Emotional Expression Predicts Treatment Outcome in Focal Psychodynamic and Cognitive Behavioural Therapy for Anorexia Nervosa: Findings from the ANTOP Study
Authors: Hans-Christoph Friederich, Timo Brockmeyer, Beate Wild, Gaby Resmark, Martina de Zwaan, Andreas Dinkel, Stephan Herpertz, Markus Burgmer, Bernd Löwe, Sefik Tagay, Eva Rothermund, Almut Zeeck, Stephan Zipfel, Wolfgang Herzog
Journal: Psychotherapy and Psychosomatics (2017)

therapeutic alliance and have learned to deal adaptively with distress.Previous psychotherapy research has demonstrated that emotional processing particularly during mid-treatment predicts favourable treatment outcomes [4] .Our main hypothesis was that greater expression of negative emotions, particularly during midtreatment, is associated with favourable outcomes in AN treatment, independent of the psychotherapeutic approach.Data were obtained from a multicentre randomised controlled trial comparing 40 sessions of manualised focal psychodynamic therapy (FPT) and enhanced cognitive behaviour therapy (CBT-E) against optimised treatment-as-usual in adult outpatients with AN (for more details of the ANTOP study see [5] ).Participants were female, ≥ 18 years, and had a DSM-IV diagnosis of full-syndrome/ subthreshold AN (BMI 15.0-18.5).Written informed consent was obtained from each participant.Independent research ethics committees approved the study.Participants were randomised to receive either FPT, CBT-E, or optimised treatment-as-usual.Sessions were recorded and stored as audio files only in the FPT and CBT-E condition.Recordings were not available in 21% of the cases because either the patient or the therapist refused to give informed consent to use the recordings, and in 23% of the cases recordings were either incomplete or of insufficient quality.The analysis is thus based on the data from 89 patients (FPT: 43; CBT-E: 46), i.e., 56% of the original samples, which corresponds to similar studies [6] .These patients did not differ from those excluded regarding BMI, illness duration, eating disorder psychopathology, proportion of restricting subtype, and comorbid disorders at baseline (all p > 0.073).Likewise, FPT and CBT-E participants in this sample did not differ in these variables at baseline, end of treatment, and follow-up (all p > 0.129), except for more common comorbid MDD among CBT-E patients at baseline, χ 2 (1) = 5.169, p = 0.023.However, patients with and without comorbid MDD did not differ regarding emotional expression in any treatment phase (all p > 0.156).FPT comprised 3 treatment phases: sessions 1-15 focused on therapeutic alliance, pro-anorectic behaviour/beliefs, and self-esteem, sessions 16-32 emphasised emotional experiencing, interpersonal relationships, and their association with problematic eating behaviour, and sessions 33-40 focused on transfer to everyday life, anticipation of treatment termination, and parting.CBT-E comprised several modules: motivation, normalisation of nutrition, creating a formulation, and relapse prevention (mandatory), and cognitive restructuring, mood regulation, social skills, shape concern, and self-esteem (optional).BMI (calculated as kilograms/metres squared) at end of treatment and at the 12-month follow-up served as the primary outcome.Secondary outcomes were self-reported (Eating Disorders