Reprinted from Eating Disorders Review
March/April 2005 Volume 16, Number 2
©2005 Gürze Books
Recovery from anorexia nervosa (AN) usually takes years, and 10% to 20% of patients have severe and chronic long-term illness. Inpatient treatment is usually recommended for anorexic patients with very low weights.
Patients usually show a strong ambivalence about treatment and weight gain and have a high dropout rate and generally poor compliance. Dropping out of psychotherapy is common, as is lack of adherence to psychopharmacological treatment. Dissatisfaction with treatment or with a therapist may also be reasons for dropping out. Ironically, improvement is another reason AN patients leave inpatient therapy.
A treatment program with contract, weight gain goals
To identify factors that might lead an AN patient to drop out of therapy, University of Freiberg (Germany) researchers studied 133 consecutively admitted inpatients diagnosed with AN. Patients ranged from 16 to 50 years of age, and 93% were women. The center’s treatment program consists of an initial ambulatory program, followed by a treatment contract with patients wherein a target weight is defined. Patients are given a week to consider the contract before being admitted for inpatient care.
The inpatient program consists of individual and group sessions, body-oriented therapy, art therapy, and symptom-oriented components, such as work on eating diaries, meal plans, nutritional education and intervention directed at dysfunctional cognitive thoughts. Family involvement is determined on an individual basis, and patients agree to gain at least 500 to 750 gm per week. When the patient stops gaining weight, the staff considers this a signal that the patient has withdrawn his or her agreement to the treatment contract and has no motivation to go further. The patient is discharged with the possibility of returning at a later time. Those who reach their target weights are treated for another 8 weeks to stabilize the weight gain.
Why did patients drop out?
About 68% of the patients (91/133) finished the program, while nearly 19% (25/133) dropped out of treatment on their own initiative. Nearly 13% of patients (17/133) were discharged by the team because of insufficient weight gain or perceived lack of motivation to gain weight. More than half of patients leaving on their own dropped out abruptly without discussing reasons for doing so. In the group of patients discharged by the team, this topic was worked on in therapy. Outside factors, such as intervention from family and employers, played a part in dropout for 10% of patients.
The overall dropout rate of nearly 32% compares with dropout rates reported in other studies. One of the authors’ main findings was that patients with depression stayed in psychotherapy whereas those who completed treatment could not be differentiated from dropouts by other types of comorbidity. Patients who had been hospitalized before were less likely to drop out a second time. Age at admission, duration of illness, educational level, subtype or weight at admission was not predictive of dropping out. Another surprising finding was that, unlike other studies, bulimic features were not associated with dropping out of treatment.
Dropouts also tended to be more assertive and more expressive than completers. Patients who were discharged by the team reported the highest number of symptoms and left at the lowest weights. External factors played only a minor role—78.6% of dropouts had no discernable external reasons for dropping out of treatment.
A similar percentage of patients dropped out over all phases of therapy. Early dropouts tended to be more obsessive-compulsive and perfectionistic. Those who dropped out in the middle phase of therapy reported experiencing more anger and hostility than did late dropouts. These late dropouts tended to leave treatment programs during intensive phases of therapy. According to the authors, this might point to a failure to resolve and work through developing feelings and conflicts during the phase of continuous weight gain.