Outpatient Treatment Of Anorexia Nervosa Research Articles

Anorexia nervosa: Outpatient treatment and medical management.

Anorexia nervosa (AN) is a disabling, costly and potentially deadly illness. Treatment failure and relapse are common after completing treatment, and a substantial proportion of patients develop severe and enduring AN. The time from AN debut to the treatment initiation is normally unreasonably long. Over the past 20 years there has been empirical support for the efficacy of several treatments for AN. Moreover, outpatient treatment with family-based therapy or individual psychotherapy is associated with good outcomes for a substantial proportion of patients. Early intervention improves outcomes and should be a priority for all patients. Outpatient treatment is usually the best format for early intervention, and it has been demonstrated that even patients with severe or extreme AN can be treated as outpatients if they are medically stable. Inpatient care is more disruptive, more costly, and usually has a longer waiting list than does outpatient care. The decision as to whether to proceed with outpatient treatment or to transfer the patient for inpatient therapy may be difficult. The core aim of this opinion review is to provide the knowledge base needed for performing safe outpatient treatment of AN. The scientific essentials for outpatient treatment are described, including how to assess and manage the medical risks of AN and how to decide when transition to inpatient care is indicated. The following aspects are discussed: early intervention, outpatient treatment of AN, including outpatient psychotherapy for severe and extreme AN, how to determine when outpatient treatment is safe, and when transfer to inpatient healthcare is indicated. Emerging treatments, ethical issues and outstanding research questions are also addressed.

Does inpatient treatment result in higher rates of remission than outpatient treatment of anorexia nervosa?

Does inpatient treatment result in higher rates of remission than outpatient treatment of anorexia nervosa?

Sudden gains in the outpatient treatment of anorexia nervosa: A process-outcome study.

Sudden gains (SGs), broadly defined as sudden symptom reductions occurring between two consecutive treatment sessions, have been associated with improved treatment outcomes in anxiety and depression. The present study is the first to formally define SGs in anorexia nervosa and explore the characteristics, demographic and baseline clinical predictors, and clinical impact of SGs in anorexia nervosa. This is a secondary analysis of data from 89 outpatients with broadly defined anorexia nervosa who received one of two psychotherapeutic interventions as part of the MOSAIC trial (Schmidt et al., 2015). SGs were defined using session-by-session body mass index (BMI) measures. This study investigated whether SGs were associated with changes in BMI, eating disorder symptomology, general psychopathology, and psychosocial impairment between baseline and 6, 12, and 24 months follow-up. SGs, experienced by 61.8% of patients, mostly occurred during the early and middle phases of treatment. A larger proportion of SGs predicted larger increases in BMI between baseline and 6, 12, and 24 months follow-up. Amongst those experiencing at least one SG, fewer days between baseline and a patient's first SG predicted a larger increase in BMI between baseline and both 6 and 12 months follow-up. The proportion and timing of SGs did not predict changes in other outcome measures. SGs in BMI during the outpatient treatment of anorexia nervosa are clinically useful predictors of longer-term weight outcomes.

The Intersession Process in Psychotherapy for Anorexia Nervosa: Characteristics and Relation to Outcome.

The "inter session process" (ISP) is defined as therapy-related conscious thoughts, memories, and emotions that patients and therapists experience between psychotherapy sessions. It indicates how the participants process and use treatment. The main aim of this study is to describe the ISP characteristics of patients in outpatient treatment for anorexia nervosa (AN). An additional aim is to explore the relation between patients' ISP and treatment outcome. Patients taking part in a randomized controlled trial on outpatient psychotherapy for AN (ANTOP) filled in the Intersession Experience Questionnaire before each of the 40 psychotherapy sessions. Trajectories of different aspects of the ISP were analyzed with growth curve models based on orthogonal polynomials and tested for differences between 3 outcome categories (recovery, partially recovered, full syndrome AN). Data from 108 cases were available for analysis. ISP facets showed diverse, mostly nonlinear, trajectories over the course of treatment. Less favorable outcomes were associated with higher levels of patients' experiencing negative emotions when recalling therapeutic dialogue, thinking about therapy during dreaming/drowsy states, and applying therapeutic learning (in the second half of treatment). Findings confirm an overall relation between ISP and treatment outcome. In outpatient treatment in AN, patients with a less successful course seem to be more preoccupied with therapy and therapist between sessions. For the ISP facet "applying therapeutic learning," findings point to an optimal range dependent on treatment phase. Growth curve modeling is required to describe the nonlinear trajectories of ISP facets.

The Objective and Subjective Caregiving Burden and Caregiving Behaviours of Parents of Adolescents with Anorexia Nervosa.

The study aimed to examine caregiving burden and levels of distress, accommodating behaviours, expressed emotion (EE) and carers' skills, in parents of adolescents with anorexia nervosa. A semi-structured interview assessed the objective burden (time spent across caregiving tasks) in parents (n = 196) of adolescents (n = 144) receiving outpatient treatment for anorexia nervosa. Subjective burden (carers' distress), accommodating behaviours, EE and carers' skills were measured by self-report. Mothers, on average, spent 2.5 h/day of care, mainly providing food and emotional support, compared with 1 h/day by fathers. The level of distress and accommodating behaviour was significantly lower in fathers than in mothers. Accommodating behaviours mediated the relationship between objective burden and subjective burden in mothers, whereas EE and carers' skills did not mediate this relationship for either parent. The objective burden for most mothers is high. In order to reduce subjective burden, it may be helpful to target accommodating behaviours. ISRCTN83003225 - Expert Carers Helping Others (ECHO). Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Process evaluation of the MOSAIC trial: treatment experience of two psychological therapies for out-patient treatment of Anorexia Nervosa.

BackgroundThis study is part of a series of process evaluations within the MOSAIC Trial (Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions). This randomised controlled trial (RCT) compared two psychological treatments, the Maudsley Model for Treatment of Adults with Anorexia Nervosa (MANTRA) and Specialist Supportive Clinical Management (SSCM) for adult outpatients with Anorexia Nervosa. The present process study integrates quantitative (treatment acceptability and credibility) and qualitative (written) feedback to evaluate patients’ treatment experiences.MethodAll 142 MOSAIC participants were asked to (a) rate treatment acceptability and credibility on visual analogue scales (VAS) at six and 12 months post-randomisation, and (b) provide written feedback regarding their views on their treatment at 12 months. Transcripts were first analysed thematically and then rated according to the global valence of feedback (positive, mixed/negative).Results114/142 (80.3 %) MOSAIC participants provided VAS data and 82 (57.7 %) provided written feedback. At 12 months, MANTRA patients gave significantly higher acceptability and credibility ratings compared to SSCM patients. A significantly higher proportion of MANTRA patients provided written feedback. MANTRA patients also tended to write in more detail and to give globally more positive feedback when compared to individuals receiving SSCM. Qualitative themes suggest that patients experienced the two treatments differently in terms of characteristics and outcomes.ConclusionsThis study highlights the benefits of incorporating qualitative and quantitative data into RCT process evaluations. MANTRA patients were more willing to express their views on treatment and generally felt more positively about this than those receiving SSCM.

“Exercising hard or hardly exercising?” Objective and subjective measures of physical activity in patients with anorexia nervosa

Compulsive exercise in anorexia nervosa (AN) has been associated with adverse effects in treatment, and is a major risk factor for relapse. However, exercise is often surreptitious and measurement problematic. For example, females in community samples have been found to over-report physical activity when compared to objective assessment. The current study aimed to explore the relationships between objectively recorded and subjectively reported physical activity (PA) in AN outpatients. Participants were 34 females with AN enrolled in a randomised-controlled trial of outpatient treatment of anorexia nervosa (Hay et al., in progress). They completed the Eating Disorder Examination (EDE) interview; self-report questionnaires assessing eating disorder and exercise cognitions and behaviours; and wore an accelerometer for 4 days as an objective PA measure. Participants also self-reported their average daily PA. Results demonstrated significant under-reporting (objective PA greater than self-report PA) on light and total PA, but not vigorous or moderate PA. Discrepancy scores between moderate PA (accelerometer – self-report) were also negatively correlated with motivation to change in AN (p<0.05). Clinically, it is important that professionals are aware of such discrepancies between methods, as well as the limitations of accelerometer devices and self-report measures.

An examination of autism spectrum traits in adolescents with anorexia nervosa and their parents.

BackgroundThere may be a link between anorexia nervosa and autism spectrum disorders. The aims of this study were to examine whether adolescents with anorexia nervosa have autism spectrum and/or obsessive-compulsive traits, how many would meet diagnostic criteria for autism spectrum disorder, and whether these traits are shared by parents.MethodsA total of 150 adolescents receiving outpatient treatment for anorexia nervosa or subthreshold anorexia nervosa and their parents completed the autism spectrum disorder and eating disorder sections of the Development and Well-being Assessment. Patients also completed the Children Yale-Brown Obsessive-Compulsive Scale and other measures of psychiatric morbidity, and parents completed the short Autism Quotient and Obsessive-Compulsive Inventory Revised.ResultsAdolescents with anorexia nervosa had a below average social aptitude (19% below cut-off) and high levels of peer relationship problems (39% above cut-off) and obsessive-compulsive symptoms (56% above cut-off). Six cases (4%, all females) were assigned a possible (n = 5) or definite (n = 1) diagnosis of autism spectrum disorder. Parental levels of autism spectrum and obsessive-compulsive traits were within the normal range.ConclusionsThis study suggests that adolescents with anorexia nervosa have elevated levels of autism spectrum traits, obsessive-compulsive symptoms, and a small proportion fulfil diagnostic criteria for a probable autism spectrum disorder. These traits did not appear to be familial. This comorbidity has been associated with a poorer prognosis. Therefore, adaptation of treatment for this subgroup may be warranted.Trial registrationControlled-trials.com: ISRCTN83003225. Registered on 29 September 2011.

Is outpatient cognitive remediation therapy feasible to use in randomized clinical trials for anorexia nervosa?

There are limited data supporting specific treatments for adults with anorexia nervosa (AN). Randomized clinical trials (RCTs) for adults with AN are characterized by high attrition limiting the feasibility of conducting and interpreting existing studies. High dropout rates may be related to the inflexible and obsessional cognitive style of patients with AN. This study evaluated the feasibility of using cognitive remediation therapy (CRT) to reduce attrition in RCTs for AN. Forty-six participants (mean age of 22.7 years and mean duration of AN of 6.4 years) were randomized to receive eight sessions of either CRT or cognitive behavioral therapy (CBT) over 2 months followed by 16 sessions of CBT for 4 months. During the 2-month CRT vs. CBT treatment, rates of attrition were lower in CRT (13%) compared with that of CBT (33%). There were greater improvements in cognitive inefficiencies in the CRT compared with that of the CBT group at the end of 2 months. There were no differences in other outcomes. These results suggest that CRT is acceptable and feasible for use in RCTs for outpatient treatment of AN. CRT may reduce attrition in the short term. Adequately powered future studies are needed to examine CRT as an outpatient treatment for AN.

A systematic review of dropout from treatment in outpatients with anorexia nervosa

Dropout from treatment has serious implications for patients, clinicians, and researchers. The aim of this study was to examine rates of dropout from outpatient treatment for anorexia nervosa (AN) and critically examine the various definitions of dropout used. A systematic review was conducted, including pharmacological and psychological interventions. All articles in PubMed, Web of Science, and the Cochrane Library were considered, and screened against a priori inclusion/exclusion criteria. Relationships between treatment outcome and dropout rate were examined across studies. Nineteen relevant studies were identified, with dropout rates ranging from 4.8% (family therapy) to 100% (dietary advice). In most cases, dropout was in the range of 20-40%. Definitions of dropout used varied widely. A significant negative correlation was found between rate of dropout and body mass index (BMI) at 1 year, but this did not remain significant when differences in BMI at baseline were taken into account. High rates of dropout from treatment for AN have serious implications for recovery, research, and the development of new treatments. A suggested reporting structure is proposed, with the aim of increasing the consistency of dropout reporting and facilitating greater understanding of this phenomenon.

Transdiagnostic Theory and Application of Family-Based Treatment for Youth With Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.

Anorexia Nervosa

Anorexia Nervosa

A Randomized Controlled Study of Cognitive Behavior Therapy and Behavioral Family Therapy for Anorexia Nervosa Patients

Very few studies have examined the role of cognitive behavior therapy (CBT) in the outpatient treatment of anorexia nervosa. This study used a randomized, controlled design to evaluate a 12-month, manual based program of CBT, with behavioral family therapy as the comparison group. Twenty-five adolescents and young adults with anorexia nervosa, currently living with their families, were recruited into the study with both treatment groups receiving 21–25 sessions of therapy. Outcome measures included nutritional status, eating behaviors, mood, self-esteem, and family communication. Sixty percent of the total sample and 72% of treatment completers had “good” outcome (defined as maintaining weight within 10% of average body weight and regular menstrual cycles) at post-treatment and at six months follow-up. No significant differences between treatment groups were found and the majority of patients did not reach symptomatic recovery. While limited by the small sample size, the findings compliment and extend previous research.

E-mail as a therapeutic adjunct in the outpatient treatment of anorexia nervosa: Illustrative case material and discussion of the issues

To explore using adjunctive e-mail in treating anorexia nervosa. Four treatment plans were supplemented by obligatory e-mail emphasizing patients' reports of specific eating-related behaviors. Office visits occurred weekly to once every few months. E-mail contact occurred once to several times per week. Patients also saw other providers. All patients have shown good clinical improvement. Patients provided their assessments of contributions made by the use of e-mail and generally found it to be helpful. E-mail has had excellent patient acceptability and adherence. Benefits have been attributed to increased therapeutic contact, "talking" on demand, and having to frequently confront one's integrity, honesty, and eating behaviors. Little clinician time is needed for reading and responding to e-mails. Informed consent and confidentiality issues must be carefully addressed. Controlled trials are warranted to further evaluate the roles that adjunctive e-mail may play in clinical research and practice.

Cognitive therapy versus dietary counselling in the outpatient treatment of anorexia nervosa: effects of the treatment phase

Objective Cognitive therapy (CT) has been used in anorexia nervosa, but little is known about its effectiveness. A randomized controlled trial was undertaken comparing dietary advice (DA) with cognitive therapy in the outpatient treatment of AN. Method Thirty-five patients were randomly allocated to either cognitive therapy (n=25) or dietary advice (n=10). There were no significant differences in the groups pre-treatment. Twenty sessions of cognitive therapy or dietary advice were offered. Results At 6 months 23 cognitive therapy patients remained engaged whereas all the dietary advice controls dropped out. Cognitive therapy patients showed significant changes in Body Mass Index (p=0.001), Eating Disorder Inventory Scores (p=0.035), Beck Depression Inventory Scores (p<0.0001) and Locus of Control of Behaviour Scores (p=0.017). Conclusions Significant improvements were observed in patients allocated to cognitive therapy, but not in those allocated to dietary advice on an intention to treat analysis. Cognitive therapy has advantages of promoting engagement and facilitating recovery. Copyright © 1999 John Wiley & Sons, Ltd and Eating Disorders Association.

Cognitive therapy versus dietary counselling in the outpatient treatment of anorexia nervosa: effects of the treatment phase

Objective: Cognitive therapy (CT) has been used in anorexia nervosa, but little is known about its effectiveness, A randomized controlled trial was undertaken comparing dietary advice (DA) with cognitive therapy in the outpatient treatment of AN.Method: Thirty-five patients were randomly allocated to either cognitive therapy (n = 25) or dietary advice (n = 10). There were no significant differences in the groups pre-treatment. Twenty sessions of cognitive therapy or dietary advice were offered.Results: At 6 months 23 cognitive therapy patients remained engaged whereas all the dietary advice controls dropped out. Cognitive therapy patients showed significant changes in Body Mass Index (p = 0.001). Eating Disorder Inventory Scores (p = 0.035). Beck Depression Inventory Scores (p < 0.0001) and Locus of. Control of Behaviour Scores (p = 0.017),Conclusions: Significant improvements were observed in patients allocated to cognitive therapy, but not in those allocated to dietary advice on an intention to treat analysis. Cognitive therapy has advantages of promoting engagement and facilitating recovery. Copyright (C) 1999 John Wiley & Sons, Ltd and Eating Disorders Association.

Multiple family weight pathology and outcome in anorexia nervosa: A longitudinal case study

A prospective family case study was conducted whilst one member, a 14-year-old girl, underwent individual outpatient treatment for anorexia nervosa. Despite her being a twin within a family with multiple weight and other pathologies, substantial recovery was achieved and continued at two-year follow-up. Evidence of decompensation in other family members was suggested by clinical interview data but not by concurrent self-report measures of eating disorder or neurotic symptomatology.

Food as the reinforcer in the outpatient treatment of anorexia nervosa

This case report illustrates that food can be used as a positive reinforcer in the treatment of anorexia nervosa in an outpatient setting. The patient had complete control of the diet, eliminating the negative consequences of control by the parents or the therapist.