Investigators evaluated two new treatment strategies and compared the outcomes to a treatment as normal group. They found that even after the conclusion of therapy, the new approaches fostered continued weight gains.
Nevertheless, despite the generally postive outcomes, one quarter of the study participants did not experience rapid improvements.
Study findings are published in the journal Lancet. The study was the world’s largest therapy trial on anorexia nervosa and was conducted at ten German university eating disorder centers.
Psychotherapy has been recognized as the treatment of choice for anorexia nervosa and in Germany, is covered by health insurance.
However, to date there have been no large-scale clinical studies that examine the efficacy of different treatment methods on a comparative basis, constituting a glaring research gap considering the severity of the disease.
Anorexia nervosa is known as a particularly deadly illness.
“In the long-term course, in up to 20 percent of the cases, anorexia leads to death, making it the most lethal of all of the mental disorders. Patients with anorexia often suffer from the psychological or physical consequences of the disease their entire lives,” said Professor Wolfgang Zipfel.
To date, no convincing studies on specific therapy programs have been available in adults. Furthermore, randomized controlled studies comparing promising therapy methods are rare.
“Well-controlled, clinical studies with a high level of reliability are rare, especially for outpatient therapy, creating enormous problems,” said Professor Stephan Herzog.
Around 1 percent of the population has anorexia nervosa, with the disorder primarily affecting girls and young women.
Patients with anorexia are very underweight due to their long-term food restriction and, in many cases, their urge to over-exercise. Self-induced vomiting, the use of laxatives, diuretics or appetite suppressants exacerbate the weight loss. The patients’ body weight is no more than 85 percent of normal weight (body mass index (BMI) of less than 17.5 kg/m²).
Patients with anorexia have an intense fear of gaining weight and their perception of their own figure is distorted. They often have other mental disorders such as depression, anxiety and compulsive disorders.
Treatment by experienced psychotherapists in cooperation with family physicians is recommended although the efficacy of different therapy approaches had not been studied.
The current study, which accompanied 242 adult women over a period of 22 months (10 months of therapy, 12 months of follow-up observation) now allows scientific conclusions to be drawn about the efficacy of different types of psychotherapy for the first time.
Three groups of either 82 or 80 patients each underwent a different method of outpatient psychotherapy.
The therapy involved two new psychotherapy methods that were specially developed for outpatient treatment of anorexia and an optimized form of the currently practiced standard psychotherapy (“optimized treatment as usual”).
For the specific therapies, treatment manuals were developed in conjunction with international eating disorder experts. The therapy comprises 40 outpatient individual therapy sessions over a period of 10 months.
For all 242 patients, specially trained psychotherapists conducted the therapy with the patients.
The patients’ family physicians were informed about the therapy and were involved in the treatments and the patients were examined by their family physician at least once a month.
Around one-third of the patients had to be admitted for inpatient treatment temporarily due to their poor state of health. Approximately one-quarter of the patients discontinued their participation before the trial had ended.
Three psychotherapy methods were compared:
Focal psychodynamic therapy addresses the way negative associations of relationships and disturbances affect the way patients process emotions. The working relationship between the therapist and the patient plays a key role in this method. The patients are specifically prepared for everyday life after conclusion of the therapy.
Cognitive-behavioral therapy has two focuses: normalization of the eating behavior and weight gain, as well as addressing the problem areas connected to the eating disorders, such as deficits in social competence or in problem-solving ability. The patients are also assigned “homework” by their therapists.
Standard psychotherapy was conducted as optimized treatment as usual by experienced psychotherapists selected by the patients themselves. The patients’ family physicians were included in the treatment. The patients also visited their respective study center five times during the study.
The patients with anorexia in all three groups had made significant weight gains after the end of therapy and at a 12-month follow-up visit. Their BMI had increased by 1.4 BMI points on average (the equivalent of an average of 3.8 kg).
“Overall, the two new types of therapy demonstrated advantages compared to the optimized therapy as usual,” said Zipfel. “At the end of our study, focal psychodynamic therapy proved to be the most successful method, while the specific cognitive-behavioral therapy resulted in more rapid weight gain.”
Furthermore, the patients undergoing focal psychodynamic therapy required additional inpatient treatment less often. While the acceptance of the two new psychotherapy methods by the patients was very high, at one year after the end of therapy, about one-quarter of the patients continued to have full syndrome anorexia nervosa.
Researchers believe the specific therapies give adult patients a realistic chance of recovery or long-term improvement. However, great challenges for the prevention and early treatment of anorexia nervosa remain.