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Anorexia: When looking in the mirror becomes torture

World's largest treatment study of psychotherapy for anorexia nervosa: five-year follow-up results of internationally renowned ANTOP study published in Lancet Psychiatr

Researchers at Heidelberg University Hospital (UKHD) and Tübingen University Hospital have now published the results of a follow-up study on the world's largest psychotherapy study for outpatient anorexia patients (ANTOP study) in the renowned journal Lancet Psychiatry: five years after the end of therapy, 41 percent of patients could be classified as recovered, while another 41 percent showed partial symptoms of anorexia and 18 percent were still suffering from the full symptoms of the disease. According to the experts, further improvements in diagnostics and therapy are necessary in order to identify those affected who are particularly at risk and to be able to treat them successfully in the long term.

Anorexia nervosa is a serious psychosomatic disorder that affects women in particular and can often be fatal. Those affected are exposed to enormous physical and psychological impairments. But their relatives are also under great pressure of suffering. Back in 2014, the world's largest psychotherapy study for outpatient anorexia patients resulted from a cooperation of ten German psychosomatic university hospitals under the direction of Prof. Dr. Stephan Zipfel (Tübingen University Hospital) and Prof. Dr. Wolfgang Herzog (Heidelberg University Hospital). The current five-year follow-up follows on from this with both hopeful and alarming results.

Psychosomatic illness with strong physical effects

For anorexia nervosa patients, looking in the mirror is a real ordeal. They perceive themselves as overweight, although their body mass index has already taken on a threatening form. Weight reduction is achieved by chronically low food intake. Women are disproportionately affected by the disease (ratio 1:12). Although at first glance the disease has purely external features, such as a severely emaciated appearance, it is primarily a severe psychosomatic illness. Therefore, international treatment guidelines state that psychotherapy is the treatment of choice for adults with anorexia. Depending on the severity of the disorder and the weight of the person, patients may be treated as outpatients.

One study whose findings have already been incorporated into international treatment guidelines is the "Anorexia Nervosa Treatment of Outpatients" or ANTOP, funded by the German Federal Ministry of Education and Research. Innovative treatment programs, such as focal psychodynamic therapy and an innovative cognitive behavioral therapy, were compared with optimized treatments of guideline psychotherapy in a randomized controlled trial. "Focal psychodynamic therapy" works on the unfavorable shaping of relationships as well as impairments in the processing of emotions in therapy sessions. "Cognitive behavioral therapy" aims to normalize eating behavior and weight gain, as well as to work on problem areas associated with the eating disorder, such as deficits in social skills. The optimized treatments of "guideline psychotherapy," in turn, are based on methods of standard psychotherapy.

Significant improvements in all three therapy groups five years after end of treatment

"Five years after the end of therapy, the patients showed significant improvements on average in all three therapy groups, e.g. an increase in weight, less disturbed eating behavior, fewer psychological symptoms," Prof. Herzog and his successor, Prof. Hans-Christoph Friederich, summarize the results. The aim of the five-year follow-up of the ANTOP study was, first, to assess the long-term outcomes of a well-described and fairly homogeneous sample of adult female patients and, second, to investigate whether the treatment benefits observed at the one-year follow-up would persist more than four years later.

Originally, 242 patients diagnosed with anorexia were randomly assigned to the three therapy groups. Five years after the end of therapy, 41 percent could be classified as recovered, another 41 percent showed partial anorexia symptoms and 18 percent still suffered from the full-blown disease. "A good course of therapy is favored by a higher initial weight, a shorter duration of the disease and the absence of depression at the start of therapy," says Prof. Beate Wild from the UKHD, characterizing robust variables of the course of the disease.

However, since a group of patients that should not be underestimated unfortunately showed an unfavorable course, Prof. Stephan Zipfel from the University Hospital Tübingen also calls for further improvements in diagnostics and therapy: "We need further and more specific markers in the early phase of the disease in order to be able to successfully treat potentially particularly at-risk patients in a more targeted manner."

Original title of the publication: Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in female outpatients with anorexisa nervosa (ANTOP study): 5-year follow-up of a randomised controlled trial in Germany.“ Lancet Psychiatry 2022; 9:280-90.

DOI: https://doi.org/10.1016/S2215-0366(22)00028-1 

The publication is available at the following link: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(22)00028-1/fulltext  

For more information on anorexia nervosa, please see the following links:

https://www.medizin.uni-tuebingen.de/de/das-klinikum/einrichtungen/kliniken/medizinische-klinik/psychosomatik

https://www.medizin.uni-tuebingen.de/en-de/das-klinikum/einrichtungen/zentren/kompetenzzentrum-fuer-essstoerungen  

Universitätsklinikum Heidelberg: Klinik für Allgemeine Innere Medizin und Psychosomatik (uni-heidelberg.de) 

https://www.klinikum.uni-heidelberg.de/zentrum-fuer-innere-medizin-medizin-klinik/klinik-fuer-allgemeine-innere-medizin-und-psychosomatik/ueber-uns/sektionen/psychosomatische-interventions-und-prozessforschung