توسعه یک مرحله از اندازه گیری تغییرات برای ارزیابی بهبودی بی اشتهایی عصبی

The purpose of this study was to advance understanding of the self-change process in recovery from anorexia nervosa (AN). This included the development of a measure for assessing readiness to change behaviors and/or cognitions associated with recovery from AN across five stages of change, based on the transtheoretical model of behavior change. Two-hundred and seventy-eight anorexics, predominantly female, completed questionnaires that measured all constructs of the TTM, as well as the EAT-26, demographic items, and other self-reported recovery measures. Based on a quantitative and qualitative comparison of five staging definitions in this relatively large sample of anorexics, it was concluded that the most meaningful staging measure was one that measured progress through the stages by readiness to stop restricting/bingeing/purging behaviors. The development of an algorithm to measure stages of change for recovery from AN has the potential to accelerate clinical research and to augment available treatments in this area.

Extensive research in this field of eating disorders has focused on a variety of psychological, biological, and sociocultural treatment models Compas et al., 1998, Greben & Kaplan, 1995 and Herzog et al., 1992, no one of which has proven wholly successful in the prevention or treatment of anorexia nervosa (AN). Several researchers have stated the need for treatment of AN that recognizes multiple factors of causation and utilizes a range of treatment modalities Bemis, 1978, Fisher, 1996 and Greben & Kaplan, 1995, yet no integrative approaches exist that capitalize on the modest success rates of different specific interventions. A substantial body of research has already developed in the treatment of various problem behaviors, suggesting that treatment outcome is much improved when treatment is tailored to the individual's stage of readiness to change CDC, 1999, Marcus et al., 1998, Prochaska et al., 1993, Prochaska et al., 2001, Rakowski et al., 1998, Redding et al., 1999, Rossi et al., 1997 and Velicer et al., 1999. It has been previously suggested that the therapeutic process for a patient with AN may occur in stages (Fisher, 1996), with different interventions most effectively applied at different stages (Greben & Kaplan, 1995). Since tailoring treatments to an individual's level of readiness or stage of change improves treatment outcome (progress to action) across many other health behavior changes, this may be a useful strategy to test in the treatment of eating disorders. The transtheoretical model of behavior change (TTM; for review, see Prochaska & Velicer, 1997) explains intentional behavior change along a temporal dimension that utilizes both cognitive and performance-based components. Based on more than two decades of research, the TTM has found that individuals move through a series of stages—precontemplation (PC), contemplation (C), preparation (PR), action (A), and maintenance (M)—in the adoption of healthy behaviors or cessation of unhealthy ones (Prochaska & Velicer, 1997). The TTM uses the stages of change to integrate cognitive and behavioral processes and principles of change, including 10 processes of change (i.e., how one changes; Prochaska, 1979 and Prochaska et al., 1988), pros and cons (i.e., the benefits and costs of changing; Janis & Mann, 1977, Prochaska et al., 1994 and Prochaska et al., 1994), and self-efficacy (i.e., confidence in one's ability to change; Bandura, 1977 and DiClemente et al., 1985)—all of which have demonstrated reliability and consistency in describing and predicting movement through the stages (Prochaska & Velicer, 1997). Initial applications of the TTM to eating disorders have also demonstrated encouraging results for understanding change in illnesses such as AN (Ward, Troop, Todd, & Treasure, 1996) and bulimia nervosa Levy, 1999 and Stanton et al., 1986. The purpose of this study was to advance understanding of the self-change process in recovery from AN through the development of a stage of change measure for assessing readiness to change behaviors and/or cognitions associated with recovery from AN. 1.1. The stages of change The TTM or stages of change model has its origins in psychotherapy (Prochaska, 1979) and was elaborated in smoking cessation research DiClemente & Prochaska, 1982 and Prochaska & DiClemente, 1983. The stage model is best conceived as both linear and cyclical in nature (Prochaska, DiClemente, & Norcross, 1992). Individuals are described as progressing in a spiral fashion from PC to C, C to PR, and so on. Although rare, linear progression is possible; however, most individuals attempting a health-behavior change will relapse and recycle through previous stages, gradually learning how to successfully progress to maintenance (Prochaska et al., 1992). PC is the stage in which an individual has no intent to change behavior in the near future, usually measured as the next 6 months. Precontemplators are often characterized as resistant or unmotivated and tend to avoid information, discussion, or thought with regard to the targeted health behavior (Prochaska et al., 1992). Individuals in the C stage openly state their intent to change within the next 6 months. They are more aware of the benefits of changing, but remain keenly aware of the costs (Prochaska, Redding, & Evers, 1997). Contemplators are often seen as ambivalent to change or as procrastinators (Prochaska & DiClemente, 1984). PR is the stage in which individuals intend to take steps to change, usually within the next month (DiClemente et al., 1991). PR is viewed as a transition rather than stable stage, with individuals intending progress to A in the next 30 days (Grimley, Prochaska, Velicer, Blais, & DiClemente, 1994). The A stage is one in which an individual has made overt, perceptible lifestyle modifications for fewer than 6 months (Prochaska et al., 1997), while those in M are working to prevent relapse and consolidate gains secured during A (Prochaska et al., 1992). Maintainers are distinguishable from those in the A stage in that they report the highest levels of self-efficacy and are less frequently tempted to relapse (Prochaska & DiClemente, 1984). Current research utilizing the TTM assesses each participant's readiness to change a specific behavior with the use of a staging measure or algorithm. The purpose of the algorithm is to unambiguously classify an individual into one of the stages of change. Previous research applying the TTM to AN Rieger et al., 1998 and Ward et al., 1996 utilized adaptations of the University of Rhode Island Change Assessment (URICA) McConnaughy et al., 1989 and McConnaughy et al., 1983 as a continuous change assessment scale. The primary purpose of the URICA is to identify specific stage profiles characteristic of transitions between PC, C, A, and M, or to identify subtypes of individuals within a stage (Rossi, Rossi, Velicer, & Prochaska, 1995). However, this measure is lengthy (32 items), and is general in format—subjects respond to each item with respect to a “problem for treatment,” not specific behaviors associated with AN per se—and its use is often discouraged (Rossi et al., 1995). Studies using staging measures created specifically for AN have thus far provided inconsistent behavioral definitions upon which participants must base their responses (Blake, Turnbull, & Treasure, 1997). One study in the area of exercise addressed both of these issues, concluding that a good staging algorithm should include: (1) a complete definition of the criterion behavior and (2) a true/false or five-choice response format (Reed, Velicer, Prochaska, Rossi, & Marcus, 1997). The main difficulty with developing a staging algorithm in this area is that to-date there is no agreed upon definition for recovery in AN (Herzog et al., 1993), nor is there one that has been used consistently in the literature. Restoration and maintenance of weight are frequently utilized indicators of improvement; however, some argue that weight gain is not as critical as other factors, such as improvement in intrapsychic and interpersonal conflicts, menstrual regularity, adequate sexual functioning, or normal eating (Garfinkel, Garner, & Molodofsky, 1977). Such issues also make study comparisons difficult. The lack of consensus about what constitutes an appropriate outcome by which to assess recovery from AN has significant implications for effective utilization of the TTM. Quantitative assessment of the remaining TTM constructs is partially based on their comparative levels of utilization at each stage. In order to accurately determine an individual's stage of recovery from AN, it is important to create a valid instrument that can assess a person's readiness to change one or more specific behaviors that exemplify recovery from AN. Studies requiring a symptom-free state for recovery may present an overly pessimistic view of recovery from AN by not permitting the observation of less dramatic improvements in the course of the disorder Herzog et al., 1993 and Schacter, 1982. Prochaska et al. (1992) found that the vast majority of addicted people are not in the A stage when they enter treatment, which may account for the high rates of recidivism in these areas. Furthermore, the amount of progress individuals make following intervention tends to be a direct function of their pretreatment stage of readiness for change (Prochaska et al., 1992). This finding mirrors that found in patients with AN who often deny having a problem (Bemis Vitousek, Daly, & Heiser, 1991) and are notoriously ambivalent about treatment (Ward et al., 1996). This study compared five different definitional approaches to stages of change for recovery from AN and determined an optimal staging measure, based on theoretical and empirical criteria. This is a necessary first step in the application of the TTM to recovery from AN.