Denial of illness in anorexia nervosa—a conceptual review: part 2 different forms and meanings

Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists

INTRODUCTION

Anorexia nervosa poses an important bioethical dilemma, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa.

METHODS

Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used.

RESULTS

The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity.

CONCLUSIONS

It is concluded that the difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.

Methods used to assess insight in individuals with eating disorders: a scoping review

Insight can be impaired in individuals with an eating disorder and the nature of this impairment can vary. Although this topic has been the focus of several studies and reviews, methodologies used to assess insight have received less attention. A scoping review was conducted using a systematic search of articles before January 2021 to elucidate the methodologies used to assess insight in those with an eating disorder, with discussion of strengths and limitations. A total of 3089 studies were screened, and 24 quantitative studies which assessed at least one aspect of insight in individuals with an eating disorder were included in the review. Methods of assessing insight included coding of clinical notes, low scores on measures of self-report symptoms, direct assessment of insight, vignette, and self-report single-item questions. Insight into disordered eating symptoms was most frequently assessed. Most research used samples who were female, white, diagnosed with anorexia nervosa, and were seeking or receiving treatment. In designing future research and interventions, optimal methods used to assess insight should consider the research/clinical question, available resources, and the targeted demographic. Further, descriptions of which aspects of insight are being assessed should be considered in the interpretation of both current and future findings.

Depression, perceived disability and unemployment are associated with reduced life satisfaction in anorexia nervosa

Life satisfaction is a core aspect of an individual's wellbeing and describes the subjective assessment of their quality of life. Reduced life satisfaction is frequently reported in anorexia nervosa (AN),  but the factors contributing to this are still unclear. This study sought to extend previous work by examining 12 potential correlates of AN life satisfaction. One hundred and five female AN patients were administered questionnaires assessing life satisfaction, depression, anxiety, stress, employment status, marital status, body mass index, eating disorder symptomatology, perceived disability and readiness for change. A stepwise linear regression revealed that only depression, perceived disability and employment status were significantly associated with AN life satisfaction. The findings thus highlight prevailing mood and personal functioning as critical foci for clinical management strategies in people with AN. Addressing depressive symptoms and perceived disability while bettering employment prospects could facilitate improved AN life satisfaction.

Polygenic association with severity and long-term outcome in eating disorder cases

About 20% of individuals with anorexia nervosa (AN) remain chronically ill. Therefore, early identification of poor outcome could improve care. Genetic research has identified regions of the genome associated with AN. Patients with anorexia nervosa were identified via the Swedish eating disorder quality registers Stepwise and Riksät and invited to participate in the Anorexia Nervosa Genetics Initiative. First, we associated genetic information longitudinally with eating disorder severity indexed by scores on the Clinical Impairment Assessment (CIA) in 2843 patients with lifetime AN with or without diagnostic migration to other forms of eating disorders followed for up to 16 years (mean = 5.3 years). Second, we indexed the development of a severe and enduring eating disorder (SEED) by a high CIA score plus a follow-up time ≥5 years. We associated individual polygenic scores (PGSs) indexing polygenic liability for AN, schizophrenia, and body mass index (BMI) with severity and SEED. After multiple testing correction, only the BMI PGS when calculated with traditional clumping and p value thresholding was robustly associated with disorder severity (β_PGS = 1.30; 95% CI: 0.72, 1.88; p = 1.2 × 10^-5) across all p value thresholds at which we generated the PGS. However, using the alternative PGS calculation method PRS-CS yielded inconsistent results for all PGS. The positive association stands in contrast to the negative genetic correlation between BMI and AN. Larger discovery GWASs to calculate PGS will increase power, and it is essential to increase sample sizes of the AN GWASs to generate clinically meaningful PGS as adjunct risk prediction variables. Nevertheless, this study provides the first evidence of potential clinical utility of PGSs for eating disorders.

Compliance and resistance to treatment in an Italian residential Centre for eating disorders

The dominant biomedical model perceives eating disorders as mental disorders and its 'sufferers' as people who need to be healed. It follows that people diagnosed with an eating disorder are pressured to accept medical and psychological care due to the moral obligations that are associated with the sick role, as delineated by Parsons. This, however, does not necessarily imply that they are willing to heal. By analysing compliance and resistance to treatment in an Italian residential Centre for eating disorders, this paper suggests that patients may accept medical care in order to achieve objectives other than those for which power is exerted over them. By complying with treatment, patients may in fact attempt to (re)become anorexic or escape from their everyday environment and problems. It is therefore argued that biomedical power can be subverted from within through the adoption of what De Certeau defines as tactics.

Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists

INTRODUCTION

Anorexia nervosa poses an important bioethical quandary, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa.

METHODS

Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used.

RESULTS

The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity.

CONCLUSIONS

The difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.

Development and evaluation of an adapted physical activity program in anorexia nervosa inpatients: A pilot study

BACKGROUND AND CONTEXT

Problematic use of physical activity is frequent in subjects with anorexia nervosa (AN). Although it increases resistance to therapeutic treatment, paradoxically, physical activity in AN can also improve mental and physical health. Based on the literature review we hypothesized that adding an adapted physical activity (APA) program to treatment programs could be more beneficial than a total suppression of physical activities. We designed this open study to evaluate the outcome of AN inpatients after an APA program implementation as well as the perceived effect of APA.

METHOD

Forty-one women with AN (17.2 (±2.5) years old, BMI of 16.86 (±2.0)) were included. An eight-session (1 h30/session/week) standardized APA program was delivered and evaluated by structured questionnaires assessing exercise dependence, perceived physical activity, eating disorder (ED) symptoms, body mass index (BMI), along with an interview before and after the APA program.

RESULTS

Twenty-nine women complete the PA program and evaluation. BMI and perceived PA score significantly increased, ED and exercise dependence scores significantly decreased (p < .01). Participants appreciated the program.

DISCUSSION/CONCLUSION

The inpatient program which included APA program helped AN inpatients in decreasing their ED symptoms and their dependence to PA, without any deleterious effect on BMI. Furthermore, APA was appreciated by participants.

Eating Disorder Symptomatology in Adolescent Boys and Girls: Identifying Distinct Developmental Trajectory Classes

Eating disorder symptomatology is highly prevalent in adolescence and is regarded one of the most important precursors of clinical eating disorders. The present longitudinal study examined the development of eating disorder symptomatology in adolescents over two years. At Time 1,528 high school students filled out self-report questionnaires (50.5% female; M_age = 15 years). Multivariate latent growth curve modeling and latent class growth analyses were performed to model latent trajectories and to identify latent trajectory classes. Stable trajectories of drive for thinness and body dissatisfaction were found, whereas bulimia and BMI increased over time. Important gender differences pointed to girls experiencing more eating disorder symptoms at each time point. Additionally, more diverse trajectory classes were found in girls than in boys. Finally, classes with the most eating disorder symptoms also experienced the most problems in identity development, internalizing symptoms, and the least effortful control. The present study underscores the importance of identifying vulnerable adolescents that experience greater eating disorder symptomatology, as they also seem to experience the worst psychosocial development.

Disparities in psychological well-being based on subjective and objective eating disorder recovery statuses, and recovery status concordance

This research examines how eudaimonic psychological well-being (PWB) relates to variant levels of eating disorder (ED) recovery (full, partial, active ED), both self-defined and objectively determined, and to subjective-objective recovery status concordance. Participants (N = 132; Mage = 30.1) completed an online survey targeting ED symptomology, PWB, and recovery. MANOVAs revealed idiosyncratic relationships between recovery and PWB when objective criteria, subjective perceptions, and concordance were considered. Generally, superior levels of recovery were associated with superior PWB. PWB and clients' perceptions of recovery should be considered during treatment and in establishing a uniform definition of ED recovery.

The Science Behind the Academy for Eating Disorders' Nine Truths About Eating Disorders

OBJECTIVE

In 2015, the Academy for Eating Disorders collaborated with international patient, advocacy, and parent organizations to craft the 'Nine Truths About Eating Disorders'. This document has been translated into over 30 languages and has been distributed globally to replace outdated and erroneous stereotypes about eating disorders with factual information. In this paper, we review the state of the science supporting the 'Nine Truths'.

METHODS

The literature supporting each of the 'Nine Truths' was reviewed, summarized and richly annotated.

RESULTS

Most of the 'Nine Truths' arise from well-established foundations in the scientific literature. Additional evidence is required to further substantiate some of the assertions in the document. Future investigations are needed in all areas to deepen our understanding of eating disorders, their causes and their treatments.

CONCLUSIONS

The 'Nine Truths About Eating Disorders' is a guiding document to accelerate global dissemination of accurate and evidence-informed information about eating disorders. 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.

Meta-analysis of theory of mind in anorexia nervosa and bulimia nervosa: A specific İmpairment of cognitive perspective taking in anorexia nervosa?

OBJECTIVE

Deficits in theory of mind (ToM), ability to infer mental states of others, can play a significant role in interpersonal difficulties and/or unawareness of illness observed in AN and other eating disorders including bulimia Nervosa (BN).

METHOD

Current meta-analysis aimed to summarize available evidence for deficits in ToM in AN and BN and examine the effects of number of study-level variables on observed findings. In this meta-analysis, 15 studies (22 samples with eating disorders) investigating ToM performances of 677 individuals with AN or BN and 514 healthy controls were included.

RESULTS

AN was associated with significant deficits in ToM (d = 0.59) which were more pronounced in the acute patients (d = 0.67). Small sized deficits in ToM were observed in BN (d = 0.34) and recovered AN (d = 0.35). Both cognitive perspective-taking (ToM-PT) (d = 0.99) and decoding mental states (ToM-decoding) (d = 0.61) aspects of ToM were impaired in acute AN. ToM-decoding impairment in BN was modest. There was no evidence for significant ToM-PT deficit in BN. Several study-level variables including longer duration of illness, lower BMI, and depressive symptoms were associated with more severe deficits in ToM in AN.

DISCUSSION

ToM deficits, particularly in ToM-PT, can be a specific feature of AN but not BN. ToM impairment can contribute to poor insight, treatment resistance, and social impairment in AN. © 2016 Wiley Periodicals, Inc. RESUMEN META ANÁLISIS DE LA TEORÍA DE LA MENTE EN ANOREXIA NERVOSA Y BULIMIA NERVOSA: ¿Un deterioro de la toma de perspectiva cognitiva en Anorexia Nervosa?

OBJETIVO

Las deficiencias en la teoría de la mente (ToM), la habilidad parar inferir los estados mentales de otros, pueden jugar una función significativa en las dificultades interpersonales y/o falta de reconocimiento de la enfermedad observada en Anorexia Nervosa (AN) y otros trastornos de la conducta alimentaria incluyendo la Bulimia Nervosa (BN).

MÉTODO

Los meta análisis actuales dirigidos a resumir la evidencia disponible sobre el déficit en ToM en AN y BN y examinar los efectos de un número de variables a nivel estudio en los resultados observados. En este meta análisis fueron incluidos 15 estudios (22 muestras con trastornos alimenticios) investigando la función de ToM de 677 individuos con AN o BN y 514 controles sanos.

RESULTADOS

La AN fue relacionada con déficit significativo en ToM (d=0.59) los cuales fueron pronunciados en los pacientes agudos (d=0.67). Se observaron déficits de tamaño pequeño en BN (d=0.34) y AN recuperada (d=0.35). La toma de perspectiva cognitiva (ToM-PT) (d=0.99) y la descodificación de los procesos mentales (descodificación de ToM) (d=0.61) fueron deteriorados en la AN aguda. El deterioro en la descodificación de ToM en BN fue moderado. No se encontró evidencia significativa de déficit en ToM-PT en BN. Algunas variables a nivel estudio incluyendo la larga duración de la enfermedad, índice de masa corporal (IMC) bajo y síntomas depresivos fueron asociados con mayores déficit severos en ToM en AN. DISCUSIÓN: El déficit en ToM, particularmente en ToM-PT puede ser una característica específica en la AN pero no en la BN. El deterioro en la descodificación de ToM puede contribuir a mala percepción, resistencia al tratamiento y deterioro social en AN. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:739-749).

Revisiting poor insight into illness in anorexia nervosa: true unawareness or conscious disagreement?

BACKGROUND

To investigate and validate a novel approach to distinguishing between two possible sources of poor insight in anorexia nervosa: true unawareness, in which a patient is not aware that other people think there is a problem, and disagreement, in which a patient does recognize that others think there is a problem.

METHODS

Thirty-nine patients with anorexia nervosa or eating disorder not otherwise specified-anorexia nervosa were given two versions of the Scale of Unawareness of Mental Disorder (SUMD), one in which they were asked about their own opinion and one in which they were asked about their clinicians' opinion. Clinicians also completed the SUMD with their opinion about the patient's illness. Patients and clinicians both also completed a Visual Analog Scale assessing treatment acceptance.

RESULTS

About 57% of the overall level of poor insight was explained by disagreement. Prediction of treatment acceptance was significantly improved when poor insight was broken down into true unawareness and disagreement.

CONCLUSIONS

These data suggest that impaired insight in anorexia nervosa is an additive outcome of true unawareness and disagreement.

The neurocognitive basis of insight into illness in anorexia nervosa: a pilot metacognitive study

The primary goal of the present study was to explore the neuropsychological basis of insight into illness in anorexia nervosa by evaluating its differential and joint links with cognitive vs. metacognitive performance. Participants in the study were 25 women with anorexia nervosa (AN) and 25 healthy comparisons (HC). All participants completed a computerized version of the Wisconsin Card Sorting Task (WCST) and the Computerized Body-Size Discrimination task (CBSD). In addition to the standard administration of the tasks, subjects were also asked to rate their level of confidence in the correctness of each sort and to choose whether they wanted each sort to be "counted" toward their overall performance score on the test. Insight into illness in the AN group was assessed with the Scale of Unawareness of Mental Disorder (SUMD). Prediction of poor insight was significantly improved when adding the new, free-choice metacognitive measures to the conventional measures in both tasks, but not the other way around. These preliminary results suggest that metacognition might be an important mediator between basic cognitive deficits and poor insight and that it might be even more relevant to poor insight than cognitive deficits per se.

Trajectories of eating and clinical symptoms over the course of a day hospital program for eating disorders

Although it is well-established that day hospital programs for eating disorders significantly reduce clinical symptoms, the pre-test/post-test designs that were previously used do not provide information regarding the trajectory of symptoms during treatment. This study observed, on a weekly basis, the evolution of symptoms of 61 women suffering from eating disorders engaged in a day hospital program, and compared the trajectories of specific subgroups of patients. Results show that (a) the first half of the program was crucial for symptom changes; (b) although completers and non-completers presented similar initial improvement, their trajectories rapidly differentiated; and (c) poorer respondents initially reported more symptoms, showed a slower improvement, and never reached the non-clinical zone, whereas better-respondents reached the non-clinical cut-off point more rapidly.

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.

Delusionality of body image beliefs in eating disorders

Preoccupation with body shape and weight is characteristic of both anorexia nervosa and bulimia nervosa. Despite their diagnostic and clinical significance, evidence on the nature of the underlying beliefs is relatively scarce. We used the Brown Assessment of Beliefs Scale (BABS) to assess the degree of delusionality of body image beliefs in seventy-two participants: 39 with anorexia and 33 with bulimia nervosa. We also investigated the relationship between body image delusionality and other clinical characteristics in eating disorders. Only patients with anorexia nervosa (28.8%) had delusional body image beliefs, whereas overvalued ideas appeared to be frequent in both anorexia and bulimia nervosa. Body image delusionality in anorexia nervosa was associated with restrictive eating pathology, early onset of the disorder and body dissatisfaction, whereas in the bulimia group it was linked to shorter duration of the illness, more intense dieting behaviors and specific psychological factors: ineffectiveness and maturity fears. Results suggest that a delusional variant of anorexia nervosa represents the one end of a continuum of insight among patients with eating disorders. Categorization of patients with eating disorders based on the level of delusionality of body image beliefs could facilitate further research on the role of insight deficits in these disorders.

Being men with eating disorders: Perspectives of male eating disorder service-users

This study aimed to explore experiences of men currently using eating disorder services. Eight men from two eating disorder services were interviewed about their experiences of seeking and receiving treatment. Two superordinate themes emerged from Interpretative Phenomenological Analysis: (1) difficulty seeing self as having an eating disorder; and (2) experiences of treatment: how important is gender? The underlying themes varied in their specificity to men, with some echoing findings from the female eating disorder literature. Difficulty admitting the eating disorder may link with eating disorder psychopathology as well as gender-specific issues. Implications for clinical practice and future research are discussed.

Self-report and startle-based measures of emotional reactions to body image cues as predictors of Drive for Thinness and Body Dissatisfaction in female college students

The purpose was to compare self-report and psychophysiological assessment techniques in the measurement of emotional response to body image cues. Female college students (n=53; % Caucasian=53.6; M body mass index=26.1 kg/m²) completed the Eating Disorder Inventory (EDI-3) and viewed photos of themselves both unaltered and morphed to simulate weight gain. Response to the photos was assessed by self-report and the affect modulated startle paradigm. EDI-3 Drive for Thinness (DT) and Body Dissatisfaction (BD) scale scores were correlated with startled amplitude for the largest simulated weight gain photo. Startle eye blink amplitude predicted more variance in DT and BD subscales than self-reported response to the image. The affect modulated startle paradigm may provide unique information in the assessment of eating disorder symptomatology that cannot be captured via self-report techniques, and has potential to inform evaluation of treatment outcomes of eating and body image disorders.

The possible selves of adult women with anorexia nervosa

Adopting the construct of possible selves, which are conceptions of our selves in future situations, the objective of this study was to investigate how anorexia patients differ from a non-clinical control group in their conceptions of the future on qualitative content, and the four quantitative dimensions positive and negative emotional valence, and beliefs about probability and controllability. The Possible Selves Statements Test was employed. Participants presented 14 possible selves by completing the question "I can see myself …" and rating each possible self on the 4 dimensions. The patients reported a larger number of negative possible selves, with higher negative valence, often seeing future everyday situations as negative, whereas the control group saw similar situations as positive. The anorexia patients also reported negative possible selves with high controllability and high probability in relation to such situations and in some cases rated recovery from anorexia with a negative valence. Clinical implications are discussed.

Insight in eating disorders: clinical and cognitive correlates

BACKGROUND

The aim of this study was to explore the extent of lack of insight and its components in eating disorders (EDs) and to investigate the relationship between insight and clinical and cognitive characteristics in this group.

METHOD

Seventy-five participants were enrolled in the study: 25 with anorexia nervosa (AN), 15 with bulimia nervosa (BN) and 35 healthy controls (HC). Insight was assessed with a modified version of the Schedule for the Assessment of Insight for EDs (SAI-ED) and multi-dimensional scaling (MDS) analysis was used to clarify the internal structure of the scale. Neuropsychological tests included the Trail Making Test (TMT), the Brixton Test and a Verbal Fluency Task.

RESULTS

Only a subgroup of AN patients (24%) had severe impairment of insight. Patients with the restricting type of AN (AN-R) had poorer overall insight than patients with the binge-purge type of the disorder (AN-B/P). More of the ED patients displayed a deliberate denial of illness rather than a lack of awareness of the illness. A regression model revealed that only performance in part B of the TMT (TMT-B) was a moderate predictor of insight level. No association was found between insight and other cognitive or clinical variables.

CONCLUSIONS

Impaired insight is a significant feature of some ED patients. Insight in EDs seems to be partially dependent on intact mental flexibility.

The concept of body image disturbance in anorexia nervosa: an empirical inquiry utilizing patients' subjective experiences

We explored the concept body image disturbance (BID) by utilizing the subjective experience of 32 women (aged 20-39 years) diagnosed with AN (DSM-V). Using methods from Grounded Theory we identified four phenotypes of BID-"Integration," "Denial," "Dissociation," and "Delusion"-which differed according to whether the patients overestimated their own body size ("Subjective reality"), and whether they acknowledged the objective truth that they were underweight ("Objective reality"). The results suggest that BID should be conceptualized as a dynamic failure to integrate subjective experiences of one's own body appearance with an objective appraisal of the body. Conceptual, diagnostic and clinical implications are discussed.

Assessment methods for eating disorders and body image disorders

The growing interest in the treatment and research of eating disorders has stimulated the development of assessment methods, and there are now many questionnaires for evaluating behavioral and attitudinal characteristics of eating pathology. The present article sets out to review the assessment tools that are widely used in clinical practice and research. In particular, it covers self-report measures with summaries of their psychometric properties. It also presents diagnostic questionnaires based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria. The instruments described include screening questionnaires, measurement tools for specific eating disorder symptoms, measurement of quality of life in eating disorders, and some tools for the measurement of body image disorder, a common feature of eating disorders. There is also a discussion of distorting factors that decrease the authenticity of assessment tools. These problems arise from the definition of some constructs and from the phenomena of denial and concealment, which are frequent among eating-disordered individuals. The frequent co-occurrence of other psychopathological features (e.g., multiimpulsive symptoms) shows that other psychological phenomena should also be evaluated in line with the assessment of eating disorders.

Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice 1ψ7

Motivation has received increasing attention across counseling approaches, presumably because clients’ motivation is key for treatment effectiveness. The authors define motivation using a self-determination theory taxonomy that conceptualizes motivation along a relative-autonomy continuum. The authors apply the taxonomy in discussing how various counseling approaches address client motivation and autonomy, both in theory and in practice. The authors also consider the motivational implications of nonspecific factors such as therapeutic alliance. Across approaches, the authors find convergence around the idea that clients’ autonomy should be respected and collaborative engagement fostered. The authors also address ethical considerations regarding respect for autonomy and relations of autonomy to multicultural counseling. The authors conclude that supporting autonomy is differentially grounded in theories and differentially implemented in approaches. Specifically, outcome-oriented treatments tend to consider motivation a prerequisite for treatment and emphasize transparency and up-front consent; process-oriented treatments tend to consider motivation a treatment aspect and give less emphasis to transparency and consent.

Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V

OBJECTIVE

This article reviews literature relevant to challenges in clinical ascertainment of cognitively-based diagnostic criteria of anorexia nervosa (AN) and bulimia nervosa (BN) to examine whether revision might enhance their clinical utility.

METHOD

We performed a systematic literature search to identify publications relevant to clinical evaluation of cognitive symptoms of AN and BN.

RESULTS

The literature supports several reasons that individuals with an eating disorder may not endorse cognitive symptoms, despite their presence. These include limited insight, minimization, or denial, as well as intentional concealment related to perceived stigma, social desirability, or investment in maintaining behavioral symptoms. We also identified reasons that the word "refusal" in AN criterion A may render its application problematic.

DISCUSSION

We conclude that specific guidance for ascertainment of cognitive signs for AN and BN in the absence of patient disclosure or endorsement, longitudinal evaluation, and/or collateral data may improve clinical utility of these diagnostic criteria.

Anorexic self-control and bulimic self-hate: differential outcome prediction from initial self-image

OBJECTIVE

The study investigated initial self-image (structural analysis of social behavior) and its relation to 36-month outcome, among patients with anorexia nervosa and bulimia nervosa. Hypotheses were that degree of different aspects of self-image would predict outcome in the groups.

METHOD

Participants were 52 patients with anorexia and 91 with bulimia from a longitudinal naturalistic database, and outcome measures included eating disorder and psychiatric symptoms and a general outcome index. Stepwise regression was used to investigate which self-image variables were related to outcome, and multiple regression contrasted the groups directly on each obtained predictor.

RESULTS

Consistent with hypotheses, in bulimia degree of self-hate/self-love moderately predicted outcome, whereas self-control-related variables powerfully predicted outcome in anorexia.

DISCUSSION

It is important to focus on self-image in the treatment of both diagnostic groups, but especially in anorexia nervosa, where control-submission interactions between patient and therapist should be handled with care.

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.

Denial and concealment of eating disorders: a retrospective survey

OBJECTIVE

To get an idea of how (ex-)patients deal with the recognition of an emergent eating disorder.

METHOD

A retrospective survey was carried out via the websites of two organizations for (ex-)patients with an eating disorder.

RESULTS

The respondents (N = 401) reported a variety of attempts to conceal their eating disorder: excuses to avoid eating together, methods to give the false impression of having eaten, avoidance of being weighed and falsifying weight. Often these methods were described as a deliberate strategy. Information about possible health risks had little or no impact on most respondents, who were familiar with the notion of eating disorder but did not apply it to themselves. Many believed they would have recognized their eating disorder earlier if they had met a clinician who was familiar with this disorder.

CONCLUSION

Denial of illness together with concealment often reflects a deliberate refusal of self-disclosure within a specific interpersonal context.

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.