Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

Werz, J; Voderholzer, Ulrich; Tuschen‐Caffier, Brunna

doi:10.1007/s40519-021-01281-7

Cited by 19 publications

(18 citation statements)

References 67 publications

(149 reference statements)

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“…In a recent multidisciplinary review of medication in AN [ 11 ], no psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data showing it can alleviate certain negative psychological symptoms. Nonetheless, during the clinical course of AN treatment, relief of negative symptoms is important for the construct of therapeutic alliance (TA), which was found to be a reliable predictor of outcome for various disorders in some large meta-analyses, with a positive influence on outcomes [ 16 , 17 ].…”

Section: Introductionmentioning

confidence: 99%

A retrospective study of pharmacological treatment in anorexia nervosa: 6-month and 12-month follow-up

et al. 2023

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Background Anorexia nervosa (AN) is a serious and potentially life-threatening eating disorder characterized by starvation and malnutrition, a high prevalence of coexisting psychiatric conditions, marked treatment resistance, frequent medical complications, and a substantial risk of death. Body mass index (BMI) is a key measure of treatment outcome of AN and it is necessary to evaluate the long-term prognosis of AN. This study aimed to better assess the BMI course trend between different medications and timepoints in order to improve AN treatment in clinical practice. Methods During the period 2010–2021, we retrospectively reviewed historical data of all patients diagnosed with AN. There were two groups in this study, which were based on the duration of follow-up. Group A was a 6-month follow-up group, comprising 93 patients (mean age 19.6 ± 6.8 years), with BMI assessed at three consecutive time points: first outpatient visit (T0), three months follow-up (T3), and six months follow-up (T6). Group B was a 12-month follow-up group comprising 36 patients (mean age 17.0 ± 5.2 years) with BMI assessed at five consecutive time points: first outpatient visit (T0), three months follow-up (T3), six months follow-up (T6), nine months follow-up (T9), and twelve months follow-up (T12). In our study, we retrospectively compared BMI courses based on patients’ usage of medication using the following variables: single medication, switching medications, combined medications, and without medications. The primary outcome measurement was BMI recorded at the 6-month follow-up and the 12-month follow-up respectively. In our study, which was conducted at Taichung Veterans General Hospital, we reviewed outpatient medical records of all patients with AN who were seen at the hospital during the period 2010–2021. Results In Group A (6-month follow-up), patients treated with antidepressants showed a mean BMI increase of 1.3 (p < 0.001); patients treated with antipsychotics showed a mean BMI increase of 1.1 (p = 0.01); patients treated with switching medications showed a mean BMI increase of 0.1 (p = 0.397); patients treated with combined medications showed a mean BMI increase of 0.5 (p = 0.208); and patients treated without medications showed a mean BMI increase of 0.1 (p = 0.821). The results indicated that patients with AN had a significant BMI increase after treatment with antidepressants and antipsychotics in the 6-month follow-up group. In Group B (12-month follow-up), patients treated with antidepressants showed a mean BMI increase of 2.7 (p < 0.001); patients treated with antipsychotics showed a mean BMI increase of 2.8 (p = 0.168); patients treated with switching medications showed a mean BMI decrease of 0.8 (p = 0.595); patients treated with combined medications showed a mean BMI increase of 1.6 (p = 0.368); and patients treated without medications showed a mean BMI increase of 1.0 (p = 0.262). The results indicated that patients with AN had a significant BMI increase after treatment with antidepressants at the 12-month follow-up. Conclusions AN is a complex disease caused by multiple factors. Evaluating its long-term prognosis is crucial. Our study provides insights and highlights three key findings: 1) medication adherence is crucial in treating AN, 2) frequent switching of medications may not promote weight gain and may also require a re-establishment of rapport with patients with AN, and 3) pharmacotherapy, especially antidepressants, is more effective than no treatment. Further research is needed to confirm these findings.

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Section: Introductionmentioning

confidence: 99%

A retrospective study of pharmacological treatment in anorexia nervosa: 6-month and 12-month follow-up

et al. 2023

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“…The initial work in people with ED consists mainly of a sort of emotional literacy, that is, a recognition, acceptance, and definition of those emotional states that previously had the effect of overwhelming and confusing and were felt only as annoying turbulence that prompted impulsive responses. In such a path, it is always fundamental to create a network, a psychic place in which to make space for those emotional states that were previously unacceptable due to an insufficiency of the psychic container (Werz et al, 2022).…”

Section: Discussionmentioning

confidence: 99%

Defense Mechanisms and Parenting Styles in Patients With Anorexia and Bulimia

et al. 2023

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Dysfunctional parenting styles are risk factors for eating disorders (EDs). In this observational study, we examined 57 women with ED, a psychiatric control group (n = 26), and healthy participants (n = 60). Several instruments were administered: Defense Style Questionnaire (DSQ-40) to examine the type of defense mechanism used, Parental Bonding Instrument (PBI) to investigate the perception of the relationship with parents, Eating Disorder Examination Questionnaire and Eating Disorder Inventory-3 to assess the severity of the ED, and Body Shape Questionnaire to investigate the perception of their body shape. In patients with anorexia and bulimia, neurotic factor (p = 0.007) and immature factor (p = 0.002) are associated with perception of relationship with their own parents. In the PBI, maternal care was associated with higher scores in the DSQ-40 in the immature factor (p = 0.012), whereas paternal overprotection was associated with lower scores in the DSQ-40 in the mature factor (p = 0.016). Patients with anorexia and bulimia overutilize more neurotic and primitive defense mechanisms compared with nonclinical subjects, and this use is associated with greater severity of eating symptomatology. This can be related to diversified ego forces, can inform about the nature and severity of disease, and can characterize prognostic and psychotherapeutic value.

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“…Despite the established merit of therapeutic relationships, participants in this study described a practice culture that privileged biomedical focus on weight gain. Paradoxically, the biomedical focus on weight may reduce the effectiveness of inpatient treatment for achieving weight gain and ultimately impact treatment outcomes (Werz et al, 2022). Research highlights that therapeutic alliances can increase the effectiveness of treatment outcomes (Salzmann‐Erikson & Dahlén, 2017; Werz et al, 2022).…”

Section: Discussionmentioning

confidence: 99%

“…Paradoxically, the biomedical focus on weight may reduce the effectiveness of inpatient treatment for achieving weight gain and ultimately impact treatment outcomes (Werz et al, 2022). Research highlights that therapeutic alliances can increase the effectiveness of treatment outcomes (Salzmann‐Erikson & Dahlén, 2017; Werz et al, 2022). For example, Bourion‐Bedes et al (2013) identified a correlation between consumers with AN and their perceptions of therapeutic alliances with health professionals and shorter times in achieving weight targets.…”

Section: Discussionmentioning

confidence: 99%

The focus on weight in the inpatient care of anorexia nervosa: A qualitative investigation of consumer perspectives

Zugai,

Gill,

Molloy

et al. 2023

Int J Mental Health Nurs

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Anorexia nervosa has a high mortality rate and is often treated in the inpatient setting, where close monitoring and medical support are available. Consistent with objective biomedical benchmarks, conventional inpatient treatment is often focussed on weight gain. Consumers report that clinicians provide care focussed on weight and physical restoration without adequate consideration of their full spectrum of needs. The aim of this study was to explore consumers' perspectives of the biomedical focus on weight gain in the inpatient care of anorexia nervosa. This study employed a qualitative approach, involving semistructured interviews, and participants were recruited from relevant social media communities. This study was ethically approved by a university ethics committee and the COREQ checklist ensured ethical reporting. Ten women participated in interviews. Participants reported that the biomedical imperative of weight gain is focussed on at the exclusion of other relevant determinants of well‐being, and the narrow focus on weight gain does not suitably prepare consumers for discharge. The conflict between clinicians' biomedical focus and consumers' broader unmet needs leads to harmful interpersonal dynamics and feelings of invalidation. The inpatient care of anorexia nervosa needs to develop beyond biomedically driven objectives and incorporate the merits of an approach that substantively integrates person‐centred care, therapeutic relationships and trauma‐informed principles.

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Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

Cited by 19 publications

References 67 publications

A retrospective study of pharmacological treatment in anorexia nervosa: 6-month and 12-month follow-up

A retrospective study of pharmacological treatment in anorexia nervosa: 6-month and 12-month follow-up

Defense Mechanisms and Parenting Styles in Patients With Anorexia and Bulimia

The focus on weight in the inpatient care of anorexia nervosa: A qualitative investigation of consumer perspectives

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