What Prompts Change in Younger Anorexia Nervosa Patients?

Measuring reasons for change among teens was not easy.

Two major roadblocks to change among patients with anorexia nervosa (AN) include ambivalence toward changing eating behaviors, and denial of the illness. Attempts to measure motivation to change among patients with eating disorders have led to development of instruments such as the Readiness and Motivation Interview (Int J Eat Disord. 2002; 46:755) and the Attitudes Towards Change in Eating Disorders Scale (ACTA) (Int J Eat Disord. 2000; 28:387; Acta Esp Psiquiatr. 2003; 31:111). A 20-item questionnaire, the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), examines three key factors in motivation, weight gain, eating, shape and weight concerns, and ‘ego-alien aspects.’

Dr. Dagmar Paul and colleagues at the University Hospital of Psychiatry, Zurich, Switzerland, evaluated the German translation of the ANOSCQ among a Swiss-German sample of 92 teens with AN diagnosed by the International Classification of Diseases, Tenth Revision (ICD-10) criteria who were referred to the authors’ specialist eating disorders clinic. The researchers hypothesized that low coping capacity as well as low self-esteem could be linked to lower motivation to change patterns of disordered eating. The authors also explored whether motivation to change in AN patients is due to readiness to change, or if readiness to make changes should be regarded as only one of many other factors.

The mean body mass index (BMI, kg/m2) of the patient sample was 16.4 kg/m2, below the third percentile for age standards. The mean age of the 87 females and 9 males was 15.6 years; 84 had restricting type AN, while 8 had binge-purge type AN. All participants also were evaluated with the Eating Disorders Inventory (EDI-2), the Eating Attitudes Test (EAT), the Body Image Questionnaire (BIQ), the Self-related Cognitions Questionnaire, which measures self-esteem and self-awareness, and the Coping Across Situations Questionnaire (CASQ), which addresses coping in 4 problem areas: problems with school, parents, peers, and the opposite sex. Treatment outcome was defined as treatment satisfaction by the treating clinician, drop-out from treatment, and remission of AN (no longer fulfilling criteria for AN).

Changes at follow-up

At follow-up 9 months later, 66% of patients no longer met the criteria for AN, and of the remaining 30 patients, 20 had restrictive-type AN, 5 had binge-purge type AN, and 5 were diagnosed with atypical AN.

A negative correlation between ANOSCQ scores and BMI emerged: The authors’ findings indicated that BMI was inversely correlated to motivation to change, just as reported in earlier studies. Dr. Paul and his coauthors surmised that this might be due to the fact that young patients who are in the first phase of weight loss have not yet come face-to-face with the disadvantages of their illness, and thus are determined to lose even more weight. Their level of motivation to change is thus low. The study subjects had had AN for about 1 year; only 3.3% were in the action state, and none in the maintenance state. This finding contrasted with earlier studies, in which 20.5% of patients were in action or maintenance states.

The authors concluded that while the ANSOCQ questionnaire was valid and consistent, it might be less useful for young patients in the early stages of AN. The authors pointed out that younger patients at an early stage of an eating disorder are less aware of the negative consequences of the illness, and therefore “experience most of the symptoms as rather ego-syntonic or may ignore ego-dystonic aspects.” There is a need to assess motivation more systematically to enhance therapeutic strategies in younger patients.

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