This manual presents an evidence-based focal psychodynamic approach for the outpatient treatment of adults with Anorexia Nervosa, which has been shown to produce lasting changes for patients. The reader first gains a thorough understanding of the general models and theories of Anorexia Nervosa. The book then describes in detail a three-phase treatment using focal psychodynamic psychotherapy. It provides extensive hands-on tips, including precise assessment of psychodynamic themes and structures using the Operationalized Psychodynamic Diagnosis (OPD) system, real-life case studies, and clinical pearls. Clinicians also learn how to identify and treat typical ego structural deficits in the areas of affect experience and differentiation, impulse control, self-worth regulation, and body perception. Detailed case vignettes provide deepened insight into the therapeutic process. A final chapter explores the extensive empirical studies on which this manual is based, in particular the renowned multicenter ANTOP study. Printable tools in the appendices can be used in daily practice. This book is of interest to clinical psychologists, psychotherapists, psychiatrists, counselors, and students.
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Focal Psychodynamic Psychotherapy
Hans-Christoph Friederich, Beate Wild, Stephan Zipfel, Henning Schauenburg, and Wolfgang Herzog
In collaboration with Sandra Schild and Miriam Komo-Lang
About the Authors
Hans-Christoph Friederich, MD, is Head of the Department of Psychosomatic Medicine and Psychotherapy at the University Düsseldorf. His main research interests are the neurobiology and psychotherapy of eating disorders.
Beate Wild, PhD, is a senior scientist whose research mainly focuses on eating disorders, mental comorbidity in older age, and statistical methods.
Stephan Zipfel, MD, is Head of the Department of Psychosomatic Medicine and Psychotherapy at the University Hospital Tübingen. His research focuses on eating disorders, psychooncology, somatic symptom disorder, and research in medical education.
Henning Schauenburg, MD, is a senior physician and scientist in the field of psychotherapy and psychotherapy process research in mental disorders.
Wolfgang Herzog, MD, is Head of the Department of General Internal Medicine and Psychosomatics at the University Hospital Heidelberg. His research mainly focuses on eating disorders, somatic symptom disorder, and health care research.
Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2018952869
Library and Archives Canada Cataloguing in Publication
Friederich, Hans-Christoph [Anorexia nervosa. English]
Anorexia nervosa : focal psychodynamic psychotherapy / Hans-Christoph Friederich, Beate Wild, Stephan Zipfel, Henning Schauenburg, and Wolfgang Herzog ; in collaboration with Sandra Schild and Miriam Komo-Lang.
Translation of: Anorexia nervosa : fokale psychodynamische Psychotherapie. Includes bibliographical references. Issued in print and electronic formats.
ISBN 978-0-88937-554-3 (softcover).--ISBN 978-1-61676-554-5 (PDF).--ISBN 978-1-61334-554-2 (EPUB)
1. Anorexia nervosa--Handbooks, manuals, etc. 2. Anorexia nervosa--Diagnosis--Handbooks, manuals, etc. 3. Anorexia nervosa--Treatment--Handbooks, manuals, etc. 4. Psychodynamic psychotherapy--Handbooks, manuals, etc. I. Title. II. Title: Anorexia nervosa. English.
The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.
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The present volume is a translation of Hans-Christoph Friederich, Wolfgang Herzog, Beate Wild, Stephan Zipfel, & Henning Schauenburg, Anorexia nervosa: Fokale psychodynamische Psychotherapie (2014, ISBN 978-3-8017-2582-2), published under license from Hogrefe Verlag GmbH & Co. KG, Germany; revised and adapted for the English-speaking market.
English translation by Viola Renner
English editing by Lena Warrington
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“I do not suffer and must then be well.”
“Not only does she not sigh for recovery, but she is not ill pleased with her condition, notwithstanding all the unpleasantness it is attended with.”
Lasègue (1873/1997, p. 495)
Much of what we know about the perplexing nature of and contradictions in the psychology of anorexia nervosa goes back to Charles Lasègue’s careful and nuanced observations above. Based on these, he issued the following stark warning to clinicians:
“Woe to the physician who, misunderstanding the peril, treats as a fancy without object or duration, an obstinacy which he hopes to vanquish by medicines, friendly advice, or by the still more defective resource, intimidation.” (Lasègue, 1873/1997, p. 493)
In other words, never mistake anorexia nervosa for a passing phase that can easily be fixed.
Today, 150 years later, Lasègue’s early descriptions are still very pertinent, as anorexia nervosa remains an extremely challenging disorder to treat. Psychological therapy of anorexia nervosa is hard, as the confluence of several factors creates a “perfect storm.” Patients themselves present as inexpressive, or even outwardly bland, giving little away on how they feel. Typically they are very attached to their symptoms, minimize or down-play the seriousness of, or outright threat to their life, from their disorder and are highly ambivalent about treatment. In contrast, family members are understandably often extremely vociferous about their concerns and, in their desperation, may helplessly vacillate between bribery and threats to their relative. Clinicians themselves may feel overwhelmed, fearful, or torn between different feelings and courses of action.
This book is the first-ever evidence-based psychodynamic psychotherapy treatment manual for clinicians working with people with anorexia nervosa. It was written by leading experts in brief psychodynamic psychotherapy and in clinical management and research into psychobiology of anorexia nervosa. Based on their rich clinical and research expertise, these authors have modified the |vi|psychodynamic treatment approach to tailor it to the characteristics and needs of this challenging patient group.
The efficacy of the manualized disorder-focused treatment approach presented here was confirmed by the multi-centre randomized controlled ANTOP study of outpatient treatments of anorexia nervosa, currently the largest study of its kind. Patients found the approach highly acceptable. The authors are to be congratulated on the development of this novel, evidence-based treatment manual, which constitutes a very useful clinical and research resource.
The present manual is primarily geared towards therapists with a psychodynamic treatment orientation. However, for therapists working with other treatment approaches it constitutes a valuable aid, to help inform about the unique characteristics and paradoxes of this devastating illness. The book opens insights into the preoccupations, anxieties, and broader inner world of patients with anorexia nervosa, which form the basis for the understanding of the specific psychopathology and are crucial for the development of a robust therapeutic relationship. To help decide on the main treatment focus in a given case, the starting point for the treatment is a detailed initial interview, using criteria of the Operationalized Psychodynamic Diagnosis system. Treatment is centred around a specific therapeutic focus and, combined with a particular therapeutic stance, is structured into three therapy phases. These phases are described in detail in the book, through illustrative case stories and examples of intervention strategies and helpful patient–therapist dialog. The manual is a wonderful resource for broadening therapist understanding and behavior in relation to key features of the illness. To address nutritional aspects of anorexia nervosa, a dietetic guidance document is integrated into the manual.
The evidence from the large ANTOP study, supporting the efficacy of this approach, together with the fact that the manual has been road tested by therapists from ten large eating disorder centres across Germany, attests to the practical applicability of this manual. It is hoped that in its current translation the manual will reach a wide readership and thereby broaden options for outpatient treatment of patients with anorexia nervosa in the English-speaking world. In addition, it is hoped that the manual will act as a catalyst for future psychotherapy research.
|vii|Taken together, there are many compelling reasons to wish this book wide dissemination and uptake amongst psychotherapists and researchers alike.
Ulrike Schmidt, December 2018
Professor of Eating Disorders, Head of the Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
Lasègue, E.-C. (1873/1997). On hysterical anorexia (a).Obesity Research, 5, 492–497.
Anorexia nervosa, unlike any other chronic illness, provokes a wide range of reactions in observers from “sympathetic identification with the affected person, to curiosity and surprise, or even admiration” (Habermas, 1994, p. 14).
Restrictive eating behavior and self-induced extreme underweight are the most obvious distinguishing characteristics of anorexia nervosa. Observed from a psychodynamic vantage point, patients can be seen to be attempting to stabilize their fragile feelings of self-worth, identity, and autonomy, with the key function of triumphing over their powerful feelings of “hunger” and denouncing other primary needs. Interconnected with this are feelings of uniqueness and exceptionality. The self-destructive consequences of their forced attempts at independence are an increasing state of being underweight, which is associated with social isolation and loss of positive interpersonal contacts, and which may lead to premature death. This set of dynamics, for its part, is disconcerting, and causes in turn an intensification of the patient’s anorexic symptoms. The disease-related symptom of restrictive eating behavior is influenced by constitutional factors (genetic, epigenetic, endocrinological, etc.) and also includes sociocultural aspects.
The treatment of anorexia nervosa is seen as challenging, mostly because of the pronounced difficulty of winning patients over for treatment and having them adhere to a predetermined therapy setting. This is due to the strong fixation patients have on their symptoms (often combined with partial disease denial), which is accompanied by a pronounced avoidance, an extreme need for autonomy, and a strong subjective gratification in the symptoms. This is the reason the basic initial goal of every anorexia nervosa treatment plan is winning the patient over to the therapeutic process. In relation to treatment success, it is preferable that treatment begins in the early stages, especially because the chronic underweight tends to lead, together with psychophysiological adaptation processes, to the perpetuation of the anorexic symptomatology.
According to the national treatment guidelines for eating disorders of the American Psychiatric Association (APA, 2006), the Association of the Medical Societies in Germany (AWMF, 2011), and the UK National Institute for Health and Care Excellence (NICE, 2017), physically stable patients who are not suffering from |x|severe physical or psychological comorbidities should primarily receive outpatient psychotherapeutic treatment. Systematic analysis of the efficacy of such outpatient psychotherapy has recently been intensified. In the context of the promotion of psychotherapy networks in Germany and funded by the German National Ministry for Education and Research between 2006 and 2013, the efficacy of outpatient psychodynamic psychotherapy for the treatment of anorexia nervosa has been closely investigated. In a large, multicenter randomized controlled trial (the Anorexia Nervosa Treatment of Outpatients study, or ANTOP study), evidence from secondary analyses was collected that showed that a manualized and specifically tailored psychodynamic approach could be superior to treatment as usual (i.e., conventional treatments) at 1-year follow-up (see Section 6.2: The ANTOP Study).
Anorexia nervosa is characterized by multiple contradictory behaviors: the pursuit of an ideal autonomy and the wish for security, inner uncertainty and “splendid isolation”, the hoarding of food and starving. These aporia constitute the fascination of anorexia nervosa and are all part of the challenge of treating this disorder. The goal of this manual is to provide a deeper understanding of the discrepancies in the inner experiential world of patients suffering from anorexia nervosa. At the same time, suggestions are made for disorder-specific adaptations of psychodynamic interventions and of the therapeutic stance. Our suggestions specifically focus on the repertoire of therapeutic behavior in order to expand the range of competences in the treatment of anorexia nervosa patients.
While we were developing this manual, many patients and their families, as well as our colleagues, showed interest in, and helped contribute to, our research. A heartfelt thank you goes out to them. Especially noteworthy has been the work of C. Growther, I. Eisler, and U. Schmidt from the Maudsley Group (Institute of Psychiatry, Kings College London, UK); the work of the members of the workgroup Anorexia Nervosa in generating the German guidelines for eating disorders (under the charge of S. Herpertz), and more specifically, those for anorexia nervosa (under the charge of A. Zeeck); and that of the therapists involved in the ANTOP study, in providing valuable suggestions for the manual during the workshops; as well as the contributions of H. Kächele, A. Sandholz, and T. Grande in sharing their extensive experience as supervisors for psychodynamic therapy in the treatment of anorexia nervosa patients.
This manual was first published in German in April 2014. Due to the considerable international interest in the landmark ANTOP study, published in the journal Lancet (Zipfel et al., 2014), |xi|we decided to also publish an English translation of the manual. The current book represents a complete revision of the German publication and integrates the published research findings of the ANTOP study to date.
1 Description of the Disorder
1.3 Epidemiological and Sociodemographic Data
1.4 Predisposing Factors
1.5 Course and Prognosis
1.6 Differential Diagnoses
1.6.1 Psychological Differential Diagnoses
1.6.2 Medical Differential Diagnoses
1.8 Diagnostic Instruments and Documentation
2 Theories and Models
2.1 Psychodynamic Understanding
2.1.1 The Intrapsychic Dynamic
2.1.2 The Interpersonal Dynamic
2.2 Concepts of the Cognitive Behavior Theory Model
2.3 Family Dynamic Aspects
2.4 Sociocultural Aspects
2.5 Biological Aspects
3.1 Operationalized Psychodynamic Diagnosis
3.1.1 Axis I: Experience of Illness and Prerequisites for Treatment
3.1.2 Axis II: Interpersonal Relations
3.1.3 Axis III: Conflicts
3.1.4 Axis IV: Structure
3.2 Initial Interview and Deriving a Focus for Therapy
3.3 Operationalized Psychodynamic Diagnosis of Anorexia Nervosa
3.3.1 Relationship Patterns
3.3.2 Topics of Conflict
3.3.3 Structural Impairments
3.4 Therapeutic Handling of the Focus
4.1 Treatment Setting
4.2 Therapeutic Framework
4.2.1 Managing Weight
4.3 General Principles of Therapy
4.3.1 Basic Characteristics of Psychodynamic Therapy
4.3.2 Handling of Transference and Countertransference Dynamics
4.3.3 Work on Body Image
4.3.4 Inclusion of the Family
4.4 Treatment Setup and the Initial Phase
4.4.1 Diagnosis, Therapeutic Alliance, and Deriving the Focus
4.4.2 Basic Therapeutic Stance
4.4.3 Working on the Therapeutic Alliance
4.4.4 Uncovering Proanorexic Beliefs
4.4.5 Focusing in on Self-Esteem Problems and Depressive Experiences
4.4.6 Amendments to the Initial Phase
4.5 Middle Phase (Working With the Focus)
4.5.1 Basic Therapeutic Stance
4.5.2 Focusing on Affective–Emotional Experiences
4.5.3 Additional Work on the Relationship Focus
4.5.4 Level of Structural Integration
4.6 Closure Phase
4.6.1 Basic Therapeutic Stance
4.6.2 Stabilizing New Skills
4.6.3 Applying New Skills in Day-to-Day Life
4.6.4 Anticipating Relapses
4.6.5 Persistence of Symptoms
4.6.6 Follow-Up Care
4.7 Procedural Challenges
4.7.1 Strong Ambivalence
4.7.2 Setting a Weight Goal (When Patients Are Unable to Formulate One)
4.7.3 When Patients Hold Onto Their Anorexic Behavior, Even When Negative Consequences Escalate
4.7.4 Weight Loss in Therapy, Particularly in Regard to Weight Manipulation
4.7.5 Newly Emerging Bulimic Behavior
4.7.6 Self-Injuring Behavior
4.7.7 Medical Complications, Such as Dehydration
4.7.8 Meddling by Others – For Example, Family
4.7.9 Handling the Indication for Inpatient Admission
4.7.10 Excessive Endurance Sports
4.8 Adjuvant Therapies
4.8.1 Adjuvant Therapy With Psychopharmacology
4.8.2 Adjuvant Intake of High-Calorie Dietary Supplements
5 Case Examples
Ms. P., Age 26, With Anorexia Nervosa, Binge-Eating/Purging Type
Selecting a Focus
Beginning Phase of Therapy
Middle Phase of Therapy
Closing Phase of Therapy
Ms. R., Age 19, Anorexia Nervosa, Restrictive Type
Selecting a Focus
Beginning Phase of Therapy
Middle Phase of Therapy
Closing Phase of Therapy
6.1 Research Background
6.2 The ANTOP Study
6.2.1 Design and Participants
6.2.2 Weight Gain and Recovery
6.2.3 Predictors of Outcome
6.2.4 Therapeutic Process and Outcome
6.2.5 Cost-of-Illness and Cost-Effectiveness Analyses
8 Appendix: Tools and Resources
Nutrition Guidelines for Patients With Anorexia Nervosa
1. When Do I Eat? (Building up a Regular Meal Plan)
2. What and How Much Do I Eat? (Nutrition Components and Portion Size)
3. Taste and Enjoyment
How to Use the Weight Curve
The case studies of the French physician Ernest-Charles Lasègue (using the term anorexia hysterica) and of the British physician Sir William Gull (anorexia nervosa), both published in 1873, constituted the first detailed descriptions of anorexia nervosa (Gull, 1873; Lasègue, 1873/1997). Both authors emphasized the psychological causes of anorexia nervosa and the missing disease insight and compliance of the affected individuals. Anorexia nervosa was thus the first autonomously defined eating disorder entity. Exaggerated fasting for religious motives had been documented even earlier, with case descriptions of ascetic, fasting saints going back to the 12th century.
The current use of the term anorexia nervosa (translating as “loss of appetite due to a nervous state”) is misleading, since affected persons by no means lack appetite. On the contrary, patients suffering from anorexia nervosa of the binge-eating/purging type show fits of repeated overeating, similar to those of bulimic patients. Instead, it is the preemptive intense fear of gaining weight and the associated bodily changes that are the distinguishing symptoms. The phobia of gaining weight as the central motive for prolonged fasting was delineated as the core differential diagnostic criterion by the German-American psychoanalytic therapist Hilde Bruch. In her popular book The Golden Cage: The Enigma of Anorexia Nervosa (Bruch, 1978), Bruch helped form an awareness and understanding of the disease, not only for doctors and therapists, but also for the general public.
The diagnostic criteria of the International Classification of Mental and Behavioral Disorders (ICD-10; Chapter VF) of the World |2|Health Association (WHO, 1992) and of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) of the American Psychiatric Association (APA, 2013), with a few exceptions, show agreement regarding the disorder of the disease anorexia nervosa (see Table 1). A stable version of the 11th revision of the ICD was released on June 18, 2018 for the implementation phase (WHO, 2018). The final version is due to be released in 2022.
|5|Both classification systems define the central characteristics of the illness as underweight, a distortion of perceived body shape, and weight phobia. In addition, two subgroups (types) of anorexia patients are differentiated in the DSM-5 and the upcoming ICD-11.
Patients of the ascetic subtype show an extremely restrictive eating behavior, while patients of the binge-eating/purging subtype have, additionally, episodes of binge eating paired with active measures to effect weight loss (such as self-induced vomiting and/or the misuse of laxatives and diuretics). The validity of these subtypes has not been ascertained, because affected individuals often show a transition between the two subtypes. Especially in the first 3 years after onset, a transition from the restrictive to the purging subtype can be observed. To take this dynamic into account, the DSM-5 includes a time frame for dominant symptoms of “the past 3 months” to better differentiate the subtypes.
In comparison to ICD-10 (WHO, 1992), where the weight criteria are defined using a body mass index (BMI) of ≤ 17.5 kg/m² in adults and a body weight that falls below the 10th age-percentile in children and adolescents, the ICD-11 weight criterion is defined as a BMI of ≤ 18.5 kg/m² in adults (WHO, 2018). In the DSM-5, the weight criterion of the 4th revision (DSM-IV; “< 85% of the minimally expected weight”) was repealed and replaced with the definition of “a weight less than minimally normal” (APA, 2013). Thus, the revised weight criteria in the DSM-5 and ICD-11 will include a significantly larger group of adult patients than before.
A further classification criterion of anorexia nervosa appears in the ICD-10, which highlights endocrinological disorders for both women (amenorrhea) and men (loss of libido and/or suffering impotence). In clinical practice, the criterion of amenorrhea is often not determinable, because the use of contraceptives prior to the onset of menstruation by youths and the state of being postmenopausal in older women confound it. Thus, for the DSM-5 and for ICD-11, it was proposed that this criterion should not be included. However, it should be pointed out that anorexia nervosa patients with amenorrhea exhibit a lower bone density and a higher risk for osteoporosis compared with patients with a regular menorrhea.
A further change in the DSM-5 (see Table 1) involves a passage that, in the DSM-IV-TR, suggested a conscious refusal of patients to retain a minimum weight (APA, 2009). This description is suited neither for patients still in the stage of disease denial, nor for those motivated to take part in therapy but who have not managed to gain weight despite their efforts. Depending on the severity and duration |6|of a patient’s extreme low weight, a dysfunctional interaction begins between the physiological and psychological processes that increasingly hinder weight gain and perpetuate anorexic behavior. Appropriately, in the DSM-5 and ICD-11, the focus is on the restricted intake of energy by patients, without the suggestion of conscious or willful behavior. Furthermore, a significant number of patients deny having any fear or phobia of weight gain in their reports. Thus the phobia of weight gain criterion was extended to include any behaviors implemented to stabilize low weight, regardless of the patient’s emotional motives.
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