Let eating disorder patients decide: Providing choice may reduce early drop-out from inpatient treatment

Two identical twin pairs discordant for longstanding anorexia nervosa and OSFED: lived experience accounts of eating disorder and recovery processes

Research into the risk of anorexia nervosa (AN) has examined twin pairs to further the understanding of the contributions of genetics, trait inheritance, and environmental factors to eating disorder (ED) development. Investigations of twin experiences of EDs have been biologically-based and have not considered the qualitative, phenomenological aspects of twin experiences. A gap in the literature exists regarding understanding of discordant twins with EDs. This research was developed in response, with the aim to deepen understanding of AN in discordant twins and to create novel ideas for further research and testing. The case studies presented in this article provide lived experience insights of two identical discordant twin pairs: one twin pair discordant for longstanding AN and one twin pair discordant for 'atypical' AN (the twin with AN has recovered). The perspectives and experiences of each co-twin (one with AN and one without) explore a number of factors that may have contributed to twin discordance in these cases, and how each twin has responded to the impact of AN in their lives. Through use of first-person accounts in case study presentation, this article centres social justice values of lived experience leadership and involvement in research. This article aims to extend current knowledge and understanding of EDs in discordant twins, particularly regarding risk for ED development, ED duration, diagnosis and treatment, and recovery processes.

Premature termination of inpatient eating disorder treatment: Does timing matter?

BACKGROUND

Premature termination of treatment is a serious problem in the treatment of eating disorders. Prior research attempting to differentiate patients who are able to complete treatment from those who terminate early has yielded mixed results. One proposed explanation for this is a failure to examine the time course of treatment termination. This study was designed to explore associations between baseline patient characteristics and timing of treatment termination.

METHODS

Participants were 124 eating disorder patients admitted voluntarily to the inpatient program at Toronto General Hospital between 2009 and 2015. At admission, all patients completed measures of eating disorder symptoms, eating disorder cognitions, depressive symptoms and emotional dysregulation. Body weight was measured weekly. Data analyses were completed using one-way ANOVAs and Chi Square tests.

RESULTS

Results showed significant associations between timing of treatment termination and eating disorder diagnosis, severity of eating disorder cognitions and severity of depressive symptoms. Post-hoc analyses revealed that patients who left treatment early had more severe depressive symptoms, eating disorder cognitions related to eating and difficulties engaging in goal directed behaviors when emotionally dysregulated.

CONCLUSIONS

Patients who terminated inpatient treatment early in their admissions differ from patients who terminated later and those who completed treatment. These differences have potential clinical implications for the clinical management of patients with severe eating disorders requiring inpatient admission. Trial registration This paper is not associated with a clinical trial.

Anorexia nervosa through the lens of primary health care practitioners in the Kyrgyz Republic

BACKGROUND

Anorexia nervosa was investigated in a large number of studies. Several of the studies in our review highlighted how important it is to factor in the opinion of health care practitioners if we want to improve the quality of the medical care provided to patients with anorexia nervosa. Additionally, the dominance of studies focused on anorexia nervosa within the Western culture raised the need for cultural diversity in such research.

AIM

The present study endeavored to explore how primary healthcare practitioners in Bishkek, Kyrgyz Republic, perceive anorexia nervosa and people who suffer from it.

METHODS

The study used the qualitative approach of Interpretative Phenomenological Analysis. Six semi-structured interviews with six primary health care practitioners from Bishkek were conducted.

RESULTS

The analysis of the collected data pointed towards four themes: (1) Anorexia nervosa as a reaction to distressing events in the form of loss of appetite; (2) Attributing blame for developing anorexia nervosa by a patient to family members; (3) Local versus Western socio-cultural standards in the development of anorexia nervosa and seeking treatment; and (4) Denial of mental health disorders by patients.

CONCLUSION

The discussion of the interpreted results led us to the conclusion that the perceptions of the health care providers in Bishkek represent the common prism through which anorexia nervosa is viewed in the larger population, which is constructed out of information received from the physical and virtual environments.

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.

Impulsive behaviors and clinical outcomes following a flexible intensive inpatient treatment for eating disorders: findings from an observational study

PURPOSE

The aim of the study was to assess the differences between impulsive and non-impulsive patients in response to a multidisciplinary intensive inpatient treatment for eating disorders (EDs).

METHODS

320 patients with EDs were consecutively recruited in an eating disorders unit (EDU). They were assessed by clinical interviews and self-reported questionnaires. The treatment was characterized by a patient-centric approach and included both an intensive and comprehensive standardized multidisciplinary program based on cognitive-behavioral therapy and a flexible and personalized component according to the needs and the history of each patient.

RESULTS

Impulsive ED patients showed greater improvement in specific psychopathological areas, in particular: interpersonal sensitivity of Symptom Checklist-90 (SCL-90) (p = 0.007); Eating Disorder Examination Questionnaire (EDE-Q) Global Score (p = 0.009), EDE-Q eating concern (p < 0.001) and EDE-Q shape concern (p = 0.025). The two groups also showed a different pattern on the Body Uneasiness Test, with impulsive patients uniquely showing improvement on Global Severity Index (p = 0.006), body image concern (p = 0.008), compulsive self monitoring (p = 0.002), and weight phobia (p = 0.037).

DISCUSSION

Results support the hypothesis that patients with impulsive behaviors might benefit from treatments characterized by a standardized cognitive behavioral therapy implemented by third-wave interventions according to each patient's clinical profile. Personalized treatment approaches could be an answer to the complexity of ED, addressing individual psychopathology. Further studies are needed to confirm these preliminary findings.

LEVEL OF EVIDENCE

III, cohort or case-control analytic studies.

Post-hospitalization Daycare Treatment for Adolescents With Eating Disorders

Background: There are several possible facilities for the treatment of eating disorders (EDs). Specifically, there is the issue of the use of specialized daycare and ambulatory services over inpatient settings and the place of daycare programs following inpatient treatment. Aim: We sought to examine the contribution of post-hospitalization daycare program to the treatment of adolescents hospitalized with an ED. Methods: We assessed 61 female adolescents hospitalized with an ED. All but three were diagnosed with clinical or subthreshold anorexia nervosa (AN). Three were diagnosed with bulimia nervosa. Thirty-seven patients continued with a post-hospitalization daycare program for at least 5 months, whereas 24 did not enter or were enrolled in the program for <5 months. Patients completed on admission to, and discharge from, inpatient treatment self-rating questionnaires assessing ED-related symptoms, body-related attitudes and behaviors, and depression and anxiety. Social functioning was assessed 1 year from discharge using open-ended questions. One-year ED outcome was evaluated according to the patients' body mass index (BMI) and according to composite remission criteria, assessed with a standardized semistructured interview. To be remitted from an ED, patients were required to maintain a stable weight, to have regular menstrual cycles, and not to engage in binging, purging, and restricting behaviors for at least eight consecutive weeks before their assessment. Results: BMI was within normal range at follow-up, whether completing or not completing daycare treatment, and around 75% of the patients had menstrual cycles. By contrast, when using comprehensive composite remission criteria, less than a quarter of former inpatients not entering/not completing daycare program achieved remission vs. almost a half of the completers. In addition, a greater percentage of completers continued with psychotherapy following discharge. Fifty percent of both groups showed good post-discharge social functioning. No between-group differences were found in the BMI and the scores of the self-rating questionnaires at admission to, and discharge from, inpatient treatment. Conclusion: Adolescent females with EDs can maintain a normal-range BMI from discharge to 1-year follow-up, even if not completing daycare treatment. By contrast, completion of a post-hospitalization daycare program may improve the 1-year follow-up ED-related outcome of former ED inpatients.

Blind versus open weighing from an eating disorder patient perspective

BACKGROUND

Weighing is a key component in the treatment of eating disorders. Most treatment protocols advocate for open weighing, however, many clinicians choose to use blind weighing, especially during the early phase of treatment. Despite considerable debate about this issue in the literature, there is no empirical evidence supporting the superiority of one weighing approach over the other. In addition, little is known about patients' perspectives of open and blind weighing and which weighing practice they view as more acceptable and/or beneficial for their treatment.

METHODS

Semi-structured qualitative interviews were conducted with 41 women with a current or past diagnosis of Anorexia or Bulimia Nervosa: 26 were undergoing specialist inpatient treatment (n = 13 being blind weighed; n = 13 being open weighed) and 15 were community members who have recovered from an eating disorder. Interviews were audiotaped, transcribed verbatim and analysed thematically using framework methods. Participant demographics, clinical characteristics, weighing anxiety and weight concerns were also assessed.

RESULTS

Qualitative analyses yielded five themes: (1) therapy engagement and progress; (2) Control and tolerance of weight uncertainty; (3) treatment team relationships and autonomy; (4) life outside of treatment; and (5) weighing practice preferences and rationale. Participants stated that blind weighing decreased anxiety and eating disorder psychopathology (e.g., weight preoccupation) and increased treatment responsivity. For many, relinquishing control over their weight facilitated body trust and was a necessary step towards recovery. Participants found that not knowing their exact weight helped challenge their overconcern with weight. Lack of support post-discharge was identified as a major difficulty of blind weighing. Overall, the majority of participants preferred blind weighing, particularly at the early, acute stage of treatment, whereas open weighing was viewed as more suitable at later stages of recovery. Quantitative analyses found current blind-weighed patients felt significantly less anxiety around being weighed and had greater tolerance of weight uncertainty than current open-weighed patients.

CONCLUSIONS

This study provided in-depth patient insights into open versus blind weighing practices. The next step for future research will be to supplement these insights with treatment outcomes gained from randomised controlled trials comparing the two weighing practices.

Shared Decision Making for Psychiatric Rehabilitation Services Before Discharge from Psychiatric Hospitals

Shared decision making (SDM) is an effective health communication model designed to facilitate patient engagement in treatment decision making. In mental health, SDM has been applied and evaluated for medications decision making but less for its contribution to personal recovery and rehabilitation in psychiatric settings. The purpose of this pilot study was to assess the effect of SDM in choosing community psychiatric rehabilitation services before discharge from psychiatric hospitalization. A pre-post non-randomized design with two consecutive inpatient cohorts, SDM intervention (N = 51) and standard care (N = 50), was applied in two psychiatric hospitals in Israel. Participants in the intervention cohort reported greater engagement and knowledge after choosing rehabilitation services and greater services use at 6-to-12-month follow-up than those receiving standard care. No difference was found for rehospitalization rate. Two significant interaction effects indicated greater improvement in personal recovery over time for the SDM cohort. SDM can be applied to psychiatric rehabilitation decision making and can help promote personal recovery as part of the discharge process.

Is stage of change enough? Confidence as a predictor of outcome in inpatient treatment for eating disorders

OBJECTIVE

While stage of change has been shown to be a robust predictor of eating disorder treatment outcome, little attention has been paid to the role of confidence. This study sought to better understand the role of confidence and the possible interaction it may have with stage of change in promoting eating disorder symptom change.

METHOD

Participants were adult women in inpatient treatment for eating disorders. They completed measures of motivation for change, which assessed precontemplation, action, confidence and internality (changing for oneself vs. others) and eating disorder symptom severity at pretreatment (N = 159) and posttreatment (n = 59). Only treatment completer analyses were used.

RESULTS

Precontemplation and confidence had significant effects on pretreatment and posttreatment symptom severity, while action only had a significant effect on pretreatment symptoms. Confidence was shown to moderate relations between both measures of stage of change (i.e., precontemplation and action) and symptoms posttreatment. Follow-up analyses indicated that high precontemplation was associated with poor outcome, irrespective of confidence, however, low precontemplation was associated with better outcome at high levels of confidence. The interaction between confidence and action was also significant at very high levels of confidence. That is, among individuals who had high action at baseline, those with low confidence had significantly poorer outcomes relative to those with high confidence.

DISCUSSION

Findings indicate that stage of change and confidence are both important prognostic factors and suggest that early behavior change in the absence of confidence may not guarantee best outcomes in inpatient eating disorder treatment.

Prognostic value of autonomous and controlled motivation in outpatient eating-disorder treatment

According to Self-Determination Theory, when motivation to reach an objective is fully internal, it is said to be "autonomous"; when driven by external incentives, it is said to be "controlled". Previous research has indicated that autonomously motivated individuals show better response to treatments for eating disorders.

OBJECTIVE

In individuals undergoing different intensities of outpatient treatment for an eating disorder, we sought to assess associations between autonomous and controlled motivations and response to treatment on the one hand, and likelihood of dropping out of treatment, on the other.

METHOD

Seven hundred seventy adults meeting DSM-5 criteria for an eating disorder (216 with Anorexia Nervosa, 282 with Bulimia Nervosa, and 272 with Other Specified Feeding or Eating Disorder) were included in this study. Before an interval of outpatient treatment, individuals completed the Eating Disorder Examination Questionnaire and the Autonomous and Controlled Motivations for Treatment Questionnaire. Participants completed the Eating Disorder Examination Questionnaire again at one or two subsequent timepoints.

RESULTS

After controlling for diagnosis, treatment intensity, and number of previous treatments, analyses showed that higher autonomous motivation was associated with better response on eating-disorder overall symptoms and lower likelihood of dropping out of treatment. In contrast, controlled motivation was not associated with response to treatment.

DISCUSSION

Our results suggest that autonomous motivation has trans-diagnostic influence upon response to various intensities of treatment for an eating disorder. In support of an autonomy supportive approach to treatment, findings link autonomous motivation with more favorable outcome.

Changes in Psychological Need Fulfillment Over the Course of Treatment for Major Depressive Disorder

Self-determination theory (Ryan & Deci, 2017) maintains that the psychological needs for autonomy, competence, and relatedness are essential qualities of experience that individuals require to thrive. The present research examined the role of psychological need fulfillment in a clinical sample undergoing treatment for major depressive disorder. Fifty-one patients with a SCID-IV diagnosis for major depressive disorder were randomly assigned to 16 weeks of cognitive behavioral therapy or antidepressant medication. Depressive symptoms, cognitive errors, dysfunctional attitudes, and psychological need fulfillment were assessed at four time points (pre-treatment, week 4, week 8, and week 16). Psychological need fulfillment increased over the course of treatment and did not differ significantly between treatment conditions. Furthermore, increases in psychological need fulfillment were associated with decreases in depression severity over and above the effects of time, cognitive errors, and dysfunctional attitudes. Given the incremental predictive validity of need fulfillment, a better understanding of its role in the treatment for depression may prove beneficial to mental health researchers and practitioners.

Autonomy support in people with mild-to-borderline intellectual disability: Testing the Health Care Climate Questionnaire-Intellectual Disability

BACKGROUND

Autonomy support in people with intellectual disability (ID) is an important yet understudied topic. Psychometrically sound instruments are lacking. This study tested the factor structure and reliability of an instrument for assessing the extent people with intellectual disability perceive their support staff as autonomy supportive.

METHOD

In a single wave, 185 adults with mild-to-borderline intellectual disability filled in an adapted version of the Health Care Climate Questionnaire (i.e., HCCQ-ID). Forty of them participated in a second wave to determine test-retest-reliability. The HCCQ-ID consists of 15 items on a 5-point Likert scale.

RESULTS

The expected one-factor structure was found. Internal consistency (α = 0.93) and test-retest reliability (r = .85) were good. The score distribution was skewed towards high satisfaction.

CONCLUSIONS

The factor structure and reliability of the HCCQ-ID were supported for people with mild-to-borderline intellectual disability. Given the homogeneous factor structure and the high reliability, the number of items may be further optimized.

Comparable efficacy of behavioral and pharmacological treatments among African American and White cocaine users

Multiple randomized clinical trials (RCTs) have evaluated a range of treatments for cocaine dependence, but few of these have focused specifically on the racial diversity observed among cocaine-dependent patients. The present analyses evaluated racial variation in cocaine use and addiction-related psychosocial outcomes at baseline and follow-up among 388 African American and White adults participating in 1 of 5 RCTs evaluating a range of pharmacological and behavioral treatments for cocaine use disorders. General linear modeling (GLM) indicated significant racial variation in cocaine and psychosocial indicators at baseline. At baseline, there were significant racial differences in the number of days paid for work in the 30 days prior to the study, age, days of cocaine use in the past month, age of first cocaine use, psychosocial problems (i.e., employment, cocaine, legal, and family), public assistance status, and prevalence of lifetime anxiety disorders. There were no significant main or interaction effects of race and study on treatment outcomes at posttreatment. These findings suggest that despite significant racial differences at baseline, the pharmacological and behavioral treatments resulted in fairly comparable outcomes across racial groups in these 5 RCTs.

Low pre-treatment end-tidal CO2 predicts dropout from cognitive-behavioral therapy for anxiety and related disorders

Recent clinical trial research suggests that baseline low end-tidal CO₂ (ETCO₂, the biological marker of hyperventilation) may predict poorer response to cognitive-behavioral therapy (CBT) for anxiety-related disorders. The present study examined the predictive value of baseline ETCO₂ among patients treated for such disorders in a naturalistic clinical setting. Sixty-nine adults with a primary diagnosis of a DSM-5 anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder completed a 4-min assessment of resting ETCO₂, and respiration rate (the first minute was analyzed). Lower ETCO₂ was not associated with a diagnosis of panic disorder, and was associated with lower subjective distress ratings on certain measures. Baseline ETCO₂ significantly predicted treatment dropout: those meeting cutoff criteria for hypocapnia were more than twice as likely to drop out of treatment, and ETCO₂ significantly predicted dropout beyond other pre-treatment variables. Weekly measurement suggested that the lower-ETCO₂ patients who dropped out were not responding well to treatment prior to dropout. The present results, along with previous clinical trial data, suggest that lower pre-treatment ETCO₂ is a negative prognostic indicator for CBT for anxiety-related disorders. It is suggested that patients with lower ETCO₂ might benefit from additional intervention that targets respiratory abnormality.

Exploring Patients' Experiences of Eating Disorder Treatment Services From a Motivational Perspective

This study employed qualitative methods to explore eating disorder (ED) patients' perspectives on their treatment experiences to gain insight into those factors that influenced their motivational trajectory. Semistructured interviews were conducted with a purposive female sample of current (N = 11) and discharged (N = 3) ED service users, aged 18 to 31 years (M = 23.21, SD = 4.19). An interpretive thematic analytic approach, comprising both inductive and deductive methods of analysis, was employed to identify key themes in the data. Self-determination theory (SDT) provided a conceptual lens for analyzing data. Participants highlighted that factors such as physical design and nature of the treatment environment, relational aspects of care, and therapeutic methods all played a role in treatment engagement. The findings highlight ways in which current ED services might more effectively meet the needs of service users and support the utility of applying SDT to the study of motivational dynamics in the treatment of EDs.

A pilot evaluation of group-based programming offered at a Canadian outpatient adult eating disorders clinic

Eating disorder clinics across Canada place heavy reliance on group-based programming. However, little work has examined whether this modality of treatment is well-received by patients and results in clinical improvements. The purpose of this pilot study was to evaluate patient satisfaction and outcomes for group-based programming offered through an adult eating disorders clinic. Participants were 81 adults who met DSM-5 criteria for an eating disorder and participated in the study as part of the clinic's program evaluation. Participants received medical monitoring, psychiatric follow-up, adjunct nutrition and pre-psychological treatment, and participated in the clinic's core cognitive behavioural therapy (CBT) group. Demographic information and weight were collected at intake. Participants also completed pre- and post-group programming measures of life satisfaction, depressive and anxiety symptoms, psychological symptoms of the eating disorder, and satisfaction with the programming. Participants' experienced a significant increase in satisfaction with life, and decreases in depressive symptoms and psychological symptoms of the eating disorder post-group. Adults endorsed feeling fairly satisfied with the group-based services provided. Results draw attention to the importance of program evaluation as an integral component of an adult outpatient eating disorder clinic by providing a voice for patients' views of the services received and program outcomes.

Aggregating factors of the change process in the treatment of anorexia nervosa

PURPOSE

We aimed to reduce the large body of factors which may be associated with the change process in treatments for Anorexia Nervosa (AN) into a clinically and scientifically useful number of higher-rank dimensions. In addition, we examined the associations between the identified factors and eating disorder psychopathology and body mass index (BMI) in exploratory analyses.

METHODS

Within a naturalistic multicenter study we administered the Change Process Questionnaire (CPQ-AN) to inpatients with AN upon admission. The factorial structure of the CPQ-AN was explored via factor analysis. Multiple regression analyses were performed to examine the associations with BMI and eating disorder symptomatology (EDI-2).

RESULTS

In total 233 female inpatients with AN (mean BMI=14.9 kg/m(2), SD=1.7) participated. The factor analysis yielded four latent factors: basic need satisfaction, AN-specific cognitions and behavior, emotional involvement and commitment to treatment, and alliance and treatment confidence. Furthermore, greater basic need satisfaction and less AN-specific cognitions and behavior predicted lower EDI-2 scores. Higher alliance and treatment confidence were associated with higher BMI as well as a lower EDI-2 score.

CONCLUSION

The associations between the newly derived dimensions and BMI and AN-psychopathology provide evidence to support the clinical relevance of the identified change process dimensions. Future investigations could provide further insights to deepen our understanding of the change process in AN.

Motivating continued knowledge sharing in crowdsourcing

Purpose

– The purpose of this paper is to investigate the impact of system-generated visual feedback and continued contribution on individuals’ motivation to share knowledge in a crowdsourcing environment.

Design/methodology/approach

– An experimental setting was designed to investigate participants’ motivation to contribute knowledge in a crowdsourcing environment. Responses from a total of 101 participants were analyzed. The independent variables were visual feedback and time. The dependent variable was the participants’ self-expressed willingness to further contribute in the experimental knowledge-sharing activity.

Findings

– A significant main effect of time was found, showing overall gains in the mean willingness to participate over time. It was also found that the mean willingness of the control and top assimilation groups were higher than the mean willingness of the rank contrast and status groups. The mean difference obtained for the control group was mainly during the first half of the knowledge-sharing tasks, while the mean difference obtained for the top assimilation group was mainly during the second half of the knowledge-sharing tasks.

Originality/value

– This study contributes to the literature related to motivation in knowledge sharing by providing theory-based, empirical evidence of the potential for external interventions to improve willingness to contribute and sustain knowledge sharing. The findings additionally provide practical implications for motivating and sustaining knowledge sharing.

Anorexia Nervosa und Bulimia Nervosa: Ein Individuationsversuch?

Zusammenfassung. Theoretischer Hintergrund: Verschiedene Theorien thematisieren Konflikte um Autonomie, Autarkie und Kontrolle in der Ätiologie von Essstörungen. Fragestellung: Diese Studie untersucht die bisher kaum empirisch überprüfte Hypothese zu einem hohen Autonomie-, Autarkie- und Kontrolle-Motiv im Zusammenhang mit Essstörungen. Methode: Insgesamt 270 ProbandInnen ohne und mit den Essstörungen Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED) und remittierten Essstörungen (REC) beantworteten den Fragebogen zur Analyse Motivationaler Schemata (FAMOS). Ergebnisse: ProbandInnen mit Essstörungen berichteten ein höheres Autonomie-, Autarkie- und Kontrolle-Motiv als ProbandInnen ohne Essstörungen. Außerdem zeigten sich Unterschiede in den Motiven zwischen den Essstörungsdiagnosen. Schlussfolgerungen: Die Studienergebnisse deuten auf einen Zusammenhang zwischen einem ausgeprägten Autonomie-, Autarkie- und Kontrolle-Motiv und Essstörungen hin, der für die Therapie von Essstörungen relevant sein könnte.

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.

"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.

Pre-treatment predictors of attrition in a randomised controlled trial of psychological therapy for severe and enduring anorexia nervosa

BACKGROUND

Attrition is common in the treatment of anorexia nervosa and its causes are complex and incompletely understood. In particular, its relationship with adaptive function and motivational stage of change has been little studied. This study aimed to (1) investigate and (2) compare the strength of associations between adaptive function, stage of change and other previously found factors such as illness sub-type and treatment attrition in women with severe and enduring anorexia nervosa (SE-AN).

METHODS

Participants were 63 adult women with SE-AN of at least 7 years duration who were enrolled in a multi-site randomized controlled trial conducted from July 2007 through June 2011. Treatment comprised 30 outpatient visits over 8 months of either Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN) or Specialist Supportive Clinical Management (SSCM) both of which were modified for severe and enduring illness. Assessments were done at baseline, end of treatment, and 6 and 12 month post treatment follow-up. Demographic variables, duration of illness, specific and generic health related quality of life (QoL), eating disorder (ED) and mood disorder symptoms, social adjustment, body mass index (BMI), and motivation for change were assessed with interview and self-report questionnaires. Treatment attrition was defined as leaving therapy after either premature termination according to trial protocol or self-instigated discharge. Binary logistic regression was used to investigate relative strength of associations.

RESULTS

Those who did not complete treatment were significantly more likely to have the purging sub-type of anorexia nervosa and poorer ED related QoL. There were no significant differences between attrition and which therapy was received, educational level, and global ED psychopathology, stage of change, BMI, social adjustment, duration of illness or level of depression. The strongest predictors on multivariable analysis were ED QoL and AN-purging subtype.

CONCLUSION

This study supported previous findings of associations between attrition and purging subtype. Furthermore, we found associations between a potentially important cycle of attrition, and poorer EDQoL, which has not been previously reported. Contrary to expectations we did not find an association with BMI, severity of ED symptoms, low level of motivation to change ED features, or level of education.

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.

Longitudinal testing of a dietary self-care motivational model in adolescents with diabetes

OBJECTIVE

Based on self-determination theory, this study tests a model positing that perceived autonomy support from parents and health care providers positively predicts self-efficacy and autonomous self-regulation in dietary self-care. In turn, self-efficacy and autonomous self-regulation predict better dietary self-care over time.

METHOD

Longitudinal data were collected in a consecutive series of 289 adolescent patients with type I diabetes at two time points separated by a two-year interval.

RESULTS

Structural equation modeling analysis revealed that perceived autonomy support from health care providers at Time 1 (T1) positively predicted self-efficacy and autonomous self-regulation at Time 2 (T2), T1 self-efficacy and autonomous self-regulation positively predicted T2 dietary self-care, and T1 dietary self-care positively predicted T2 autonomous self-regulation.

CONCLUSION

Autonomy support from health care providers appears to help adolescents develop motivational factors for dietary self-care and adhere to dietary recommendations.

What knowledge do patients have about the physical consequences of their eating disorder?

BACKGROUND

A poor knowledge of the physical consequences or health risks of an eating disorder may be a sign of denial or minimization of the problem linked to a poor willingness to change.

AIM

Testing the knowledge of eating disorder patients about the physical consequences of their disorder and whether this can be improved by means of a psychoeducational program.

METHOD

Shortly after admission to a specialized inpatient eating disorder unit, a total of 66 female patients filled out a questionnaire with 20 items testing their knowledge about physical aspects of eating disorders. After about one month, 40 patients repeated the assessment. In between, they had received some psychoeducation in the form of an interactive group session and a special brochure.

RESULTS

The average knowledge was rather good (14 correct answers on a total of 20 questions), although a considerable number answered "I don't know" on 11 questions. The majority of these switched to correct answers after 1 month leading to a significant improvement of the general knowledge (on average 17/20), independently of the subtype of eating disorder. One question turned out to elicit the greatest number of incorrect answers: 'As long as a woman does not menstruate, she cannot get pregnant in a natural way'.

DISCUSSION

Assessing the (insufficient) knowledge about the physical consequences of an eating disorder may serve as the starting point for a specific psychoeducation, which can have an impact on the motivational process in these patients.

Interpersonal motives in anorexia nervosa: the fear of losing one's autonomy

OBJECTIVE

This study examined the widely held but insufficiently studied hypothesis of autonomy disturbances in anorexia nervosa.

METHOD

A total sample of 112 participants comprising patients with acute anorexia nervosa (AN), women recovered from anorexia nervosa (REC), clinical controls (CC), and healthy controls (HC) completed measures of dependency and intimacy strivings, as well as measures of frustrations of these same strivings.

RESULTS

In comparison to HC and CC, AN showed a stronger motivation to avoid dependency and lower strivings for intimacy. Compared with HC, but not with CC, AN also showed stronger frustrations of the same motives. Whereas REC did not differ from AN regarding avoidance of dependency, they reported lower frustration of dependency avoidance (i.e., less actual experiences of dependency). Finally, REC reported higher intimacy motivation as well as better satisfaction of intimacy motivation as compared with AN.

CONCLUSIONS

The present findings suggest that a pronounced motive of avoiding dependency may be a vulnerability factor for anorexia nervosa that is disorder-specific and trait-like. Frustrations of this motive seem to be associated with psychopathology.

Why do people with eating disorders drop out from inpatient treatment?: the role of personality factors

Dropout rates from inpatient treatment for eating disorders are very high and have a negative impact on outcome. The purpose of this study was to identify personality factors predictive of dropout from hospitalization. A total of 64 adult patients with anorexia nervosa consecutively hospitalized in a specialized unit were included; 19 patients dropped out. The dropout group and the completer group were compared for demographic variables, clinical features, personality dimensions, and personality disorders. There was no link between clinical features and dropout, and among demographic variables, only age was associated with dropout. Personality factors, comorbidity with a personality disorder and Self-transcendence dimension, were statistically predictive of premature termination of hospitalization. In a multivariate model, these two factors remain significant. Personality traits (Temperament and Character Inventory personality dimension and comorbid personality disorder) are significantly associated with dropout from inpatient treatment for anorexia nervosa. Implications for clinical practice, to diminish the dropout rate, will be discussed.

Toward systematic integration between self-determination theory and motivational interviewing as examples of top-down and bottom-up intervention development: autonomy or volition as a fundamental theoretical principle

Clinical interventions can be developed through two distinct pathways. In the first, which we call top-down, a well-articulated theory drives the development of the intervention, whereas in the case of a bottom-up approach, clinical experience, more so than a dedicated theoretical perspective, drives the intervention. Using this dialectic, this paper discusses Self-Determination Theory (SDT) [1,2] and Motivational Interviewing (MI) [3] as prototypical examples of a top-down and bottom-up approaches, respectively. We sketch the different starting points, foci and developmental processes of SDT and MI, but equally note the complementary character and the potential for systematic integration between both approaches. Nevertheless, for a deeper integration to take place, we contend that MI researchers might want to embrace autonomy as a fundamental basic process underlying therapeutic change and we discuss the advantages of doing so.

Motivational dynamics of eating regulation: a self-determination theory perspective

Within Western society, many people have difficulties adequately regulating their eating behaviors and weight. Although the literature on eating regulation is vast, little attention has been given to motivational dynamics involved in eating regulation. Grounded in Self-Determination Theory (SDT), the present contribution aims to provide a motivational perspective on eating regulation. The role of satisfaction and thwarting of the basic psychological needs for autonomy, competence, and relatedness is introduced as a mechanism to (a) explain the etiology of body image concerns and disordered eating and (b) understand the optimal regulation of ongoing eating behavior for healthy weight maintenance. An overview of empirical studies on these two research lines is provided. In a final section, the potential relevance and value of SDT in relation to prevailing theoretical models in the domain of eating regulation is discussed. Although research on SDT in the domain of eating regulation is still in its early stages and more research is clearly needed, this review suggests that the SDT represents a promising framework to more thoroughly study and understand the motivational processes involved in eating regulation and associated problems.

Influence of attitudes towards change and self-directness on dropout in eating disorders: a 2-year follow-up study

OBJECTIVE

This study examined dropout-related factors at the Outpatient Eating Disorders Treatment Programme.

METHOD

One hundred ninety-six eating disorders patients following DSM-IV diagnostic criteria that consecutively commenced treatment were recruited and followed up for a 2-year period. A total of 151 patients completed the whole assessment with a set of questionnaires evaluating eating and general psychopathology. The Attitudes towards Change in Eating Disorders questionnaire was used, and personality was evaluated using the Temperament and Character Inventory. During the follow-up period, patients were re-assessed. Two years later, 102 patients continued on treatment.

RESULTS

Scores on Precontemplation at the beginning were predictors for dropout at 2-year follow-up. Character variables, as Responsibility, Integrity and Self-acceptance were protective factors to be at Precontemplation stage.

DISCUSSION

The clinician's challenge is to help eating disorders patients to develop an unyielding sense of responsibility and self-acceptance, aimed to integrate the therapeutic choice into their own intrapersonal frame of goals.

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.

All better? How former anorexia nervosa patients define recovery and engaged in treatment

The purpose of this study was to explore how individuals with anorexia nervosa (AN) engage in treatment and define recovery. A mixed methods design was used to triangulate the experience of 20 women with a history of AN. Interview data were analysed thematically to explore frequency of emergent themes and current eating disorder psychopathology was assessed using standardized self-report measures. Participants' mean age was 29.35 (SD = 12.11). Participants' scores were indicative of persistent psychopathology. Those with more involvement in treatment choice had better motivation to change and normalized eating. Participants' definition of recovery mapped on well to current research conceptualizations, though a substantial proportion of the group expressed some ambivalence around the concept. Results are interpreted in the context of self-determination theory of motivation and suggest that patients should be involved collaboratively in the formulation of shared goals and concepts of recovery in treatment settings.

Dropping out from a specialized inpatient treatment for eating disorders: the perception of patients and staff

Most studies of treatment drop-outs have focused on demographic and clinical patient characteristics as possible predictors. To get a better insight in the meaning of dropping-out from therapy, during 1 year the viewpoints of patients and staff were compared in each case (N = 21 or 15.2%) of premature termination of an inpatient treatment program for eating disorders. Both patients and staff were reporting as important reasons of drop-out: not enough freedom, treatment being too difficult, and lack of trust. Contrary to the staff, patients were more often satisfied with the therapy and therefore did not expect further benefit in continuing the inpatient treatment. The findings are discussed mainly within the context of patient-staff interaction. The authors propose to abandon the term "drop-out" because of its negative connotation.

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.