Skip to main content
    • Aa
    • Aa
  • Get access
    Check if you have access via personal or institutional login
  • Cited by 29
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Askenazy, Florence 2016. Anorexie à l’adolescence et séparation. Annales Médico-psychologiques, revue psychiatrique, Vol. 174, Issue. 6, p. 426.

    Goldschmidt, A.B. Fitzsimmons-Craft, E.E. and Le Grange, D. 2016. Encyclopedia of Mental Health.

    Mitchell, Sarah A. Newton, Richard Harrison, Philippa Castle, David and Brennan, Leah 2016. Does Collaborative Case Conceptualisation enhance engagement and outcome in the treatment of anorexia nervosa? Rational, design and methods. Contemporary Clinical Trials, Vol. 47, p. 296.

    Parling, Thomas Cernvall, Martin Ramklint, Mia Holmgren, Sven and Ghaderi, Ata 2016. A randomised trial of Acceptance and Commitment Therapy for Anorexia Nervosa after daycare treatment, including five-year follow-up. BMC Psychiatry, Vol. 16, Issue. 1,

    Stiles-Shields, Colleen Bamford, Bryony H. Touyz, Stephen Le Grange, Daniel Hay, Phillipa and Lacey, Hubert 2016. Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. Journal of Eating Disorders, Vol. 4, Issue. 1,

    Waller, Glenn 2016. Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions. Current Psychiatry Reports, Vol. 18, Issue. 4,

    WESTMORELAND, PATRICIA and MEHLER, PHILLIP S. 2016. Caring for Patients With Severe and Enduring Eating Disorders (SEED). Journal of Psychiatric Practice, Vol. 22, Issue. 4, p. 313.

    Zainal, Kelly Ann Renwick, Beth Keyes, Alexandra Lose, Anna Kenyon, Martha DeJong, Hannah Broadbent, Hannah Serpell, Lucy Richards, Lorna Johnson-Sabine, Eric Boughton, Nicky Whitehead, Linette Treasure, Janet and Schmidt, Ulrike 2016. Process evaluation of the MOSAIC trial: treatment experience of two psychological therapies for out-patient treatment of Anorexia Nervosa. Journal of Eating Disorders, Vol. 4, Issue. 1,

    Abbate-Daga, Giovanni Marzola, Enrica De-Bacco, Carlotta Buzzichelli, Sara Brustolin, Annalisa Campisi, Stefania Amianto, Federico Migliaretti, Giuseppe and Fassino, Secondo 2015. Day Hospital Treatment for Anorexia Nervosa: A 12-Month Follow-up Study. European Eating Disorders Review, Vol. 23, Issue. 5, p. 390.

    Bartholdy, Savani McClelland, Jessica Kekic, Maria O’Daly, Owen G. Campbell, Iain C. Werthmann, Jessica Rennalls, Samantha J. Rubia, Katya David, Anthony S. Glennon, Danielle Kern, Nikola and Schmidt, Ulrike 2015. Clinical outcomes and neural correlates of 20 sessions of repetitive transcranial magnetic stimulation in severe and enduring anorexia nervosa (the TIARA study): study protocol for a randomised controlled feasibility trial. Trials, Vol. 16, Issue. 1,

    Cardi, Valentina Esposito, Mirko Bird, Geoff Rhind, Charlotte Yiend, Jenny Schifano, Sylvia Hirsch, Colette and Treasure, Janet 2015. A preliminary investigation of a novel training to target cognitive biases towards negative social stimuli in Anorexia Nervosa. Journal of Affective Disorders, Vol. 188, p. 188.

    Chen, Eunice Y. Segal, Kay Weissman, Jessica Zeffiro, Thomas A. Gallop, Robert Linehan, Marsha M. Bohus, Martin and Lynch, Thomas R. 2015. Adapting dialectical behavior therapy for outpatient adult anorexia nervosa-A pilot study. International Journal of Eating Disorders, Vol. 48, Issue. 1, p. 123.

    Fursland, Anthea and Byrne, Susan M. 2015. The Wiley Handbook of Eating Disorders.

    Garte, Marianne Hagen, Benny Reas, Deborah L. Isdahl, Per J. Hinderaker, Elisabeth and Rø, Øyvind 2015. Implementation of a day hospital treatment programme based on CBT-E for severe eating disorders in adults: an open trial. Advances in Eating Disorders, Vol. 3, Issue. 1, p. 48.

    Hay, Phillipa and Touyz, Stephen 2015. Treatment of patients with severe and enduring eating disorders. Current Opinion in Psychiatry, Vol. 28, Issue. 6, p. 473.

    Hay, Phillipa J Claudino, Angélica M Smith, Caroline A Touyz, Stephen Lujic, Sanja Le Grange, Daniel Lacey, J Hubert Sud, Rishi and Hay, Phillipa J 2015. Cochrane Database of Systematic Reviews.

    Kaye, Walter H. Wierenga, Christina E. Knatz, Stephanie Liang, June Boutelle, Kerri Hill, Laura and Eisler, Ivan 2015. Temperament-based Treatment for Anorexia Nervosa. European Eating Disorders Review, Vol. 23, Issue. 1, p. 12.

    Kezelman, Sarah Touyz, Stephen Hunt, Caroline and Rhodes, Paul 2015. Does anxiety improve during weight restoration in anorexia nervosa? A systematic review. Journal of Eating Disorders, Vol. 3, Issue. 1,

    Lock, James Le Grange, Daniel Agras, W. Stewart Fitzpatrick, Kathleen Kara Jo, Booil Accurso, Erin Forsberg, Sarah Anderson, Kristen Arnow, Kate and Stainer, Maya 2015. Can adaptive treatment improve outcomes in family-based therapy for adolescents with anorexia nervosa? Feasibility and treatment effects of a multi-site treatment study. Behaviour Research and Therapy, Vol. 73, p. 90.

    Mackenzie, Robin 2015. Ms X: A Promising New View of Anorexia Nervosa, Futility, and End-of-Life Decisions in a Very Recent English Case. The American Journal of Bioethics, Vol. 15, Issue. 7, p. 57.


Treating severe and enduring anorexia nervosa: a randomized controlled trial

  • S. Touyz (a1), D. Le Grange (a2), H. Lacey (a3), P. Hay (a4) (a5), R. Smith (a1), S. Maguire (a1), B. Bamford (a3), K. M. Pike (a6) and R. D. Crosby (a7)
  • DOI:
  • Published online: 03 May 2013

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.


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.


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.


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.

Corresponding author
*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:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

J Arkell , P Robinson (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, 650656.

CM Bulik , ND Berkman , KA Brownley , JA Sedway , KN Lohr (2007). Anorexia nervosa treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders 40, 310320.

J Carter , T MacFarlane , C Bewell , M Olmstead , B Woodside , A Kaplan , R Crosby (2009). Maintenance treatment for anorexia nervosa: a comparison of cognitive behavioral therapy and treatment as usual. International Journal of Eating Disorders 42, 202207.

C Dare , I Eisler , G Russell , J Treasure , L Dodge (2001). Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments. British Journal of Psychiatry 178, 216221.

E Goldner (1989). Treatment refusal in anorexia nervosa. International Journal of Eating Disorders 8, 297306.

KA Halmi , WS Agras , S Crow , J Mitchell , GT Wilson , SW Bryson , HC Kraemer (2005). Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Archives of General Psychiatry 62, 776781.

A Hatch , S Madden , M Kohn , S Clarke , S Touyz , LM Williams (2010). Anorexia nervosa: towards an integrative neuroscience model. European Eating Disorders Review 18, 165179.

PF Hay , S Touyz , R Sud (2012). Treatment for severe and enduring anorexia nervosa: a review. Australian and New Zealand Journal of Psychiatry 46, 11361144.

D Le Grange , RD Crosby , SG Engel , L Cao , A Ndungu , SJ Crow , CB Peterson , JE Mitchell , SA Wonderlich (2013). DSM-IV-defined anorexia nervosa versus subthreshold anorexia nervosa (EDNOS-AN). European Eating Disorders Review 21, 17.

VV McIntosh , J Jordan , FA Carter , SE Luty , JM McKenzie , CM Bulik , CM Frampton , PR Joyce (2005). Three psychotherapies for anorexia nervosa: a randomized, controlled trial. American Journal of Psychiatry 162, 741747.

VV McIntosh , J Jordan , SE Luty , FA Carter , JM McKenzie , CM Bulik , PR Joyce (2006). Specialist supportive clinical management for anorexia nervosa. International Journal of Eating Disorders 39, 625632.

KM Pike , TB Walsh , K Vitousek , TG Wilson , J Bauer (2003). Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. American Journal of Psychiatry 160, 20462049.

E Rieger , SW Touyz , PJ Beumont (2002). The Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ): information regarding its psychometric properties. International Journal of Eating Disorders 32, 2438.

JL Schafer (1997). Analysis of Incomplete Multivariate Data. Chapman & Hall: London, UK.

U Schmidt , A Oldershaw , F Jichi , L Sternheim , H Startup , V McIntosh , J Jordan , K Tchanturia , G Wolff , M Rooney , S Landau , J Treasure (2012). Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial. British Journal of Psychiatry 201, 392399.

HC Steinhausen (2002). The outcome of anorexia nervosa in the 20th century. American Journal of Psychiatry 159, 12841293.

RH Striegel-Moore , L DeBar , GH Wilson , J Dickerson , F Rosselli , N Perrin , F Lynch , HC Kraemer (2008). Health services use in eating disorders. Psychological Medicine 38, 14651474.

M Strober (2004 a). Managing the chronic, treatment-resistant patient with anorexia nervosa. International Journal of Eating Disorders 36, 245255.

M Strober (2004 b). Pathologic fear conditioning and anorexia nervosa: on the search for novel paradigms. International Journal of Eating Disorders 35, 504508.

M Strober , C Johnson (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, 155178.

S Tierney , JR Fox (2009). Chronic anorexia nervosa: a Delphi study to explore practitioners’ views. International Journal Eating Disorders 42, 6267.

J Treasure , T Murphy , G Szmukler , G Todd , K Gavan , J Joyce (2001). The experience of caregiving for severe mental illness: a comparison between anorexia nervosa and psychosis. Social Psychiatry and Psychiatric Epidemiology 36, 343347.

J Treasure , G Russell (2011). The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors. British Journal of Psychiatry 199, 57.

K Vitousek , S Watson , GT Wilson (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Psychology Review 18, 391420.

G Waller (2012). The myths of motivation: time for a fresh look at some received wisdom in the eating disorders? International Journal of Eating Disorders 45, 116.

JE Ware , M Kosinski , SD Keller (1996). A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Medical Care 34, 220233.

KD Williams , T Dobney , J Geller (2010). Setting the eating disorder aside: an alternative model of care. European Eating Disorder Review 18, 9096.

S Wonderlich , JE Mitchell , RD Crosby , TC Myers , K Kadlec , K Lahaise , L Swan-Kremeier , J Dokken , M Lange , J Dinkel , M Jorgensen , L Schander (2012). Minimizing and treating chronicity in the eating disorders: a clinical overview. International Journal of Eating Disorders 45, 467475.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *