Gregertsen, Eva Cecilie; (2021) Ambivalence in Anorexia: The Role of Perceived Benefits and Burdens of Anorexia Nervosa. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: This project focusses on the egosyntonic nature of anorexia nervosa (AN), referring to the valued nature of the illness by those impacted by it. The egosyntonicity of the illness is highlighted as a key feature of the disorder, and theorised to be a maintaining factor in cognitive models, in that valuing the illness may reduce motivation for recovery (Schmidt & Treasure, 2006; Wolf & Serpell, 1998). As such, gaining insight into the egosyntonic nature of AN may help inform future treatments. Aims and Methods: This thesis aimed to improve the understanding of the egosyntonic nature of AN, particularly to investigate its value in predicting outcomes of AN treatment, as well as to validate the Pros and Cons of Anorexia Nervosa Scale (P-CAN), a psychometric measure which aims to capture perceived benefits and burdens of the illness. The first objective was to systematically review the evidence base for pre-treatment patient predictors of drop-out and outcome in AN treatment. Then, a narrative review was undertaken to better understand egosyntonicity. Following this, a cross-sectional study was conducted to validate the P-CAN in a sample of adolescent and adult female outpatients, inpatients or daypatients, undergoing either treatment or monitoring at an eating disorder clinic. It was hypothesised that greater endorsement of benefits of AN would be linked with greater illness severity and lower motivation, whereas greater endorsement of the burdens of AN was hypothesised to be linked with greater motivation. The study also aimed to investigate whether there was a link between endorsement of pros and cons of AN and confidence in one’s ability to recover, and whether binge-purge and restrictive subtypes differed on endorsement of pros and cons. Finally, it was hypothesised that motivation would mediate the relationship between endorsement of pros and eating disorder pathology. Lastly, a longitudinal study examined the predictive value of the P-CAN, as well as explored its links with autism traits, in a sample of adolescent and adult female outpatients undergoing treatment for AN. It was predicted that greater motivation, lower eating disorder pathology, lower endorsement of pros, greater endorsement of the “hatred” con, and lower autism traits would predict better outcome. Results: The systematic review and meta-analysis demonstrated that admission BMI, binge-purge subtype, lower motivation and greater eating disorder pathology predicted drop-out and/or outcome. The narrative review established that individuals with AN endorse a range of benefits linked with their illness, whilst also recognising cons, thus likely leading to ambivalence towards recovery. The cross-sectional study established the concurrent validity of the P-CAN, whilst also demonstrating that the link between endorsement of perceived benefits and eating disorder pathology was partially mediated by motivation. Further, the relationship between both decisional balance and self-efficacy and eating disorder pathology was fully mediated by motivation. In the longitudinal study, endorsement of the “hatred” con, motivation and eating disorder pathology predicted outcome. Lastly, a positive relationship was found between autism traits and perceived benefits of AN. Conclusions: These findings suggest that egosyntonicity may play a role in impacting eating disorder pathology through its effect on motivation. Enhancing endorsement of the “hatred” con and motivation could be useful in therapy. A key limitation was the small sample size in the longitudinal study. Future research should examine the predictive value of the P-CAN sub-scales in a sufficiently large sample.

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