Poulsen et al. (2014) «Poulsen S, Lunn S, Daniel SI, ym. A randomized con...»1. A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa
P: 70 patients with bulimia nervosa (BN)
I: 2 years of weekly psychoanalytic psychotherapy
C: 20 sessions of CBT over 5 months
O: Objective binges/28 days, purging episodes/28 days, Eating Disorder Examination interview
The inclusion criteria were age at least 18 years, being available for the duration of the longer of the two treatments, and meeting DSM-IV criteria for bulimia nervosa. The exclusion criteria were severe physical and psychiatric conditions that would interfere with treatment (e.g., psychosis), pregnancy, current psychotherapeutic treatment, and difficulty speaking or understanding Danish.
34 patients were randomly selected for psychoanalytic psychotherapy and 36 for CBT. Twenty-four (70.6 %) of the patients in psychoanalytic psychotherapy completed their 2 years of treatment, and 28 (77.8 %) of the CBT patients completed their 5 months of treatment. Analysis was based on the intention-to-treat principle.
Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42 % of patients in CBT (N = 36) and 6 % of patients in psychoanalytic psychotherapy (N = 34) had stopped binge eating and purging (odds ratio=13.40, 95 % confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44 % in the CBT group and 15 % in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95 % CI=1.33-14.21; p = 0.02). Substantial improvements were observed in both groups on global eating disorder psychopathology. These improvements had occurred by the respective endpoints of the two treatments and to a similar extent, i.e. no significant differences in EDE at 24 months. Improvements took place more rapidly in the CBT group (p<0.01).
Comment
There is further need for research of PDT for bulimia nervosa in which the implementation of the therapy is more appropriately symptom-focused.
Stefini et al. (2017) «Stefini A, Salzer S, Reich G, ym. Cognitive-Behavi...»2. Cognitive-Behavioral and Psychodynamic Therapy in Female Adolescents With Bulimia Nervosa: A Randomized Controlled Trial
P: 81 female adolescents with BN or partial BN according to the DSM-IV
I: Manualized disorder-oriented Psychodynamic psychotherapy (PDT)
C: Manualized disorder-oriented cognitive-behavioral therapy (CBT)
O: The primary outcome was the rate of remission, defined as a lack of DSM-IV diagnosis for BN or partial BN at the end of therapy. Several secondary outcome measures were evaluated.
Trained psychologists blinded to treatment condition administered the outcome measures at baseline, during treatment, at the end of treatment, and 12 months after treatment. 55 of 81 randomized participants completed the treatment (attended at least 30 sessions, mean number of attended session was 36.6. Analysis was based on the intention-to-treat principle.
The remission rates for CBT and PDT were 33.3 % and 31.0 %, respectively, with no significant differences between them (odds ratio [OR] = 0.90, 95 % CI = 0.35-2.28, p = 0.82). The within-group effect sizes were h = 1.22 for CBT and h = 1.18 for PDT.
Significant improvements in all secondary outcome measures were found for both CBT (d = 0.51-0.82) and PDT (d = 0.24-1.10). The improvements remained stable at the 12-month follow-up in both groups.
There were small between-group effect sizes for binge eating (d = 0.23) and purging (d = 0.26) in favor of CBT and for eating concern (d = -0.35) in favor of PDT.
CBT and PDT were effective in promoting recovery from BN in female adolescents. The rates of remission for both therapies were similar to those in other studies evaluating CBT.
Zipfel al. (2014) «Zipfel S, Wild B, Groß G, ym. Focal psychodynamic ...»3. Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial
P: 242 adults with Anorexia Nervosa (AN): 80 randomized to 10 months of focal psychodynamic therapy, 80 to 10 months of enhanced cognitive behaviour therapy, and 82 to 10 months of optimised treatment as usual. Mean BMI 16.7, range 15-18.5.
I: focal psychodynamic therapy and enhanced cognitive behaviour therapy
C: optimised treatment as usual
O: Primary outcome was weight gain, key secondary outcome was rate of recovery (based on a combination of weight gain and eating disorder-specific psychopathology).
Of 727 adults screened for inclusion, 242 (33 %) underwent randomisation. At the end of treatment, 54 patients (22 %) were lost to follow-up, and at 12-month follow-up a total of 73 (30 %) had dropped out. Analysis was based on the intention-to-treat principle.
At the end of treatment, BMI had increased in all study groups (focal psychodynamic therapy 0.73 kg/m(2), enhanced cognitive behaviour therapy 0.93 kg/m(2), optimised treatment as usual 0.69 kg/m(2)); no differences were noted between groups. At 12-month follow-up, the mean gain in BMI had risen further (1.64 kg/m(2), 1.30 kg/m(2), and 1.22 kg/m(2), respectively), but no differences between groups were recorded.
Study groups did not differ in terms of global outcome between baseline and the end of treatment. At 12-month follow-up, however, patients assigned focal psychodynamic therapy had a significantly higher recovery rate compared with optimised treatment as usual (full recovery, 35 % vs 13 %; p = 0.036).
Interpretation by authors: Optimised treatment as usual, combining psychotherapy and structured care from a family doctor, should be regarded as solid baseline treatment for adult outpatients with anorexia nervosa. Focal psychodynamic therapy proved advantageous in terms of recovery at 12-month follow-up, and enhanced cognitive behaviour therapy was more effective with respect to speed of weight gain and improvements in eating disorder psychopathology.
Dare et al. (2001) «Dare C, Eisler I, Russell G, ym. Psychological the...»4. Psychological therapies for adults with anorexia nervosa: randomised controlled trial of out-patient treatments
P: Eighty-four adult patients with AN (DSM-IV) were randomised to four treatments
I: Three specific psychotherapies - (a) a year of focal psychoanalytic psychotherapy; (b) 7 months of cognitive-analytic therapy (CAT); (c) family therapy for 1 year
C: low contact, 'routine' treatment for 1 year
O: Morgan-Russell clinical ratings
Focal psychoanalytic psychotherapy in the study was a standardised form of time-limited psychoanalytic psychotherapy. The time limitation and standardisation distinguish the treatment from much current psychoanalytic psychotherapy practice, which is one reason why little empirical investigation of the treatment has been undertaken. The therapist takes a non-directive stance, gives no advice about the eating behaviour or other problems of symptom management, but addresses: (a) the conscious and unconscious meanings of the symptom in terms of the patient's history and of their experience with their family; (b) the effects of the symptom and its influence upon the patient's current relationship; and (c) the manifestation of those influences in the patient's relationship with the therapist in the present and as it controls the patient's desire to get benefit from therapy (a focus on the transference).
Of the 84 patients recruited to the study, 4 failed to attend their first treatment session with the assigned therapist. Fifty-four patients completed the full year of treatment (focal 12; family therapy 16; CAT 13; ‘routine' 13). Six people dropped out within the first 2 months of treatment (focal 2; family therapy 2; CAT 0; ‘routine' 2) and a further 19 dropped out during the later stages of treatment (focal 5; family therapy 3; CAT 9; ‘routine' 2). None of the differences between treatments in the rates of engagement was statistically significant. Analysis was based on the intention-to-treat principle.
A small number of patients (12 in total) required admission to hospital during the course of out-patient treatment (2 focal; 3 family therapy; 2 CAT; 5 ‘routine'), and one patient in the ‘routine' treatment group died during the course of the study. Overall, the three specialist treatments were more likely to maintain patients in outpatient treatment than the ‘routine' treatment (p = 0.04).
There were no statistically significant differences between treatments on any of the Morgan-Russell clinical ratings. There were, however, differences in weight gain favouring the specialised treatments in comparison with the ‘routine' treatment. The difference in weight at 1 year (using initial weight as covariate) between the specialist psychotherapies and ‘routine' treatment was statistically significant (F=5.1; p = 0.03). There were also significant contrasts between focal psychotherapy and ‘routine' treatment (F=5.4; p = 0.02) and family therapy and ‘routine' treatment (F=3.9; p = 0.05). The difference between CAT and ‘routine' treatment did not reach statistical significance.
About a third of the patients in the three specialist psychotherapies no longer met diagnostic DSM criteria for anorexia nervosa (that is, their weight was >85 % ABW) at the end of the 1-year treatment period, whereas only 5 % of those in the ‘routine' treatment group escaped from this diagnostic criterion (p = 0.01). The differences were clearest for family therapy (P = 0.02) and focal psychoanalytic psychotherapy (p = 0.03). The difference between CAT and the routine treatment did not reach the criterion for statistical significance (p = 0.07).