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Another reason for difficulties in interpreting some
of these study results of individual psychotherapy for AN relates
to an extraordinarily high dropout and attrition rate in the nonactive
treatment cell in some of these trials. For example, the study by
Serfaty and others broke down after 100% of patients assigned to
nutritional counselling alone dropped out of the study (7).
Although, for several decades prior to the 1970s, psychoanalysis
was the preferred and only psychological treatment available for
AN, there are no controlled trials evaluating its effectiveness
in this disorder (8). More recent psychoanalytic studies have focused
not on treatment outcome but on the psychological disturbances present
in patients with AN, including asceticism and the pathologic sense
of self (9).
In summary, the value of formal psychotherapy in the acute outpatient
treatment of AN remains ill-defined and uncertain (10).
There are studies that have evaluated the effectiveness of in-hospital
weight restoration programs using behavioural or operant conditioning
techniques. The difficulty in interpreting the results of these
interventions is that the methodology usually involved determining
whether 1 particular psychological intervention aimed at inducing
weight gain actually benefits a comprehensive multifaceted hospitalization
program, including supervised eating, medication, nutritional counselling,
and other psychotherapies. This creates a “ceiling effect”
that interferes with the ability to demonstrate any benefit for
the additional intervention (11). Strict vs lenient in-hospital
programs for weight gain were compared in 1 study of 65 hospitalized
persons with AN (12). The rate of weight gain was similar for the
2 approaches; importantly, the more lenient approach was far more
acceptable to patients, was associated with greater motivation to
participate in further treatment, and required less nursing time.
Eckert and others randomly assigned 81 hospitalized persons with
AN to standard in-hospital milieu therapy or behavioural treatment
(13). There were no significant differences in the amount of weight
gained over the 35-day treatment between the 2 groups.
In a comprehensive metaanalysis of treatment for AN, Agras and
Kraemer compared the findings of 21 published treatment studies
in hospitalized patients with AN (14). These trials were classified
as drug therapy, behaviour therapy, or medical therapy. They found
that medication did not add benefit to hospitalization, and while
the amount of weight gain for medical and behavioural therapies
was similar, the rate of weight gain for behavioural treatment was
more rapid and led to shorter hospitalizations. Again, these studies
suffered from the same methodological limitations as described for
outpatient trials, especially small sample sizes.
Family Psychotherapies With or Without Individual Psychotherapy
Several studies have examined the effectiveness of various types
of family therapy, usually in adolescent subjects with acute AN.
The results of these investigations tend to be more promising than
those studies examining individual psychotherapy in adult patients.
In an earlier study, 90 adolescent patients with acute AN were randomized
to 1 of 4 treatments: traditional inpatient treatment; outpatient
individual and family psychotherapy and dietary counselling; outpatient
group therapy for both the parents and patients treated separately,
plus dietary counselling; and assessment only, with no active treatment,
other than periodic monitoring by a family doctor (15). Following
6 months of treatment, active treatment groups did not differ, with
all 3 groups having gained a significant amount of weight, compared
with entry into the study and compared with the no-treatment group
at the end of active treatment. Weight gain was maintained in the
3 treatment groups at 1-year follow-up. The study was fraught with
the difficulties encountered in many randomized trials with AN subjects;
for example, 40% of those randomized to the inpatient treatment
cell dropped out of treatment. A later study reported on the 2-year
outcome of this patient group (16). The group that received outpatient
treatment fared much better at 2 years than did the no-treatment
group, with a mean body mass index (BMI) of 20 in the treated group,
compared with 17.8 in the nontreated group. In a somewhat related
study, le Grange and others randomly assigned 18 adolescent outpatients
with active AN to receive either conjoint family therapy or family
counselling (in which the parents are treated separately from the
AN patient) (17). The difference in weight gain for the 2 treatment
groups was not significant, and weight was in the normal range for
both groups after 6 months of treatment. A larger study of 40 randomized
adolescent subjects confirmed the earlier findings (18).
More recently, Geist and others randomized 25 hospitalized adolescents
with acute AN to receive either family therapy or family–group
psychoeducation for 4 months; most of the treatment was delivered
postdischarge from hospital (19). Both subject groups gained an
equal amount of weight, with the end-of-study weight for both groups
approximately 90% of ideal body weight, and no significant group
differences were found on any of the outcome measures.
Published studies examining the outcome of family treatments compared
with other psychological interventions in adult patients are less
positive than those in adolescents. In an early study, 30 adult
outpatients with AN were randomly assigned to either 12 sessions
of dietary advice or 12 sessions of combined individual and family
psychotherapy (20). The mean change in body weight after 12 sessions
of treatment and at 1-year follow-up was approximately 10% of ideal
body weight and was the same for both groups. Most subjects still
remained significantly underweight at the end of treatment and at
follow-up. In the most recently published study examining adult
patients, Dare and others randomly assigned 84 adult outpatients
with AN to 1 of 4 treatments: 1 year of focal psychoanalytic psychotherapy,
7 months of cognitive analytic therapy, 1 year of family therapy,
or 1 year of routine treatment (nonspecific supportive psychotherapy)
(21). Of the subjects, 54 (64%) completed the full course of treatment.
Focal psychotherapy and family therapy were more effective in producing
weight gain than was the control routine treatment. The difference
between cognitive analytic treatment and routine treatment in inducing
weight gain did not reach statistical significance. However, overall
mean weight gain was relatively small across the active treatment
groups, and two-thirds of the subjects across all 3 active treatments
were still significantly underweight and continued to meet criteria
for AN at the end of treatment.
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Group Therapies
There have been no systematic studies evaluating the effectiveness
of group therapies for AN, as there have been for BN (22). There
are published clinical descriptions of group therapy for AN (23–
26); these descriptions tend to emphasize the difficulties inherent
in treating patients with AN in a group format and do not recommend
it as the sole psychological intervention for the disorder. There
are even those who claim that group psychotherapy during the acute
phase of treatment for underweight persons with AN can be harmful;
patients tend to compete with each other in a group (who can be
the thinnest) and can exchange novel techniques to counteract weight
gain (27).
Randomized Controlled Trials of Weight-Restored
Anorexia Nervosa
Individual Psychotherapies
In the last decade, several randomized controlled trials have examined
a variety of psychosocial interventions in weight-restored individuals
with AN. Some of these relapse-prevention studies have suffered
from the same methodological difficulties as the studies evaluating
psychosocial interventions for the acute treatment of AN. For example,
in an unpublished study comparing the effectiveness of individual
CBT with nutritional counselling and medical management in adult
weight-restored subjects with AN, in a preliminary analysis of the
data, Pike and others found that 73% of the subjects randomized
to receive nutritional counselling had either relapsed or dropped
out of the study by 12 months after weight restoration (28). A significantly
greater percentage of individuals in the CBT condition, compared
with nutritional counselling, met criteria for good outcome at the
end of treatment (44% vs 6%; P < 0.02). In another unpublished
controlled trial (Halmi and others 1999) comparing CBT, fluoxetine,
and combined treatments in weight-restored patients with AN, there
was an exceedingly high dropout rate across all the conditions—but
especially in the drug-only condition— making interpretation
of the results difficult. There was a suggestion that those receiving
CBT, either alone or in combination with a drug, stayed in treatment
longer than those receiving a drug alone (29).
Family Psychotherapies With or Without Individual Therapy
There has been 1 well-done controlled study of patients with adolescent-onset
AN who were weight restored and whose duration of illness was less
than 3 years, comparing family therapy with individual therapy (30).
This study found that those individuals treated with family therapy
showed greater improvement over the year of outpatient treatment
after discharge from hospital than those treated with individual
therapy. These benefits were maintained at 5-year follow-up (31).
The prophylactic benefits of family therapy for weight-restored
adult patients with AN are much less clear.
Group Therapies
There are no published clinical descriptions or research studies
examining the use of group therapies for relapse prevention in weight-restored
persons with AN.
New Psychosocial Approaches to Anorexia Nervosa
Motivational Enhancement Therapy
In considering new innovative approaches to the treatment of AN,
it is useful to reconceptualize the primary symptom to target in
treatment. Traditionally, the symptoms that have been targeted are
the behavioural concomitants of the AN patient’s drive for
thinness (that is, caloric restriction and other behaviours that
promote weight loss). However, one major difficulty encountered
in the treatment of AN is the AN sufferer’s denial of illness
and resistance to changing any of these weight-loss facilitating
behaviours. It is this denial and resistance to change that has
led to the AN patient’s ambivalence about engaging in treatments
that are focused on eliminating these egosyntonic behaviours; these
symptoms are generally viewed by others as problematic and distressing
but, curiously, not by the patient. It is also this denial and resistance
to change that has led to the perception among clinicians that patients
with AN are notoriously difficult to treat (32). Clinical descriptions
dating back decades have noted, probably more than any other psychiatric
disorder, the strong negative reactions evoked in caregivers by
AN patients (33,34).
A reformulation of the disorder that specifically identifies ambivalence
and resistance to change as the primary symptom in AN—which
treatment has to address before any focus on behavioural change—may
be helpful in devising new psychological interventions. Much can
be learned about such interventions from examining other treatment-resistant
populations of patients, most notably those with substance-abuse
difficulties. Attitudinally, patients with AN have much in common
with substance-abusing individuals. Both patient populations are
commonly seen as unmotivated to change and reluctant to seek treatment
volitionally. Both groups tend to alienate caregivers because of
the perception that they are working against treatment rather than
toward recovery. Both groups of patients tend to rationalize and
deny their symptoms, and they are often perceived by therapists
as deceitful. It is noteworthy that despite the central prominence
of denial and resistance in the phenomenology of AN, historically,
there have been relatively few attempts to rigorously measure these
phenomena in AN patients, as is done in the field of substance abuse,
where such disorder-specific psychometric instruments are available.
More recently, investigators have developed standardized psychometric
instruments that attempt to measure denial and concerns about change
in AN (35–37).
Stages of Change
Because of the above-described similarities between AN and substance
abuse, it is useful to consider applying to AN patients the motivational
enhancement approaches that have been studied and successfully applied
for years in the field of addictions. The Trans-Theoretical Model
of Change, initially described by Prochaska and DiClemente in 1983
(38), while exploring the process of change during smoking cessation,
was further expanded to try to encompass and understand how individuals
change problematic behaviours in general (39). The model describes
a series of stages that individuals pass through while attempting
to change such behaviours. These stages are precontemplation, contemplation,
preparation, action, and maintenance.
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