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

Outcomes and associated clinical features of people with eating disorders participating in residential treatment facilities: a scoping review

Residential treatment programs for eating disorders (EDs) have gained popularity in recent years, expanding beyond the United States to countries such as Canada, Italy, and the United Kingdom. These programs offer a "home-like" environment where individuals reside for several weeks or months, emphasising both physical restoration and psychological recovery. This scoping review aimed to provide an update since the most recent reviews on the literature regarding outcomes of residential treatment programs for EDs and to explore clinical features that were associated with these outcomes. Methods used followed the Joanna Briggs Institute guidelines for scoping reviews. A systematic search of electronic databases was conducted, and 12 studies met the inclusion criteria. All studies reported improvements in various outcomes from admission to discharge, including changes in eating psychopathology, weight restoration, depression, anxiety, and quality of life. Additionally, three studies reported positive outcomes at intervals after discharge and three predictive factors (self-compassion, personality organisation, and resistance to emotional vulnerability) were reported in a small number of studies. While residential treatment facilities consistently showed positive outcomes, the review highlights the need for randomised controlled studies to establish the efficacy of these programs for EDs. Future research should include controlled studies comparing residential facilities to other treatment settings and incorporate long-term follow-up outcomes and further studies of emergent predictive factors identified in this review.

The sequential approach in eating disorders: A scoping systematic review

OBJECTIVE

The sequential model has been defined as an intensive, two-stage approach that comprises administering two types of treatment consecutively to improve treatment outcomes in cases of non-optimal or absence of treatment response. A psychiatric population that would potentially benefit from the application of the sequential model is the eating disorders (EDs) population. The current scoping review aimed to explore the emerging literature on the application of sequential treatments in EDs.

METHOD

Using PRISMA and Population intervention comparison outcomes study guidelines, Pubmed and PsycINFO were systematically searched for studies which applied temporally sequential treatments in patients diagnosed with EDs from inception to April 2022 using a combination of keywords. Studies utilising combined or integrated approaches were excluded.

RESULTS

A total of 12 studies were selected and reviewed. Studies included Bulimia Nervosa, Binge Eating Disorder (BED), or mixed ED samples with a majority of female patients. No studies on AN samples were identified. The majority of studies contained a Cognitive-Behavioural Therapy module of treatment, were conducted on BED patients, were in outpatient settings, and included a group format in one or more treatment conditions. Studies varied in number of comparison groups and study design. Secondary and sequentially applied treatment modules were consistent with treatment recommendations of clinical guidelines.

CONCLUSIONS

The available data on sequential treatments in EDs is scarce and exhibits methodological limitations that should be addressed in future studies. Definition of sequential treatments in EDs should be further developed to guide robust clinical research and improve empirical support of sequential treatment for complex ED cases and for non-optimal ED treatment response.

Metacognitive interpersonal therapy-eating disorders versus cognitive behavioral therapy for eating disorders for non-underweight adults with eating disorders: study protocol for a pilot pre-registered randomized controlled trial

Eating disorders (ED) are serious disorders characterized by an alteration of eating habits and excessive concern about weight and body shapes (Fairburn, 2002), accompanied by significant impairment inequality of life, high mortality rates and serious organic consequences (Jenkins et al., 2011; Treasure et al., 2015; 2020). Although evidence-based psychological therapies for nonunderweight ED presentations such as cognitive behavioral therapy for eating disorders (CBT-ED) are widely available, there is substantial scope for improvements, particularly in terms of efficacy and adherence. One option is to develop interventions to address elements of pathology not fully addressed by existing empirical supported treatments, such as incorporating techniques aimed at addressing interpersonal problems and personality disorder features into existing treatment delivery. We adapted Metacognitive Interpersonal Therapy, a psychological intervention supported by evidence for treating personality disorders and integrated it with existing CBT techniques for eating disorders (MIT-ED). MIT-ED targets aspects of ED that are not included in the transdiagnostic CBT-E model such as poor metacognition, or maladaptive interpersonal schemas. This is a pre-registered (Protocol number: 0000781) pilot randomized clinical trial aimed at assessing acceptability and feasibility of MIT-ED and establishing preliminary evidence of effectiveness for future larger studies. Twenty patients (10 in each arm) will be randomized to 20 sessions of individual psychotherapy, either MIT-ED or CBTE. Repeated follow-ups will be collected up to 24 months. Participants are recruited at a private outpatient clinic for ED treatment. Acceptability will be assessed via session attendance, completion rates and preliminary outcomes. The primary outcome is ED pathology assessed with the Eating Disorder Examination Questionnaire-6. Other ED outcomes assessed will be eating disorder attitudes, clinical impairment and binge eating pathology. Secondary treatment outcomes are anxiety, depression, and global symptomatology. We will also assess emotional awareness, emotion regulation and therapeutic alliance. Based on previous studies of MIT for personality disorders we hypothesize that MIT-ED will be acceptable to patients, evidenced by high treatment adherence and retention. We hypothesize that MIT-ED will be associated with reductions in eating disorder pathology, at least equivalent to CBT-E. Results will be used to inform the study design, sampling, likely effect sizes and choice of outcome measures for future larger trials of MIT-ED in ED samples.

Optimizing digital health technologies to improve therapeutic skill use and acquisition alongside enhanced cognitive-behavior therapy for binge-spectrum eating disorders: Protocol for a randomized controlled trial

OBJECTIVE

Adjunctive mobile health (mHealth) technologies offer promise for improving treatment response to enhanced cognitive-behavior therapy (CBT-E) among individuals with binge-spectrum eating disorders, but research on the key "active" components of these technologies has been very limited. The present study will use a full factorial design to (1) evaluate the optimal combination of complexity of two commonly used mHealth components (i.e., self-monitoring and microinterventions) alongside CBT-E and (2) test whether the optimal complexity level of these interventions is moderated by baseline self-regulation. Secondary aims of the present study include evaluating target engagement associated with each level of these intervention components and quantifying the component interaction effects (i.e., partially additive, fully additive, or synergistic effects).

METHOD

Two hundred and sixty-four participants with binge-spectrum eating disorders will be randomized to six treatment conditions determined by the combination of self-monitoring condition (i.e., standard self-monitoring or skills monitoring) and microinterventions condition (i.e., no microinterventions, automated microinterventions, or just-in-time adaptive interventions) as an augmentation to 16 sessions of CBT-E. Treatment outcomes will be measured using the Eating Disorder Examination and compared by treatment condition using multilevel models.

RESULTS

Results will clarify the "active" components in mHealth interventions for binge eating.

DISCUSSION

The present study will provide critical insight into the efficacy of commonly used digital intervention components (i.e., skills monitoring and microinterventions) alongside CBT-E. Furthermore, results of this study may inform personalization of digital intervention intensity based on patient profiles of self-regulation.

PUBLIC SIGNIFICANCE

This study will examine the relative effectiveness of commonly used components of application-based interventions as an augmentation to cognitive-behavioral therapy for binge eating. Findings from this study will inform the development of an optimized digital intervention for individuals with binge eating.

Adolescents with developmental traumas in therapy in a child and adolescent mental health service, outpatient unit: experiences of daily living and expectations for therapy - a qualitative study

Background

Developmental trauma has a profound effect on people's lives. There are few studies of the perceived difficulties and treatment needs of adolescents with developmental trauma. More studies are called for to explore the perspectives and experiences of these patients, especially adolescents.

Method

Semi-structured interviews were conducted with eight adolescents with developmental trauma aged 14-18 years in a Child and Adolescent Mental Health Service, Outpatient Unit. The interviews were analyzed using systematic text condensation.

Results

A main finding in this study regards the participants' understanding of why they needed therapy: symptom alleviation and coping tools. They expressed a need for talking with a safe and reliable adult who understood their situation. Their stories of daily functioning and bodily sensations align mainly with symptoms described for adolescents with developmental trauma. The study also shows that the participants' experiences of trauma affected their lives to a greater or lesser extent, in the form of ambivalence, avoidance, regulation, and coping strategies. They also described various physical problems, especially insomnia and inner restlessness. Their subjective stories revealed insights into their experiences.

Conclusion

Based on the results, we recommend that adolescents with developmental trauma be allowed to express their understandings of their difficulties and their treatment expectations at an early stage of their therapy. An emphasis on patient involvement and the therapeutic relationship can increase their autonomy and control over their own lives and treatment.

Study Protocol for "Psilocybin as a Treatment for Anorexia Nervosa: A Pilot Study"

Background: Anorexia nervosa (AN) is a serious and life-threatening psychiatric condition. With a paucity of approved treatments, there is a desperate need for novel treatment avenues to be explored. Here, we present (1) an overview of the ways through which Public Patient Involvement (PPI) has informed a trial of psilocybin-assisted therapy for AN and (2) a protocol for a pilot study of psilocybin-assisted therapy in AN currently underway at Imperial College London. The study aims to assess the feasibility, brain mechanisms and preliminary outcomes of treating anorexia nervosa with psilocybin. Methods: (1) PPI: Across two online focus groups, eleven individuals with lived experience of AN were presented with an overview of the protocol. Their feedback not only identified solutions to possible barriers for future participants, but also helped the research team to better understand the concept of "recovery" from the perspective of those with lived experience. (2) Protocol: Twenty female participants [21-65 years old, body mass index (BMI) 15 kg/m2 or above] will receive three oral doses of psilocybin (up to 25 mg) over a 6-week period delivered in a therapeutic environment and enveloped by psychological preparation and integration. We will work with participant support networks (care teams and an identified support person) throughout and there will be an extended remote follow-up period of 12 months. Our two-fold primary outcomes are (1) psychopathology (Eating Disorder Examination) across the 6-month follow-up and (2) readiness and motivation to engage in recovery (Readiness and Motivation Questionnaire) across the 6-week trial period. Neurophysiological outcome measures will be: (1) functional magnetic resonance imaging (fMRI) brain changes from baseline to 6-week endpoint and (2) post-acute changes in electroencephalography (EEG) activity, including an electrophysiological marker of neuronal plasticity. Discussion: The results of this pilot study will not only shed light on the acceptability, brain mechanisms, and impression of the potential efficacy of psilocybin as an adjunct treatment for AN but will be essential in shaping a subsequent Randomised Control Trial (RCT) that would test this treatment against a suitable control condition. Clinical Trial Registration: identifier: NCT04505189.

Enhanced cognitive behavior therapy for severe and extreme anorexia nervosa: An outpatient case series

OBJECTIVE

The study aimed to assess outcomes in patients with severe and extreme anorexia nervosa managed with enhanced cognitive behavior therapy (CBT-E) in a real-world outpatient setting.

METHOD

Thirty patients with anorexia nervosa and body mass index (BMI) <16 aged ≥17 years were recruited from consecutive referrals to an eating disorder service clinic offering outpatient CBT-E. BMI and Eating Disorder Examination Questionnaire (EDE-Q), Brief Symptom Inventory (BSI), and Clinical Impairment Assessment (CIA) scores were recorded at admission, end of treatment, and 20- and 60-week follow-ups for treatment completers.

RESULTS

Twenty patients (66.7%) completed the treatment and showed both considerable weight gain (Cohen's f = 1.43), and significantly reduced scores for clinical impairment (f = 1.26) and eating-disorder (f = 1.03) and general psychopathology (f = 0.99). Changes remained stable at both follow-ups. About half of the patients who completed treatment had a BMI ≥18.5 at the end of treatment and follow-ups.

DISCUSSION

CBT-E seems suitable and promising for patients with severe and extreme anorexia nervosa seeking treatment in a real-world clinical setting, provided that their medical conditions are stable, and they have no current major depressive episodes or substance abuse; it may represent a valid alternative to inpatient treatment for those who are able to sustain engagement in a full course of outpatient treatment.

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 systematic review of enhanced cognitive behavioral therapy (CBT-E) for eating disorders

OBJECTIVE

To review the literature examining the efficacy and effectiveness of enhanced cognitive behavioral therapy (CBT-E) for adults and older adolescents with eating disorders.

METHOD

A systematic search of the literature (using PsycINFO and PubMed) was conducted in order to identify relevant publications (randomized controlled trials [RCTs] and uncontrolled trials) up to June 2019. Effect sizes were reported for outcomes including treatment attrition and remission rates, eating disorder behaviors, body mass index (BMI), and core eating disorder psychopathology. The Downs and Black checklist was used to assess the quality of included studies.

RESULTS

Twenty studies (10 RCTs and 10 uncontrolled trials) met criteria for inclusion. Support was found for the efficacy and effectiveness of CBT-E for the full spectrum of eating disorders, with respect to reducing eating disorder behaviors and core psychopathology. BMI also increased, with large effects, for individuals with AN. However, the majority of the randomized trials included in this review did not demonstrate superiority of CBT-E over comparison treatments, particularly in the longer-term. Furthermore, rates of attrition and remission for CBT-E among individuals without AN did not appear to differ from rates for CBT-BN.

DISCUSSION

There is evidence to support CBT-E as an efficacious and effective treatment for adults and older adolescents with a range of eating disorder diagnoses. Future research would benefit from directly comparing CBT-E to CBT-BN, expanding measured outcomes to include driven exercise and subjective binge eating, increasing consistency in the definition and measurement of outcomes, and exploring factors associated with treatment retention.

Treatment outcome research of enhanced cognitive behaviour therapy for eating disorders: a systematic review with narrative and meta-analytic synthesis

Enhanced cognitive behaviour therapy (CBT-E) has recently generated interest as a potentially useful treatment for eating disorders (ED). In the current study, we conducted a systematic review of the outcome literature on CBT-E, with both narrative and meta-analytic synthesis. We included single-group uncontrolled pre-post design studies and randomised control trials (RCTs) of CBT-E, which allowed us to include a larger number of studies, and also compare the two methodologies in terms of effect size. The primary analysis included 15 CBT-E studies with a total of 948 participants. Narrative synthesis examined bingeing and purging episodes, BMI change, and follow-up results. A large, statistically significant effect supported CBT-E as a treatment for all EDs (g = 1.06). When comparing methodologies, both pre-post design studies (g = 1.26) and RCTs (g = 0.82) yielded large effects. Narrative synthesis outlined reductions in ED behaviours and increases in BMI which were maintained at follow-up. Limitations include that further RCTs of CBT-E are needed to establish clinical effectiveness of this treatment approach for all EDs; however, results from narrative exploration indicate this endeavour would be worthwhile. Despite the limitations, this study provides additional support for CBT-E as a successful treatment across the range of EDs.

Ready or Not: Examining Self-Reported Readiness for Behavior Change at Intake Assessment for Adults With an Eating Disorder

We explored whether a single-item self-report measure (i.e., the Readiness Ruler) was an appropriate measure of treatment engagement in adult outpatients with eating disorders. In total, 108 women diagnosed with an eating disorder completed the Readiness Ruler and measures of symptom severity at intake to a hospital-based outpatient treatment program. Treatment engagement was operationalized as attendance to a minimum of one session of a cognitive-behavioral therapy (CBT) treatment group, the number of CBT group sessions attended, and whether the participants dropped out of the CBT group prematurely. Results suggest that the Readiness Ruler was not associated with attending the CBT group. Among the participants who attended the program, the Readiness Ruler was not associated with the number of CBT group sessions attended or CBT group dropout. Higher Readiness Ruler score was associated with more severe symptomatology. In conclusion, the Readiness Ruler may not be a good predictor of CBT group treatment engagement for individuals with eating disorders and may instead be a proxy for symptom severity.

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.

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.

Was passiert nach dem letzten Klick?

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

Do symptom-specific stages of change predict eating disorder treatment outcome?

PURPOSE

Interview methods to assess stages of change (SOC) in eating disorders (ED) indicate that SOC are positively correlated with symptom improvement over time. However, interviews require significant time and staff training and global measures of SOC do not capture varying levels of motivation across ED symptoms. This study used a self-report, ED symptom-specific SOC measure to determine prevalence of stages across symptoms and identify if SOC predict treatment outcome.

METHODS

Participants [N = 182; age 13-58 years; 92% Caucasian; 96% female; average BMI 21.7 (SD = 5.9); 50% ED not otherwise specified (EDNOS), 30.8% bulimia nervosa (BN), 19.2% anorexia nervosa (AN)] seeking ED treatment at a diverse-milieu multi-disciplinary facility in the United States completed stages of change, behavioral (ED symptom use and frequency) and psychological (ED concerns, anxiety, depression) measures at intake assessment and at 3, 6 and 12 months thereafter. Descriptive summaries were generated using ANOVA or Kruskal-Wallis (continuous) and χ (2) (categorical) tests. Repeated measures linear regression models with autoregressive correlation structure predicted treatment outcome.

RESULTS

At intake assessment, 53.3% of AN, 34.0% of BN and 18.1% of EDNOS patients were in Preparation/Action. Readiness to change specific symptoms was highest for binge-eating (57.8%) and vomiting (56.5%). Frequency of fasting and restricting behaviors, and scores on all eating disorder and psychological measures improved over time regardless of SOC at intake assessment. Symptom-specific SOC did not predict reductions in ED symptom frequency. Overall SOC predicted neither improvement in Eating Disorder Examination Questionnaire (EDE-Q) scores nor reduction in depression or trait anxiety; however, higher overall SOC predicted lower state anxiety across follow-up.

CONCLUSIONS

Readiness to change ED behaviors varies considerably. Most patients reduced eating disorder behaviors and increased psychological functioning regardless of stages of change, indicating the benefits of treatment and effectiveness of treatment-as-usual for overall psychiatric improvement.

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.

The therapeutic process in psychological treatments for eating disorders: a systematic review

OBJECTIVE

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled.

METHOD

Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified.

RESULTS

Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated.

DISCUSSION

As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Internet-based motivation program for women with eating disorders: eating disorder pathology and depressive mood predict dropout

BACKGROUND

One of the main problems of Internet-delivered interventions for a range of disorders is the high dropout rate, yet little is known about the factors associated with this. We recently developed and tested a Web-based 6-session program to enhance motivation to change for women with anorexia nervosa, bulimia nervosa, or related subthreshold eating pathology.

OBJECTIVE

The aim of the present study was to identify predictors of dropout from this Web program.

METHODS

A total of 179 women took part in the study. We used survival analyses (Cox regression) to investigate the predictive effect of eating disorder pathology (assessed by the Eating Disorders Examination-Questionnaire; EDE-Q), depressive mood (Hopkins Symptom Checklist), motivation to change (University of Rhode Island Change Assessment Scale; URICA), and participants' age at dropout. To identify predictors, we used the least absolute shrinkage and selection operator (LASSO) method.

RESULTS

The dropout rate was 50.8% (91/179) and was equally distributed across the 6 treatment sessions. The LASSO analysis revealed that higher scores on the Shape Concerns subscale of the EDE-Q, a higher frequency of binge eating episodes and vomiting, as well as higher depression scores significantly increased the probability of dropout. However, we did not find any effect of the URICA or age on dropout.

CONCLUSIONS

Women with more severe eating disorder pathology and depressive mood had a higher likelihood of dropping out from a Web-based motivational enhancement program. Interventions such as ours need to address the specific needs of women with more severe eating disorder pathology and depressive mood and offer them additional support to prevent them from prematurely discontinuing treatment.

Assessing motivation to change in eating disorders: a systematic review

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

The impact of age and BMI on Eating Disorder Examination Questionnaire (EDE-Q) scores in a community sample

OBJECTIVES

The primary objectives for this study were to establish normative data for the EDE-Q in a nationally representative sample of women and to investigate the unique and relative effects of age and BMI.

METHODS

A community sample of 3000 women aged 16-50 was randomly selected from the Norwegian National Population Register.

RESULTS

Mean global EDE-Q was 1.27 (SD=1.19). EDE-Q scores decreased significantly with age yet increased with BMI. In the regression model, BMI and age accounted for 19% versus 2%, respectively, of the global EDE-Q. Extreme shape and weight concerns appeared to drive the higher global EDE-Q scores for individuals with overweight or obesity, with 30-40% scoring above the recommended clinical cut-off for Shape and Weight Concern.

CONCLUSIONS

Higher EDE-Q scores, largely driven by elevated shape and weight concerns, appear normative among individuals with obesity in a nationally representative population. BMI should be routinely considered when establishing criteria for defining recovery and determining clinical significance using the EDE-Q.