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Treating severe and enduring anorexia nervosa: a randomized controlled trial

Published online by Cambridge University Press:  03 May 2013

S. Touyz ,
D. Le Grange ,
H. Lacey ,
P. Hay ,
R. Smith ,
S. Maguire ,
B. Bamford ,
K. M. Pike  and
R. D. Crosby
S. Touyz*
Affiliation:
School of Psychology and Centre for Eating and Dieting Disorders (Boden Institute), School of Psychology, University of Sydney, NSW, Australia
D. Le Grange
Affiliation:
Department of Psychiatry, The University of Chicago, Chicago, IL, USA
H. Lacey
Affiliation:
Eating Disorders Research Team, PHSE, St George's, University of London, UK
P. Hay
Affiliation:
School of Medicine, University of Western Sydney, NSW, Australia School of Medicine, James Cook University, Queensland, Australia
R. Smith
Affiliation:
School of Psychology and Centre for Eating and Dieting Disorders (Boden Institute), School of Psychology, University of Sydney, NSW, Australia
S. Maguire
Affiliation:
School of Psychology and Centre for Eating and Dieting Disorders (Boden Institute), School of Psychology, University of Sydney, NSW, Australia
B. Bamford
Affiliation:
Eating Disorders Research Team, PHSE, St George's, University of London, UK
K. M. Pike
Affiliation:
Department of Psychiatry, Columbia University, New York, NY, USA
R. D. Crosby
Affiliation:
Neuropsychiatric Research Institute and the University of North Dakota School of Medicine and Health Sciences, Fargo, ND, USA
*
*Address for correspondence: S. Touyz, Ph.D., School of Psychology and Centre for Eating and Dieting Disorders (Boden Institute), School of Psychology, Room 151, Mackie Bldg K01, University of Sydney, 2006 NSW, Australia. (Email: Stephen.touyz@sydney.edu.au)
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Abstract

Background

There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN.

Method

Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes.

Results

Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM.

Conclusions

Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

Keywords

Chronic enduring anorexia nervosacognitive-behavior therapyspecialist supportive clinical management
Type
Original Articles
Information
Psychological Medicine , Volume 43 , Issue 12 , December 2013 , pp. 2501 - 2511
Copyright
Copyright © Cambridge University Press 2013 

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References

APA (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. American Psychiatric Association: Washington, DC.Google Scholar
Arkell, J, Robinson, P (2008). A pilot case series using qualitative and quantitative methods: biological, psychological and social outcome in severe and enduring eating disorder (anorexia nervosa). International Journal of Eating Disorders 41, 650–656.CrossRefGoogle ScholarPubMed
Beck, AT, Steer, RA, Brown, GK (1996). Manual for the Beck Depression Inventory-II. Psychological Corporation: San Antonia, TX.Google Scholar
Birmingham, C, Treasure, J (2010). Medical Management of Anorexia Nervosa, 2nd edn.Cambridge University Press: Cambridge.Google Scholar
Bulik, CM, Berkman, ND, Brownley, KA, Sedway, JA, Lohr, KN (2007). Anorexia nervosa treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders 40, 310–320.CrossRefGoogle ScholarPubMed
Carter, J, MacFarlane, T, Bewell, C, Olmstead, M, Woodside, B, Kaplan, A, Crosby, R (2009). Maintenance treatment for anorexia nervosa: a comparison of cognitive behavioral therapy and treatment as usual. International Journal of Eating Disorders 42, 202–207.CrossRefGoogle ScholarPubMed
Cohen, J (1998). Statistical Power Analysis for the Behavioral Sciences, 2nd edn.Lawrence Erlbaum Associates: Hillsdale, NJ.Google Scholar
Dare, C, Eisler, I, Russell, G, Treasure, J, Dodge, L (2001). Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments. British Journal of Psychiatry 178, 216–221.CrossRefGoogle ScholarPubMed
Engel, SG, Wittrock, DA, Crosby, RD, Wonderlich, SA, Mitchell, JE, Kolotkin, RL (2006). Development and psychometric validation of an eating disorder-specific health-related quality of life instrument. International Journal of Eating Disorders 39, 62–71.CrossRefGoogle ScholarPubMed
Fairburn, CG, Cooper, Z (1993). The Eating Disorder Examination. In Binge Eating: Nature, Assessment and Treatment, 12th edn (ed. Fairburn, C. G. and Wilson, G. T.), pp. 317–331. Guilford Press: New York.Google Scholar
First, MB, Spitzer, RL, Gibbo, M, Williams, JBW (2002). Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P). Biometrics Research, New York State Psychiatric Institute: New York.Google Scholar
Glasofer, DR, Attia, E, Pike, KM (in press). Eating disorders. In Psychopathology: Bridging the Gap Between Basic Empirical Findings and Clinical Practice (ed. Castonguay, L. G. and Oltmams, T. F.). Guilford Press: New York.Google Scholar
Goldner, E (1989). Treatment refusal in anorexia nervosa. International Journal of Eating Disorders 8, 297–306.3.0.CO;2-H>CrossRefGoogle ScholarPubMed
Halmi, KA, Agras, WS, Crow, S, Mitchell, J, Wilson, GT, Bryson, SW, Kraemer, HC (2005). Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Archives of General Psychiatry 62, 776–781.CrossRefGoogle ScholarPubMed
Harbottle, EJ, Birmingham, CL, Sayani, F (2008). Anorexia nervosa: a survival analysis. Eating and Weight Disorders 13, e32–e34.Google ScholarPubMed
Hatch, A, Madden, S, Kohn, M, Clarke, S, Touyz, S, Williams, LM (2010). Anorexia nervosa: towards an integrative neuroscience model. European Eating Disorders Review 18, 165–179.CrossRefGoogle ScholarPubMed
Hay, PF, Touyz, S, Sud, R (2012). Treatment for severe and enduring anorexia nervosa: a review. Australian and New Zealand Journal of Psychiatry 46, 1136–1144.CrossRefGoogle ScholarPubMed
Kaplan, AS, Buchanan, S (2012). Is there a role for palliative care in the management of treatment resistant chronic anorexia nervosa? The International Conference on Eating Disorders, Austin, TX.Google Scholar
Le Grange, D, Crosby, RD, Engel, SG, Cao, L, Ndungu, A, Crow, SJ, Peterson, CB, Mitchell, JE, Wonderlich, SA (2013). DSM-IV-defined anorexia nervosa versus subthreshold anorexia nervosa (EDNOS-AN). European Eating Disorders Review 21, 1–7.CrossRefGoogle ScholarPubMed
Lopez, A, Yager, J, Feinstein, RE (2010). Medical futility and psychiatry: palliative care and hospice care as a last resort in the treatment of refractory anorexia nervosa. International Journal of Eating Disorders 43, 372–377.CrossRefGoogle ScholarPubMed
McIntosh, VV, Jordan, J, Bulik, CM (2010). Specialist supportive clinical management for anorexia nervosa. In The Treatment of Eating Disorders: A Clinical Handbook (ed. Grilo, M. and Mitchell, J. E.), pp. 108–129. Guilford Press: New York.Google Scholar
McIntosh, VV, Jordan, J, Carter, FA, Luty, SE, McKenzie, JM, Bulik, CM, Frampton, CM, Joyce, PR (2005). Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal of Psychiatry 162, 741–747.CrossRefGoogle ScholarPubMed
McIntosh, VV, Jordan, J, Luty, SE, Carter, FA, McKenzie, JM, Bulik, CM, Joyce, PR (2006). Specialist supportive clinical management for anorexia nervosa. International Journal of Eating Disorders 39, 625–632.CrossRefGoogle ScholarPubMed
NICE (2004). Eating Disorders: Care Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Disorders. Clinical Guideline Number 9. National Institute for Clinical Excellence (NICE): London.Google Scholar
Pike, KM, Walsh, TB, Vitousek, K, Wilson, TG, Bauer, J (2003). Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. American Journal of Psychiatry 160, 2046–2049.CrossRefGoogle ScholarPubMed
Rieger, E, Touyz, SW, Beumont, PJ (2002). The Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ): information regarding its psychometric properties. International Journal of Eating Disorders 32, 24–38.CrossRefGoogle ScholarPubMed
Robinson, P (2009). Severe and Enduring Anorexia Nervosa: Management of Complex Presentations of Anorexia Nervosa and Bulimia Nervosa. Wiley: West Sussex.Google Scholar
Rubin, DB (2009). Multiple Imputation for Nonresponse in Surveys. John Wiley & Sons: New York.Google Scholar
Schafer, JL (1997). Analysis of Incomplete Multivariate Data. Chapman & Hall: London, UK.CrossRefGoogle Scholar
Schmidt, U, Oldershaw, A, Jichi, F, Sternheim, L, Startup, H, McIntosh, V, Jordan, J, Tchanturia, K, Wolff, G, Rooney, M, Landau, S, Treasure, J (2012). Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial. British Journal of Psychiatry 201, 392–399.CrossRefGoogle ScholarPubMed
Schmidt, U, Treasure, J (2006). Anorexia nervosa: valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology 45, 343–366.CrossRefGoogle ScholarPubMed
Steinhausen, HC (2002). The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry 159, 1284–1293.CrossRefGoogle Scholar
Striegel-Moore, RH, DeBar, L, Wilson, GH, Dickerson, J, Rosselli, F, Perrin, N, Lynch, F, Kraemer, HC (2008). Health services use in eating disorders. Psychological Medicine 38, 1465–1474.CrossRefGoogle ScholarPubMed
Strober, M (2004 a). Managing the chronic, treatment-resistant patient with anorexia nervosa. International Journal of Eating Disorders 36, 245–255.CrossRefGoogle ScholarPubMed
Strober, M (2004 b). Pathologic fear conditioning and anorexia nervosa: on the search for novel paradigms. International Journal of Eating Disorders 35, 504–508.CrossRefGoogle ScholarPubMed
Strober, M (2009). The chronically ill patient with anorexia nervosa. In The Treatment of Eating Disorders: A Clinical Handbook (ed. Grilo, M. and Mitchell, J. E.), pp. 225–237. Guilford Press: New York.Google Scholar
Strober, M, Johnson, C (2012). The need for complex ideas in anorexia nervosa: why biology, environment, and psyche all matter, why therapists make mistakes, and why clinical benchmarks are needed for managing weight correction. International Journal of Eating Disorders 45, 155–178.CrossRefGoogle ScholarPubMed
Tierney, S, Fox, JR (2009). Chronic anorexia nervosa: a Delphi study to explore practitioners’ views. International Journal Eating Disorders 42, 62–67.CrossRefGoogle ScholarPubMed
Treasure, J, Murphy, T, Szmukler, G, Todd, G, Gavan, K, Joyce, J (2001). The experience of caregiving for severe mental illness: a comparison between anorexia nervosa and psychosis. Social Psychiatry and Psychiatric Epidemiology 36, 343–347.CrossRefGoogle ScholarPubMed
Treasure, J, Russell, G (2011). The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors. British Journal of Psychiatry 199, 5–7.CrossRefGoogle ScholarPubMed
Vitousek, K, Watson, S, Wilson, GT (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Psychology Review 18, 391–420.CrossRefGoogle ScholarPubMed
Waller, G (2012). The myths of motivation: time for a fresh look at some received wisdom in the eating disorders? International Journal of Eating Disorders 45, 1–16.CrossRefGoogle Scholar
Walsh, BT, Kaplan, AS, Attia, E, Olmsted, M, Parides, M, Carter, JC, Pike, KM, Devlin, KH, Woodside, B, Roberto, CA, Rockert, W (2006). Fluoxetine after weight restoration: a randomized controlled trial. Journal of the American Medical Association 295, 2605–2612.Google ScholarPubMed
Ware, JE, Kosinski, M, Keller, SD (1996). A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Medical Care 34, 220–233.CrossRefGoogle ScholarPubMed
Weissman, MM, Bothwell, S (1976). Assessment of social adjustment by patient self-report. Archives of General Psychiatry 33, 1111–1115.CrossRefGoogle ScholarPubMed
Williams, KD, Dobney, T, Geller, J (2010). Setting the eating disorder aside: an alternative model of care. European Eating Disorder Review 18, 90–96.CrossRefGoogle ScholarPubMed
Wonderlich, S, Mitchell, JE, Crosby, RD, Myers, TC, Kadlec, K, Lahaise, K, Swan-Kremeier, L, Dokken, J, Lange, M, Dinkel, J, Jorgensen, M, Schander, L (2012). Minimizing and treating chronicity in the eating disorders: a clinical overview. International Journal of Eating Disorders 45, 467–475.CrossRefGoogle ScholarPubMed
Yager, J (1992). Patients with chronic recalcitrant eating disorders. In Special Problems in Managing Eating Disorders (ed. Yager, J., Gwirtsman, H. E. and Edelstein, C. K.), pp. 205–232. Anderson Psychiatric Press: Washington, DC.Google Scholar