Alexis Ruffault
email: alexis.ruffault@parisdescartes.fr

Marjorie Bernier

Nicolas Juge

Jean F Fournier

Mindfulness may moderate the relationship between intrinsic motivation and physical activity: A cross-sectional study

Keywords: Health behavior, Physical activity, Motivation, Mindfulness, Students

This study aims to characterize the relationships between intrinsic motivation towards physical activity, mindfulness, and physical activity level. We measured self-reported mindfulness, motivational regulation towards exercise, and physical activity level in 280 French students. Analyses conducted on 244 participants revealed that self-reported mindfulness moderates the relationship between intrinsic motivation towards exercise and physical activity levels. These findings may have implications for interventionists seeking to promote increased physical activity with mindfulness-based techniques. In fact, it seems that increasing mindfulness skills of individuals could improve their intrinsic motivation to exercise and thus, physical activity.

Introduction

The World Health Organization (2010) considers the lack of physical activity (PA) as the fourth leading risk factor of mortality in the world, and reported that sedentarity affects 60 per cent of the world population. Several researchers have come to the conclusion that a sedentary lifestyle increases health risks for conditions such as cancer [START_REF] Ramírez | Correlates and geographic patterns of knowledge that physical activity decreases cancer risk[END_REF], obesity, diabetes [START_REF] Keadle | The influence of free-living activity and inactivity on health outcomes and responsiveness to exercise training[END_REF], and heart disease [START_REF] Lloyd-Jones | Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association's strategic impact goal through 2020 and beyond[END_REF]. Thus, [START_REF] Orrow | Effectiveness of physical activity promotion based in primary care: Systematic review and meta-analysis of randomised controlled trials[END_REF] recommended the promotion of PA to reduce these health risks. To this end, [START_REF] Biddle | Psychology of physical activity: Determinants, well-being, and interventions[END_REF] argued that the promotion of PA should include cognitive-behavioral principles of behavior change. Two principal cognitive-behavioral parameters of PA promotion examined in the recent literature are intrinsic motivation [START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF] and dispositional mindfulness (DM) [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF].

Exploring the associations between mindfulness and health behaviors, [START_REF] Roberts | Mindfulness and health behaviors: Is paying attention good for you[END_REF], Gilbert andWaltz (2010), andMurphy, Mermelstein, Edwards, andGidycz (2012) have shown that students who report higher scores of self-reported mindfulness are more likely to practice healthy habits such as getting enough sleep, eating well, and exercising compared to less mindful individuals. With obese individuals, studies have shown that an Acceptance and Commitment Therapy (ACT) program based on workshops helping participants to change their approach to their thoughts and emotions about obesity, and to accept them, resulted in lower psychological distress, greater weight loss and an increase in PA [START_REF] Lillis | Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model[END_REF][START_REF] Tapper | Exploratory randomised controlled trial of a mindfulness-based weight loss intervention for women[END_REF]. Thus, by becoming aware of their thoughts, emotions, and sensations due to behavior change, and by accepting them, individuals showed heightened awareness of good health behavior [START_REF] Dutton | The role of mindfulness in health behavior change[END_REF]. On the other hand, Mothes, Klaperski, Seelig, Schmidt, and Fuchs (2014) have shown in a randomized controlled trial that an aerobic exercise intervention increased self-reported mindfulness in men.

In the promotion of PA most especially, the literature showed the beneficial effects of mindful exercises (e.g., Yoga and Feldenkrais) [START_REF] Netz | Mood alterations in mindful vers aerobic exercise modes[END_REF][START_REF] Salmon | Yoga and mindfulness: Clinical aspects of an ancient mind/body practice[END_REF] and acceptance-and mindfulness-based methods to increase mindfulness and PA levels [START_REF] Butryn | A pilot study of acceptance and commitment therapy for promotion of physical activity[END_REF]Chatzisarantis & Hagger, 2007;[START_REF] Ulmer | Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers[END_REF]. While most of these studies could not draw conclusions with regards to the maintainance of the recommended PA level, [START_REF] Ulmer | Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers[END_REF] showed that highest scores of mindfulness and acceptance are linked to a long term PA increase and maintenance, and conclude that "mindfulness and acceptance facilitate the relapse prevention in those who have succesfully initiated an exercise regimen" (p.808).

In the behavior change motivation literature, great attention has been paid to Self-Determination Theory (SDT; [START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF]. This meta-theory postulates that human behaviors are autonomous, or self-determined. Thus, to satisfy their three universal basic psychological needs (i.e., need for autonomy, for competence, and for relatedness), individuals have to change their behaviors in an autonomous way. On the autonomy continuum, there are three kinds of motivation: (a) intrinsic motivation, when one changes for enjoyment or pleasure, (b) extrinsic motivation, when one expects something in exchange for his/her behavior, which is composed of four kinds of regulation (i.e., integrated, identified, introjected, and external), and (c) amotivation, which is the absence of intentionality (Hagger & Chatzisarantis, 2007). According to [START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF], when acting in an autonomous way (i.e., with intrinsic motivation or with identified regulation), one satisfies his/her three basic psychological needs.

Context, social factors and environmental factors modulate self-determined motivation. Thus, one could change his/her PA habits if this new behavior procures pleasure, satisfaction, and if he/she values and places importance on this new behavior [START_REF] Ryan | Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being[END_REF]. This means he/she knows that a recommended PA level will be healthy and without constraints. Several studies have investigated the effects of SDT-based interventions on the increase of PA level (Hagger & Chatzisarantis, 2007). The main findings of these studies were that PA levels and intrinsic motivation increased [START_REF] Fortier | A selfdetermination process model of physical activity adoption in the context of a randomized controlled trial[END_REF][START_REF] Jolly | Evaluation of a standard provision versus an autonomy promotive exercise referral programme: Rationale and study design[END_REF], and participants of the SDT-group better satisfied they basic psychological needs [START_REF] Edmunds | Testing a self-determination theory-based teaching style intervention in the exercise domain[END_REF].

For the promotion of PA, studies have investigated the effects of a mindfulness-based intervention or an SDT-based intervention, and measured mindfulness or SDT outcomes respectively. In the original texts of SDT [START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF] and DM [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF], some links between mindfulness and intrinsic motivation are central to both of these theories. [START_REF] Levesque | Mindfulness as a moderator of the effect of implicit motivational self-concept on day-to-day behavioral motivation[END_REF] highlighted the agreement between both theories by arguing that: (a) in SDT, awareness facilitates self-regulated functioning, and (b) selfreported mindfulness predicts higher levels of self-regulated behavior. This highlights the suggested links between mindfulness and motivation, although these links have never been empirically tested. Thus, we expect some common mecanisms in SDT and mindfulness related to self-regulation. [START_REF] Rigby | Mindfulness, interest-taking, and selfregulation[END_REF] suggested theoretical links between mindfulness and SDT. For each motivational regulation, the authors explained how mindfulness and motivation are linked through the self-determination continuum. Moreover, [START_REF] Butryn | A pilot study of acceptance and commitment therapy for promotion of physical activity[END_REF] argued that the relationship between DM and PA could be related to motivation to engage in such behavior. [START_REF] Tsafou | Mindfulness and satisfaction in physical activity: A cross-sectional study in the Dutch population[END_REF] showed that satisfaction (i.e., an intrinsic motive) is a predictor of the effects of self-reported mindfulness on PA behavior.

So it is known that both motivational regulation and mindfulness skills favor higher PA levels, separately. Thus, mindfulness could either moderate or mediate the relationship between intrinsic motivation and PA level. Likewise, intrinsic motivation could either moderate or mediate the relationship between self-reported mindfulness and PA level, or selfreported mindfulness and intrinsic motivation could both be linked to PA level with neither moderation nor mediation types of relationships. Our study aims to characterize the relationships between intrinsic motivation relative to PA, mindfulness, and PA level. The literature did not make it possible to hypothesize any specific model, which is why we considered five different models (see Figure 1) to determine the precise relationship among self-reported mindfulness, motivational regulation and PA level.

Fig. 1

Candidate models used to characterize the relationships between motivational regulation, self-reported mindfulness, and physical activity (PA) level. Note: Model (a) represents the possible moderating effect of self-reported mindfulness in the relationship between motivational regulation and PA level. Model (b) represents the possible moderating effect of motivational regulation in the relationship between self-reported mindfulness and PA level. In model (c) self-reported mindfulness and motivational regulation are two possible independent predictive variables of PA level. Model (d) represents the possible mediating effect (full or partial) of motivational regulation between self-reported mindfulness and PA level. Model (e) represents the possible mediating effect (full or partial) of self-reported mindfulness between motivational regulation and PA level.

Method Participants

Two hundred and eighty French students (41.79% males and 58.21% females) aged between 18 and 37 years old (M = 21; SD = 2.73) with a mean body mass index (BMI) of 21.86 kg/m 2 (SD = 2.81), were asked to fill out self-report questionnaires measuring selfreported mindfulness, motivational regulation towards exercise, and PA level. Recruitment was conducted in three different-sized university towns: Paris, Montpellier, and Caen.

Procedure

Participants had to indicate which major they were pursuing, in which year, and whether they practiced sport regularly or not. To control for the bias of knowing the questionnaires or being extremely physically active, students in psychology and PA sciences were excluded from this study. All the participants gave their signed agreement to participate in the study. Participants were given a random code to withdraw from the study at any time after they filled out the questionnaires, upon their request. Institutional ethical approval was sought and given. Participants' characteristics are displayed in Table 1.

Measures

To assess DM as self-reported mindfulness, the Mindful Attention Awareness Scale (MAAS) [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF] was used in its French validated version. [START_REF] Csillik | The mindful attention awareness scale (MAAS) French validation: Convergent and divergent validity[END_REF] adapted the French version of the MAAS, which is a single factor 15-items self-report instrument measuring the frequency of mindful states in day-to-day life. Each item is rated on a 6-point Likert scale ranging from 1 ("almost always") to 6 ("almost never"), and the score is the mean of all items, ranging from 1 (i.e., low frequency of mindful states) to 6 (i.e., high frequency of mindful states). In our sample, the French version of MAAS showed good internal consistency (α = 0.78).

To assess the motivational regulation towards exercise, the Behavioral Regulation towards Exercise Questionnaire (BREQ-II; [START_REF] Markland | A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation[END_REF]) (French version) was used. The BREQ-II is a self-report 19-item questionnaire measuring motivational regulation towards exercise. Each item is rated on a 5-point Likert scale ranging from 0 ("not true for me") to 4 ("very true for me"). This questionnaire is based on five subscales, which represent the motivational regulation of SDT: amotivation (A), external regulation (ER), introjected regulation (ITR), identified regulation (IDR), and intrinsic regulation (IR). In our sample, the five subscales of BREQ-II showed good internal consistency (α A = 0.79; α ER = 0.77; α ITR = 0.72; α IDR = 0.74; α IR = 0.91).

PA level was measured with the International Physical Activity Questionnaire (IPAQ; [START_REF] Craig | International physical activity questionnaire: 12-country reliability and validity[END_REF]. The French version of the IPAQ is a widely used self-report 7-items measure of PA level [START_REF] Keadle | The influence of free-living activity and inactivity on health outcomes and responsiveness to exercise training[END_REF][START_REF] Ulmer | Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers[END_REF]. It provides information on the participants' time spent walking and doing vigorous and moderate physical activities during the past seven days (if not representative of the perceived average PA, participants were asked to think about the most representative past 7-day time frame). The unit of this measure is an overall energy expenditure expressed in Metabolic Equivalent Total (MET). In short, the IPAQ calculations are: Walking MET-min/week = 3.3 × walking minutes × walking days; Moderate MET-min/week = 4.0 × moderate-intensity activity minutes × moderate days; Vigorous MET-min/week = 8.0 × vigorous-intensity activity minutes × vigorous-intensity days. Total PA MET-min/week = sum of Walking + Moderate + Vigorous MET minutes. The total MET-min per week was used as a continuous indicator for PA.

Data Analyses

The data were analysed on R (R Core Team, 2013) after exclusion of the participants who did not reply to the questionnaires entirely (n = 33) and participants who did not respect the IPAQ guidelines (n = 3) [START_REF] Craig | International physical activity questionnaire: 12-country reliability and validity[END_REF]. Thus, correlational analysis and hierarchical regression analyses were run on 244 participants. The dependant variable in the models is the IPAQ scores, and we tested the predictive properties of intrinsic motivation (according to BREQ-II subscale) in step 1, self-reported mindfulness in step 2 (simple linear regression model), and the moderation or the mediation between intrinsic motivation and self-reported mindfulness in step 3. Mean scores and correlational statistics are displayed in Table 2. The non-parametric Kendall correlation test was used because it does not rely on any asumptions about the underlying distributions (BREQ sub-scales do not have a normal distribution).

We defined the PA level variable as the log 2 of the IPAQ score. This choice was motivated by the nature of the IPAQ scoring as METs roughly double when the perceived PA intensity increases by 1 (from low, to moderate, to vigorous). Moreover, the distribution of the PA levels has the property of being normally distributed, in contrast to the raw IPAQ scores (e.g., Rzewnicki, Auweele, & De Bourdeaudhuij, 2003).

Results

Preliminary analyses were conducted to ensure no violation of the assumptions of normality, linearity, and homoscedasticity. Models (b), (d) and (e) were discarded because of the absence of significant correlation between self-reported mindfulness and PA level (see Table 2), which indicated that self-reported mindfulness could not be a predictor of PA level [START_REF] Baron | The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations[END_REF]. Only two models remained: the moderation model (a) and the simple linear model (c), which represents the main effect of the moderation model. Model (c) was tested at step 2. Plotting the Pearson residuals enabled us to check the normality of their distribution. The basic assumptions for a multiple regression analysis were satisfied.

As expected, self-reported mindfulness showed positive correlations to the automous motivational regulations (i.e., intrinsic and identified), and negative to the controlled motivational regulations (i.e., external and amotivation) (see Table 2). PA level showed positive significant correlations to the autonomous motivational regulations; such as intrinsic (τ = .21; p < .001), identified (τ = .20; p < .001). In contrast, PA level was negatively correlated with external regulation (τ = -.06; ns) and amotivation (τ = -.22; p < .001). In our sample, BMI showed no significant correlation to any other variable. The moderation model (a) is displayed in step 3 in Table 3. At step 2, self-reported mindfulness was not a significant predictor of PA level. The moderation model explained the greatest variance in PA level (R 2 = 11.97%; F(3, 240) = 10.88; p < .001). This model followed [START_REF] Baron | The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations[END_REF] criteria for a moderation effect, with self-reported mindfulness as moderator of the predicting effect of intrinsic motivation on PA level. At step 3, intrinsic motivation was a significant predictor of PA level (β = .29; t = 4.54; p < .001), while self-reported mindfulness did not significantly predict PA level (β = .02; t = .39; ns), and the interaction between intrinsic motivation and self-reported mindfulness was a significant predictor of PA level (β = -.14; t = -2.02; p < .05). Moreover, ANOVA between models at each step showed that the model at step 3 had a significant change in R 2 from the linear model at step 2 (R 2 change = .02; F(1, 240) = 4.11; p < .05). Figure 2 illustrates the moderating effect of self-reported mindfulness between intrinsic motivation and PA level. Participants were split into three distinct groups of self-reported mindfulness levels:

a. participants with self-reported mindfulness scores below the mean minus 1 standard deviation (crosses); b. participants with self-reported mindfulness scores distant from the mean by no more than 1 standard deviation (triangles); c. participants with self-reported mindfulness scores greater than the mean plus 1 standard deviation (squares). In this graphic, we see that when self-reported mindfulness is low, intrinsic motivation is not related to PA level. But, as self-reported mindfulness increases, the link between instrinsic motivation and PA levels becomes positively correlated and much stronger. Fig. 2 Moderating effect of self-reported mindfulness on the relationship between intrinsic motivation and physical activity (PA) level Note: On the y-axis, PA level is the log 2 of the IPAQ score. A high self-reported mindfulness score (greater than +1 SD, in squares) leads to a stronger relationship between intrinsic motivation and PA level compared to a medium self-reported mindfulness score (in triangles) or a low self-reported mindfulness score (lower than -1 SD, in crosses).

Discussion

The aim of this study was to characterize the relationships among intrinsic motivation towards PA, mindfulness, and PA level. Theoretical links between mindfulness and motivation have been described in original research in these fields [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF][START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF], but no empirical evidence has been found. Most studies investigated the relationships between motivation and PA level (Hagger & Chatzisarantis, 2007) or between mindfulness and PA level [START_REF] Butryn | A pilot study of acceptance and commitment therapy for promotion of physical activity[END_REF][START_REF] Ulmer | Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers[END_REF], resulting in an association of higher PA levels in individuals with higher intrinsic motivation on the one hand, and higher mindfulness skills on the other. To our knowledge, this study is the first to try to empirically test the links suggested in previous works [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF][START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF][START_REF] Levesque | Mindfulness as a moderator of the effect of implicit motivational self-concept on day-to-day behavioral motivation[END_REF][START_REF] Rigby | Mindfulness, interest-taking, and selfregulation[END_REF] among the three variables (i.e., DM, intrinsic motivation, PA level). The correlation data we obtained from an ad-hoc sample of 244 students across three French cities enabled us to propose a model explaining the relationship among intrinsic motivation towards PA, self-reported mindfulness, and PA level.

Motivation regulation subscales showed a high proportion of low levels of amotivation and external regulation, stable distribution of introjected regulation, and high proportions of high levels of identified and intrinsic regulations. All these tendencies are in accordance with SDT. In fact, when more intrinsically motivated, one is more autonomous [START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF]. These tendencies may be specific to the youthful characteristic of the population that we studied, and may differ from the general population. [START_REF] Hagger | Intrinsic motivation and self-determination in exercise and sport[END_REF] argued that motives such as appearance and weight are autonomous. We know that adolescents and young adults are more likely to be interested in their body image. This could explain the dispersion of the BREQ-II scores.

Literature on behavior change has described the role of DM in healthy behaviors. Studies have shown that mindful individuals are more likely to engage in and maintain healthy behaviors [START_REF] Roberts | Mindfulness and health behaviors: Is paying attention good for you[END_REF][START_REF] Ulmer | Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers[END_REF]. Moreover, authors argued that self-regulation of thoughts and emotions linked to behavior change, convinced mindful individuals to change their behavior more easily than individuals with lower mindfulness skills [START_REF] Levesque | Mindfulness as a moderator of the effect of implicit motivational self-concept on day-to-day behavioral motivation[END_REF]. In our sample, high levels of self-reported mindfulness were associated with higher levels of intrinsic motivation, and higher levels of PA, which confirms previous work [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF][START_REF] Deci | Intrinsic motivation and self-determination in human behavior[END_REF]. These results suggest that DM leads to more intrinsic, and healthier behavior choices. This tendency was observed in the correlation matrix (Table 2), in which we can see that the more intrinsically motivated towards exercise participants were the more mindful.

Considering the moderation model, why would DM impact motivational regulation of PA practice? First, it is known that lacking in specific awareness leads to habitual or automatic behaviors. [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF] highlighted the reverse relationship between DM and impulsivity (i.e., automatic behavior). Studies have shown that self-reported mindfulness is linked to healthier behaviors such as exercise. This relationship could be due to better life decisions made while one is mindful [START_REF] Williams | Mindfulness: Diverse perspectives on its meanings, origins and applications[END_REF]. Second, according to [START_REF] Brown | The benefits of being present: Mindfulness and its role in psychological well-being[END_REF], bringing an open awareness to the present experience is linked to "self-regulation". According to the authors, self-regulation leads to behavior choices that are in accordance with one's needs (i.e., SDT's universal basic psychological needs, such as autonomy). Furthermore, self-regulation and awareness appear to be central components in SDT and DM conceptualisations. Our model showed that mindfulness (i.e., specific awareness of the present experience in a non-judgemental way) and intrinsic motivation (i.e., behaviors driven more autonomously) could be effective predictors of PA, with a moderation effect of mindfulness in the relationship between intrinsically motivated intentions and actual behavior (i.e., PA). Further research investigating this relationship applied to another health-related behavior, such as diet, could be of interest. Third, ACT authors [START_REF] Hayes | Measuring experiential avoidance: A preliminary test of a working model[END_REF] argued that awareness and acceptance of thoughts and emotions protects from experiental and cognitive avoidance, ruminations, and other cognitive distortions. In their book, [START_REF] Biddle | Psychology of physical activity: Determinants, well-being, and interventions[END_REF] highlighted that there might be a gap between self-perceptions of competence to change and actual competence to change. This gap could induce cognitive distortions, and being aware of it could protect individuals from these distortions. Further studies could assess perceived stress towards behavior change, and investigate the links between mindfulness skills and cognitive processes in the context of a behavior change.

However, the present study has limitations. The exclusively self-reported and subjective data limit the conclusions of the study to participants' self-perceptions. For example, PA level could have been measured with accelerometers providing an objective energy expenditure. Furthermore, the relationaship between motivational regulation and PA behavior could be explained with different unassessed variables such as psychopathology, time for leisure, or even environemental facilities to exercise. Another limitation is the use of a one-factor scale as a measure for mindfulness skills while a multi-scales measure could have brought more information regarding the specific facets of mindfulness implicated in the relationship between motivation and behavior. Moreover, only students with an average age of 21 years were included into this study, thus results cannot necessarily be generalized to the population at large.

In our ad-hoc sample, self-reported mindfulness had a moderating role on the relationship between intrinsic motivation towards exercise and actual PA level. The results suggest that mindful individuals are more likely to have an increased PA level while they are intrinsically motivated, and that mindless individuals have concerns in being active even if they are intrinsically motivated. It is necessary to test whether this model remains unchanged in the general population by controlling the distribution in subgroups (e.g., gender, age, occupation, income). The next stage would entail doing a true randomized experiment, testing the moderation effect of DM while controlling the mindfulness variable with a mindfulness-based intervention aiming at increasing PA level.

Table 1

 1 Ad-hoc sample characteristics

	Variables	M	SD	%	Range
	Gender (% female)			58.21
	Age (years)	21.00 2.734		[18.00; 37.00]
	BMI (kg/m 2 )	21.86 2.813		[16.71; 35.93]
	Major
	Literature			31.43
	Sciences			28.93
	Law and politics			26.43
	Medicine			13.21
	School year
	Undergraduate			76.42
	Graduate			20.70
	PhD students			2.88
	Sport practice (% "yes")			38.93
	Mean (M); standard deviation (SD); body mass index (BMI).

Table 2

 2 Descriptive and correlational statistics Hierarchical regression analyses reporting the variance in physical activity level explained by dispositional mindfulness and intrinsic motivation , the proportion of the criterion variance explained by predictors over and above response; R 2 change, the difference between R 2 in step by step regression; B, unstandardized regression coefficients; SE, standard error; β, standardized regression coefficients

				Descriptive statistics					Correlations
	Variables	Mean	SD	Possible range	Observed range	1	2	3	4	5	6	7	8
	1. Mindfulness	3.78	0.672	[1; 6]	[2.13; 5.8]		.17*	.11*	.01	-.11* -.25*	.04	.02
	2. Intrinsic regulation	3.02	1.085	[0; 4]	[0; 4]			.51*	.12* -.25* -.46* .21*	-.02
	3. Identified regulation	2.82	0.900	[0; 4]	[0; 4]				.41* -.11* -.43* .20*	.06
	4. Introjected regulation	1.51	1.102	[0; 4]	[0; 4]					.11* -.15* .16*	.08
	5. External regulation	0.40	0.633	[0; 4]	[0; 3.5]					.23*	-.06	.06
	6. Amotivation	0.44	0.758	[0; 4]	[0; 3.75]							-.22*	.02
	7. Physical activity	11.32	1.20		[5.63; 14.62]								.06
	8. BMI		21.84	2.797
	Step Independent variable		R 2	R 2 change	B	B SE	β	β SE		t	F
	1	Intrinsic motivation			.10***		.36	.07		.32***	.06		5.32	28.26
	2	Mindfulness			.10***	.00	.01	.11		<.01	.06		.12	14.08
	3	Intrinsic motivation × Mindfulness	.12***	.02	-.23	.11		-.14*	.07		-2.02	10.88
	*p < .05; **p < .01; ***p < .001.
	R 2

*p < .05; standard deviation (SD). Correlation coefficients are non-parametric Kendall's Tau. Pysical activity scores are log 2 (IPAQ). BMI scores are in kg/m 2 .

Table

3

Acknowledgements

Lise Anhoury (French Institute of Sport) and Joan Tihy (University of Caen) for the data collection. Nelly Erichot (Paris Descartes University) and Christophe Gernigon (Univeristy of Montpellier) for various comments on the manuscript. Catherine O'Malley and Laura Killian for translation corrections.

Funding source

None.

Conflict of Interest

None.


Alexis Ruffault
email: alexis.ruffault@gmail.com

Solène Grégoire

Kelsie Hendrickson

Cécile Flahault

Cognitive Behavioral Therapy with Daily Mindfulness Training: a Case Report of Comorbid Binge Eating and Bipolar Disorders

des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

 1.

99

The patient reported less cognitive restriction with food, as One of the determinants of BED is the difficulty to cope 119 with psychological distress (Baer et al. 2005a, b), and bipolar 120 disorder can be viewed as a dysfunction in mood regulation 121 [START_REF] Swann | Manic symptoms and 268 impulsivity during bipolar depressive episodes[END_REF]). As BD-I includes manic and depressive 122 episodes, the associations with behavioral impulsivity 123 (including substance abuse) are well known regardless of the 124 type of episode [START_REF] Swann | Manic symptoms and 268 impulsivity during bipolar depressive episodes[END_REF]). This clinical case report

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  of Comorbid Binge Eating and Bipolar Disorders 6 Alexis Ruffault 1 & Solène Grégoire 1 & Kelsie Hendrickson 2 & Cécile Flahault 1 Springer Science+Business Media New York 2015 10 Brown and Ryan (2003) conceptualized dispositional mind-11 fulness as a self-regulatory function, which is characterized by 12 "being attentive to and aware of what is taking place in the 13 present moment" (p.882). Mindfulness training added to cog-14 nitive behavioral therapy (CBT) has been shown to reduce 15 binge eating behavior, drive for thinness, and body dissatis-16 faction while increasing psychological well-being and quality 17 of life for obese individuals diagnosed with binge eating dis-18 order (BED; Carrard et al. 2011). In order to integrate mind-19 fulness into general psychological practice, clinicians often 20 utilize practical strategies with their clients such as the use of 21 daily reminders, the integration into daily activities, and 22 psychoeducational techniques like educational skill building 23 and stress management ( Q1 Dimidjian and Kleiber 2013; Shonin 24 et al. 2014). Mindfulness meditation can be trained with 25 between-session practice (Bowen and Kurz 2012). 26 Moreover, mindfulness has been shown to reduce negative 27 mood and impulsivity, as well as increase psychological 28 well-being with clinical and nonclinical populations (Bowen 29 and Kurz 2012; Brown and Ryan 2003). 30 Highlighting the effects of mindfulness on cognitive and 31 emotional regulation, several studies have shown its benefits 32 for healthier eating patterns and less binge eating (e.g., Baer 33 et al. 2005a, b; Compare et al. 2012; Jordan et al. 2014; Levin 34 et al. 2014). Furthermore, in the treatment of BED, Baer et al. (2005a, b) argued that instead of changing thoughts or nega-36 tive emotional states, the focus should be on making more , the therapist and patient first 71 discussed the diagnostic criteria for bipolar disorder and 72 BED, and then the therapist provided psychoeducation about mindfulness and how to use it in daily life. Moreover, to in-74 crease her mindfulness skills, the patient listened to a mind-75 fulness recording for 10 min each day as practice. A notebook 76 including (a) a diary for planning mindfulness sessions and 77 writing comments about it, (b) columns to restructure cogni-78 tions, and (c) columns to describe the emotional determinants 79 and outcomes of binge episodes was offered to the patient. 80 This tool was provided so that she could engage in self-81 management care of her disorders. Once per week for 82 12 weeks, the patient reviewed the notebook with the thera-83 pist. During these 1-h face-to-face sessions, the therapist and 84 the patient worked together in an effort to understand the 85 barriers that prevented her from using the notebook through-86 out the week and to foster the patient's autonomous motiva-87 tion toward therapy. 88 At baseline and after every four sessions, the patient com-89 pleted several self-report questionnaires that measured eating 90 behavior (Three-Factor Eating Questionnaire TFEQ-R18), de-91 pression (Beck Depression Inventory, BDI-II; Hospital 92 Anxiety and Depression Scale, HADS-D), anxiety (Hospital 93 Anxiety and Depression Scale, HADS-A), impulsivity 94 (Barratt Impulsiveness Scale, BIS-11), motivation toward 95 therapy (Client Motivation for Therapy Scale, CMOTS), and 96 mindfulness skills (Mindful Attention Awareness Scale, 97 MAAS; Acceptance and Action Question, AAQ-II). The re-98 sults are displayed in Table

100

  well as better controlled and less emotional eating after 12 101 sessions of weekly psychotherapy. Moreover, she reported a 102 decrease in cognitive impulsivity but maintained high scores 103 in motor impulsivity and nonplanning. Surprisingly, the pa-104 tient's anxiety scores increased and dispositional mindfulness 105 scores remained stable across the 12-week psychotherapy pe-106 riod. Depression scores were consistent with a major depres-107 sive episode experienced within bipolar disorder: the patient 108 showed moderate or severe depression scores every 4 weeks. 109 Motivation scores showed that the patient was more intrinsi-110 cally motivated toward therapy but more extrinsically moti-111 vated when she endorsed severe depression (i.e., after 4 weeks 112 and at post-therapy). Surprisingly, the patient seemed to be as 113 mindful at the end of the therapy as she was at baseline, al-114 though her psychological flexibility increased across time in 115 therapy. Furthermore, the patient reported less binge episodes 116 and a more structured meal organization during the second 117 half of psychotherapy.

  118

125

  aimed to highlight the wide range of applications of daily 126 mindfulness training in obese individuals with BED and other 127 psychiatric comorbidities. 128 The results reported by the patient are important for clini-129 cians to note for several reasons. First, depression scores 130 assessed with the BDI-II was sensitive to change across ther-131 apy while the HADS-D was not. Second, while dispositional 132 mindfulness remained stable, psychological flexibility (i.e., 133 acceptance) increased during the 12-week program. These 134 results suggest that daily mindfulness training and discussions 135 during sessions foster acceptance of thoughts, emotions, 136 and bodily sensations in daily life. Moreover, the patient 137 became more intrinsically and extrinsically motivated 138 toward therapy as the number of sessions progressed. 139 These changes in motivational regulation could be ex-140 plained by the positive alliance between patient and 141 therapist and by the early stage of change of the patient 142 regarding binge episodes. In fact, the patient never 143 attempted to seek support for her BED prior to the 144 current treatment. Furthermore, the results showed that 145 when depression increased, the patient's motives for at-146 tending therapy were more extrinsic (i.e., while feeling 147 depressed, she stated she was attending therapy for the happi-148 ness of her therapist instead of her own). This association is 149 similar to literature arguing that motivation is modulated 150 by the satisfaction of psychological needs (Deci and 151 Ryan 1985). Previous research has shown that negative 152 states of mind (e.g., depression) are associated with mo-153 tivation for change, which may be one explanation for the 154 current observed patterns. 155 On the other hand, during therapy, the patient reported that 156 she was not always compliant with the daily mindfulness 157 training. She first argued that she did not understand how 158 mindfulness could help her; hence, the therapist educated 159 her on the effects and mechanisms of action of mindfulness. 160 After the psychoeducation sessions, the patient began to put 161 an alarm on her phone to enhance adherence to daily 162 mindfulness training. It seems that understanding the 163 potential benefits of mindfulness training facilitated her 164 involvement and autonomy in her own care. Bowen and 165 Kurz (2012) argued that maintaining long-term mindfulness 166 training and its implementation in everyday life could be ob-167 tained by daily practice. In this case, the patient reported that 168 she succeeded at being mindful when difficult situations came 169 in her life, which is in accordance with previous predictions 170 (Bowen and Kurz 2012). A recent study investigating the role 171 played by therapeutic alliance, adherence, and competence in 172 treatment failure showed that both therapeutic alliance and 173 competence are mediators between adherence and treatment 174 success (Weck et al. 2015), suggesting that feeling competent 175 and having a strong alliance with the therapist increases and probability for a successful outcome. 177 In our case, the negative states of mood experienced by the 178 patient could have decreased her feeling of competence, 179 disrupted the relationship between therapeutic alliance, and 180 decreased treatment adherence. 181 After the 12 planned weeks of therapy, the patient de-182 cided to stop seeing AR, stating that the therapy was stress-183 ful due to the changes in her "diet" (i.e., from binge epi-184 sodes to structured eating). The anxiety scores increasing 185 from baseline to post-therapy seem to show the patient's 186 uncertainty during the therapy process. In fact, during 187 weekly sessions, she reported that she did not feel compe-188 tent. As a clinical health psychologist, it was challenging to 189 address the patient's concurrent mood alterations and con-190 cerns about the subjective effectiveness of the therapy. 191 Positive feedback was given when the patient reported im-192 provements in the management of her daily life, but it 193 seems that other techniques should be implemented to min-194 imize anxiety in the behavior change process (i.e., 195 readapting alimentation to replace BED). 196 These findings should be considered in the context of 197 several limitations. First, the therapeutic relationship 198 may have led the patient to give responses she wanted 199 the therapist to see (i.e., response bias), although infor-200 mation given to her about the outcome measures was 201 limited. Second, this is a case of one 49-year-old female 202 patient that should not be taken as representative of the 203 population of patients with BED and BD-I. To our 204 knowledge, this is the first report of a mindfulness-205 based intervention for bipolar disorder with multiple suicide 206 attempts and BED. Mindfulness training should be considered 207 as a complementary tool in CBT for improving cognitive reg-208 ulation of negative emotions across illnesses including obesi-209 ty, BED, and BD-I.

  Acceptance and Action Questionnaire, BDI-II Beck Depression Inventory, BIS-11 Barratt Impulsiveness Scale, CMOTS Client Motivation for Therapy Scale, HADS Hospital Anxiety and Depression Scale, MAAS Mindful Attention Awareness Scale, TFEQ-R18 Three-Factor Eating Questionnaire

	t1:1 Table 1 Scores of the psychological self-reported measures, filled out online every four sessions t1:2 t1:3 t1:4 t1:5 t1:6 t1:7 t1:8 t1:9 t1:10 t1:11 t1:12 t1:13 t1:14 t1:15 t1:16 t1:17 t1:18 t1:19 t1:20 t1:21 t1:22 t1:23 t1:24 t1:25 t1:26 t1:27 t1:28 t1:29 t1:30 t1:31 N Psychological measures Eating behavior (TFEQ-R18) Cognitive restraint Uncontrolled eating Emotional eating Depression BDI-II score BDI-II category HADS-D Anxiety (HADS-A) Impulsivity (BIS-11) Cognitive Attention Cognitive instability Motor Motor Perseverance Nonplanning Self-control Cognitive complexity Motivation toward therapy (CMOTS) Amotivation External regulation Introjected regulation Identified regulation Integrated regulation Intrinsic regulation Mindfulness skills Dispositional mindfulness (MAAS) Psychological flexibility (AAQ-II) C O R R E C T E D Possible range (0 to 100) (0 to 100) (0 to 100) (0 to 63) (0 to 21) (0 to 21) (1 to 4) (1 to 4) (1 to 4) (1 to 4) (1 to 4) (1 to 4) (-36 to 36) (1 to 7) (1 to 7) (1 to 7) (1 to 7) (1 to 7) (1 to 7) (1 to 6) (10 to 70) P R Baseline 27.78 92.59 100.00 22 Moderate 11 6 100.94 25.60 3.15 3.00 34.22 3.71 2.50 37.13 3.33 3.40 24.92 1.67 1.00 4.33 6.00 6.50 5.75 3.47 37 O O F 4 weeks 22.22 96.30 100.00 32 Severe 15 13 109.69 28.80 3.95 3.00 34.22 3.43 3.25 41.53 3.67 3.60 13.00 3.33 3.50 5.00 5.75 4.50 6.75 3.13 39 210 Compliance with Ethical Standards AAQ-II AUTHOR'S PROOF 211	8 weeks 0.00 92.59 88.89 21 Moderate 14 12 101.25 27.20 2.40 3.00 34.22 3.43 3.00 36.30 3.83 3.20 25.83 1.33 3.50 2.67 7.00 5.75 7.00 3.13 35	12 weeks 16.67 74.07 88.89 36 Severe 14 14 95.00 20.80 2.80 2.00 36.67 3.14 3.00 35.20 3.17 3.20 12.33 4.00 4.75 3.67 6.75 5.25 6.75 3.07 44
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tance in the treatment of disordered eating. Journal of Rational-

Emotive & Cognitive-Behavior Therapy, 23(4), 281-300. doi:10.

Conflict of Interest

The authors declare that they have no competing 213 interests.