Túry Ferenc, Pászthy Bea (szerk.)

Az evészavarok pszichoterpiájának aktuális kérdései

1. Introduction

Response to therapy or therapy response in general refers to the improvements of patients in terms of symptom status during a therapy. An initial attempt towards the definition of the word “response” can be made by its common perception: generally response is spoken of, if first signs of the efficacy (of a therapy or a medication) occur in the patient. That mainly refers to a substantial reduction of the symptom load and does not necessarily imply that the symptom status of the patient accedes back to the healthy range (Richard, 2001). In other words, it refers to how the therapeutic intervention is activating or addressing the patient’s status and leading to changes in the symptoms (and/or wellbeing) indicating an important step of improvement on the way to recovery. Frank and colleagues (1991) suggested an operationalization of the therapy response in depression research, referring to the terms symptom severity and duration of a certain symptom status during the therapy process. They suggested the terms partial remission, full remission, relapse, recovery and recurrence, which has later been adapted in eating disorders research giving a way to encounter response for eating disordered patients (Kordy et al., 2002). According to that response is the beginning of a partial remission whilst being under treatment.

Following this, the adaptation of therapeutic interventions during the therapy has the main aim to change the treatment according to the proceeding (or not proceeding) progress (response or non-response) the patient made and achieve a successful therapy outcome finally. This implies learning from the individual therapy course of a patient to set the course for the ongoing treatment. The adaptive changes/indications, related to the therapy course can on the one hand side, be drawn from the therapist’s experience, subjective evaluation, intuition and/or evoked by supervision: implying that a decision is made upon a subjective prognosis by the therapist in charge. On the other hand side data from objective symptom monitoring during the therapy in combination with empirically based findings on important time stamps can serve as the basis for a decision to adapt the therapy. Ideally, both should be combined in order to maximize the benefit by individually tailoring therapy for the (changing) needs of the patient.

However, it is important to state here that, evaluating and monitoring symptom changes of patients itself cannot provide any prognostic information in the first instance. A clarification of the relationship between the changes and the events during the therapy with its outcome is needed. The knowledge and empirical results on which changes are positively or negatively associated with the upcoming therapy course and the therapy outcome are limited. Additionally, insights terms of time aspects and important time points from where prognosis forward would be relevant and possible do not exist at a satisfying level yet.

One of the main and oldest questions regarding psychotherapies is (based on Paul, 1969): Which treatment is in which setting, under what conditions, done by which therapist effective for which client and why? But, being able to answer these questions before a therapy starts (differential indication) in order to possibly reach the highest response rates for patients would be as resumed by Grawe (1998) rather a psychotherapeutic utopia than close to any real possibilities in health care systems. First, a prediction of therapy response and outcome by a priori or in the early phase of the treatment available patient information is limited in general by empirical congruent findings and secondly, it is rarely applicable as the practical implementation of this knowledge is accompanied by rigid health care delivery routines all over Europe which constrains comprehensive individually tailored approaches. The primary as well as the secondary treatment for eating disorders are mainly standardized and thus, follow an implicit service allocation strategy that is independent of the individual patient (Kordy et al., 2006). This is not very promising in terms of prognosis as well as cost–effectiveness of a therapy and far beyond a sound match between individual patient’s needs and treatment characteristics and thus raising voices in the international literature for an individually stepped care for patients with eating disorders.

Like response to therapy, the non-response is of main importance as well and should not be lost sight of: assuming that a positive therapy outcome could be predicted for a patient showing an early, rapid, or intense response would have clearly the same therapeutic implication and extent of information as the prediction of a negative therapy outcome for patients not responding to a certain intervention. That would probably be followed by various changes and adaptations of the intervention (type, length of session, total duration of the therapy). In case that this assumption does not hold to be true or is not empirically supported, meaning both groups of patients – responders and non-responders – could have the same probability to reach a positive therapy outcome, which would regardless of the therapy outcome have important information substance for therapists and the planning and possible adaptation of an ongoing therapies.

Moreover, it is quite obvious that response to therapy for different eating disorders has common features (e.g. reduction in symptoms such as purging, if applicable, fear of gaining weight, perfectionism) and explicit features for anorexia (e.g. weight gain) and bulimia (reduction in purging/bingeing). The vast majority of studies conducted on therapy response are based on bulimia nervosa (BN) so far, but there are some empirical results in process and outcome studies on anorexia nervosa (AN) patients available as well and will be reviewed in this chapter. So far, there have been various different and intense ways of operationalizing therapy response in the general psychiatric literature body found. But all of them have in common that they are mainly assuming several and high frequent measurement points during the treatment and are dependent on the assumption what kind of events are important in line with the therapy and for the further course (e.g. length of follow-up period). Ideally, measurements of the patient and the therapist are combined. Moreover, there are basically two ways of encountering a definition of response: one via a more general approach of the status (e.g. general wellbeing or global functioning) or a symptom and disorder specific approach (e.g. BMI, purging behaviour), whereas a combination of both is applicable as well. Here, it is important to pay attention to the status itself, the amount of change which led to an improved status and the time of finally being in a remitted/improved status. The key question in most of the studies is to address the characteristics of the relationship between therapy response and therapy outcome, with respect to the predictive value of early therapy response as well as if the response itself could be predicted.

To summarize, response to therapy can be understood as a state between full symptomatic and full abstinence of symptoms during an ongoing therapy, meaning that the response to the therapy is expressed by a symptom reduction in the patient.

Patient´s response to therapy, especially the early response (or rapid response), respectively non-response to therapy have raised the attention in the field of eating disorders in the past years. The early phase of a therapy is very important for several reasons: a working alliance and patient-therapist-relationship is established, motivation for treatment is addressed and built up, the main aims for the treatment are arranged and the key symptoms of the eating disorder are assessed and treated with various therapeutic tools and ingredients. During the phase of the treatment there are contradictory results and views on early response to therapy being rather of capital importance or having marginal effects on the further course of the therapy and its outcome.

One of the earliest studies by Olmsted and colleagues (1996) examined the patterns of response to treatment in BN, with the aim of clarifying the usefulness of differentiating between patients responding rapidly vs. slowly to the therapy. Before this study, immediate/rapid/early responses had only been described in a couple of case reports. The authors found an overall large reduction in symptom status in the first week of this intense group day hospital treatment: by week 1, there was a reduction of 85% in symptoms found which only slightly increased towards 95% by termination of the treatment. Rapid responders, in total 41% of the patients, were defined as patients who had frequencies of three or less symptoms at maximum during the first 4 weeks of treatment. Whereas slower responders were defined as those who had frequencies of at least four symptoms at maximum during the first 4 weeks of treatment and less than or equal to three over the last 4 weeks of treatment (31% of the patients were in this group). All remaining patients were classified as partial responders or non-responders. The rapid responders had a 98% reduction in their symptoms during the first week of treatment and a 99% reduction by the end of treatment. However, the pattern of large reductions in symptoms during the first week also applied to the other response groups and it is thus not discriminating highly between the groups, which do not allow any further conclusions by this result. Possible explanations given by Olmsted and colleagues (1996) for these substantial high reductions for the whole sample may be the behavioural controls imposed by the treatment program which spans 40 hours per week, the patient and therapist expectations and/or the philosophy of the treatment program aiming a symptom control as soon as possible. But in general, the rapid responders were less symptomatic than slower responders at the end of treatment and were less likely to relapse over a 2-year follow-up period (15% out of the eligible rapid responders vs. 57% of the slow responders relapsed).

In a multisite study by Agras and colleagues (2000) on outcome predictors for the cognitive behaviour treatment for BN, the predictive value of early response to treatment was also among other potential predictors addressed. The authors analyzed data from 194 women diagnosed with BN. One of the main results of the analysis was that early progress in the treatment best predicted outcome. The authors used signal detection analysis to determine the most sensitive and specific algorithm to identify treatment dropouts and treatment non-responders, yielding the best predictor for poor outcome: a reduction in purging less than 70% by treatment session six. The authors concluded that this could allow an identification of a substantial proportion of prospective failures. Furthermore, they suggested that the identified cut off point (reduction in purging behaviour) by session six would usefully differentiate between patients who potentially will and will not respond to cognitive behaviour therapy for BN. According to the authors, this could allow for an early change of the therapy or implementation of a new therapy for those patients not responding and to a certain probability not benefiting from the started therapeutic intervention.

Wilson and colleagues (2002) examined the time course and mechanisms of change for cognitive behavioural therapy (CBT) for BN. The results indicated that a reduction in dietary restraint as early as week 4 mediated the post-treatment improvement in binge eating and vomiting. Moreover, by week 6 in treatment 62% of the final post-treatment improvement associated with CBT was found to be evident. Vomiting had been reduced by 80% of the patients treated with CBT and 52% of the patients treated with interpersonal psychotherapy (IPT) at the end of treatment. The authors concluded that the results were consistent with findings from others studies and that the rapid effect of CBT was not confined to BN and it appeared to be a more general phenomenon as studies in depression had shown as well (see excurse in this chapter). Following this, the authors raised questions related to methodological and theoretical implications of a rapid effect of CBT for BN as well. The main questions were related to the mediators of this early response to CBT. Wilson and colleagues (2002) stated that the effect could not be dismissed as a non-specific response to a “common factor” among equally efficacious therapies. They argued that although different psychological therapies show an initial common effect which can be interpreted as a common factor, CBT quickly shows to be more effective than alternative other therapies and produces significantly more rapid improvements, providing support for the specificity of the therapy response in this treatment modalities. Finally, the authors discussed potential explanations such as therapeutic alliance and homework assignments as not sufficient to explain these rapid effects solely.

Richard (2001) studied early treatment response as well and defined response and outcome via three key symptoms: BMI (underweight), fear of gaining weight, body perception disturbance for AN and binge eating attacks, purging behaviour, preoccupation with weight and shape for BN. Therapy success was classified as being asymptomatic or having only one out of these three key symptoms in minimal state present (not applicable for BMI and binge eating as main symptoms). The author applied several response operationalization categories depending on different outcome measures for AN and BN nervosa (for details: Richard, 2001). In total, BN patients showed higher response rates according to the applied definitions, whereas differences among AN patients were found within the different operationalization categories. In terms of response vs. non-response to treatment in relation to a successful therapy outcome, there was a difference found between the diagnoses: among all operationalizations, BN patients had a higher probability to reach a positive outcome. Additionally, therapy outcome could be better predicted by using a priori information for AN patients than for BN patients. Even while combining pre-treatment information and therapy response it still yielded in a positive association between response to treatment and outcome for BN patients. Moreover, therapy response was related to symptom status at admission: having lower symptom scores brings higher probability of showing response. Further, the results suggested therapy response to be related to long-term outcome as well, as the patients in the responder group could be classified as “success” after 2.5 years more often, but this was not holding true for all kind of applied operationalizations. One major lack of this study is that timing of response could not be assessed continuously (weekly) as a symptoms status was only available once within four weeks during the treatment. But while comparing 4 weeks and 8 weeks status there was no substantial differences noted. Moreover, aggregating the available data to four possible groups of therapy courses (responders with success, responders with no success, non-responders with success, non-responders with no success) can be considered as another limitation leading to loss of information.

According to a study by Fairburn and colleagues (2004) the prediction of outcome in BN by early change in frequency of purging is possible. The authors analyzed data from 220 patients treated with either CBT or IPT. The authors found no purging at session 6 (week 4 in treatment) as first predictor and as a second predictor the percentage of change in purging frequency at week 4 for those patients who continued to purge at week 4, whereas a reduction of at least 49% had to be achieved. The results of the study suggested that an early change in the frequency of purging was the best predictor of response both at the end of the treatment and at 8 month follow-up. It was not possible to determine whether it was certain types of patients making these significant early behaviour changes yielding in a good prognosis or whether it was the behaviour change itself that was functioning as a predictor for outcome or whether both factors played a role. But, the results imply that the first weeks in treatment seem to be especially important and particular effort should be made to maximize early behaviour change. Fairburn and colleagues (2004) refer as well to the fact that early changes predicting outcome is not only found in BN, but in psychiatric disorders as well.

Clausen (2004) broadened these results with a first study on time course of symptom remission in eating disorders. The results suggested that a remission status was reached by a long and stepwise course for both AN and BN patients. The results showed that anorexic physical symptoms remitted before the psychological symptoms of both AN and BN. For BN, bingeing and purging symptoms remitted first, whilst non-purging compensatory behaviour and obsession with weight and shape were the last symptoms to remit. Differences between the anorexic and bulimic groups between the remission orders of psychological symptoms were identified as well (for a detailed overview see: Clausen, 2004).

A recent study by le Grange and colleagues (2008) was conducted to determine whether early response predicts remission at the end of a controlled trial for adolescents with BN. The study is clearly in line with Agras and colleagues’ (2000) findings, that in trials of CBT for BN (with and without concurrent antidepressant medication) individuals reducing bingeing and purging to 50–75% from baseline level by the fourth week had a higher probability to show abstinence from bulimic symptoms at post-treatment status.

Le Grange and colleagues (2008) analyzed data from 80 adolescents with a mean age of 16 enrolled in a randomized controlled trial comparing outpatient familybased treatment and supportive psychotherapy over a duration of 6 months. The authors used receiver operating characteristics (ROC) in order to examine whether a reduction in binge-purge symptoms in the beginning of a treatment is predictive of remission status. The results of the analysis suggested that reduction in binge-purge symptoms at each session is associated with post-treatment status, whereas symptom reduction at week 6 was the strongest predictor of remission at post-treatment (and 6-month follow-up status). The optimal balance in terms of sensitivity and specificity in distinguishing between patients who reached remission status and those who did not was found to be 85% reduction in baseline binge-purge symptoms at session 6. The authors referred to the clinical implications of these findings promoting a stepped care approach, in which an adaptation of the therapy for those patients not responding by session 6 as well as a decision whether a full course of treatment is necessary for those responding early could be considered. Therefore, further research will be needed in this respect.

Fernández-Aranda and colleagues (2009) analyzed data from 241 patients seeking treatment for BN and assigned to a six-session psychoeducational group setting in order to identify predictors of treatment response. The results suggested that patients showing substantial symptom changes were younger had higher eating symptomatology at baseline and no obesity or overweight during childhood. The authors concluded from some inconsistencies in previous reports and studies and that predictors of treatment response required further research.

There have been recently a couple of studies conducted which provide further insight in the timing of response to treatment in eating disorders. For example, McFarlane and colleagues (2008) examined timing and prediction of relapse in a transdiagnostic sample of eating disordered patients. They defined “rapid response” as the immediate adherence to the prescribed meal plan, with an adherence of at least 90% for at least two weeks within the first three weeks of treatment. This was shown by 69% of the sample. The results suggested that rapid response according to this definition was a predictor, as slow response to the meal plan was associated with a higher probability of relapse: the mean time to relapse for slow responders was significantly shorter (12 months) than for rapid responders (18 months). Resuming from these results, the authors suggested as clinical recommendations to encourage clients to adopt the recommended behaviour changes immediately at the beginning of the treatment and make complete symptom control a priority.

Furthermore, Marrone and colleagues (2009) compared CBT for BN delivered via face-to-face and telemedicine and its predictors of response. The authors found significant differences between responders and non-responders to treatment: abstinence at the end of treatment and at one year follow-up was predicted by the percentage of reduction in binge eating behaviour, whereas the abstinence at 3 month follow up was predicted by the percentage of reduction in purging behaviour. The authors concluded that an evaluation of the percentage of reduction in bingeing and purging at the weeks 2, 4, 6 and 8 during the treatment are a clinically useful tool for predicting treatment response at the end of the treatment and at 3 month and one year follow-up.

Krug and colleagues (2008) studied full and subthreshold BN in terms of personality, clinical characteristics and short-term response to therapy. At the end of treatment, no significant between-group differences on abstinence rates for binge eating and purging were found, as no differences in therapy outcome, which suggests that subthreshold and full BN share the same psychopathology in terms of symptoms and recovery in line with psychotherapy.

Early response to therapy has been reported in a couple of studies on pharmacotherapeutical treatment for eating disorders in relation to the dose-effect paradigm as well. For example Walsh and colleagues (2006) found that eventual non responders to desipramine could be reliably identified in the first 2 weeks of treatment.

Contradictory to the reported findings, the results from Percevic and colleagues (2006), found no relationship between the changes made in the early phase of the therapy and the further course. The early and late change rates were independent from each other and could be described as “random walk”. Patients who did not report an improvement in their symptoms at the beginning of the therapy (nonresponder) had the same chance to improve in the further course of the therapy as the responders; on average these improvements were even higher; although the responders showed better therapy outcomes. The authors concluded that the time in therapy (duration) was not sufficient for non-responders to catch up with the level of initial improvement that the responders made. Finally, no hints could be found that early therapy session would contribute more to the final outcome than later therapy sessions do.

As described earlier, the vast majority of studies on response to therapy and especially early response to therapy addresses patients with BN. Nevertheless there are some studies examining AN patients as well. Lock and colleagues (2006) explored predictors of drop out and remission in the family therapy of adolescents with AN in a randomized controlled trial. Besides other changes during treatment, they identified an early weight gain increasing the chance of remission and thus serving as an important factor for the prediction of dropouts and success of the therapy for adolescents with AN. Another recent study by Doyle and colleagues (2009) addressed the question of whether the early weight gain could serve as a predictor of remission in a family-based treatment for adolescents with AN as well. Response to treatment was assessed by reaching a percentage of ideal body weight (IBW), with remission defined as having achieved minimum as much as 95% of the IBW at the end of the treatment. The analysis showed that reaching a weight gain of at least 2.88% in ideal body weight by session 4 was the best predictor of remission at the end of the treatment. This result implies as well that adolescents treated with family therapy and not showing a substantial early weight gain are unlikely to remit by the end of the treatment.

After a couple of studies conducted on response and especially early response to treatment in eating disorders in the past two decades, it can be summarized that there are various empirical results supporting the predictive value of early treatment response, some being not comparable due to different methodological approaches and definitions and some others rather contradictory or suggesting no relationship between the response in the beginning and the outcome or posttreatment outcome.

Finally, early response can be described as a quite robust predictor of posttreatment outcome for bulimic patients. Studies addressing response or early response in AN are rather rare and no common agreement on the predictive value, nor the concept can be drawn from the literature so far.

Az evészavarok pszichoterpiájának aktuális kérdései

Tartalomjegyzék

Kiadó: Semmelweis Kiadó

Online megjelenés éve: 2026

ISBN: 978 963 331 725 9

A jelenlegi összeállítás 13 fejezetben taglalja az evészavarok pszichoterápiájának legkülönbözőbb kérdéseit. Természetesen nincs szó arról, hogy teljességre törekedtünk, annyira sokszínűvé vált a pszichoterápia alkalmazása e krónikus pszichoszomatikus zavarokban. A fejezetek különböző terápiás lehetőségeket, gyakorlati ötleteket nyújtanak, s egy-egy új irányt is kijelölnek a pszichoterápiás kutatások alapján. Az első fejezet Walter Vandereycken professzor írása a betegségtagadásról – ő a nemzetközi evészavar-kutatás egyik vezéralakja (mellesleg a Magyar Pszichiátriai Társaság tiszteletbeli tagja). A téma a betegségtudattal nem rendelkező anorexiások megértésében és kezelésében alapvető. A második fejezet szintén elméleti jellegű, s a pszichoterápiás folyamat során jelentkező ellenállást tekinti át. A harmadik fejezet is nagy gyakorlati fontosságú, az elhízás kognitív terápiáját mutatja be. A negyedik fejezet egy hazánkban még kevéssé ismert pszichoterápiás eljárást ismertet, az interperszonális pszichoterápiát. Ezután az ötödik fejezetben a családterápia gyakorlati vonatkozásainak, a lehetséges csapdáknak az áttekintését találja az olvasó. Az új információs technológiák pszichoterápiás alkalmazásáról szól a hatodik, angol nyelvű fejezet. Mivel az angol nyelv használata közkeletűvé vált a hazai szakmai színtéren is, a fejezetet nem fordítottuk le (egy EU-projekt kapcsán hazánkban kutató szakemberek írásáról van szó). A hetedik fejezet az izomdiszmorfia terápiáját foglalja össze, a nyolcadik pedig egy hasonlóan új keletű evészavartípust, az orthorexiát veszi szemügyre. E két új zavar a közeljövőben feltehetőn egyre nagyobb figyelmet kap. A kilencedik, szintén angol nyelvű írás a pszichoterápiás folyamat időbeli sajátosságainak összegzése. A tizedik fejezet a pszichoterápiás hatékonyságvizsgálatok főbb adatait summázza, így a bizonyítékokra alapozott orvoslás jegyében igyekszik háttértudást szolgáltatni. A kötet második része három esettanulmányt tartalmaz. Ezek egy-egy érdekes részterületet dolgoznak fel: a súlyos, életveszélyes anorexia kezelését, az anorexia by proxy nevű érdekes altípust, valamint az evészavarokban szenvedő ikrek terápiáját. Bízunk benne, hogy az olvasó hasznos gyakorlati szempontokkal gyarapodik a kötet olvastán. Az összeállítást elsősorban pszichológusoknak, pszichiátereknek szántuk, de haszonnal forgathatják az evészavarok pszichoterápiájában érdekelt más szakemberek is.

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