Motivation to change in the eating disorders: a systematic review

Individual differences in motivation to change in individuals with eating disorders: A systematic review

OBJECTIVE

Motivation to change has been suggested to significantly impact treatment outcomes in eating disorders (EDs). This review will investigate factors associated with motivation to change in EDs with the aim of supporting clinicians to be aware and sensitive to factors that might obstruct recovery and to inform motivation-based interventions.

METHOD

Using PRISMA guidelines, this article identified 24 studies through database searches meeting eligibility criteria. Only correlates of motivation were identified, limiting the ability of this review to identify causal relationships. Factors that changed alongside changes in motivation were identified from longitudinal studies.

RESULTS

This review identified factors such as individual characteristics, co-morbid psychopathology, lack of treatment autonomy and relationships with others to be associated with motivation to change in individuals with EDs. In addition, motivation to change significantly increased alongside self-esteem and identity re-negotiation when measured longitudinally.

DISCUSSION

Motivational interviewing can typically focus on exploring ambivalence to treatment, identifying goals and values, and increasing self-efficacy. However, this review identifies individual and relational factors to be particularly significant and may obstruct recovery from an ED. As such, evidence-based targets have been identified to inform clinicians and motivation-based interventions.

PUBLIC SIGNIFICANCE

Knowledge of factors associated with motivation to change in EDs is important to understand those who may have poorer treatment outcomes. Motivation may be improved by supporting individuals' relationship with others and tailoring interventions according to temperament and personality traits. Utilizing an individual's social support as they enter ED treatment may be effective in maximizing motivation to recover.

Anorexia nervosa: Enhancing motivation to change with self-determination theory

Motivational deficits (little or no motivation to change) are often reported in patients with eating disorders, particularly anorexia nervosa. The motivational approaches frequently used by French clinicians rely solely on a dichotomous view of motivation (intrinsic vs. extrinsic). In self-determination theory, certain forms of extrinsic motivation can strengthen an individual's commitment to an activity, providing they are self-determined. This theory therefore extends and enriches the dual motivational approach by highlighting potentially useful forms of extrinsic motivation and by emphasizing the importance of behavioral regulation. Empirical work is now needed to assess how clinicians can use self-determination theory to enhance motivation to change among patients with anorexia nervosa and encourage their adherence to care management plans.

A Psychometric Analysis of the Patterns of Adapted Learning Scales (PALS) with a Group Psychotherapy Patient Sample: A Measure of Motivation

Previous research has examined the role of clients' goal orientation, or the motives one uses to achieve specific tasks or goals in individual therapy highlighting the importance of clients' goal orientation within a therapeutic context. Constructing and validating a measure of clients' achievement goal orientation in group psychotherapy is needed to allow for additional methodologically sound research to examine the role of achievement goal orientation in the process and outcome of group psychotherapy. Data from 99 adult group members across 23 interpersonal process groups were used to investigate the psychometric properties of the Patterns of Adapted Learning Scales-Group Psychotherapy Version (PALS-GP), including internal reliability, structural validity, and concurrent and criterion-related validity. The PALS-GP scores revealed an overall good internal consistency (α = .76-.86) and yielded a robust three-factor structure. Evidence of concurrent and predictive validity was also demonstrated with a measure of group alliance and client improvement, respectively. The PALS-GP appears to be a promising instrument for measuring goal orientation with a clinical population participating in group therapy.

Experiencing eight psychotherapy approaches devoted to eating disorders in a single-day workshop increases insight and motivation to engage in care: a pilot study

PURPOSE

For patients with eating disorders (EDs), early engagement in care is usually considered a positive prognostic factor. The aim of the study was to investigate how a single-day intervention devoted to early, brief, experiential exposure to a variety of psychotherapy approaches might support commitment to change and the decision to engage in care in patients with EDs.

METHODS

One hundred and sixty-nine adult outpatients newly diagnosed with an ED took part in a single-day workshop for groups of up to ten patients, where they experienced eight psychotherapeutic approaches. Motivation to change care and level of insight were assessed at baseline and 10 days after the intervention.

RESULTS

Motivation and commitment to take active steps toward change (expressed by the "Committed Action" composite score) significantly improved after the intervention (p < 0.001), and a significant number of patients specifically moved from "contemplation" to "action" stage (p < 0.001). The improvement of motivation to change was significantly associated with an increase in insight capacity (p < 0.001), and this increase was observed for almost all related dimensions such as recognition of illness or awareness of need for psychological treatment.

CONCLUSION

A single-day session devoted to experiencing a range of group psychotherapies increased patients' insight and motivation to actively engage in care. To confirm potential longer-term benefits of this intervention, further studies are needed to explore the contribution of each approach and process specifically involved in patients' increased motivation for care, as well as the clinical characteristics of patients associated with better outcomes.

LEVEL OF EVIDENCE

V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Motivation to change predicts naturalistic changes in binge eating and purging, but not fasting or driven exercise among individuals with eating disorders

We examined the naturalistic relations between motivation to change and change in four specific eating disorder (ED) behaviors-binge eating (BE), purging, fasting, and driven exercise-in a community-based sample of individuals with EDs over two consecutive 6-week periods. We conducted cross-lagged generalized estimating equations using the transtheoretical model's four stages of change to predict changes in the ED behaviors 6 weeks later. Individuals reported lower pre-contemplation for behaviors typically associated with more distress (e.g., BE, purging) than they did for behaviors associated with less distress (e.g., fasting and driven exercise). Action predicted decreases in BE and purging frequencies but not fasting or driven exercise frequencies. Naturalistic relations between ED behavior severity/frequency and motivation to change these features can be detected over 6-week intervals; that is, attempts at change in individuals' natural environments can be successful over relatively brief periods of time, especially when individuals experience the motivation to change these features. The process of motivation to change ED behaviors is not linear, and our study highlights the movement between stages of change among individuals with EDs. Future research is needed to examine how much of the observed changes are sustained.

Estimating the Effect of Motivational Interventions in Patients with Eating Disorders: A Systematic Review and Meta-Analysis

Motivation to change behavior is seen as an important factor in achieving a better treatment effect in patients with eating disorders (ED). The aim of this systematic review was to assess whether motivational interviewing (MI) and motivational enhancement therapy (MET) might (1) increase motivation to change behavior and (2) improve eating disorder psychopathology (EDP) and body mass index (BMI) in patients with ED. To investigate this, a literature search was conducted on 9 March 2021 on four scientific databases: Cochrane, Embase (Ovid), MEDLINE (PubMed), and PsycInfo (EBSCO). A total of 2647 publications were identified and following a rigorous stepwise procedure to assess titles and abstracts and, thereafter, full texts of relevant publications, 13 studies were included in the data extraction and analyses. A few individual studies (n = 5) found a significant increase in motivation, two a decrease in ED symptoms (n = 2), while none found an effect on BMI. However, the meta-analysis of each outcome found effect sizes near zero, thereby confirming the results of previous narrative reviews that have described a lack of effect of MET/MI on motivation in ED. Since the individual studies differ substantially in design, and the outcomes were inconsistently assessed with regards to instruments and duration, the effect of MET/MI on motivation for behavioral change, ED psychopathology, and BMI is still unclear.

Evaluating a motivational and psycho-educational self-help intervention for athletes with mild eating disorder symptoms: A mixed methods feasibility study

Objective

The primary aim was to assess the feasibility of undertaking a study evaluating the novel Motivational and Psycho‐Educational Self‐Help Programme for Athletes with Mild Eating Disorder Symptoms (MOPED‐A). A mixed‐methods approach was adopted to explore the feasibility of recruiting and retaining participants, and to evaluate the acceptability of measures, procedures and the intervention. A secondary aim was to explore the potential efficacy of MOPED‐A in reducing athletes' eating disorder symptoms.

Method

Thirty‐five athletes were recruited. Participation involved completing MOPED‐A over a 6‐week period and completing self‐report measures at baseline (T1), post‐intervention (T2) and 4‐week follow‐up (T3). A subsample (n = 15) completed an interview at T2.

Results

Retention was good throughout the study (n = 28; 80%). Quantitative and qualitative feedback suggested the format, delivery, content and dosage of MOPED‐A were acceptable. Athletes valued that the intervention was tailored to them, and this facilitated both participation and completion. Over a third of participants reported disclosing their eating difficulties and deciding to seek further support. Large reductions in eating disorder symptoms were detected at T2 and sustained at T3.

Conclusions

The MOPED‐A intervention can be feasibly implemented, is acceptable to participants, and demonstrates potential for reducing symptoms in athletes. A larger, controlled trial is warranted.

Participant recruitment to the study was feasible, and an acceptable proportion of participants were retained throughout the study.

This is the first study to show that the format and delivery of a self‐help intervention is acceptable to athletes with mild eating disorder symptoms, and that athletes valued the intervention being tailored to them which facilitated participation and completion.

The intervention demonstrates potential for reducing athletes' eating disorder symptoms.

Early development of treatment motivation predicts adherence and symptom reduction in an internet-based guided self-help program for binge eating disorder

OBJECTIVE

Lack of motivation is widely acknowledged as a significant factor in treatment discontinuity and poor treatment outcomes in eating disorders. Treatment adherence is lower in internet-based treatment. The current study aimed to assess the relationship between treatment motivation and treatment outcomes in an internet-based therapist-guided intervention for Binge Eating Disorder (BED).

METHOD

Adults (N = 153) with mild to moderate symptoms of BED participated in a 10-session internet-based treatment program. Baseline and between-session scores of "Readiness to change" and "Belief in change" were used to predict treatment completion and eating disorder symptom reduction (EDE-Q Global, BED-Q, and weekly number of binge eating episodes) at post-treatment.

RESULTS

Baseline treatment motivation could not predict treatment completion or symptom reduction. Early measures of treatment motivation (regression slope from sessions 1-5) significantly predicted both treatment completion and post-treatment symptom reduction. "Belief in change" was the strongest predictor for completing treatment (OR = 2.18, 95%-CI: 1.06, 4.46) and reducing symptoms (EDE-Q Global: B = -0.53, p = 0.001; number of weekly binge eating episodes: B = 0.81, p < 0.01).

DISCUSSION

The results indicated that patients entering online treatment for BED feel highly motivated. However, baseline treatment motivation could not significantly predict treatment completion, which contradicts previous research. The significant predictive ability of early measures of treatment motivation supports the clinical relevance of monitoring the development of early changes to tailor and optimize individual patient care. Further research is needed to examine treatment motivation in regard to internet-based treatment for BED with more validated measures.

Motivation to recover for adolescent and adult eating disorder patients in residential treatment

OBJECTIVE

This study aimed to assess how baseline motivation to recover impacts eating disorder (ED) and comorbid symptoms at end-of-treatment (EOT) for adolescents and adults in inpatient/residential treatment.

METHOD

Two hundred and three adolescent (M = 15.90) and 395 adult (M = 25.45) patients with a Diagnostic Statistical Manual, 5th edition ED diagnosis completed the Decisional Balance Scale (DBS) at baseline, and psychosocial measures (ED symptoms, anxiety, depression, obsessive-compulsive disorder symptoms), and %body mass index (kg/m² ; BMI) or median %BMI (for adolescents) at baseline and EOT.

RESULTS

The DBS Avoidance Coping and Burdens subscales at baseline were significantly lower for adolescents than adults (p < 0.001), whereas the DBS Benefits subscale at baseline did not significantly differ between subsamples (p = 0.06). Motivation to recover via DBS subscales was a more reliable predictor of EOT outcomes for both ED and comorbid psychopathology in adults (significant predictor in 19 of 54 total analyses, and 4 significant associations post-Bonferroni correction) than adolescents (significant predictor in 5 of 54 total analyses, and 1 significant association post-Bonferroni correction).

CONCLUSIONS

Baseline motivation to recover may be an important predictor of outcome for adult patients in inpatient/residential treatment but does not appear associated with outcomes for adolescent patients.

How precisely can psychotherapists predict the long-term outcome of anorexia nervosa and bulimia nervosa at the end of inpatient treatment?

OBJECTIVE

To assess the ability of psychotherapists to predict the future outcome for inpatients with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Psychotherapists rated the prognosis of the patient's eating disorder on a five point Likert scale on several dimensions at the end of inpatient treatment. Actual outcome was assessed about 10 years after treatment. The sample comprised 1,065 patients treated for AN, and 1,192 patients treated for BN.

RESULTS

Psychotherapists' rating of their patient's prognosis was not better than chance for good outcome in AN and BN and for poor outcome in BN. Prediction of poor outcome in AN was somewhat better with approximately two thirds of correct predictions. In logistic regression analysis, psychotherapists' rating of the patients' prognosis for AN contributed to the explained variance of long-term outcome, increasing the variance explained from 7% (by conventional predictors) to 8% after including psychotherapists' prognosis. In BN, there was no significant contribution of psychotherapists' prognosis to overall prediction.

DISCUSSION

Our current knowledge of risk and protective factors for the course of eating disorders is unsatisfying. More specialized research is urgently needed.

The Causal Influence of Life Meaning on Weight and Shape Concerns in Women at Risk for Developing an Eating Disorder

Background: Although previous studies have shown an inverse relation between life meaning and eating disorder symptoms, the correlational nature of this evidence precludes causal inferences. Therefore, this study used an experimental approach to test the causal impact of life meaning on individuals' weight and shape concerns. Methods: Female students at risk for developing an eating disorder (N = 128) were randomly assigned to the control or the meaning condition, which involved thinking about and committing to pursue intrinsically valued life goals. A color-naming interference task was used to assess the motivational salience of body-related stimuli, and self-report measures were used to assess participants' overvaluation of weight and shape. Results: The meaning manipulation was effective in activating intrinsically valued life goals. However, it did not result in lower self-reported overvaluation of weight and shape or lower color-naming interference effects of body-related stimuli, compared to the control condition. Post-hoc analyses suggested that baseline meaning in life was related to the impact of the manipulation. Conclusions: This experimental study did not provide evidence for a causal influence of life meaning on the overvaluation of weight and shape in a high-risk group. The current findings suggest that we first need to examine the relationship between life meaning and eating disorder symptoms in more detail, before implementing brief meaning manipulations in clinical practice.

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.

A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa

BACKGROUND

Outpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa.

METHODS

Participants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months.

RESULTS

Adherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks.

CONCLUSIONS

Augmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.

Rituals and preoccupations associated with bulimia nervosa in adolescents: Does motivation to change matter?

This study evaluated the effects of two treatments for adolescent bulimia nervosa (BN), family-based treatment (FBT-BN), and cognitive behavioral therapy (CBT-A), on both attitudinal and behavioural outcomes at end-of-treatment. These associations were examined specifically relative to motivation for change in obsessive-compulsive (OC) features of eating disorder (ED) symptoms. Adolescents (N = 110) were randomly assigned to FBT-BN or CBT-A and completed assessments of eating pathology and OC-ED behaviour. Across both treatments, greater motivation for change in OC-ED behaviour was associated with improved attitudinal features of ED at end-of-treatment. Motivation for change did not demonstrate a direct or interaction effect on BN behavioural outcomes. Results suggest that adolescents with BN who are more motivated to change OC-ED behaviours at the start of treatment, FBT-BN or CBT-A, are more likely to demonstrate improvements in cognitions, but not behaviours associated with EDs, at treatment conclusion.

Turning the Corner: A Comparison of Collegiate Athletes’ and Non-Athletes’ Turning Points in Eating Disorder Recovery

The purpose of this qualitative study was to identify turning points in eating disorder recovery in collegiate female athletes compared to non-athletes. The sample included 12 varsity athletes and 17 non-athlete college students who previously met criteria for Anorexia Nervosa (AN; n = 17); Bulimia Nervosa (BN; n = 3); Binge Eating Disorder (n = 1); or both AN and BN (n = 8). Participants completed individual interviews and responses were analyzed inductively. There was some commonality in the athletes’ and non-athletes’ experiences. For example, the most frequent turning point for both groups was Insight/Self Realization. Regarding the next three most frequent turning points, athletes reported Sport Performance, Confrontation, and Support/Concern from Others, whereas non-athletes reported Professional Treatment, Hitting a Low, and Support/Concern from Others. This study contributes to the sparse literature on competitive athletes’ recovery. Results indicated that athletes’ turning points differed from non-athletes; therefore, findings are discussed concerning athlete-specific treatment recommendations and suggestions for coaches.

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.

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.

Disordered Eating Behaviors Through the Lens of Self-Determination Theory

This study aimed to verify a conceptual model of eating regulation based on the Self-Determination Theory. This model suggests that basic psychological needs satisfaction is related to general self-determined motivation and autonomous regulation toward eating, which in turn are associated with less disordered eating behaviors and attitudes and better satisfaction with life. Two hundred thirty-nine women without an eating disorder completed self-reported questionnaires. The hypothesized model was tested with a serial multiple mediation analysis using PROCESS macro. The overall indirect effect of basic psychological needs satisfaction on life satisfaction through the three mediators, i.e. general motivation, regulation of eating behaviors, and eating behaviors and attitudes, was significant. Results are coherent with the Self-Determination Theory and add to past research by suggesting that basic psychological needs satisfaction might be a key target when addressing women’s disordered eating behaviors and attitudes.

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.

Does level of motivation for change impact post-treatment outcomes in the eating disorders? Protocol for a systematic review with quantitative analysis

BACKGROUND

Eating Disorders are highly prevalent and widespread mental health problems, with marked risk of chronicity and refractoriness to treatment. Affected individuals are hesitant to change their behaviours and therefore struggle to maintain motivation for therapy. This review aims to produce the first high-quality meta-analysis of the literature on the impact of level of motivation for change on post-treatment outcomes in anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorder (OSFED).

METHODS

A systematic review will be conducted using Cochrane library, Embase, MEDLINE, and PsychINFO. Research registrars and bibliographies of included articles will be screened, and experts will be contacted. The search strategy consists of terms related to eating disorders, motivation, and outcome. Randomized controlled trials, clinical controlled trials, time series, and before-after studies will be included. Participants will be adolescents and adults who are diagnosed with anorexia nervosa, bulimia nervosa, binge-eating disorder or OSFED and who are entering psychotherapy treatment. The predictor studied is defined as motivation for change at the beginning of treatment. The primary outcome will be an overall change in eating-disorder symptomatology at the end of treatment and at less than, and over 6-month follow-up. Other outcomes of interest include change in restricting, binging, and compensatory behaviours, change in shape, weight and eating concerns, change in psychiatric comorbidities, weight restoration, and dropout rates. Articles will be selected, data will be extracted, and the risk of bias will be assessed by independent reviewers using forms pre-created on Eppi-Reviewer 4 software. Results will be combined using a random-effects model. Studies of all sizes and qualities will be included in the analyses. Heterogeneity will be examined by funnel plot, Cochran's Q, and I² statistic. Sensitivity analyses will be performed to account for clinical and methodological differences across studies.

DISCUSSION

This systematic review will help determine the predictive value of motivation for change on treatment outcomes in eating disorders.

TRIAL REGISTRATION

Our systematic review protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42016035285). All modifications will be available on the PROSPERO website, along with the dates, a description, and a justification.

Motivational Text Message Intervention for Eating Disorders: A Single-Case Alternating Treatment Design Using Ecological Momentary Assessment

OBJECTIVE

This study tested a motivational text message treatment adjunct for individuals with eating disorders (EDs) who exhibited high dietary restraint/restriction.

METHOD

A replicated single-case alternating treatment design was used to examine (a) the feasibility of combining a brief motivational interview with subsequent text messages and (b) the influence of the text messages on eating behaviors and motivation to change in individuals with EDs (N=12). The protocol was 8weeks and the text messages were adjunctive to cognitive-behavioral therapy.

RESULTS

The intervention was well accepted (mean rating=7/10) and feasible within the context of monetary compensation (mean daily monitoring compliance =91%). Text messages did not impact behavioral outcomes: dietary restraint and kilocalorie intake. They had mixed effects on motivation to change dietary restraint, measured by the Readiness and Motivation Questionnaire (RMQ). When receiving text messages, RMQ precontemplation scores (desire to restrict) significantly increased, indicating decreased motivation; however, action scores (effort toward reducing dietary restraint) significantly increased, indicating increased motivation. These effects were moderated by weight status. Underweight individuals (n=4; body mass index [BMI]<19.0) reported increased ambivalence-that is, an increased desire to restrict and increased action toward reducing restriction-in response to the text messages. Normal weight participants (n=8; BMI>19.0) reported only increased action toward reducing restriction in response to the text messages.

DISCUSSION

These data demonstrate text messages are a potentially feasible and acceptable treatment adjunct and may be effective at increasing motivation to change for normal weight individuals, while their influence on underweight patients is more complex. These findings provide a foundation for future research in technology-based motivational interventions for EDs and offer preliminary evidence for using these methods among normal weight individuals.

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.

Mandating weekly weight gain in a day treatment program for eating disorders

OBJECTIVE

We examined differences in treatment outcome associated with a "self-directed"- versus "external-incentive"-based day treatment protocol for individuals with eating disorders (EDs) with below normal body mass index. The self-directed protocol recommended a weekly 500 g weight gain, but allowed participants freedom to gain weight at their own rate; the "external-incentive" protocol required a minimum weight gain of 500 g/week as a requirement for staying in the program.

METHOD

Weight outcome was available for 49 individuals who were treated with the recommended weight gain protocol, and 40 individuals who were treated with the required weight gain protocol.

RESULTS

Post-treatment weight was significantly higher in patients treated in the required weight gain protocol compared to those treated in the recommended weight gain protocol. All patients, regardless of which program they completed, showed improvements in the measures of eating-disorder and comorbid-psychiatric symptoms.

DISCUSSION

This study demonstrated the benefits of an alteration in protocol that required no additional financial or human resources. Further studies are needed to validate the effectiveness of various day treatment protocol parameters.