Searching for Effective Outpatient Therapy for Adults with Anorexia Nervosa

Adult patients with relatively intractable anorexia nervosa may benefit significantly from outpatient psychological treatments, often without the need for hospital admission, according to British researchers. The group found that family therapy and psychoanalytic psychotherapy were effective outpatient approaches (Br J Psychiatry 2001;178).

Dr. Chris Dare and colleagues at the Maudsley Hospital, London, designed a randomized controlled study of 3 types of therapy, family therapy, focal psychoanalytic psychotherapy, and cognitive analytic therapy, among 84 consecutive patients referred to their hospital. These patients (average age: 26) were randomly assigned to one of four types of treatment: family therapy, focal psychoanalytic psychotherapy, cognitive analytic therapy, or low-contact routine therapy (control group) for 1 year.

Most of the patients were severely underweight (average BMI:15.4); 2 were male. Binge- eating and purging were common and frequent: 19 patients binge-ate at least weekly or daily and 30 vomited weekly or daily. The group had been ill for a mean of more than 6 years. Seventy-nine percent had been previously treated for their eating disorders. Thus, the patients had a fairly poor prognosis (late age of onset, long duration of illness, and a history of unsuccessful treatment).

Two approaches

In focal psychoanalytic psychotherapy, a short-term approach, the therapist takes a nondirective stance, giving no advice about eating behavior or other problems or symptoms. Instead, the focus is on addressing the conscious and unconscious meanings of the symptoms in terms of the patient’s history and experiences with their family. The 50-minute therapy sessions were scheduled for once a week for 1 year.

Cognitive analytic therapy includes elements for cognitive therapy and brief, focused psychodynamic psychotherapy. The therapist helps the patient develop a formal “map” of the structure and place of anorexia nervosa in their lives and experience. In the CAT sessions, some contact with parents and/or the partner of the patient took place and their relationship to the patient was a topic during therapy. CAT sessions were scheduled for 90 minutes weekly during the first 20 weeks, then monthly for 3 months.

The family therapy sessions lasted 60 to 75 minutes and were scheduled by negotiation for a time between once per week and once every 3 weeks. The therapists saw the patient with his or her partner or spouse or parents for most of the sessions. A “dose” of individual patient-therapist contact was used at least once every 3 sessions.

“Routine” treatment was designed to be low-contact outpatient management, in which patients attended 30-minute sessions with a psychiatrist in the second or third year of training. Specific information about the nature and outcome of anorexia nervosa was given and the therapist encouraged the patients to develop a more regular and sustainable diet; regular monitoring of physical activity was also included. A senior clinician supervised the psychiatrists once a week. (The authors note that a serious disadvantage of this approach was the inexperience of the psychiatric trainees and turnover when trainees left the unit after 6 months to continue their training elsewhere.)

Weight gain better in specialized treatment groups

Overall, more than two-thirds of the patients remained abnormally underweight at the end of the study. No statistically significant difference was reported between the two types of specialized treatment. However, in the “routine” treatment group, nearly half the patients gained no weight, and only 20% gained more than 10% of their pretreatment weight. In the specialized treatment groups, two-thirds of the patients gained weight, and between 23% and 38% gained at least 10%.

About a third of patients in the 3 specialized treatment groups no longer met DSM III-R criteria for anorexia nervosa at the end of the year. In contrast, only 5% of those in the “routine” treatment group no longer met the criteria for anorexia nervosa.

The authors note that patients with relatively intractable anorexia nervosa may benefit greatly from outpatient psychosocial treatment, often without the need for hospital admission. However, outpatient psychotherapy is not the treatment of choice because some patients are so ill that they will have to be hospitalized for life-saving care.