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Vol. 79, No. 4, 2010
Issue release date: June 2010
Psychother Psychosom 2010;79:238–248

Cognitive-Behavioral Therapy for Threshold and Subthreshold Anorexia Nervosa: A Three-Year Follow-Up Study

Ricca V. · Castellini G. · Lo Sauro C. · Mannucci E. · Ravaldi C. · Rotella F. · Faravelli C.
aPsychiatric Unit, Department of Neuropsychiatric Sciences, bSection of Geriatric Cardiology, Department of Cardiovascular Medicine, and cDepartment of Psychology, Florence University, Florence, Italy

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Background: Few long-term follow-up studies have evaluated the response to psychotherapeutical interventions in anorexia nervosa (AN). The effectiveness of individual cognitive-behavioral therapy (CBT) and the possible predictors of outcome in outpatients suffering from threshold and subthreshold AN (s-AN) were evaluated. Methods: At the beginning (T0) and at the end of treatment (T1), and 3 years after the end of treatment (T2), 53 subjects with AN and 50 with s-AN (all DSM-IV criteria except amenorrhea or underweight) were assessed by a face-to-face clinical interview and by self-reported questionnaires for eating attitudes and behavior (Eating Disorder Examination Questionnaire), body uneasiness (Body Uneasiness Test) and general psychopathology (Symptom Checklist, Beck Depression Inventory, State-Trait Anxiety Inventory). Results: No deaths occurred during the treatment and the follow-up period. At the end of the follow-up 34 subjects (33%) initially enrolled in the study obtained a full recovery. AN and s-AN patients did not show significant differences on most of the clinical measures at baseline and in terms of treatment response (T1, T2). The reduction in weight and shape concerns was associated with weight gain at T1 and T2, and the shape concern level at baseline represented the main risk factor for recovery and treatment resistance. According to survival analysis, patients with high shape concern had a lower probability of remission across time. Conclusions: The distinction between threshold and subthreshold AN does not seem to be of clinical relevance in terms of response to CBT. Shape concern rather than demographic or general psychopathological features represents the best predictor of outcome for CBT.

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  1. Harris EC, Barraclough B: Excess mortality of mental disorders. Br J Psychiatry 1998;11:173.
  2. Attia E, Walsh BT: Behavioral management for anorexia nervosa. N Engl J Med 2009;360:500–506.
  3. Steinhausen HC: The outcome of anorexia nervosa in the 20th century. Am J Psychiatry 2002;159:1284–1293.
  4. Herzog DB, Keller MB, Lavori PW: Outcome in anorexia nervosa and bulimia nervosa: a review of the literature. J Nerv Ment Dis 1988;176:131–143.
  5. Hsu LK: The outcome of anorexia nervosa: a reappraisal. Psychol Med 1988;18:807–812.
  6. Herzog W, Schellberg D, Deter HC: First recovery in anorexia nervosa patients in the long-term course: a discrete-time survival analysis. J Consult Clin Psychol 1997;65:169–177.
  7. Strober M, Freeman R, Morrell W: The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10–15 years in a prospective study. Int J Eat Disord 1997;22:339–360.
  8. Herpertz-Dahlmann B, Müller B, Herpertz S, Heussen N, Hebebrand J, Remschmidt H: Prospective 10-year follow-up in adolescent anorexia nervosa – course, outcome, psychiatric comorbidity, and psychosocial adaptation. J Child Psychol Psychiatry 2001;42:603–612.
  9. Deter HC, Schellberg D, Köpp W, Friederich HC, Herzog W: Predictability of a favorable outcome in anorexia nervosa. Eur Psychiatry 2005;20:165–172.
  10. Berkman ND, Lohr KN, Bulik CM: Outcomes of eating disorders: a systematic review of the literature. Int J Eat Disord 2007;40:293–309.
  11. Deter HC, Herzog W: Anorexia nervosa in a long-term perspective: results of the Heidelberg-Mannheim study. Psychosom Med 1994;56:20–27.
  12. Bulik CM, Sullivan PF, Fear JL, Pickering A: Outcome of anorexia nervosa: eating attitudes, personality, and parental bonding. Int J Eat Disord 2000;28:139–147.
  13. Ben-Tovim DI, Walker K, Gilchrist P, Freeman R, Kalucy R, Esterman A: Outcome in patients with eating disorders: a 5-year study. Lancet 2001;357:1254–1257.
  14. Löwe B, Zipfel S, Buchholz C, Dupont Y, Reas DL, Herzog W: Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychol Med 2001;31:881–890.
  15. Tanaka H, Kiriike N, Nagata T, Riku K: Outcome of severe anorexia nervosa patients receiving inpatient treatment in Japan: an 8-year follow-up study. Psychiatry Clin Neurosci 2001;55:389–396.
  16. Steinhausen HC: Outcome of eating disorders. Child Adolesc Psychiatr Clin N Am 2009;18:225–242.
  17. Fairburn CG, Cooper Z, Shafran R: Cognitive behaviour therapy for eating disorders: a ‘transdiagnostic’ theory and treatment. Behav Res Ther 2003;41:509–529.
  18. Zipfel S, Löwe B, Reas DL, Deter HC, Herzog W: Long-term prognosis in anorexia nervosa: lessons from a 21-year follow-up study. Lancet 2000;355:721–722.
  19. Dalle Grave R, Calugi S, Marchesini G: Underweight eating disorder without over-evaluation of shape and weight: atypical anorexia nervosa? Int J Eat Disord 2008;41:705–712.
  20. Shafran R, Farrell C, Lee M, Fairburn CG: Brief cognitive behavioural therapy for extreme shape concern: an evaluation. Br J Clin Psychol 2009;48:79–92.
  21. Fairburn CG: Evidence-based treatment of anorexia nervosa. Int J Eat Disord 2005;37:26–30.
  22. Ball J, Mitchell P: A randomized controlled study of cognitive behavior therapy and behavioral family therapy for anorexia nervosa patients. Eat Disord 2004;12:303–314.
  23. Channon S, de Silva P, Hemsley D, Perkins RA: Controlled trial of cognitive-behavioural and behavioural treatment of anorexia nervosa. Behav Res Ther 1989;27:529–535.
  24. McIntosh VVW, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, Frampton CM, Joyce PR: Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry 2005;162:741–747.
  25. Serfaty MA, Turkington D, Heap M, Ledsham L, Jolley E: Cognitive therapy versus dietary counselling in the outpatient treatment of anorexia nervosa: effects of the treatment phase. Eur Eat Disord Rev 1999;7:334–350.

    External Resources

  26. Wild B, Friederich HC, Gross G, Teufel M, Herzog W, Giel KE, de Zwaan M, Schauenburg H, Schade-Brittinger C, Schäfer H, Zipfel S: The ANTOP study: focal psychodynamic psychotherapy, cognitive-behavioural therapy, and treatment-as-usual in outpatients with anorexia nervosa – a randomized controlled trial. Trials 2009;23:10–23.
  27. Schmidt U: Cognitive behavioral approaches in adolescent anorexia and bulimia nervosa. Child Adolesc Psychiatr Clin N Am 2009;18:147–158.
  28. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, American Psychiatric Association, 1994.
  29. Ricca V, Mannucci E, Mezzani B, Di Bernardo M, Zucchi T, Paionni A, Placidi GP, Rotella CM, Faravelli C: Psychopathological and clinical features of outpatients with eating disorder not otherwise specified. Eat Weight Disord 2001;6:157–165.
  30. Fairburn CG, Harrison PJ: Eating disorders. Lancet 2003;361:407–416.
  31. Rockert W, Kaplan AS, Olmsted MP: Eating disorder not otherwise specified: the view from a tertiary care treatment center. Int J Eat Disord 2007;40:99–103.

    External Resources

  32. Thomas JJ, Vartanian LR, Brownell KD: The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM. Psychol Bull 2009;135:407–433.
  33. Faravelli C, Ravaldi C, Truglia E, Zucchi T, Cosci F, Ricca V: Clinical epidemiology of eating disorders: results from the Sesto Fiorentino study. Psychother Psychosom 2006;75:376–383.
  34. Machado PP, Machado BC, Gonçalves S, Hoek HW: The prevalence of eating disorders not otherwise specified. Int J Eat Disord 2007;40:212–217.
  35. Chamay-Weber C, Narring F, Michaud PA: Partial eating disorders among adolescents: a review. J Adolesc Health 2005;37:417–427.
  36. Fairburn CG, Bohn K: Eating disorder NOS (EDNOS): an example of the troublesome ‘not otherwise specified’ (NOS) category in DSM-IV. Behav Res Ther 2005;43:691–701.
  37. National Institute for Clinical Excellence: Eating Disorders – Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders. NICE Clin Guideline No 9. London, NICE, 2004, p 71.
  38. Mitchell JE, Crosby RD, Wonderlich SA, Hill L, le Grange D, Powers P, Eddy K: Latent profile analysis of a cohort of patients with eating disorders not otherwise specified. Int J Eat Disord 2007;40:95–98.
  39. Dalle Grave R, Calugi S, Marchesini G: Is amenorrhea a clinically useful criterion for the diagnosis of anorexia nervosa? Behav Res Ther 2008;46:1290–1294.
  40. Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Bohn K, Hawker DM, Wales JA, Palmer RL: Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Am J Psychiatry 2009;166:311–319.
  41. Garner DM, Vitousek K, Pike KM: Cognitive behavioral therapy for anorexia nervosa; in Garner DM, Garfinkel PE (eds): Handbook of Treatment for Eating Disorders, ed 2. Chichester, Wiley, 1997, pp 91–144.
  42. Pike KM, Loeb K, Vitousek K: Cognitive behavioral therapy for anorexia nervosa and bulimia nervosa; in Thompson JK (ed): Body Image, Eating Disorders, and Obesity: An Integrative Guide to Assessment and Treatment. Washington, American Psychological Association, 1996, pp 253–302.
  43. First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clinical Interview for DSM-IV Axis I Disorders. Patient Edition (SCID-P, Version 2). New York, New York State Psychiatric Institute, Biometrics Research, 1995.
  44. Fairburn CG, Beglin SJ: Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord 1994;16:363–370.
  45. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ: Temporal stability of the Eating Disorder Examination Questionnaire. Int J Eat Disord 2004;36:195–203.
  46. Cuzzolaro M, Vetrone G, Marano G, Battacchi MW: BUT, Body Uneasiness Test: a new attitudinal body image scale. Psichiatr Infanz Adolesc 1999;66:417–428.
  47. Beck AT, Steer R: Manual for Revised Beck Depression Inventory. New York, Psychological Corporation, 1987.
  48. Spielberger CD, Gorsuch RL, Lushene RE: Manual for the State-Trait Anxiety Inventory. Palo Alto, Consulting Psychologists Press, 1970.
  49. Derogatis LR, Lipman RS, Covi L: SCL-90: an outpatient psychiatric rating scale – preliminary report. Psychopharmacol Bull 1973;9:13–28.
  50. Fichter MM, Quadflieg N, Hedlund S: Twelve-year course and outcome predictors of anorexia nervosa. Int J Eat Disord 2006;39:87–100.
  51. Cachelin FM, Maher BA: Is amenorrhea a critical criterion for anorexia nervosa? Psychosom Res 1998;44:435–440.
  52. Poyastro Pinheiro A, Thornton LM, Plotonicov KH, Tozzi F, Klump KL, Berrettini WH, Brandt H, Crawford S, Crow S, Fichter MM, Goldman D, Halmi KA, Johnson C, Kaplan AS, Keel P, LaVia M, Mitchell J, Rotondo A, Strober M, Treasure J, Woodside DB, Von Holle A, Hamer R, Kaye WH, Bulik CM: Patterns of menstrual disturbance in eating disorders. Int J Eat Disord 2007;40:424–434.
  53. Roberto CA, Steinglass J, Mayer LE, Attia E, Walsh BT: The clinical significance of amenorrhea as a diagnostic criterion for anorexia nervosa. Int J Eat Disord 2008;41:559–563.
  54. Dancyger IF, Garfinkel PE: The relationship of partial syndrome eating disorders to anorexia nervosa and bulimia nervosa. Psychol Med 1995;25:1019–1025.
  55. Walters EE, Kendler KS: Anorexia nervosa and anorexic-like syndromes in a population-based female twin sample. Am J Psychiatry 1995;152:64–71.
  56. Braun DL, Sunday SR, Halmi KA: Psychiatric comorbidity in patients with eating disorders. Psychol Med 1994;24:859–867.
  57. Favaro A, Santonastaso P: Purging behaviors, suicide attempts, and psychiatric symptoms in 398 eating-disordered subjects. Int J Eat Disord 1996;20:99–103.
  58. Eddy KT, Keel PK, Dorer DJ, Delinsky SS, Franko DL, Herzog DB: Longitudinal comparison of anorexia nervosa subtypes. Int J Eat Disord 2002;31:191–201.
  59. Bulik CM, Sullivan PF, Fear J, Pickering A: Predictors of the development of bulimia nervosa in women with anorexia nervosa. J Nerv Ment Dis 1997;185:704–707.
  60. Kreipe RE, Dukarm CP: Eating disorders in adolescents and older children. Pediatr Rev 1999;20:410–421.
  61. Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN: Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord 2007;40:310–320.
  62. Keel PK, Dorer DJ, Franko DL, Jackson SC, Herzog DB: Postremission predictors of relapse in women with eating disorders. Am J Psychiatry 2005;162:2263–2268.
  63. Milos G, Spindler A, Schnyder U, Fairburn CG: Instability of eating disorder diagnoses: prospective study. Br J Psychiatry 2005;187:573–578.
  64. Tozzi F, Thornton LM, Klump KL, Fichter MM, Halmi KA, Kaplan AS: Symptom fluctuation in eating disorders: correlates of diagnostic crossover. Am J Psychiatry 2005;162:732–740.
  65. Patton GC: Mortality in eating disorders. Psychol Med 1988;18:947–951.
  66. Fairburn CG: Eating disorders: the transdiagnostic view and the cognitive behavioral theory; in Cognitive Behavior Therapy and Eating Disorders. New York, Guilford Press, 2008, pp 7–22.

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