Development of an instrument to assess readiness to recover in anorexia nervosa

Collaborative care in eating disorders treatment: exploring the role of clinician distress, self-compassion, and compassion for others

BACKGROUND

Collaborative care is described as showing curiosity and concern for patient experiences, providing choices, and supporting patient autonomy. In contrast, in directive care, the clinician has authority and the patient is expected to adhere to a treatment plan over which they have limited influence. In the treatment of eating disorders, collaborative care has been shown to be more acceptable and produce better outcomes than directive care. Despite widespread patient and clinician preference for collaborative care, it is common for clinicians to be directive in practice, resulting in negative patient attitudes toward treatment and poor adherence. There is a need to understand factors which contribute to its use.

PURPOSE

This study examined the contribution of clinicians' experience of distress and how they relate to themselves and others in times of difficulty (self-compassion and compassion for others), to their use of collaborative support.

METHOD

Clinicians working with individuals with eating disorders from diverse professional backgrounds (N = 123) completed an online survey.

RESULTS

Whereas clinician distress was not associated with use of collaborative or directive support behaviours, self-compassion and compassion for others were. Regression analyses indicated that compassion for others was the most important determinant of collaborative care.

DISCUSSION

Relating to their own and others' distress with compassion was most important in determining clinicians' use of collaborative support. Understanding how to cultivate conditions that foster compassion in clinical environments could promote the delivery of collaborative care.

A pilot randomized controlled trial of a cognitive-behavioral therapy guided self-help mobile app for the post-acute treatment of anorexia nervosa: A registered report

INTRODUCTION

Relapse following acute treatment for anorexia nervosa (AN) is common. Evidence suggests cognitive-behavioral therapy (CBT) may be useful in the post-acute period, but few patients have access to trained providers. mHealth technologies have potential to increase access to high-quality care for AN, including in the post-acute period. The aim of this study is to estimate the preliminary feasibility and effectiveness of a CBT-based mobile intervention plus treatment as usual (TAU), offered with and without an accompanying social networking feature.

METHOD

In the current pilot randomized controlled trial, women with AN who have been discharged from acute treatment in the past 2 months (N = 90) will be randomly assigned to a CBT-based mobile intervention plus treatment as usual (TAU), a CBT-based mobile intervention including social networking plus TAU, or TAU alone. We will examine feasibility, acceptability, and preliminary effectiveness of the three conditions in terms of reducing eating disorder psychopathology, reducing frequency of eating disorder behaviors, achieving weight maintenance, reducing depression and suicidal ideation, and reducing clinical impairment. We will examine rehospitalization and full recovery rates in an exploratory fashion. We will also examine whether the mobile intervention and social networking feature change the proposed targets and whether changes in targets are associated with benefit, as well as conduct exploratory analyses to identify within-mobile intervention predictors and moderators of outcome.

DISCUSSION

Ultimately, this research may lead to increased access to evidence-based treatment for individuals with AN and prevention of the extreme negative consequences that can result from this serious disorder.

PUBLIC SIGNIFICANCE

Relapse after acute treatment for anorexia nervosa is common, and few patients have access to trained providers to support them following acute care. This study will pilot a coached mobile app, including a social networking component, for this population. If ultimately successful, our approach could greatly increase access to evidence-based treatment for individuals with anorexia nervosa and ultimately prevent the extreme negative consequences that can result from this serious disorder.

[Feasibility of a psychoeducation group for patients with anorexia nervosa: An open study]

INTRODUCTION

Management of anorexia nervosa is difficult and few treatments have shown their effectiveness, justifying the exploration of new therapeutic approaches. Available evidence suggests an interest of psychoeducational groups in a significant number of psychiatric disorders. In patients suffering from anorexia, to date there are few groups or interventions available. We aimed to assess the feasibility and acceptability of a psycho-educational program promoting information about the disease and presenting techniques that can help to cope with anorexia and the functional impact it causes. The exploratory secondary objectives were to evaluate if such a group is associated with clinical improvement.

METHOD

Twenty-seven patients suffering from anorexia nervosa, in three groups, received eight weekly interventions in addition to their usual care. The study was open-label and non-randomized. Patients were assessed three times (baseline, at the end of the group and three months later). The assessments were both qualitative (Eating Disorder Examination questionnaire, The Anorexia Nervosa Stage of Change Questionnaire, the Eating Disorders Quality of Life questionnaire, Work and Social Adjustment Scale) and qualitative.

RESULTS

Seventy-eight percent of participants attended more than 75 % of the sessions. Seventy percent of participants found the group useful, and 95 % said it helped them improve their knowledge of the disease and its consequences. The average BMI of participants changed significantly with an average increase of 2.5kg between baseline and the three month assessment. There was an improvement of the eating disorders features in EDE-Q for the total score and for all subscores. The improvement in the total score was significant at the end of the group sessions, while the improvement in the sub scores became significant at three months. There was also a significant mood improvement at the end of the group. Finally, there was a significant improvement in daily functioning with a decrease in Work and Social Adjustment Scale scores and an improvement in quality of life. On qualitative assessment, patients were satisfied with the care proposal. They were able to appreciate the support and sharing of experience provided by the group formula. Most of them reported changes in their daily lives, either in their relationship to care and illness, or in their relationships with their loved ones, their leisure/work, their mood or their eating behavior.

CONCLUSION

Both qualitative and quantitative results suggest that this group psychoeducation program is feasible and well accepted by patients in addition to usual management. Although the methodology does not allow any conclusions, the clinical improvements observed during the group are encouraging with regard to the safety of this type of intervention and its possible effectiveness and argue for a controlled study.

Inpatients with severe-enduring anorexia nervosa: Understanding the "enduringness" specifier

Background

Despite the need for a common definition of severe and enduring anorexia nervosa (SE-AN) with the overarching goal to optimize treatments, this definition still is being debated. Therefore, in this study we conducted an in-depth investigation of the history of AN and its clinical outcomes on inpatients with AN to ascertain the eventual “profiles” for individuals with varying durations of the illness (DOI).

Methods

We recruited 169 inpatients with AN, grouping them according to DOI: <3 years (short duration, SD-AN); 3–6.99 years (medium duration, MD-AN); and ≥7 years (long duration, LD-AN). We then performed a self-report and interview-based investigation of AN history, clinical data, eating, and general psychopathology, including personality, premorbid traits, stage of change, and quality of life. We measured the clinical outcomes for hospitalization as well.

Results

The majority of the measures did not differ across groups. Those with LD-AN were older and diagnosed mostly with the binge-purging AN subtype, failed more previous AN-related treatments, reported a lower lifetime body mass index, and trended toward a younger age at onset when compared to the other groups. All patients responded equally well to hospitalization, but patients with SD-AN improved less in drive for thinness and body-related concerns.

Conclusions

We did not find the “enduringness” of AN to be a specifier of severity. Hospitalization was effective for those with LD-AN and MD-AN, while interventions for the core cognitive aspects of over-evaluation of body shape should be offered to patients with SD-AN.

Does a Skills Intervention for Parents Have a Positive Impact on Adolescents' Anorexia Nervosa Outcome? Answers from a Quasi-Randomised Feasibility Trial of SUCCEAT

Skills trainings for caregivers of patients with anorexia nervosa (AN) have been proven to be effective in improving caregiver skills and reducing caregivers’ psychopathology. The effects on patients, especially adolescents, are largely unknown. The aim of this study was to evaluate the effectiveness of a caregivers’ skills training program (Supporting Carers of Children and Adolescents with Eating Disorders in Austria, SUCCEAT, workshop or online version) on adolescents with AN delivered as workshops (WS) or online (ONL). Outcomes are Body-Mass-Index (BMI) percentile, eating psychopathology (Eating Disorder Examination, EDE), attitudinal and behavioural dimensions of eating disorders (Eating Disorder Inventory-2), motivation to change (AN Stages of Change Questionnaire), emotional and behavioural problems (Youth Self-Report) and quality of life (KINDL). All outcome variables significantly improved across both SUCCEAT groups (WS and ONL) and were sustained at 12-month follow-up. The online and workshop delivery of SUCCEAT were equally effective. Most effect sizes were in the medium-to-high range. Full or partial remission was observed in 72% (WS) and 87% (ONL) of patients. Caregiver skills trainings, either delivered as workshops or online modules, are highly recommended to complement treatment as usual.

Motivation to Change in the Course of a Pilot Study of a Step-Down Treatment Approach of Inpatient and Anorexia Nervosa-Specific Home Treatment and Its Effects on Treatment Outcome

Introduction: Anorexia nervosa (AN) is a serious mental disorder that typically manifests in adolescence. Motivation to change is an important predictor for treatment outcome in adolescent AN, even though its development over the often long therapeutic process, with transitions between treatment settings, has not yet been studied. In this pilot study, the course of motivation to change and its effect on treatment outcome were investigated over the course of a step-down treatment approach during a 12-month observation period. Methods: Twenty-one adolescents admitted to inpatient treatment because of AN received multidisciplinary home treatment (HoT) with several weekly visits after short inpatient stabilization. Eating disorder (ED-)specific cognitive [Eating Disorder Inventory 2 (EDI-2) subscales] and physical [% expected body weight (%EBW)] illness severity and motivation to change [Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ)] were assessed at the time of admission, discharge from hospital, at the end of HoT, and at a 12-month follow-up. Changes in motivation over time and its relationship with treatment outcome were investigated. Results: Mean motivation to change improved significantly over the course of treatment from the contemplation stage [2nd stage, mean ANSOCQ sum score 47.26 (SD 17.60)] at admission to the action stage [4th stage, mean ANSOCQ sum score 77.64 (SD 18.97)] at the end of HoT (p < 0.001) and remained stable during the follow-up period. At each assessment, higher motivation to change was significantly correlated with lower ED-specific cognitive illness severity (Spearman ρs: -0.53 to -0.77, all p < 0.05). Only pretreatment motivation to change significantly predicted ED-specific cognitive illness severity after the first inpatient treatment phase when taking prior illness severity into account. Conclusions: Motivation to change is an important aspect of treatment success in adolescent AN, especially in the early phase of treatment. In addition, home treatment contributed significantly to a higher motivation. Further longitudinal research into how motivation to change in adolescent patients with AN is related to outcome in this often severe and enduring disease and into targeted therapeutic strategies and interventions that reliably enhance the motivation to change in adolescent patients with AN seems promising.

Pretreatment motivation and therapy outcomes in eating disorders: A systematic review and meta-analysis

OBJECTIVE

Identifying modifiable predictors of outcomes following treatment for eating disorders may help to tailor interventions to patients' individual needs, improve treatment efficacy, and develop new interventions. The goal of this meta-analysis was to quantify the association between pretreatment motivation and posttreatment changes in eating disorder symptomology.

METHOD

We reviewed 196 longitudinal studies reporting on change on indices of overall eating-disorder symptomatology, weight gain, binge-eating, vomiting, anxiety/depression, and treatment adherence. Meta-analyses were performed using two complementary approaches: (a) combined probability analysis using the added Z's method; (b) effect size analyses. Using random-effect models, effect sizes were pooled when there were at least three studies with the same type of statistical design and reporting statistics on the same outcome. Heterogeneity in study outcome was evaluated using Q and I² statistics. Studies were reviewed qualitatively when the number of studies or reported data were insufficient to perform a meta-analysis.

RESULTS

Forty-two articles were included. Although samples and treatments differed substantially across studies, results across studies were remarkably consistent. Both combined-probability and effect-size analyses indicated positive effects of pretreatment motivation on improvement in general eating-disorder symptoms (Cohen's r = .17), and an absence of effects on anxiety/depression symptoms. Remaining outcome indices were subject to selective reporting and/or small sample size bias.

DISCUSSION

Our findings underscore the importance of incorporating treatment engagement approaches in the treatment of eating disorders. Optimal reporting of study findings and improving study quality would improve future efforts to obtain an in-depth understanding of the relationship between motivation and eating disorder symptoms.

Development and validation of the Readiness for Therapy Questionnaire (RTQ)

BACKGROUND

Motivational factors are generally regarded as an important ingredient for change in therapy. However, there is currently a lack of available instruments that can measure clients' readiness for change in therapy.

AIM

The objective of this paper was to create an instrument, the Readiness for Therapy Questionnaire (RTQ), which could measure clients' readiness for change.

METHOD

The RTQ was created by researchers following analysis of themes drawn from a review of the literature and interviews with patients at the end of therapy. This included both people who completed therapy and those who dropped out. As part of the standard assessment process, the RTQ was administered to 349 participants (69.6% female and 30.4% male; mean age 37.1 years; 90.5% Caucasian) who were patients at a psychological therapy service for common mental health difficulties.

RESULT

An initial 12-item scale was reduced to 6 items. This scale significantly correlated with post-therapy PHQ-9 and GAD-7 scores and changes in these scores across therapy. After controlling for baseline scores and demographic variables, a logistic regression showed that scores on this 6-item measure pre-therapy significantly predicted three outcome variables: completing therapy, being recovered on both PHQ-9 and GAD-7 post-therapy, and having a reliable change in both the PHQ-9 and GAD-7 post-therapy. However, receiver operating characteristic (ROC) curve analysis showed the measure had poor sensitivity and specificity. Symptom severity did not have a significant impact on motivation to change.

CONCLUSION

The RTQ is potentially a valid measure with useful clinical applications in treatment of common mental health difficulties.

To contemplate or not to contemplate evaluating a preliminary intervention proposal in an outpatient setting: the contemplation therapy group

PURPOSE

The concept for the contemplation group intervention was derived from motivational interviewing (MI) to support people suffering from an eating disorder who are reluctant to engage with treatment. This evaluation focuses on the contemplation group run by the eating disorder services in the Cardiff and Vale area between 2012 and 2016 to investigate the outcomes for participants and implications for working with people suffering from an eating disorder who are ambivalent about change.

METHOD

Quantitative measures were used to assess eating disorder symptomatology, motivation to change and location within the stages of change model. A brief qualitative evaluation of client experiences was also included.

RESULTS

While dropout was high, a number of patients displayed increased readiness for treatment at the end of the group or even started to engage in change-focussed therapy. Participants who completed the group described it as challenging but helpful.

CONCLUSIONS

This evaluation shows that explorative contemplation of their ambivalence towards their eating disorder and treatment was helpful for the participants of the group and supported them in achieving more clarity and decisiveness regarding whether to engage in treatment or not. Further research is needed to evaluate long-term outcomes for patients who feel ambivalent towards treatment, and to explore what interventions can be used to help them.

EVIDENCE LEVEL

Level IV: Evidence obtained from multiple time series with or without the intervention.

Therapeutic alliance in inpatients with severe anorexia nervosa

OBJECTIVE

Therapeutic alliance (TA) is a relevant aspect in anorexia nervosa (AN), but data on inpatients are lacking. We aimed to evaluate the influence of motivation to change, diagnostic subtypes, and duration of illness on TA at hospital discharge; we also investigated if baseline clinical characteristics were associated with discharge TA, and the TA-outcome association.

METHOD

We enrolled 137 adult inpatients with AN completing Eating Disorder Examination-Questionnaire, Beck Depression Inventory, State-Trait Anxiety Inventory, Anorexia Nervosa Stages of Change-Questionnaire, EuroQoL-Quality of Life Scale-Visual Analogue Scale, and Working Alliance Inventory-Short Revised.

RESULTS

Patients with different AN subtypes and duration of illness reported similar TA. Baseline depression, state anxiety, and motivation to change were statistically significantly associated with TA at discharge. After controlling for all these variables and duration of illness, only motivation to change remained statistically significant. Statistically significant correlations were also found between improvements in body mass index and quality of life and discharge TA.

CONCLUSIONS

Few data exist on TA in inpatients with AN and a long duration of illness. Our findings suggest that baseline motivation to change correlates with TA at discharge independently of other variables. Future studies should ascertain as to whether a causal link exists or not.

Accuracy of self-reported physical activity in patients with anorexia nervosa: links with clinical features

BACKGROUND

High levels of physical activity (PA) have long been described in patients with Anorexia Nervosa (AN). Despite the importance of measuring PA in this population, there are two important factors that remain unknown. First, it is not clear how accurate self-report measures of PA are among patients. Second, little is known about how clinical characteristics are associated with the accuracy of self-reported PA. Therefore, this study aimed to examine the accuracy of self-reported PA compared to an objective measure of PA in patients with AN. It also investigated whether levels of accuracy/inaccuracy were associated with compulsive exercise, motivation to change, and psychological distress.

METHOD

Data were analysed from 34 adult outpatients with AN. Patients wore an accelerometer device (ActiGraph) for 4 days and completed a retrospective self-report measure of exercise (Exercise Participation Screening Questionnaire). They also completed measures of compulsive exercise (Compulsive Exercise Test), motivation to change (The Anorexia Nervosa Stages of Change Questionnaire), and psychological distress (Kessler-10).

RESULTS

On the self-report measure, patients accurately reported their time spent in moderate and vigorous intensity PA, however, they significantly under-reported their light physical activity (compared to the accelerometer data). Accurate reporting of total PA was positively associated with higher levels of compulsive exercise. There was evidence to suggest that clinical features, such as motivation to change and psychological distress, may be associated with inaccurate reporting at some levels of PA intensity and not others.

CONCLUSIONS

Results indicate that patients with AN are likely to under-report their light intensity PA. We also found preliminary evidence for how compulsive exercise, motivation to change, and distress are associated with self-reported PA accuracy. Clinical implications and directions for future research are considered.

TRIAL REGISTRATION

ACTRN12610000585022. Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

The adolescent onset anorexia nervosa study (ANABEL): Design and baseline results

The anorexia nervosa adolescent longitudinal biomarker assessment study (ANABEL) is a 2-year longitudinal study.

OBJECTIVE

Evaluate several clinical, biochemical, immunological, psychological, and family variables and their interactions in adolescent onset eating disorders (EDs) patients and their 2-year clinical and biological outcome. This article illustrates the framework and the methodology behind the research questions, as well as describing general features of the sample.

METHODS

A longitudinal study of 114 adolescents with EDs seeking treatment was performed. Only adolescents were selected during 4 years (2009-2013). The variables were collected at different times: baseline, 6, 12, 18, and 24 months of the start of treatment. Diagnoses were completed through the semi-structured Kiddie-Schedule for Affective Disorders and Schizophrenia interview.

RESULTS

At baseline, the mean age was 15.11 (SD = 1.36). The mean ED duration was 10 months (SD = 5.75). The mean body mass index was 16.1 (SD = 1.8). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis at baseline for restrictive anorexia nervosa was 69.6%, 17.4% for purgative anorexia nervosa, and 24.3% for other specified feeding disorder. At 12 months, 19.4% were in partial remission, whereas at 24 months, 13.8% had fully recovered and 29.2% had partially recovered.

CONCLUSIONS

There was an acceptable physical and psychopathological improvement during the first year of treatment, with recovery being more evident during the first 6 months.

Improving motivation to change amongst individuals with eating disorders: A systematic review

OBJECTIVE

People with eating disorders can have low motivation to change their eating disorder behaviors. Interventions aiming to enhance motivation to change have been increasingly advocated in their treatment. Questions remain regarding the strength of the evidence supporting the effectiveness of interventions that specifically focus on improving motivation. This review explored the evidence for improving motivation to change in eating disorders via clinical interventions.

METHOD

Searches of the published and unpublished literature were conducted by searching databases (PubMed, PsychInfo, Web of Science) and trial registries (WHO ICTRP), and by contacting authors. Studies were included if they investigated an intervention for eating disorder patients, included a pre-post outcome measure of motivation to change and were published in English. Risk of bias was also assessed.

RESULTS

Forty-two studies were included in the final review. Evidence was found to support the use of interventions to improve motivation to change, though it was unclear whether motivational interventions present a more effective option than approaches that do not exclusively or specifically focus on motivation. However, motivational interventions were identified as being more effective than low intensity treatments. Risk of bias in included studies was generally high.

DISCUSSION

Motivation was found to increase across treatments in general, whether or not the focus of the intervention was on enhancing motivation. It is unclear if interventions specifically targeting motivation to change provide additional benefit over and above established treatment approaches.

Relationships between compulsive exercise, quality of life, psychological distress and motivation to change in adults with anorexia nervosa

BACKGROUND

For people with anorexia nervosa (AN), compulsive exercise is characterized by extreme concerns about the perceived negative consequences of stopping/reducing exercise, dysregulation of affect, and inflexible exercise routines. It is associated with increased eating disorder psychopathology and poor clinical outcome. However, its relationships with two important clinical issues, quality of life (QoL) and motivation to change, are currently unknown. This study aimed to assess the cross-sectional relationships between compulsive exercise, QoL, psychological distress (anxiety and depressive symptoms, and obsessive-compulsive traits) and motivation to change in patients with AN.

METHOD

A total of 78 adults with AN participated in this study, which was nested within a randomized controlled trial of psychological treatments for AN. At baseline (pre-treatment), participants completed questionnaires assessing compulsive exercise, eating disorder (ED) psychopathology, QoL, psychological distress and motivation to change.

RESULTS

Baseline correlational analyses demonstrated a moderate positive relationship between compulsive exercise and ED psychopathology, and a weak positive relationship between compulsive exercise and psychological distress. There was a moderate negative relationship between compulsive exercise and eating disorder QoL.

CONCLUSIONS

These results indicate compulsive exercise is moderately associated with poorer QoL and weakly associated with higher distress. Targeting compulsive exercise in the treatment of anorexia nervosa may help reduce the burden of illness and improve patients' engagement in treatment.

TRIAL REGISTRATION

ACTRN12610000585022. Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

Are recovery stories helpful for women with eating disorders? A pilot study and commentary on future research

BACKGROUND

Anecdotally it is well known that eating disorder memoirs are popular with people with anorexia nervosa and recovery stories are readily available online. However, no research to date has empirically explored whether such stories are helpful for current sufferers. The aim of the current pilot study was to explore the efficacy of recovery narratives as a means of improving motivation and self-efficacy and to qualitatively explore patient perspectives of such stories.

METHOD

Fifty-seven women with anorexia nervosa and subclinical anorexia nervosa participated in this online study. Participants were randomised to either receive recovery stories or to a wait-list control group. After completing baseline measures, participants read five stories about recovery, and completed post-intervention measures two weeks later.

RESULTS

The quantitative results indicated that reading stories of recovery had no effect on motivation and self-efficacy over a two-week period. In contrast, the qualitative results showed that the stories generated thoughts about the possibility of recovery and the majority indicated they would recommend them to others.

CONCLUSIONS

This study adds to a growing body of research exploring the integration of voices of lived experience into treatment approaches. Future research should focus on 1) identifying for whom and at which stage of illness recovery stories might be helpful; 2) the mechanism via which they might operate; and 3) the most helpful way of presenting such stories.

An evaluation of the predictive validity of the URICA and ANSOCQ scales for weight gain in adults with AN in an outpatient eating disorders program: a prospective cohort study

BACKGROUND

The Transtheoretical Model (TTM) which focuses on stage of change has been the main conceptual model used in understanding the lack of motivation to change in patients with Anorexia Nervosa (AN). Whilst there is evidence to support the prognostic value of the TTM in AN, this evidence base sufferers from limitations including limited studies in adults and none in outpatient populations. The primary aim of this study was to clarify whether readiness to change, as measured by the University Rhode Island Change Assessment Scale (URICA) and the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) could predict weight gain in adults with AN following treatment in an outpatient setting.

METHODS

This was a prospective cohort analysis, which selectively used data from an existing clinical database at an outpatient eating disorders service. 119 patients met eligibility criteria and were included in this study. This included all adult patients who had a diagnosis of AN and were assessed, but not necessarily treated at the outpatient eating disorders program (Group 1). A subgroup of 63 patients (Group 2) was also analysed which only included patients who had received treatment at the program. Baseline measures included the URICA score, the ANSOCQ score, the Eating Disorders Examination Questionnaire (EDE-Q) and body mass index (BMI). BMI was also measured on discharge.

RESULTS

The URICA scale had poor predictive validity for weight gain (r = 0.05, p = 0.725). The ANSOCQ had moderate predictive validity (Pearson's r = 0.57, p = 0.007), and accounted for 32.7% of variance in weight gain. The URICA and ANSOCQ were moderately correlated in both groups. The URICA was moderately predictive of symptom severity, measured by the EDE-Q in both groups. The ANSOCQ was moderately correlated with the EDE-Q scores in both Groups 1 and 2.

CONCLUSIONS

To the authors' knowledge this is the only study evaluating stage of change, in an adult outpatient population with AN. The findings of this study suggest that while both the URICA and ANSOCQ were associated with eating disorder symptom severity, only the ANSOCQ was able to predict weight gain in outpatients with AN suggesting its greater utility in this context.

A Readiness Ruler for Assessing Motivation to Change in People with Eating Disorders

OBJECTIVE

We examined the psychometric properties of the Eating Disorder Readiness Ruler a simple self-report instrument designed to enable rapid assessment of readiness to change problematic eating behaviours in people with clinical eating disorders.

METHOD

We administered the ED-RR, the Eating Disorders Examination Questionnaire and a measure of autonomous and controlled motivation for change to 206 individuals receiving outpatient treatment for an eating disorder.

RESULTS

A principal axis factoring analysis of the ED-RR yielded a significant two-factor solution (explaining 59% of variance)-one factor pertaining to restriction and body image preoccupation (four items), the other to binge-eating and vomiting symptoms (two items). The ED-RR showed good internal consistency (alpha coefficients for the two factors being .77 and .84 respectively). Furthermore, individuals reporting higher readiness showed higher scores on independent measures of autonomous motivation and greater symptom reductions over time.

DISCUSSION

Results suggest that the ED-RR is a psychometrically sound tool with potential clinical utility. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Motivation to change, coping, and self-esteem in adolescent anorexia nervosa: a validation study of the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ)

BACKGROUND

Understanding motivation to change is a key issue in both the assessment and the treatment of eating disorders. Therefore, sound instruments assessing this construct are of great help to clinicians. Accordingly, the present study analysed the psychometric properties of the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), including its relation to coping style and self-esteem.

METHODS

N = 92 adolescents referred to an eating disorders outpatient clinic meeting criteria for anorexia nervosa gave written informed consent to participate in this study and completed the ANSOCQ, the Eating Disorder Inventory, the Eating Attitudes Test, the Body Image Questionnaire, two questionnaires measuring Self-Related Cognitions and the Coping Across Situations Questionnaire. After a treatment period of nine months, clinical anorexia nervosa diagnosis and the body mass index were re-assessed. In addition to exploratory factor analysis, correlational analysis was used to test for the convergent validity of the ANSOCQ and logistic regression analysis was used to test its predictive validity.

RESULTS

The ANSOCQ had good psychometric properties. Factor analysis yielded two meaningful factors labelled as 'weight gain and control' and 'attitudes and feelings'. Internal consistencies of the two factors amounted to Cronbach's alpha = .87 and .76, respectively. Significant correlations with other scales measuring eating disorder psychopathology were indicative of meaningful construct validity. Higher motivation to change was related to higher self-esteem and a more active coping style. Higher (positive) ANSOCQ total scores predicted remission of anorexia nervosa after nine months of treatment. A higher score on 'attitudes and feelings' was a protective factor against drop-out from intervention.

CONCLUSIONS

The ANSOCQ is a clinically useful instrument for measuring motivation to change in adolescents with AN. Two factorial dimensions explain most of the variation. Self-esteem and coping style are relevant additional constructs for the understanding of the motivation to change in anorexia nervosa.

TRIAL REGISTRATION

NCT02828956. Retrospectively registered July 2016.

Family-Based Therapy for Young Adults with Anorexia Nervosa Restores Weight

OBJECTIVE

We examined the preliminary acceptability and efficacy of family-based therapy (FBT) for weight restoration in young adults (FBTY) with Anorexia Nervosa (AN).

METHOD

Twenty-two primarily female participants ranging from age 18 to 26, with AN or atypical AN (ICD-10) and their support adults were enrolled in a 6-month open trial of FBTY. Participants were assessed at baseline, after treatment, and at six and 12 month follow-up visits. The primary outcome was BMI and secondary outcomes included eating disorder psychopathology, current eating disorder obsessions, and compulsions, number of other Axis I disorders and global assessment of functioning.

RESULTS

Although FBTY was rated as suitable by participants and their support adults, during FBTY, 9/22 participants dropped out and 3/22 dropped out at follow-up assessments. Despite being offered 18-20 sessions over six months, a mean of 12 FBTY sessions (SD = 6) were attended. After FBTY, 15 of the intent-to-treat sample of 22 were no longer underweight (BMIs ≥ 19 kg/m(2) ) and 12 months after treatment, 13/22 were no longer underweight. The magnitude of the BMI increase during FBTY (Hedges g = 1.20, 95th percentile CI = 0.55-1.85) was comparable to findings for adolescent FBT for AN. Secondary outcomes also improved.

DISCUSSION

FBTY for young adults with AN and atypical AN, which involves support adults participants have chosen, results in weight restoration that is sustained up to a year after treatment. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:701-707).

Was passiert nach dem letzten Klick?

Zusammenfassung. Theoretischer Hintergrund: Bisherige Studien zeigen, dass internetbasierte Interventionen kurzfristig die Veränderungsmotivation bei Essstörungen verbessern können. Zur Stabilität dieser Effekte ist jedoch wenig bekannt. Fragestellung: Wie entwickeln sich die Veränderungsmotivation, die Essstörungspsychopathologie und das Selbstwertgefühl 8 Wochen nach Abschluss eines internetbasierten Motivationsprogramms? Methode: Neunzig Frauen bearbeiteten den Stages of Change Questionnaire for Eating Disorders, den Eating Disorder Examination-Questionnaire und die Rosenberg Self-Esteem-Scale unmittelbar (Post) sowie 8 Wochen nach Abschluss der Intervention (Katamnese). Ergebnisse: Es zeigten sich stabile Effekte in der Veränderungsmotivation sowie im Selbstwertgefühl. Zusätzlich zeigten sich in der Essstörungspsychopathologie signifikante Verbesserungen. Schlussfolgerungen: Die Studie belegt die längerfristige Wirksamkeit eines internetbasierten Motivationsprogramms für Frauen mit Essstörungen.

Motivation to change and perceptions of the admission process with respect to outcome in adolescent anorexia nervosa

BACKGROUND

In patients with anorexia nervosa (AN), there is evidence that readiness to change is an important predictor of outcome with respect to weight gain and improvement in eating disorder psychopathology. In particular, young patients are characterized by a low level of motivation for recovery and perceive more coercion at hospitalization. Thus, a better understanding of the variables that influence readiness to change and perception of the admission process in adolescent AN may help to support patients in initiating change and staying motivated for treatment.

METHODS

In 40 adolescent patients diagnosed with AN according to DSM-IV criteria, we assessed in a prospective clinical cohort study the motivation to change using the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) at admission to inpatient treatment, in week 9 after admission and at discharge. Additional variables were assessed, including depressive symptoms (Beck Depression Inventory, BDI), eating disorder-specific psychopathology (Eating Disorder Inventory, EDI-2), body mass index (BMI) and the percentage of expected body weight (%EBW). The patients' perceptions of the admission process and their perceived need for hospitalization were assessed using a self-report scale developed by Guarda et al. (2007).

RESULTS

Younger patients perceived more coercion than older patients did. Low %EBW and more severe eating disorder-specific psychopathology were associated with a greater perceived need for hospitalization. Moreover, low %EBW at admission and a longer duration of illness were accompanied by a greater motivation to change at admission, whereas more severe eating disorder psychopathology was associated with a low motivation to change. The motivation to change increased significantly between admission and discharge. Patients with a greater motivation to change at admission exhibited a higher weekly weight gain during treatment but did not show better outcome in eating disorder-specific psychopathology and depression.

CONCLUSIONS

Motivation to change is an important predictor of short-term outcome with respect to weight gain trajectory during treatment of adolescent AN. As patients with a higher BMI at admission and those with more severe eating disorder-specific symptoms seem to be less motivated to change, the crucial issue of motivation to change should be addressed with these patients during the therapeutic process.

Specialized inpatient treatment of adult anorexia nervosa: effectiveness and clinical significance of changes

BACKGROUND

Previous studies have predominantly evaluated the effectiveness of inpatient treatment for anorexia nervosa at the group level. The aim of this study was to evaluate treatment outcomes at an individual level based on the clinical significance of improvement. Patients' treatment outcomes were classified into four groups: deteriorated, unchanged, reliably improved and clinically significantly improved. Furthermore, the study set out to explore predictors of clinically significant changes in eating disorder psychopathology.

METHODS

A total of 435 inpatients were assessed at admission and at discharge on the following measures: body-mass-index, eating disorder symptoms, general psychopathology, depression and motivation for change.

RESULTS

20.0-32.0% of patients showed reliable changes and 34.1-55.3% showed clinically significant changes in the various outcome measures. Between 23.0% and 34.5% remained unchanged and between 1.7% and 3.0% deteriorated. Motivation for change and depressive symptoms were identified as positive predictors of clinically significant changes in eating disorder psychopathology, whereas body dissatisfaction, impulse regulation, social insecurity and education were negative predictors.

CONCLUSIONS

Despite high rates of reliable and clinically significant changes following intensive inpatient treatment, about one third of anorexia nervosa patients showed no significant response to treatment. Future studies should focus on the identification of non-responders as well as on the development of treatment strategies for these patients.

Fostering self-endorsed motivation to change in patients with an eating disorder: the role of perceived autonomy support and psychological need satisfaction

OBJECTIVE

Although several studies have established the beneficial effects of self-endorsed forms of motivation for lasting therapeutic change, the way patients with an eating disorder can be encouraged to volitionally pursue change has received less attention. On the basis of Self-Determination Theory, this longitudinal study addressed the role of an autonomy-supportive environment and psychological need satisfaction in fostering self-endorsed motivation for change and subsequent weight gain.

METHOD

Female inpatients (n = 84) with mainly anorexia nervosa and bulimia nervosa filled out questionnaires at the onset of, during, and at the end of treatment regarding their perceived autonomy support from parents, staff members, and fellow patients, their psychological need satisfaction, and their reasons for undertaking change. Furthermore, the body mass index (BMI) of the patients at the onset and end of treatment was assessed by the staff. Path analyses were used to investigate the relations between these constructs.

RESULTS

At the start of treatment, perceived parental autonomy support related positively to self-endorsed motivation through psychological need satisfaction. Perceived staff and fellow patients autonomy support related to changes in self-endorsed motivation over the course of treatment through fostering change in psychological need satisfaction. Finally, relative increases in self-endorsed motivation related to relative increases in BMI throughout treatment in a subgroup of patients with anorexia nervosa.

DISCUSSION

These results point to the importance of an autonomy-supportive context for facilitating self-endorsed motivation.

An Internet-based program to enhance motivation to change in females with symptoms of an eating disorder: a randomized controlled trial

BACKGROUND

Previous research has demonstrated an association between low motivation to change and an unfavorable treatment outcome in patients with an eating disorder. Consequently, various studies have examined the effects of motivational enhancement therapy (MET) on motivation to change and treatment outcome in eating disorders. In each of these studies, MET was administered in a face-to-face setting. However, because of its anonymity and ease of access, the internet provides several advantages as the format for such an intervention. Therefore, the current study investigated the effects of an internet-based program ('ESS-KIMO') to enhance motivation to change in eating disorders.

METHOD

In total, 212 females were accepted for participation and assigned randomly to the intervention condition (n = 103) or waiting-list control condition (n = 109). The intervention consisted of six online MET sessions. Before and after the intervention or waiting period respectively, participants completed the Eating Disorder Examination Questionnaire (EDE-Q), the Stages of Change Questionnaire for Eating Disorders (SOCQ-ED), the Pros and Cons of Eating Disorders Scale (P-CED), the Self-Efficacy Scale (SES), and the Rosenberg Self-Esteem Scale (RSES). A total of 125 participants completed the assessment post-treatment. Completer analyses and intent-to-treat analyses were performed.

RESULTS

Significant time × group interactions were found, indicating a stronger increase in motivational aspects and self-esteem, in addition to a stronger symptom reduction on some measures from pre- to post-treatment in the intervention group compared to the control group.

CONCLUSIONS

Internet-based approaches can be considered as useful for enhancing motivation to change in eating disorders and for yielding initial symptomatic improvement.

"Doing the impossible": the process of recovery from chronic anorexia nervosa

In this study, we aimed to explore the process of recovery over time from the perspective of those who had fully recovered from chronic anorexia nervosa (AN), using stringent recovery criteria. Eight women, assessed as fully recovered from chronic AN, told their story of the process of recovery. Data were analyzed using the qualitative method, narrative inquiry. Recovery was identified as a long and complex process that spanned four phases: from being unable or unready to change, to experiencing a tipping point where motivation increased and changed in quality, allowing the women to take action against the AN and finally allowing them to reflect and rehabilitate. Results provide a framework for understanding this complex process. Findings suggest that full recovery from chronic AN is possible and emphasize the importance of hope, motivation, self-efficacy, and support from others in the recovery process.

Premature termination of treatment for anorexia nervosa: differences between patient-initiated and staff-initiated discharge

OBJECTIVES

To investigate treatment drop-out by comparing clinical indicators of patients whose discharge was initiated by staff with those who initiated discharge themselves.

METHOD

Ninety participants with anorexia completed questionnaires at admission and four weeks into hospitalized treatment. Weight data was collected over this same period. At discharge, participants were categorized into completer (n = 38) or patient-initiated (n = 36) /staff-initiated (n = 16) premature termination groups.

RESULTS

Significant differences between staff-initiated and patient-initiated discharge groups were found at admission. Staff initiated groups were on average older (p = .035), and more likely to have had prior compelled treatment (p = .039). At 4 weeks those in the patient-initiated group had put on weight at a faster rate (p = .032) and reported a decrease in alliance (p = .017). At discharge, staff initiated discharge demonstrated greater time in treatment (p = .001), greater weight gain (p = .027), and a higher discharge BMI (p = .013). At discharge, staff-initiated drop-outs had comparable end-of-treatment outcomes to those who completed treatment as planned.

DISCUSSION

There are key differences between those who prematurely discharge themselves from treatment, compared to those who are prematurely discharged by clinical staff. Future research into drop-out needs to take into account and recognize these differences.

Motivation to change in the eating disorders: a systematic review

OBJECTIVE

The aim of the study was to review the eating disorder literature in order to examine the effect of pretreatment autonomous/level of motivation to change on treatment outcome as measured by change in eating disorder pathology.

METHOD

Relevant databases were systematically searched for studies in which motivation to change prior to treatment was examined in relation to treatment outcome.

RESULTS

Pretreatment autonomous/level of motivation were associated with change in restrictive eating behaviors, bingeing behaviors, and cognitive/affective measures of eating disorder pathology. There was mixed support for the effect of motivation to change on global measures of eating disorder symptoms and virtually no support for the effect of motivation to change on purging behavior.

DISCUSSION

The level of pretreatment motivation the person exhibits prior to commencement of treatment appears to be helpful in predicting treatment outcome.

Assessing motivation to change in eating disorders: a systematic review

BACKGROUND

Patients with anorexia and bulimia nervosa are often ambivalent about their eating disorder symptoms. Therefore, a lack of motivation to change is a frequent problem in the treatment of eating disorders. This is of high relevance, as a low motivation to change is a predictor of an unfavourable treatment outcome and high treatment dropout rates. In order to quantify the degree of motivation to change, valid and reliable instruments are required in research and practice. The transtheoretical model of behaviour change (TTM) offers a framework for these measurements.

OBJECTIVE

This paper reviews existing instruments assessing motivation to change in eating disorders.

METHOD

We screened N = 119 studies from the databases Medline and Psycinfo found by combinations of the search keywords 'eating disorder', 'anorexia nervosa', 'bulimia nervosa', 'motivation', 'readiness to change', 'assessment', 'measurement', and 'questionnaire'.

RESULTS

Ultimately, n = 15 studies investigating psychometric properties of different assessment tools of motivation to change in eating disorders were identified. Reviewed instruments can be divided into those assessing the stages of change according to the TTM (6 instruments) and those capturing decisional balance (3 instruments). Overall, the psychometric properties of these instruments are satisfactory to good.

DISCUSSION

Advantages, disadvantages, and limitations of the reviewed assessment tools are discussed. So far, the TTM provides the only framework to assess motivation to change in eating disorders.

Stages of change, treatment outcome and therapeutic alliance in adult inpatients with chronic anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with high rates of chronicity and relapse risk is a considerable therapeutic challenge in the disorder. The aim of the present study was to investigate the association of stages of change and outcome with a focus on the relapse struggle in the maintenance stage in patients with predominantly chronic AN. Further, therapeutic alliance and stages of change associations were explored.

METHODS

As an instrument measuring relapse struggle in the maintenance stage, we applied the short form of the University of Rhode Island Change Assessment-Short (URICA-S). We assessed stages of change in 39 patients with a predominantly chronic course of AN in early, middle, and late stages of inpatient psychotherapy. General symptom severity as assessed by the SCL-90-R and weight change were investigated as outcome measures.

RESULTS

In-line with earlier evidence, contemplation significantly predicted therapeutic alliance. Further, we demonstrated that relapse risk as operationalized by URICA-S maintenance is an important predictor of general psychopathology. BMI change was not predicted by stages of change.

CONCLUSIONS

The URICA-S maintenance scale might be applied to help identify patients at relapse risk. High URICA-S maintenance scores could be considered as one critical aspect of AN patients who might especially benefit from relapse-preventing aftercare programs.

Predicting premature termination of hospitalised treatment for anorexia nervosa: the roles of therapeutic alliance, motivation, and behaviour change

OBJECTIVES

This study aims to investigate treatment drop-out, and the associated roles of motivation, alliance, and behaviour change exhibited over the first four weeks of hospitalised treatment for anorexia.

METHODS

90 participants meeting DSM-IV criteria for anorexia nervosa completed questionnaires at admission, and four weeks into treatment. Weight data was collected over this same time period. At the end of treatment, participants were categorised into completer or premature termination groups.

RESULTS

The overall rate of premature termination was 57.8%. Those who prematurely terminated treatment demonstrated lower discharge BMI (p<.0005), and weight gain (p<.0005) than those who completed. Therapeutic alliance proved significantly different between outcome groups at admission (p=.004).

DISCUSSION

End-of-treatment outcomes for those who do not complete treatment are invariably poor. Therapeutic alliance appears to be a particularly important factor in this area.

Perceptions of carer burden: differences between individuals with an eating disorder and their carer

Carer burden in eating disorders is considerable, but to date no research has examined carer burden from the perspective of the person with an eating disorder. The current brief report assessed carer burden with a short questionnaire, as perceived by 20 matched pairs of sufferers and their carers. Those with an eating disorder significantly underestimated the overall burden experienced by their carer, particularly in relation to nutritional difficulties and conflict within the family. Domains where carers and sufferers had high agreement may be useful in facilitating collaborative involvement between sufferers and carers in treatment, such as multi-family therapy.

A prospective study of predictors of relapse in anorexia nervosa: implications for relapse prevention

Anorexia nervosa (AN) is a serious psychiatric disorder with a high rate of relapse. The goal of this study was to identify predictors of relapse in adult AN using a prospective, longitudinal design. Participants were 100 AN patients who had successfully completed specialized inpatient/day treatment, were weight-restored to a body mass index (BMI) of at least 20 for a minimum of 2 weeks, and reported less than one binge-purge (BP) episode over the previous 28 days at the end of treatment. Predictor variables included baseline demographic and clinical features, behavioral and psychological changes during treatment, residual psychopathology at post-treatment, and motivation to recover. Results indicated that 41% of participants relapsed during the 1-year follow-up period. The highest risk period for relapse was between 4 and 9 months post-treatment. Predictors of relapse included: the BP subtype of AN, severity of checking behaviors at pre-treatment, decrease in motivation to recover during treatment, and lower motivation to recover at post-treatment. These findings suggest that individuals with the BP subtype of AN are particularly susceptible to relapse. Increasing and maintaining motivation to recover during acute treatment may have an important impact on long-term outcome.

The use of motivational interviewing in eating disorders: a systematic review

This review examines the effectiveness of interventions that include the principles and techniques of motivational interviewing (MI) and its adaptations in the treatment of eating disorders. The aims are (1) to examine both the context and effectiveness of MI and Motivational Enhancement Therapy (MET) when used with either patients or carers of people with eating disorders, (2) to identify limitations and/or difficulties in this process and (3) to identify further research needs in this area. Electronic databases were searched up until April 2012. Articles were screened according to predetermined inclusion and exclusion criteria. Thirteen studies were finally selected for inclusion. A wide range of participants, interventions and outcomes were measured which made comparative analysis difficult. Promising results were found for interventions that included MI, particularly with regards to its use in increasing a readiness and motivation to change. Consequently, there is potential for using MI in the field of eating disorders, particularly with respect to 'readiness for change'. More homogeneity in study design and delivery of MI is needed along with some markers of treatment fidelity, including information as to how adherence to the intervention is assured.

The clinician administered staging instrument for anorexia nervosa: development and psychometric properties

OBJECTIVE

To develop and evaluate an instrument to assess severity in anorexia nervosa (AN), the Clinician Administered Staging Instrument for Anorexia Nervosa (CASIAN).

METHOD

Candidate items for the CASIAN were developed in three phases (domain, content, and item generation) followed by a pilot study. The psychometric properties of the resultant 34-item questionnaire were investigated in cross-sectional and longitudinal samples (N = 171) with DSM-IV AN and subthreshold AN.

RESULTS

Item and factor analysis procedures resulted in a refined 23-item CASIAN comprising of six factors ("Motivation," "Weight," "Illness Duration," "Obsessionality," "Bulimic Behaviors," and "Acute Issues"). The CASIAN had high internal consistency (.811), test-retest (.957), and interrater reliability (.973). Preliminary support for the convergent, discriminant, concurrent, and predictive validity of the CASIAN was found.

DISCUSSION

The CASIAN is a psychometrically sound instrument. Further studies are needed to confirm the factor structure and assess its clinical and research utility.

The myths of motivation: time for a fresh look at some received wisdom in the eating disorders?

The eating disorders typically involve poor motivation to change. This article reviews the evidence behind many of our beliefs about motivation and whether we need a different conceptual framework for understanding why patients commonly get "stuck." The outcome literature is reviewed, and demonstrates that there is little evidence that we are effective in enhancing motivation to induce changes in symptoms. Indeed, there are suggestions that commonly used models are unhelpful. Verbal expressions of motivation are not the best indicator of likely treatment response, and can best be understood as providing a "manifesto," which has functions that can obstruct recovery from the eating disorder. A behavioral analysis of motivation is likely to be more effective. Cognitive, emotional, and behavioral methods for enhancing motivation are outlined, with the aim of bypassing the motivational manifesto and encouraging positive therapeutic change.

The efficacy of a brief motivational intervention for individuals with eating disorders: a randomized control trial

OBJECTIVE

Individuals with eating disorders are often ambivalent about recovery, and previous research has shown that readiness for change predicts enrollment in intensive treatment, symptom change, dropout, and relapse. Given the demonstrated importance of readiness for change, researchers and clinicians have turned to investigating interventions designed to enhance motivation. The purpose of this research was to determine the efficacy of Readiness and Motivation Therapy (RMT), a five-session individual preparatory intervention for individuals with eating disorders.

METHOD

Participants completed the Readiness and Motivation Interview and measures of eating disorder symptomatology, self-esteem, and psychiatric symptoms at intake. One hundred eighty-one participants were randomly assigned to the treatment (RMT) or wait-list control condition and were reassessed at 6-week and 3-month follow-up; 113 completed assessments at all three time points and primary analyses were based on these individuals.

RESULTS

Surprisingly, improvements in readiness for change, depression, drive for thinness, and bulimia symptoms occurred over time in both RMT and control conditions. However, at post and at follow-up, individuals who received RMT were less likely to have high ambivalence than were those from the control condition.

DISCUSSION

RMT may be of benefit to highly reluctant, clinically challenging patients and help them make better use of future, action-oriented treatment.

Motivation-focused treatment for eating disorders: a sequential trial of enhanced cognitive behaviour therapy with and without preceding motivation-focused therapy

OBJECTIVE

To evaluate the effectiveness of a motivation-focused intervention prior to individual cognitive behavioural eating disorder treatment.

METHOD

Enhanced cognitive-behavioural therapy (CBT-E) in its usual form was compared with CBT-E preceded by four sessions of motivation-focused therapy (MFT) (MFT + CBT-E). Participants were adult outpatients seen at a specialist eating disorder clinic in Western Australia, who met criteria for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition eating disorder. A sequential trial of CBT-E as usual (n = 43) and MFT + CBT-E (n = 52) was conducted over a 40-month period.

RESULTS

The MFT phase was associated with significant increases in readiness to change. There were no significant between-group differences in treatment completion rates, and treatment completers in both conditions reported comparable reductions in eating disorder symptoms over time.

CONCLUSION

In this sample, MFT + CBT-E was not associated with superior treatment outcome when compared with CBT-E as usual.

[Comparison of instruments assessing the readiness to change in patients with anorexia nervosa]

OBJECTIVES

The study compares three instruments assessing the readiness to change in patients suffering from anorexia nervosa, and assesses their relationship to clinical data.

METHODS

Two of the instruments, the "Fragebogen zur Erfassung der eränderungsbereitschaft" (FEVER) and the "Anorexia Nervosa Stages of Change Questionnaire"(ANSOCQ), are questionnaires; the "Readiness and Motivation Interview"(RMI) is a semistructured interview. The sample consisted of 44 anorexia nervosa inpatients.

RESULTS

The data of the three instruments correlate with each other to a medium high degree. Clinical variables such as BMI, bodyweight, and inpatient treatment duration show only a few, and mostly low, correlations. The therapeutic prognoses correlate with the motivation to change to a medium/high degree, whereas low motivation frequently correlates with negative predictions.

CONCLUSIONS

The ambivalence of the anorexia nervosa patients shows up mostly on the RMI, which also displays the highest correlations to the clinical data and to the EDI-2 data.

The Evolution of Vocational Psychology: Questions for a Postmodern Applied Discipline

Vocational psychology has a long history of acting as a lens that focuses research in basic sciences on the particular experience of work in people’s lives. This article presents several areas on the ascendancy in the broader scientific literature and ask how vocational psychology might apply them to issues of work in people’s lives. The authors’ observations tend to revolve around the growing view of humans as less rational and more intuitive than our earlier understanding. In that vein, the authors discuss (a) differences between the environment in which we evolved and the one in which we currently exist; (b) the singularity of our evolutionary impetus to survive and reproduce (that excludes our current emphasis on happiness); (c) the modular, two-system brain that includes our unconscious/intuitive system and our conscious/rational system; and (d) several recent developments in psychotherapy that recognize and respond to some of these new understandings. For simplicity sake, our questions might be subsumed under the larger question: How do we apply post-rational theory to hyperrational humans? Rejuvenation of the field might be tied to our willingness to listen to science being done around us, and not relying too heavily on the excellent work accomplished by those who came before us.

Reluctance to recover in anorexia nervosa

OBJECTIVE

Reluctance to recover may explain poor treatment outcome and high dropout and relapse rates in the treatment of anorexia nervosa (AN). This study systematically explored what AN patients describe as interfering with their wish to recover.

METHOD

Two independent samples of women with AN (total N = 36) were interviewed in-depth using a phenomenological study design. Interviews were tape recorded, transcribed and analysed using QSR-NVivo7 (QSR International, Melbourne, Australia) software.

RESULTS

Seven core obstacles were found to interfere with informants' wish to recover as follows: (i) 'perceiving judgements'; (ii) 'feeling stuck'; (iii) 'feeling distressed'; (iv) 'denying AN'; (v) 'eating'; (vi) 'gaining weight'; and (vii) 'appreciating the benefits'.

CONCLUSION

The wish to recover is an autonomously based, fundamental motivational requirement for becoming ready to change. Understanding factors that contribute to this wish adds to the clinician's toolbox in motivational work with AN patients.

A case series evaluation of the Maudsley Model for treatment of adults with anorexia nervosa

OBJECTIVE

Outpatient psychotherapy has been largely unsuccessful in assisting adults with anorexia nervosa (AN) to achieve weight restoration. The aim of the current study was to evaluate change and attainment of good and moderate outcome at 12-month follow-up using the Maudsley Model for Treatment of Adults with AN (MANTRA).

METHODS

Of 33 people assessed, 28 people commenced therapy, and 23 completed it (82%).

RESULTS

At post-treatment, seven people (30%) met the criteria for good outcome and one person met the criteria for moderate outcome. At 12-month follow-up, six people (26%) achieved good outcome, a further five achieved a moderate outcome, and there were significant improvements in body mass index, eating psychopathology and motivation, with large intention to treat effect sizes (ES) of 0.85, 1.19 and 1.57, respectively. Those people who dropped out of therapy were significantly more likely to binge or purge, and this behaviour was also associated with a moderate effect size (0.71) when examining differences between people who obtained good/moderate outcome versus poor outcome. Also predicting poor outcome status was lower baseline self-esteem and ineffectiveness.

CONCLUSION

Further evaluation of the use of MANTRA as an outpatient therapy for AN appears justified. Improvements to this therapy could include an early focus on binge and purge behaviour, as well as modules addressing low self-esteem and ineffectiveness.

Thinking about going to the dentist: a Contemplation Ladder to assess dentally-avoidant individuals' readiness to go to a dentist

Background

The Transtheoretical Model suggests that individuals vary according to their readiness to change behavior. Previous work in smoking cessation and other health areas suggests that interventions are more successful when they are tailored to an individual's stage of change with regards to the specific behavior. We report on the performance of a single-item measure ("Ladder") to assess the readiness to change dental-avoidant behavior.

Methods

An existing Contemplation Ladder for assessing stage of change in smoking cessation was modified to assess readiness to go to a dentist. The resulting Ladder was administered to samples of English-speaking adolescents (USA), Spanish-speaking adults (USA), and Norwegian military recruits (Norway) in order to assess construct validity. The Ladder was also administered to a sample of English-speaking avoidant adolescents and young adults who were enrolled in an intervention study (USA) in order to assess criterion validity. All participants also had dental examinations, and completed other questionnaires. Correlations, chi square, t tests and one-way ANOVAs were used to assess relationships between variables.

Results

In two samples, participants who do not go to the dentist had significantly more teeth with caries; in a third sample, participants who do not go to the dentist had significantly worse caries. Ladder scores were not significantly related to age, gender, caries, or dental fear. However, Ladder scores were significantly related to statements of intention to visit a dentist in the future and the importance of oral health. In a preliminary finding, Ladder scores at baseline also predicted whether or not the participants decided to go to a dentist in the intervention sample.

Conclusions

The data provide support for the convergent and divergent construct validity of the Ladder, and preliminary support for its criterion validity. The lack of relationship between dental fear and Ladder scores suggests that avoidant individuals may be helped to decide to go to a dentist using interventions which do not explicitly target their fear.

The effectiveness of a day program for the treatment of adolescent anorexia nervosa

OBJECTIVE

The risks of anorexia nervosa (AN) are well established. Despite its severity, little certainty exists for practitioners, with ethical and financial limitations yielding few controlled studies establishing effective treatments. Thus, other methods of establishing treatment effectiveness are necessary. This study presents preliminary results of an open clinical trial of a day program for adolescents with AN.

METHOD

Participants were 26 anorectic females, 12-18 years, who completed the "Transition Program."

RESULTS

Significant change emerged on measures of weight gain, and behavioral and attitudinal measures of eating pathology. Large effect sizes were evident for weight gain at 6 month follow-up. Preliminary trends suggest that treatment gains on these and other measures of eating pathology were maintained at 6 month follow-up.

DISCUSSION

Preliminary results support day program treatment for adolescents with mild-moderately severe eating disorders. Present outcomes are discussed with respect to the dearth of efficacious treatment options for adolescents.

Addressing the EDNOS issue and improving upon the utility of DSM-IV: classifying eating disorders using symptom profiles

OBJECTIVE

To compare the descriptive and clinical utility of two classification systems: DSM-IV eating disorder diagnoses and proposed symptom profiles. The symptom profiles are based on the presence of overvalued ideas about shape/weight, as well as combinations of three key eating disorder symptoms (e.g. body mass index (BMI) above or below threshold and the presence or absence of bingeing and purging behaviours).

METHOD

The two systems were compared on their ability to offer descriptively useful information in classifying individuals with eating disorders. In addition, we examined our system's unique contribution to clinical outcome and its relation to readiness for change.

RESULTS

Classifying individuals via symptom profiles provided information about eating disorder not otherwise specified (EDNOS), a prevalent, heterogeneous and under-researched diagnostic category. Symptom profiles outperformed the DSM-IV diagnostic system in the ability to account for variation in patients' decision to enrol in treatment, performing comparably to readiness for change.

CONCLUSION

Classifying individuals according to symptom profile and readiness for change appears to have more descriptive and clinical utility than the current diagnostic system.

An evaluation of the effectiveness and short-term stability of an innovative Australian day patient programme for eating disorders

There is a dearth of literature evaluating day patient treatment for eating disorders based upon the targeted goals of treatment, to conclude that day patient programmes are effective. This study aimed to explore the effectiveness of an innovative day patient programme by examining whether the seven key treatment goals improved across treatment and were maintained 3 months after discharge. Of the 58 participants who completed measures assessing BMI, eating disorder cognitions, behaviours, core beliefs, readiness to change, quality of life and perpetuating factors at admission, discharge and follow-up, 44 completed the day programme with 14 non-completers. The results demonstrated that all seven treatment goals improved across treatment and the improvements were maintained or further improved at 3 month follow-up. The results are discussed in context of the published day patient programme literature with implications for future research to maximise optimal treatment outcomes from day patient treatment.