinical and therapeutic implications

OBJECTIVES

The aim of this study was to understand the clinical impact of the motivational stage of change on the psychopathology and symptomatology of anorexia nervosa (AN), bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS).

METHOD

The participants were 218 eating disorder (ED) patients (58 AN, 95 BN and 65 EDNOS), consecutively admitted to our hospital. All patients fulfilled DSM-IV criteria for these disorders.

ASSESSMENT

Assessment measures included the Eating Disorders Inventory (EDI), Bulimic Investigation Test Edinburgh (BITE), Beck Depression Inventory (BDI), four analogue scales of motivational stage, as well as a number of other clinical and psychopathological indices.

RESULTS

Our results indicated higher motivation for change in BN than in AN and EDNOS patients (p < 0.05). For all groups, motivation to change was predicted by chronological age (p < 0.05). However, a longer duration of illness was only predictive of the motivational levels in EDNOS (p < 0.05) patients.

CONCLUSIONS

Compared to BN, AN and EDNOS patients are most resistant to change and the younger these patients are, the less likely they are to be motivated to change their disturbed eating behaviour.

Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial

BACKGROUND

Treatment guidelines identify few adequately powered trials to guide recommendations for anorexia nervosa.

AIMS

To evaluate the effectiveness of three readily available National Health Service treatments for adolescents (aged 12-18 years) with anorexia nervosa.

METHOD

Multicentre randomised controlled trial of 167 young people comparing in-patient, specialist out-patient and general child and adolescent mental health service (CAMHS) treatment.

RESULTS

Each group made considerable progress at 1 year, with further improvement by 2 years. Full recovery rates were poor (33% at 2 years, 27% still with anorexia nervosa). Adherence to in-patient treatment was only 50%. Neither in-patient nor specialist out-patient therapy demonstrated advantages over general CAMHS treatment by intention to treat, although some CAMHS out-patients were subsequently admitted on clinical grounds. In-patient treatment (randomised or after out-patient transfer) predicted poor outcomes.

CONCLUSIONS

First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in-patient facilities.

Neuropsychological study of underweight and "weight-recovered" anorexia nervosa compared with bulimia nervosa and normal controls

OBJECTIVE

To compare executive, memory and visuospatial functioning of DSM-IV anorexia nervosa (AN), bulimia nervosa (BN), and normal controls (NC).

METHOD

A comparison of women involving: (i) 16 AN with body mass indices (BMI) < or = 17.5 kg/m(2); (ii) 12 AN with BMI > 18.5 kg/m(2) for at least 3 months; (iii) 13 BN; and (iv) 16 NC participants was performed with groups of similar age and intelligence. Groups were assessed with EDE-12, MADRS, HAMA, Cognitive Drug Research (CDR) battery, and Bechara tasks.

RESULTS

Significant impairments in CDR Power of Attention were present in underweight AN and BN participants. CDR Morse Tapping was significantly impaired in all clinical groups. The BN and weight-recovered AN groups were significantly impaired on CDR immediate word recall. The BN group alone was significantly impaired on CDR delayed word recall.

CONCLUSION

Attentional impairment is similar in AN and BN. Impaired motor tasks in AN persist after "weight-recovery" and are similar to impairments in BN. BN may be discriminated from AN on word recall.

Readiness for change and short-term outcomes of female adolescents in residential treatment for anorexia nervosa

OBJECTIVE

To determine if readiness for change (RFC) at admission predicted length of stay (LOS) and short-term outcomes among female adolescents in residential treatment for anorexia nervosa (AN).

METHOD

Using a prospective cohort design to collect data from participants (N = 65) at admission and discharge, Kaplan-Meier survival analysis and Cox regression tested whether RFC on admission predicted time in LOS to a favorable short-term outcome--a composite endpoint based on minimum criteria for weight gain, drive for thinness, depression, anxiety, and health-related quality of life (HRQOL).

RESULTS

Participants with low RFC had a mean survival time to a favorable short-term outcome of 59.4 days compared to 34.1 days for those with high RFC (log rank = 8.44, df = 1, p = .003). The probability of a favorable short-term outcome was 5.30 times greater for participants with high RFC.

CONCLUSION

Readiness for change is a useful predictor of a favorable short-term outcome and should be considered in the assessment profile of patients with AN.

Self-liking and self-competence: relationship to symptoms of anorexia nervosa

Self-esteem has been hypothesised to play a pivotal role in the development and treatment, and outcome of anorexia nervosa (AN). Though this relationship is typically investigated by considering self-esteem as a unitary construct, research suggests that this comprises of two related but distinct components of self-liking and self-competence. This study investigates the association between self-liking, self-competence, and symptomatology of AN through the course of a defined treatment episode in 77 women. Self-liking was significantly associated with laxative abuse. Self-competence was significantly associated with elevated ineffectiveness, perfectionism and interpersonal distrust. Although self-competence and eating disturbance severity significantly improved over the treatment episode, one in three participants reported a reduced self-like or self-competence. Changes in both self-competence and self-liking at the end of treatment was associated with changes in drive for thinness. Such findings have implications for treatment models concerned with improving self-esteem.

Assessing motivation to change in bulimia nervosa: the Bulimia Nervosa Stages of Change Questionnaire

OBJECTIVE

To assess motivation to change in adolescent patients with bulimia nervosa through the Bulimia Nervosa Stages of Change Questionnaire (BNSOCQ), an instrument adapted from the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) already validated in anorexic patients.

METHOD

Subjects were 30 bulimia nervosa patients (mean age = 16.3 years) who were receiving treatment at an eating disorders unit. The evaluation instruments were: the BNSOCQ, the Eating Disorders Inventory (EDI-2) and the Beck Depression Inventory (BDI). The BNSOCQ was re-administered 1 week later to evaluate test-retest reliability.

RESULTS

The BNSOCQ demonstrated good internal consistency (Cronbach's alpha = 0.94) and one week test-retest reliability (Pearson's r = 0.93). Negative significant correlations were found between the BNSOCQ and several EDI-2 scales (Pearson's r between -0.51 and -0.84) and the BDI (r = -0.74).

CONCLUSION

The study provides initial support for the reliability and validity of the BNSOCQ as a self-report instrument for assessing motivation to change in adolescents with bulimia nervosa.

The interpretation of symptoms of starvation/severe dietary restraint in eating disorder patients

The aims of the study were to test the hypotheses that some symptoms of starvation/severe dietary restraint are interpreted by patients with eating disorders in terms of control. Sixty-nine women satisfying the Diagnostic and Statistical Manual of Mental Disorders-IV edition (DSM-IV) criteria for a clinical eating disorder and 107 controls participated in the study. All the participants completed an ambiguous scenarios paradigm, the Eating Disorder Examination Questionnaire (EDE-Q) and the Beck Depression Inventory (BDI). Significantly more eating disorder patients than non clinical participants interpreted the starvation/dietary restraint symptoms of hunger, heightened satiety, and dizziness in terms of control. The data give further support to the recent cognitive-behavioural theory of eating disorders suggesting that eating disorder patients interpret some starvation/dietary restraint symptoms in terms of control.

Control and disordered eating in type 1 diabetes

Control is a major topic associated with the management of diabetes due to the importance placed on maintaining healthy blood glucose levels in this condition. Such an outcome can be influenced by individuals' sense of mastery over the disease, and more generally over their environment. In response to a diagnosis of diabetes, the self-management requirements accompanying it, and/or difficulties in other areas of life, patients may decide to undertake behaviours that are detrimental to their well-being. For instance, they may adopt fixated attitudes towards their intake and weight. This paper explores the relationship between disordered eating habits, control and diabetes in those who are insulin dependent.

Development and multi-site validation of a new condition-specific quality of life measure for eating disorders

Background

In eating disorders (EDs) treatment, outcome measurement has traditionally focused on symptom reduction rather than functioning or quality of life (QoL). Generic QoL measures lack sensitivity for some diagnoses and many not be responsive in eating disorder patients. This article describes the development and validation of a condition-specific QoL measure for adolescents and adults with eating disorders – the Eating Disorders Quality of Life Scale (EDQLS).

Methods

Multi-source and multi-stage methods were used to develop the EDQLS, with participation of patients with EDs, their family members and ED treatment providers. Sources for domain and item development included 39 articles, 12 patient and 10 treatment provider interviews, and 31 first person narratives from the internet. Four stages of validation and pre-testing involving 17 patients, 10 family members and 18 providers reduced 233 items to 40 items in 12 domains. These items were pilot tested in 41 ED patients.

Results

The final instrument was then validated in a 12 site sample of 171 individuals aged 14–60 with EDs. All items showed good dispersion. The total raw mean score was 110 out of 200 (SD 27.6) with higher scores indicating better QoL. Internal consistency was excellent (Cronbach's alpha = .96) and subscale internal consistency ranged from alpha .36 to .79 providing evidence for a strong overall construct and some multi-dimensionality. Validity was supported by significant differences in mean EDQLS according to severity levels on the EDI-2 (F = 95.3, p <.001) and the BSI (F = 86.9, p <.001). EDQLS scores were positively associated with time in treatment (F = 4.65, p = .01) suggesting responsiveness. A strong positive association was also found between EDQLS scores and stage of change (F = 15.1 p <.001). Pearson's correlations between the EDQLS and criterion instrument scores were .71 for the SF-12 mental subscale, .61 for the QoLI and .78 for the 16D, supporting construct validity. Exploratory principal components and item response theory analyses identified only a few poor fitting items.

Conclusion

The EDQLS has promising psychometric characteristics and may be useful for evaluating ED treatment effectiveness.

Management of bulimia nervosa

Bulimia nervosa is a disorder of complex etiology that tends to occur in young women. These individuals binge eat and purge by vomiting or other means, and often have depression, anxiety, substance abuse and extremes of impulse control. It is thought that binge eating and purging behaviors are, at least in part, a means of coping with dysphoric mood states and interpersonal stress. Bulimic symptoms are not likely to abate without development of new coping skills and behaviors. In the past 25 years, considerable progress has been made in developing specific psychotherapies and medication for the treatment of bulimia nervosa. Despite this progress, many individuals have partial responses to therapy and may remain chronically ill. This complex illness often requires a multidisciplinary team of professionals for effective management and, despite significant advances in treatment, bulimia nervosa continues to present major challenges for providers of care.

What happens in the course of body exposure? Emotional, cognitive, and physiological reactions to mirror confrontation in eating disorders

OBJECTIVE

Though body exposure seems to enhance outcome in cognitive-behavioural therapy of anorexia and bulimia nervosa, the underlying mechanisms are still unknown.

METHODS

Participants with eating disorders (ED; n = 21) and normal controls (NC; n = 28) were exposed to their own bodies in front of a mirror for 40 minutes under standardized conditions. Emotions, cognitions, and saliva cortisol were assessed every 10 minutes during body exposure. Heart rate and skin conductance were recorded continuously.

RESULTS

ED showed higher negative emotional and cognitive responses to body exposure compared to NC, whereas no group differences were found for physiological reactions. In the course of body exposure, the extent of negative emotions and cognitions decreased significantly with medium effects for emotions and low effects for cognitions. Physiological parameters remained stable during the task.

CONCLUSION

Body exposure is a promising technique to overcome negative body-related emotions, but additional cognitive techniques are necessary.

Internet-Delivered Targeted Group Intervention for Body Dissatisfaction and Disordered Eating in Adolescent Girls: A randomized controlled trial

This study evaluated a targeted intervention designed to alleviate body image and eating problems in adolescent girls that was delivered over the internet so as to increase access to the program. The program consisted of six, 90-minute weekly small group, synchronous on-line sessions and was facilitated by a therapist and manual. Participants were 73 girls (mean age=14.4 years, SD=1.48) who self-identified as having body image or eating problems and were randomly assigned to an intervention group (n=36) (assessed at baseline, post-intervention and at 2- and 6-months follow-up) or a delayed treatment control group (n=37) (assessed at baseline and 6-7 weeks later). Clinically significant improvements in body dissatisfaction, disordered eating, and depression were observed at post-intervention and maintained at follow-up. Internet delivery was enthusiastically endorsed. The program offers a promising approach to improve body image and eating problems that also addresses geographic access problems.

Static and dynamic body image in bulimia nervosa: mental representation of body dimensions and biological motion patterns

OBJECTIVE

The aim of the present study was to find out whether in bulimia nervosa the perceptual component of a disturbed body image is restricted to the overestimation of one's own body dimensions (static body image) or can be extended to a misperception of one's own motion patterns (dynamic body image).

METHOD

Participants with bulimia nervosa (n = 30) and normal controls (n = 55) estimated their body dimensions by means of a photo distortion technique and their walking patterns using a biological motion distortion device.

RESULTS

Not only did participants with bulimia nervosa overestimate their own body dimensions, but also they perceived their own motion patterns corresponding to a higher BMI than did controls. Static body image was correlated with shape/weight concerns and drive for thinness, whereas dynamic body image was associated with social insecurity and body image avoidance.

CONCLUSION

In bulimia nervosa, body image disturbances can be extended to a dynamic component.

Executive functioning in anorexia nervosa: exploration of the role of obsessionality, depression and starvation

Cognitive deficits related to executive functioning have been previously identified in anorexia nervosa (AN). Currently, there is limited knowledge about the degree to which other variables related to AN or executive function may influence the observed relationships. The present study examined three groups of participants, women with AN (n=22), and two control groups: women who were high in obessionality (n=20) and women who were low in obsessionality (n=21). Women reporting disordered eating over the previous 4 weeks were screened out of the control groups. Executive function was measured using the Wisconsin card sorting test (WCST) and the uses of common objects test (UCOT). In addition, depression, obsessionality and body mass index were measured. Initial analyses showed no significant differences between the groups on executive function, but moderate effect sizes were obtained for performance on UCOT total perseverations and WCST total trials. When controlling for either depression or obsessionality, the group differences on the UCOT total perseverations became significant and in the case of depression attained a large effect size. Both the AN and high obsessional groups showed significantly more perseverations than the low obsessional group. Depression appeared to suppress variance that was irrelevant to the prediction of perseverance thus enhancing the importance of group membership. It is recommended that variables strongly associated with AN be investigated in future research as this may clarify the relationship between AN and executive function.

Using imagery in cognitive-behavioral treatment for eating disorders: tackling the restrictive mode

A restrictive thinking style in the eating disorders, often referred to as "anorexic thinking," is often resistant to cognitive-behavioral interventions, even when apparent motivation is relatively high. It is argued that this difficulty is due in part to the ingrained nature of such thinking patterns, regardless of diagnosis. Those patterns reflect the ego-syntonic element of the eating disorders, and manifest as difficulty for the patient in identifying and challenging negative automatic thoughts and maladaptive core beliefs. There is a need to develop cognitive techniques that allow the individual to identify maladaptive cognitions as reflecting their restrictive schema mode, rather than being the only way of thinking and seeing the world. This study describes the use of imagery to enable patients to distinguish the restrictive thoughts from other cognitive perspectives. The restrictive "mode" is presented as part of the individual's personality structure (drawing on cognitive-behavioral models of personality), rather than being an external entity. This technique is designed to facilitate conventional cognitive-behavioral therapy, freeing the patient to challenge her cognitions and to engage in behavioral experiments. We present case material to illustrate this technique and its use in conjunction with other cognitive-behavioral techniques. Future directions and potential limitations are also discussed.

The meaning of self-starvation: qualitative study of patients' perception of anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) patients tend to place a positive value on their symptoms. Many clinicians believe that this plays a central role in maintaining the disorder. However, empirical research on how patients attribute meaning to their symptoms is lacking. This study aims at systematically exploring the meaning that the patients with AN attribute to their anorectic behavior.

METHOD

A qualitative, descriptive, phenomenological design was used. Eighteen women aged 20-34 with AN (DSM-IV) were interviewed with an informant-centered interview. The interviews were tape-recorded, verbatim transcribed, coded, and analyzed phenomenologically, using a QSR-N*Vivo software program.

RESULTS

The psychological meanings that the informants attributed to their anorectic behavior could be summarized in eight constructs: "Security" (feeling of stability and security), "Avoidance" (avoiding negative emotions), "Mental strength" (inner sense of mastery), "Self-confidence" (feeling acknowledged and worthy of compliments); "Identity" (achieving new identity), "Care" (eliciting care from others), "Communication" (communicating difficulties), and "Death" (wishing to starve oneself to death).

CONCLUSION

The eight constructs may have central functions in the maintenance of AN and should be regarded when patients' motivation and goals for treatment are assessed. Further study of the possible functions of the constructs in maintaining AN is warranted.

Development of the eating disorder recovery self-efficacy questionnaire

OBJECTIVE

The purpose of the current investigation was to develop and validate the Eating Disorder Recovery Self-Efficacy Questionnaire (EDRSQ), a self-report measure of self-efficacy to recover from an eating disorder.

METHOD

Participants were 116 female patients with anorexia nervosa, bulimia nervosa, or a subthreshold eating disorder treated at an eating disorder clinic. Patients completed the EDRSQ and measures of eating disorder symptoms and depression.

RESULTS

The EDRSQ contains two internally consistent factors, Normative Eating Self-Efficacy and Body Image Self-Efficacy. Moderate to large correlations between EDRSQ subscales and measures of eating disorder pathology support the convergent validity of the EDRSQ. The EDRSQ demonstrates theoretically consistent relations with constructs that are related to but distinct from self-efficacy. Discriminant validity is reflected in small correlations between EDRSQ subscales and measures of general psychological correlates of disordered eating.

CONCLUSION

The EDRSQ is a psychometrically sound measure to assess self-efficacy in patients with a range of eating disorder diagnoses.

The pros and cons of change in individuals with eating disorders: a broader perspective

OBJECTIVE

The goals of the current study were to develop a questionnaire measuring the pros and cons of eating disorder symptoms and to explore the themes endorsed by different eating disorder groups.

METHOD

Participants recruited from an eating disorder volunteer register and an outpatient clinic completed the Pros and Cons of Eating Disorders scale (P-CED). Principal components analyses (PCA) were performed to validate the factorial structure of the original items and to explore the factorial structure of the new items. Planned comparisons were used to compare P-CED scores between diagnostic groups.

RESULTS

PCA indicated a 10-factor solution for the original Pros and Cons of Anorexia Nervosa scale (P-CAN) items and a 4-factor solution for the new items. Participants with anorexia nervosa (AN) scored significantly higher than participants with bulimia nervosa (BN) on five of the P-CED subscales but there were no significant differences between the two AN subtypes.

CONCLUSION

The P-CED is a useful tool for identifying the positive and negative aspects of eating disorders that can be targeted in treatment or used as an outcome measure in research.

The dangers and draw of online communication: pro-anorexia websites and their implications for users, practitioners, and researchers

Recent advances in communication have enabled an underground interest group, unrestricted by geographic boarders, to evolve. The so-called pro-anorexia movement has a particular presence in the form of Internet discussion boards. This paper examines the potential impact of such online activity for those visiting these resources, for practitioners working with individuals who have anorexia, and for those conducting research into the condition. It contributes to the debate about this controversial development in the world of eating disorders.

Mechanisms of action in the process of change: helping eating disorder clients make meaningful shifts in their lives

This article describes a model for change that draws upon motivational and cognitive-behavioural theories. It is suggested that maladaptive beliefs hold individuals captive in destructive self-perpetuating cycles dominated by the illness. In the context of a trusting therapeutic relationship, inquiry and experimentation can lead to the reformulation of maladaptive beliefs, and to the development, reprioritization and/or strengthening of higher values. A clear cohesive system of higher values allows individuals to make autonomous life decisions, which reduces the need for maladaptive coping strategies.

Motivational enhancement therapy and self-help treatment for binge eaters

OBJECTIVE

The aims of this study were to evaluate whether a single session of motivational enhancement therapy (MET) would increase participant readiness to change, improve the efficacy of self-help treatment for binge eaters, and improve participant compliance with the self-help manual.

METHOD

Participants with bulimia nervosa or binge eating disorder were randomly assigned either to attend a 1-hr MET session prior to receiving the self-help manual (n = 45) or to receive the self-help manual only (n = 45). Participants were followed for 4 months for assessment of self-reported eating disorder outcome and compliance.

RESULTS

The MET intervention resulted in increased readiness to change for binge eating compared with the self-help-only (SH) condition. Few differences were found between the MET condition and the SH condition for changes in eating attitudes and frequency of binge eating and compensatory behaviors. No significant effects were found for compliance.

DISCUSSION

This research adds to the literature regarding the use of brief motivational interventions to enhance readiness for change in populations with eating disorders.

Comparison of internet and face-to-face delivery of a group body image and disordered eating intervention for women: a pilot study

Increased access to therapy for body dissatisfaction and disordered eating is required. This pilot study compared a group intervention delivered face-to-face or synchronously over the Internet. Women with body dissatisfaction and disordered eating were randomly assigned to a face-to-face (N = 19) or Internet (N = 21) group. Body dissatisfaction, disordered eating, and psychological variables were assessed at baseline, post-intervention, and two months follow-up. Significant improvements on all outcome variables were observed and maintained at follow-up in both groups. There were no significant differences between delivery modes. This program shows promise, and the Internet mode of delivery has potential to overcome geographical distance.