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Psychological therapies in anorexia nervosa

Eating Disorders Team, Havant Civic Offices, Civic Centre Road, Havant P09 2AX, UK

I would like to comment on the Maudsley trial evaluating three psychotherapies for anorexia nervosa compared with routine treatment (Dare et al, 2001). I congratulate the team on their efforts in this study in a research area fraught with difficulties and for their major contribution to knowledge in the eating disorders field. The authors rightly conclude that little can be drawn from the study regarding the differential impact of the therapies used. However, the paper did not make clear the differences between the conditions other than the models of therapy. The experience and qualifications of therapists were stated for focal psycho-analytic therapy and family therapy but not for cognitive—analytic therapy (CAT) and one can only conclude that the CAT therapists were not trained or qualified in CAT. Also, the total contact hours in each condition varied widely. The longer the contact hours the more impact the therapy. Perhaps the trial indicates that to treat moderately severe anorexia nervosa effectively, trained and experienced therapists and/or over 15 contact hours (over 18 x 50-minute sessions) are required. The need for experienced staff delivering therapies of adequate length is well known within the field (e.g. Palmer et al, 2000) but may not be fully appreciated by those commissioning or funding services. These are perhaps more important variables affecting outcome than the specific therapeutic modality used.

EDITED BY MATTHEW HOTOPF

REFERENCES

Dare, C., Eisler, I., Russell, G., et al (2001) Psychological therapies for adults with anorexia nervosa. Randomised controlled trial of out-patient treatments. British Journal of Psychiatry, 178, 216-221.[Abstract/Free Full Text]

Palmer, R. L., Gatward, N., Black, S., et al (2000) Anorexia nervosa: service consumption and outcome of local patients in the Leicester service. Psychiatric Bulletin, 24, 298-300.[Abstract/Free Full Text]

Author's reply

Eating Disorder Research Unit, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK

EDITED BY MATTHEW HOTOPF

We agree in part with the points made in these letters. Dr Okhai comments on the different treatment intensity between the conditions and in particular in the ‘control’ condition. The ‘control’ treatment was intended as a surrogate for placebo treatment. It is ethically difficult to have a placebo treatment for anorexia nervosa given the high morbidity of the condition and the lack of any placebo response. Our aim, therefore, was to have a ‘control’ condition similar to treatment as usual that would/could be offered in general adult psychiatry units. It could be argued that this therapy was better than that offered in many such positions in that regular supervision was given by an expert in eating disorders. Furthermore, the patients (2-3 per psychiatrist) were offered treatment for up to a year. We agree that in anorexia nervosa as in other conditions the therapeutic alliance is a key factor in response to therapy. We would argue that the specialist treatments have a specific focus on the therapeutic alliance. Indeed, it is perhaps noteworthy that the results of this study led to a change in the practice of cognitive—analytic therapy on the unit in that it is now preceded by a short course of motivational enhancement therapy to facilitate engagement (Treasure & Ward, 1997).

The number of sessions attended may be a sensitive marker of the therapeutic alliance in anorexia nervosa. For example, in a previous study comparing cognitive—behavioural therapy for anorexia nervosa with dietary management all patients dropped out of the dietary management group early in treatment (Serfaty, 1999).

We agree with Dr Morris that the important ‘take-home message’ is that specialised therapists following a specific therapeutic approach offer the best outcome in anorexia nervosa. This complements the analysis made by Nielsen et al (1998), in which he found that mortality was lower in regions of the country with specialised services. It is, therefore, of concern that such skills are in limited supply.

REFERENCES

Nielsen, S., Møller-Madsen, S., Isager, T., et al (1998) Standardized mortality in eating disorders — a quantitative summary of previously published and new evidence. Journal of Psychosomatic Research, 44, 413-434.[CrossRef][Medline]

Serfaty, M. A. (1999) Cognitive therapy versus dietary counselling in the outpatient treatment of anorexia nervosa: effects of the treatment phase. European Eating Disorders Review, 7, 334-350.[CrossRef]

Treasure, J. L. & Ward, A. (1997) Cognitive analytical therapy (CAT) in eating disorders. Clinical Psychology and Psychotherapy, 4, 62-71.[CrossRef]

This Article Submit an eLetter Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Bell, L. Articles by Treasure, J. Search for Related Content PubMed PubMed Citation Articles by Bell, L. Articles by Treasure, J.