[Psychoanalytically oriented treatment of anorexia nervosa. Methodology-related critical review of the literature...

Psychodynamic approaches to treatment in anorexia nervosa (AN) remain influential. It is unclear, how a psychodynamic orientation influences outcome with this patient group. To our knowledge, there exists no systematic review (sensu Cochrane) of the subject.

Extensive electronic and hand searches were conduced (updated in December 1995) to identify case reports and all longitudinal and comparison studies using "psychodynamic" treatment approaches, published in English, French and German. Case reports were examined for treatment "components". Group studies meeting operationalised criteria were independently rated for methodological quality, 12 aspects of treatment and its delivery (setting, type, orientation and focus) and therapy dose and duration. Effect sizes were calculated for post treatment and follow-up. Multiple regression analysis was used to identify outcome predictors.

Six treatment comparison studies and seven follow-up studies met criteria. In most case reports and studies treatment included different settings and techniques and an explicit focus on the symptom. In the two studies directly comparing undifferentiated psychodynamic treatment and "treatment as usual" resp. With psychodynamically based disorder specific treatments the latter had better results. Outpatient treatment was as successful as inpatient treatment (in somewhat different populations). It was not possible to identify outcome predictors.

"Psychodynamic" treatment in AN is more pragmatic and disorder orientated than generally acknowledged; patients seem to fare better in specialized treatment programmes delivered by experienced teams; less cachectic patients can be treated as outpatients by a specialized team. The exact contribution to treatment outcome of the psychodynamic orientation remains to be delineated. There is a great need for well designed and well presented treatment outcome studies.