Psychological Medicine

Original Articles

Treating severe and enduring anorexia nervosa: a randomized controlled trial

S. Touyza1 c1, D. Le Grangea2, H. Laceya3, P. Haya4a5, R. Smitha1, S. Maguirea1, B. Bamforda3, K. M. Pikea6 and R. D. Crosbya7

a1 School of Psychology and Centre for Eating and Dieting Disorders (Boden Institute), School of Psychology, University of Sydney, NSW, Australia

a2 Department of Psychiatry, The University of Chicago, Chicago, IL, USA

a3 Eating Disorders Research Team, PHSE, St George's, University of London, UK

a4 School of Medicine, University of Western Sydney, NSW, Australia

a5 School of Medicine, James Cook University, Queensland, Australia

a6 Department of Psychiatry, Columbia University, New York, NY, USA

a7 Neuropsychiatric Research Institute and the University of North Dakota School of Medicine and Health Sciences, Fargo, ND, USA


Background There are no evidence-based treatments for severe and enduring anorexia nervosa (SE-AN). This study evaluated the relative efficacy of cognitive behavioral therapy (CBT-AN) and specialist supportive clinical management (SSCM) for adults with SE-AN.

Method Sixty-three participants with a diagnosis of AN, who had at least a 7-year illness history, were treated in a multi-site randomized controlled trial (RCT). During 30 out-patient visits spread over 8 months, they received either CBT-AN or SSCM, both modified for SE-AN. Participants were assessed at baseline, end of treatment (EOT), and at 6- and 12-month post-treatment follow-ups. The main outcome measures were quality of life, mood disorder symptoms and social adjustment. Weight, eating disorder (ED) psychopathology, motivation for change and health-care burden were secondary outcomes.

Results Thirty-one participants were randomized to CBT-AN and 32 to SSCM with a retention rate of 85% achieved at the end of the study. At EOT and follow-up, both groups showed significant improvement. There were no differences between treatment groups at EOT. At the 6-month follow-up, CBT-AN participants had higher scores on the Weissman Social Adjustment Scale (WSAS; p = 0.038) and at 12 months they had lower Eating Disorder Examination (EDE) global scores (p = 0.004) and higher readiness for recovery (p = 0.013) compared to SSCM.

Conclusions Patients with SE-AN can make meaningful improvements with both therapies. Both treatments were acceptable and high retention rates at follow-up were achieved. Between-group differences at follow-up were consistent with the nature of the treatments given.

(Received December 18 2012)

(Revised March 19 2013)

(Accepted March 29 2013)

(Online publication May 03 2013)

Key words

  • Chronic enduring anorexia nervosa;
  • cognitive-behavior therapy;
  • specialist supportive clinical management


c1 Address for correspondence: S. Touyz, Ph.D., School of Psychology and Centre for Eating and Dieting Disorders (Boden Institute), School of Psychology, Room 151, Mackie Bldg K01, University of Sydney, 2006 NSW, Australia. (Email: