A large-scale study has now shown that adult women with anorexia whose disorder is not too severe can be treated successfully on an out-patient basis. Even after conclusion of therapy, they continue to make significant weight gains. Two new psychotherapeutic methods offer improved opportunities for successful therapy. However, one quarter of the patients participating in the study did not show rapid results. These are the findings of the world's largest therapy trial on anorexia nervosa published in the renowned medical journal The Lancet. The Anorexia Nervosa Treatment of OutPatients (ANTOP) study was conducted at ten German university eating disorder centers and was designed by the departments for psychosomatic medicine at the university hospitals of Heidelberg (Director: Prof. Wolfgang Herzog) and Tübingen (Director: Prof. Stephan Zipfel).
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 - the most lethal mental disorder
"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," explained Prof. 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 out-patient therapy, creating enormous problems," said Prof. Herzog.
Around 1 percent of the population has anorexia nervosa, with the disorder affecting nearly only 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
The ANTOP 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 out-patient psychotherapy. The therapy involved two new psychotherapy methods that were specially developed for out-patient 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 out-patient 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 in-patient treatment temporarily due to their poor state of health. Approx. one quarter of the patients discontinued their participation before the trial had ended.
Three psychotherapy methods were compared:
1. 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.
2. Cognitive behavior 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.
3. 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.
Specific psychotherapies offer realistic chances for cure
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 Prof. Zipfel. "At the end of our study, focal psychodynamic therapy proved to be the most successful method, while the specific cognitive behavior therapy resulted in more rapid weight gain." Furthermore, the patients undergoing focal psychodynamic therapy required additional in-patient treatment less often. While the acceptance of the two new psychotherapy methods by the patients was very high, at 1 year after the end of therapy, approx. one quarter of the patients continued to have full syndrome anorexia nervosa.
The scientists from Tübingen and Heidelberg drew the following conclusion: 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.
Head of the ANTOP Study
Prof. Stephan Zipfel
Medical Director of the Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen
Co-head of the ANTOP Study
Prof. Wolfgang Herzog
Medical Director of the Department for General Internal and Psychosomatic Medicine
Heidelberg University Hospital
Zipfel et al. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. The Lancet. Published online October 14, 2013
See Online/Comment : Bulik CM. The challenge of treating anorexia nervosa. The Lancet http://dx.doi.org/10.1016/S0140-6736(13)61940-6
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Heidelberg University Hospital is one of the largest and most prestigious medical centers in Germany. The Medical Faculty of Heidelberg University belongs to the internationally most renowned biomedical research institutions in Europe. Both institutions have the common goal of developing new therapies and implementing them rapidly for patients. With about 11,000 employees, training and qualification is an important issue. Every year, around 118,000 patients are treated on an inpatient basis and around 1.000.000 cases on an outpatient basis in more than 50 clinics and departments with 2,200 beds. Currently, about 3,500 future physicians are studying in Heidelberg; the reform Heidelberg Curriculum Medicinale (HeiCuMed) is one of the top medical training programs in Germany.
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