Outpatient Approaches for Anorexia Nervosa

Anorexia nervosa (AN) is still the most deadly psychiatric disease, with mortality rates reaching 20% in some studies. Adult women with AN that is not too severe can be successfully treated on an outpatient basis, according to early results from a large-scale German trial. The Anorexia Nervosa Treatment of Outpatients (ANTOP), directed by Professors Wolfgang Herzog and Stephan Zipfel (Lancet. 2014; 3843:127), compared new outpatient approaches involving manual-based approaches with optimized treatment as usual.

The randomized, controlled, efficacy trial of adults included patients from 10 university hospitals in Germany; 242 women with AN were randomized to 10 months of one of three treatments: (1) focal psychodynamic therapy (80 patients), (2) enhanced cognitive behavioral therapy (80 patients), or (3) optimized treatment as usual (82 patients), including outpatient psychotherapy and structured care by a family physician.

Focal psychodynamic therapy addressed the associations of interpersonal relationships, and the working relationship of the therapist and patient (therapeutic alliance) was emphasized. The form of CBT-E followed Fairburn’s model (Psychiatr Clin North Am. 2010; 33:611) and used aspects of both the focused and broad versions; regular eating and weight gain were emphasized. In addition, these patients were assigned “homework” by the therapists. The final approach, optimized treatment as usual, was provided by experienced psychotherapists selected by the patients themselves. The patients’ family physicians were also included in the treatment process. Participants in the optimized treatment as usual group visited their respective study centers 5 times during the study.

The main outcome was weight gain, measured as increased body mass index (BMI, or kg/m²) at the end of the 10 months of treatment. Therapists were extensively trained and closely supervised. The women in the focal psychodynamic therapy and CBT groups had 40 outpatient individual therapy sessions during the 10 months of the study, and all were followed for 12 months after treatment ended.

Patients in all three treatment groups had significant weight gains at the end of treatment, and again at the end of follow-up. At the end of treatment and follow-up, their BMIs had increased an average of 1.4 BMI points, or the equivalent of 3.8 kg (8.3 lb).

According to the authors, optimized treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with AN. Focal psychodynamic therapy was advantageous in terms of recovery at 12-month follow-up, and enhanced CBT therapy was more effective than the other approaches with respect to speed of weight gain and improvements in eating disorder psychopathology. Longer-term outcome data will be helpful to adapt and improve these novel manual-based treatment methods.