Antop Manual Workshop Handout

12.11.
2019
Thursday
• 09:30 -11:00 Part 5: Middle phase
• 11:00 -11:15 Coffee break
Overview • 11:15 – 12:30 Part 6 Closure Phase,
Procedural challenges
• 12:30 -13:30 Lunch
• 13:30 -15:15 Part 7 Efficacy, Research
findings, Case Example, summary
Focal Psychodynamic Psychotherapy • 15.15 -15:30 Coffee break
for Anorexia Nervosa (ANTOP-Study) • 15: 30 Roundtable discussion
Hans-Christoph Friederich
hans-christoph.friederich@med.uni-heidelberg.de
Heidelberg University Hospital | Februar 2019 | Prof. Dr. Hans-Christoph Friederich Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann
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What reactions does this

Introduction
picture triggers? • Contradictions and paradoxes
– pursuit of autonomy and whish for security
– Inner uncertainty and „splendid isolation“
– hoarding of food and starving
• The challenges of treating anorexia nervosa are

T. Habermas – strong fixation to their symptoms
Anorexia nervosa, unlike any other chronic illness, provokes a – strong subjective gratification in the symptoms
wide range of reactions in observers from „sympathetic – lack of disease insight combined with partial disease denial
identification with the affected person, to curiosity and surprise, – pronounced avoidance behaviour
or even admiration“ (Habermas, 1994, p. 14)
• -> difficulty of winning patients over for treatment
Heidelberg University Hospital | Februar
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich Heidelberg University Hospital | Februar
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
2 5
Wednesday
• 09:30 -11:00 Part 1: Epidemiology,
Classification, Medical Risk, Long-term
Overview damages Overview
• 11:00 -11:15 Coffee break
• 11:15 – 12:30 Part 2: Theories and models,
Part 1
• Epidemiology
psychodynamic treatment, OPD
• 12:30 -13:30 Lunch • Classification (ICD-11, DSM 5)
• 13:30 - 14:30 Part 3: ANTOP study, • Medical risk
therapeutic framework
• Long-term damages
• 14:30 – 14:45 Coffe break
• 14:45 – 16:00 Part 4: Treatment set-up and
the initial phase
Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann
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Spectrum of eating disorders Course and prognosis

BMI
• High rate of chronic manifestation
Binge-Eating Bulimia Anorexia
Disorder nervosa • Recovery from the disorder after 6 years on average
nervosa
• Up to 50 % are not recorded by the health system (spontaneous remission
after 5 years approx. 67 %) (Keski-Rahkonen et al. 2007)
• Clinical sample: 50 % recovery, 30 % residual symptoms, 20 % chronic form

Restrained Eating • Course of children and adolescents significantly more favourable
Weight
Impulse control
Impulsivity
Perfectionism
Irritability of Eating Behaviour
-> Early start of treatment is an important prognostic factor!
Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann

Treasure & Friederich
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2006 CUP Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann
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Epidemiology Epidemiology
Prevalence & Onset of illness Mortality (SMR) of Eating Disorders
Meta-Analysis SMR*
over 35 studies
Anorexia nervosa 5.9 Highest mortality rate of all
psychiatric diseases
3.0%
Bulimia nervosa 1.9 3 of 12 studies showed no
deaths
1.0% Increased by obesity

Binge Eating 2.3
0.6%
Disorder
*standardised mortality rate
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Hudson et al. 2007 Biol Psychiatry Heidelberg University Hospital | Februar
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Arcelus et al. 2011
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ICD 11 (Beta Version, 2017) DSM-5 (APA 2015)

Predisposing factors Diagnostische Kriterien
1) Anorexia Nervosa is characterized by
A) Restriction of energy intake relative to
significantly low body weight for the requirements, leading to a significantly low
• Main risk factors individual’s height, age and developmental body weight in the context of age, sex,
stage (body mass index (BMI) less than 18.5 development trajectory, and physical health.
– Female sex kg/m² in adults that is not due to another Significantly low weight is defined as a
– Age between 11 and 25 years health condition or to the unavailability of weight that is less than minimally normal,
food. or, for children and adolescents, less than
• Dissatisfaction with the body figure that minimally expected.
– Increased striving for slimness 2) Low body weight is accompanied by a B) Intense fear of gaining weight or of
persistent pattern of behaviours to prevent becoming fat, or persistent behavior that
– Aesthetic sports restoration of normal weight, which may interferes with weight gain, even though at
include behaviours aimed at reducing a significantly low weight.
– „Fashion Models“ energy intake (restricted eating), purging
behaviours (e.g., self-induced vomiting,
• Premorbid personality structure
misuse of laxatives), and behaviours aimed
– Emotional instability and dominance of negative affects (neuroticism) at increasing energy expenditure (e.g.,
excessive exercise), typically associated with
– Low self-esteem a fear of weight gain.
– Anancastic and anxiety avoiding personality disorder 3) Low body weight or shape is central to the C) Disturbance in the way in which one’s body
person's self-evaluation or is inaccurately weight or shape is experienced, undue
– Difficulties in socioemotional processing and affect regulation perceived to be normal or even excessive. influence of body weight or shape on self-
• Perinatal complications, feeding disorder evaluation, or persistent lack of recognition
of the seriousness of the current low body
weight.
9 Subtypes of anorexia nervosa 12
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Recommendations for medical diagnostic methods

Severity classification
ICD 11 (Beta Version, 2017) DSM-5 (APA 2015)
A) Signifikantly low underweight A) Mild anorexia nervosa
BMI ≤ 18.5 kg/m² BMI ≥ 17.0 kg/m²
• Physical examination
– Inspection oral cavity, parotid gland, skin surface, neurological assessment
B) Dangerously low underweight B) Moderate anorexia nervosa
– measurements of weight, height, blood pressure, pulse rate, and temperature
BMI ≤ 14.0 kg/m² BMI 16-16.99 kg/m²
C) Severe anorexia nervosa
BMI 15-15.99 kg/m²
• Lab analysis
– complete blood count, tests for sodium, potassium, magnesium, phosphates,
D) Extreme anorexia nervosa creatinine kinase, creatinine, urea, amylase, thyroid-stimulating hormone, and
BMI < 15 kg/m² liver enzymes
– Urine analysis
Partial remission
Criterion A (low body weight) has not been
met for a sustained period, but either Criterion • Instrumental tests
B or C is still met. – ECG, where appropriate chest x-ray, ultrasound of the abdomen,
Full remission – Bone density measurement for patients with amenorrhea > 2 years
none of the criteria have been met for a – If specifically indicated MRI, EEG
sustained period of time.
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What stands out? Psychiatric comorbidity
• Anxiety disorders, including OCD (60-83%)

• Depression (31-89%)
• Personality disorders
– Restrictive type: anxious-avoidant, obsessive-compulsive,
and dependent PS
• Anxiety disorder often precede anorexia nervosa

• Depression and OCD frequently improve with weight gain
• Comorbidities should be considered at the beginning and in

the course of treatment
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Zahnstatus Decision-making aids for inpatient

treatment
• Medical Complications
• Weight (BMI < approx. 15kg/m²)
• Suicidal tendency
• Lack of motivation for treatment / weight gain
• Psychiatric comorbidity / substance abuse / impulse
control disorder ("purging" behavior)
• Persistent weight loss or no increase over 3 months
despite outpatient therapy
• Social environment/ support, family situation
• Availability of supply structures
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Assessment of medical risk I Refeeding Syndrom

• Nutritional status • Glucose becomes a primary source of energy again after a long period of food
restriction and the insulin level
Assessment Yellow Red – Glucose, phosphate, potassium, magnesium
and H20 into the cells
BMI (kg/m²) < 15 < 13 – Protein synthesis  and with it the Vitamin B1-need 
Weight loss/ week (kg, Ibs) > 0.5/ 1.1 > 1.0/2.2 • Potential consequences:
– Phosphate   cardiac arrhythmia, dysfunction of the brain
– Magnesium   CNS-problems, cardiac arrhythmia
Trophic skin alteration (cm, <2 cm/0.8 >2 cm/0.8 – Potassium   cardiac arrhythmia, Hypotonsion
– Vitamin B1  Enzephalopathy, Coma
in)
• Temperature
->step-by-step refeeding and daily laboratory controls for
Hypothermia (°C) < 35/ 95 <34.5/94.1 anorexia patients with extreme underweight (BMI < 13kg/m²)
Treasure et 19al. 2010 Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann
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Assessment of medical risk II Long-term damages

• Cardiovascular function
Assessment Yellow Red
• Dental damages
Puls, ECG <50 <40
• Reduction of length growth
Syst. blood pressure mmHg <90 <80 • Osteoporosis, kyphoscoliosis, pain
Diast. blood pressure mmHg <70 <60 • Renal insufficiency (e.g. hypokalemic nephropathy)
BP-drop when actively > 10 > 20
• Fertility- and pregnancy rate ↓
standing-up (Orthostasis) • Pregnancy complications , birth weigtht ↓
• Muskelkraft
„Squat Test“ (active support of to balance for active support
the arms)
Treasure
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et al. 2010 Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann
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Assessment of medical risk III Dental status
• Lab
Assessment Yellow Red
Potassium (mmol/l) < 3.0 < 2.5
Sodium (mmol/l) < 135 < 130
Phosphate (mmol/l) < 0.8 < 0.5
Cave severe hypokalemia in patients from the purging subtype

through the interaction of vomiting and simultaneous misuse
of diuretics and/ or laxatives. Treasure et al. 2010
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Normal vs. osteoporotic bone Theories and Models
• Psychodynamic understanding
• Cognitive Behaviour Theory Model
• Family Dynamic Aspects
• Sociocultural Aspects
• Biological Aspects
National Osteoporotic Foundation
Notice: No oestrogen therapy in adolescents!

Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann Heidelberg University Hospital | Februar
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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Psychodynamic understanding
Intrapsychic and Interpersonal Dynamic
Overview – The Intrapsychic Dynamic (struggle for autonomy,
Part 2 general loss of control, adolescent ascetism, emotional safety)
• „Stops time“ and becomes an „eternal daughter“– remain an „integral
• Manualisation of treatment
object“ for father and mother
• Psychodynamic theories and models
 The Interpersonal Dynamic (a dysfunctional compromise between fear
• Operationalized psychodynamic of object loss and pursuit for autonomy/ independence)
diagnostic (OPD) • „I need no one, not even food“
• Separate themselves from their family by the disorder, and at the same
time prevent the physical separation from parental home through the
disorder
• The anorexic modus establishes a dysfunctional compromise between extreme

fear of object loss and the pursuit of autonomy
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2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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Manualisation of psychodynamic Psychodynamic Understanding

Family Dynamic Aspects
psychotherapy
• Adolescent process of detachment
• A contradiction?
– threshold situation for the whole family
• Task Force APA: Without a treatment manual a valide efficacy
– associated with ambivalence, moods, fast changing needs
study is not possible (internal validity!)
– Experiences of the parents with their own personal
• Manuals are not meant to learn psychotherapy, but to learn
detachment (non-detachment)
modifications in the treatment of specific diseases
• Dysfunctional attempt at solving interpersonal conflicts within
• Internalisation of the „essence“ – no cookbook
the family?
• Dissemination in clinical practice is low
• There is no scientific proof for a prototypical „anorexic family“
• But involvement of family is important for the course of
anorexia nervosa (NICE, 2017)
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2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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Basic assumption of focal psychodynamic PT Elements of the diagnostic interview II

– Dealing with detachment situations
– Dealing with loss, death, and illness
– Dealing with aggression, and self-assertion
The treatment’s relevant foci are those – Deportment when seeking help
characteristics determined by the OPD • 5. Important structural features:
findings that cause and/or – Self-perception, self-worth (What kind of a person are you? How much
appreciation do you have for yourself?)
perpetuate the disorder.
– Object perception (through the depiction of important caregivers)
It is assumed that progress in therapy can
– Affect differentiation (the experience of aggressive and affectionate
only take place if some aspects of the foci
impulses, and tensions)
are changed.

November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann
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Operationalized Psychodynamic Diagnosis OPD – Axis II interpersonal relations

Basic structure
• FPT requires thorough and precise
I
psychodynamic diagnostics
Perspective A: Experiences of the patient
• The interview guidelines of the OPD-2 allow
for a comprehensive psychodynamic The patient experience herself The patient experiences others again
towards others again and again that and again, that they …
diagnostics on four axis she…
– patient‘s disease experience (I) takes special care of others overlook/ abandon her
– maladaptive interpersonal relations (II)
– life-determining, dysfunctional conflicts (III) II Perspective B: Experiences of others, also the therapist IV
– deficits in psychological ego functions (IV) Others, including the therapist Others, including the therapist
• This approach ensures that the main experience the patient that she again experience themselves against the
and again … patient again and again, that they
psychodynamic aspects are the main focus of
treatment determines, controls and make withdraw from the patient, closes
demands themselves off
• The correct use of the interview guidelines
III
requires the completion of a training seminar
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2017
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| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
32 35
Elements of the diagnostic interview I Operationalized Psychodynamic Diagnosis

• 1. Symptoms and their severity and chronicity, and comorbidities Example relationship pattern
• 2. Symptom presentation, the degree of illness denial and subjective
suffering, as well as social and personal resources • Typical relationship dynamic
• 3. Distinguishing central interaction partners, and patterns underlying
these relationships Anorexia nervosa helps me
– Description of parental figures and changes over the years, central establish a border between
conflicts with parental figures myself and others without having to separate myself
– Important sibling and peer relationships, personal role in the peer
group
from them. This is important to me because I
– Relationship experiences, and fears and wishes for romantic experience others as being particularly dominating,
relationships and friendships while at the same time I harbor an intense fear of
• 4. Central conflict themes: possibly losing them. Therefore, I express my need for
– Most frequently experienced: need for care versus self-sufficiency,
submission versus control, and occasional individuation versus
care with my skinniness. However, when someone
dependency cares for me, I react by feeling guilty and withdrawal.
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2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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OPD – Axis III: Conflicts

Vignette 2
• 1. Individuation versus dependency „Professional goal: Criminal court judge”
– Central motive is intense closeness/ striving for independence
– Lead affect: existential fear of loss/ existential fear of closeness
• 2. Submission versus control • Audiofile
– Central motive is to dominate the other/ is to submit to the other
– Lead affect: lust to submit, rage/ defiant aggressivity, lust for power
• 3. Need for care versus self-sufficiency
– Central motive is to whish for care/ is to care for others (altruistic mode)
– Lead affect: Sadness, depression/ worry about others, latent depression
• 4. Conflicts of self-value
• 5. Guilt conflicts
• 6. Oedipal sexual conflicts
• 7. Identity conflicts
• 8. Limited perception of conflicts and feelings
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Vignette 1 „The good daughter“ Vignette 2

„Professional goal: Criminal court judge”
• Audiofile • She weighs herself about 30 times per day and uses every
opportunity to look at her figure in either mirrors or windows
• Massive discussions about the basic conditions of therapy and
first goal agreements: “You cannot give me an ultimatum; I will
fight against that with everything in my power.”
• She experiences the therapy contract as an external regulation
and reacts to it with defiant aggression in ripping up the therapy
contract or, remaining silent for entire session.
Lead affect: defiant aggression
Conflict: Control versus submission conflict, with an active

mode
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Vignette 1 „The good daughter“ Vignette 3

The „unapproachable beauty“
• “She studies a lot for school, gives tutorials, helps her mother
with housework and grocery shopping, volunteers at church, • Audiofile
etc. She “cannot allow herself any breaks” and feels
overburdened and under pressure.
• “Ms. U. has the notion that as the youngest, she needs to
“hold everything together” and live up to her parents’
expectations; she therefore involves herself at church.”
• Ms. U. reports a constant anxiety to please others (parents,
peers at school, friends, siblings).
Lead affect: worry about others in order to repress feelings of
depression
Conflict: Need for care versus self-sufficiency conflict, with a
mixed but active mode
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Vignette 3 The „unapproachable beauty“

• The critical development was, in part, brought about by her
mother’s cancer diagnosis (metastasis of breast cancer), and
was intensified because of the increasingly close relationship Overview
to her boyfriend (e.g., plans for moving in together). Part 3
• Ms. B. always viewed independence as an important quality. • ANTOP Study
At only 13 years of age she went on a student exchange
• Therapeutic framework
program; when she was 17 years old she joined a group that
took a bike tour through America.
• While living with her boyfriend, she experienced his every
departure as abandonment.
Lead affect: existential fear of closeness and merging
Conflict: Individuation versus dependency conflict, with an

active mode
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Axis IV: Structural impairments Research background
• Basic questions in patients with structural impairments

• Methodological obstacles
• Is the patient unwilling or not able? – Control group that wait for treatment or receive an
• How much responsibility can I put in her? inadequately supportive therapy is ethically not justifiable
• Should I confront her or should I be careful?
– low prevalence rate make RCTs expensive
• Should I encourage her to take the initiative, or should I rather guide her?
– high dropout rates
– physical complications or extreme underweight that
The clearer the structural impairments, require inpatient treatment
the greater the focus on stabilising interventions
– median duration to recovery is about 5-6 years
The basic approach in this patient is…
– > to date, only marginal evidence exists for the efficacy for
Conflict related mixed Structure related psychotherapy
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2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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Operationalized Psychodynamic Diagnosis Research Background

Examples of Structural impairments RCTs
• In recent reviews, 5 clinical trials of individual outpatient
• Experience of affect and affect differentiation
psychotherapy of adult anorexia nervosa patients were
– Affect avoidance and difficulties to differentiate between varying
feelings (e.g., fear, anger, boredom) identified (Brockmeyer et al. 2017, Stuart et al. 2018)
• Impulse control • CBT-E, MANTRA, FPT (one trial) showed some advantages
– experience their own affective impulses as being „bad“ - over treatment as usual or SSCM (Brockmeyer et al. 2017)
-> either suppressing their affects or transferring their affects into • But, no specific approach has proven superior with respect to
physical activity
weight gain
• Self-worth regulation
– high level of offense -> self-depreciation or social withdrawal • Most studies used small samples and short treatments (e.g.
• Detaching from relationships 20 sessions)
– Subliminal object dependence (despite a superficial autonomy) • ANTOP study (Zipfel et al. 2014): large multicentre RCT with a
• Accepting help treatment length of 10 months incl. 40 sessions
– Unability to ask for or accept help, despite heightened levels of
neediness
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Zipfel et al. 2014 Lancet
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ANTOP Treatment
Therapeutic framework
FPT, CBT-E versus „treatment as usual“
10 Centres Centre directors
Bochum Prof. Herpertz The framework imparts security and
Erlangen Prof. de Zwaan supports weight gain as well as
Essen Prof. Senf
the integration of new
Freiburg Prof. Zeeck
Hamburg Prof. Löwe experiences
Heidelberg Prof. Herzog
München Prof. Henningsen
Münster Prof. Heuft
Tübingen Prof. Zipfel
Ulm Prof. v. Wietersheim
Data management:
Coordination Centre for Clinical Studies
(KKS) Marburg
Biometry: Heidelberg
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Zipfel et al.49 2014 Lancet
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ANTOP Treatment
Study protocol (N=242)
Therapeutic framework
• Body weight monitoring weekly prior
to the session
CBT-E – Weekly goal for weight gain: about 400-600g [14-21 ounces] (not to
(10 months/
40 sessions) Study Visits: T4 exceed 1000g [35 ounces])
T1 1-year – Documentation on a weight curve by the patient
(after 4
months of
follow-up
• At the beginning, weight should be discussed at the opening
FPT treatment)
Anorexia Randomi- (10 months/ of every therapy session (until e.g. an increase of > 1 BMI unit)
zation 40 sessions) T2
nervosa
(EoT)
– Cave: cheating and deception
T3
• Regular meal structure (three main meals, three snacks)
TAU-O
(3-month FU) – Nutrition guidelines for patients with AN are handed out to the
(10 months) patients
• Regular medical monitoring by their general practitioner
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
(Treasure et al. 2010)
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2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Wild et
50 al. 2009
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ANTOP Nutrition Guidelines for Patients with AN

Treatment manuals Dear Patient,
CBT-E FPT With the following guidelines, we would like to inform you about
the general aspects of a balanced and healthy diet, as well as
describing the specific noteworthy aspects of rebuilding
nutrition after long periods of undernourishment and
malnutrition…..
• When Do I Eat (Building up a regular Meal Plan)
• Mandatory modules: motivation, nutrition,
• Operationalised, psychodynamic diagnostic • What and How Much Do I Eat? (Nutrition Components and
interview (OPD), selecting a focus
creating a formulation, relapse prevention.
• Optional modules: cognitive restructuring,
• First Phase: therapeutic alliance, self-esteem, Portion Size)
ego-syntonic beliefs, ..
shape concern, mood regulations, social
skills, etc.
• Middle Phase: Relevant relationships and
association with anorectic behaviour
• Particular Specifics After Long-Term Fasting or Laxative Use
• Homework
• Closing Phase: transfer to everyday life,
 Weighing by therapist
treatment termination • Examples of daily plans
Weighing by study assistants
• Taste and Enjyoment
TAU-O
(„treatment as usual - optimized“ ; outpatient psychotherapy
and structured visits with family doctors) 51
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Treatment General Principles of Therapy

Therapeutic framework Basic Characteristics of Psychodynamic Therapy
• Weight and its progression are helpful barometers in therapy • Observation of habitual defense mechanisms and finding an
– „The normalization of weight is not everything, but without appropriate discourse for them (e.g., by challenging the
it everything is naught“ (Schors and Huber, 2003) avoidance of difficult topics during therapy)
• Explanation of the medical complications and consequences
• A prerequisite for processing underlying fears, affects and of anorexia nervosa
conflicts is the abstinence from symptom behaviour • If indicated, careful determination of unconscious or
preconscious wishes, impulses, or anxieties (e.g., by working
with dream content)
• Weight loss and extreme low weight cause an emotional
numbness (Brockmeyer et al. 2018) • If indicated, the handling of tensions in the client–therapist
relationship (e.g., wishes and fears in relation to the therapist)

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| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
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Treatment General Principles of Therapy

General Principles of Therapy Handling Transference and Countertransference Dynamics
• Using general psychodynamic principles of intervention
(Summers and Barber 2012) • Tension between free development and individuality and the
– Empathy with the inner experience of affect and fears and their rules and boundaries inherent to treatment („tightrope walk“)
verbalization • The therapist has to overcome (endure) the patient‘s feelings
– The broaching of „unacceptable“ feelings of helplessness, impulses of withdrawal, defenses and self-
– Connecting current experience to past experience control
• Handling transference and countertransference dynamics • Therapy success should be adapted to the severity of the
– Balancing allowing for autonomy and assuming care involves a disorder (even small sucesses should be valued!, Supervision
tightrope walk is of importance)
• Body image • Countertransference of a heightened effort to be helpful
– Work on body awareness is an essential prerequisite for the could be interpreted by the patient as a signal of the
subsequent work on self-confidence
therapists own neediness
• Inclusion of the family
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2017
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| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
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General Principles of Therapy Ambivalence in the relationship

Basic Characteristics of Psychodynamic Therapy dynamic
• A respectful, empathic, accepting, and impartial (i.e., not
oriented to personal interests) therapeutic stance
• Facilitation of the patient’s freedom of expression
• Empathy with the inner experience of affect and fears and
their verbalization
Support
• The broaching of “unacceptable” feelings Autonomy Take care
• Centering in on interpersonal relationships, especially on
repeatedly unfavorable relationship patterns
• Connecting current experience to past experience
• Illustration of symptom-triggering situations
• Development of an alternative understanding of conflict
situations
Tightrope Walk
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General Principles of Therapy

Work on Body Image
Inclusion Family – Organization of Session
• Awareness of the body should be incoporated in therapy
• No primary deficit in body perception, but rather a disturbed affective Adressing frequent doubts that surround family sessions
modulation of body perception • Therapist: Maybe you are worried about what could be uncovered and
• Body checking should be discussed which emotions could bubble up, including your own, when everyone gets
together here?
• Body Image problems usually increase with weight gain and are closely
associated with affective comorbidity • Therapist: What are you expecting? How will your parents react when you
reveal how you are really feeling?
• Imagination techniques allow the patient to experience „hands on“ how
emotional factors influence the perception of their body • Therapist: Our experience is that problems and anxieties are often left
undiscussed in families. The family session can be a venue in which such
• To develop a more empathetic and friendly relationship to their body
topics can be discussed.
(reduction of self-damaging behaviours)
• Patient‘s reactions: While growing up I never learned to confront conflicts,
• Symbolic interpretation of body perception can be a first step in gaining an
and I was never really honest. During the family session, this became clear,
understanding of repressed emotions
and I felt like I was sitting next to strangers. A lot of things weren’t talked
Intervention Example: Discontent with body image about in our family. I have learned to be honest with myself and also with
Therapist: What does your body want to communicate to you? others. I can now accept my weaknesses more easily and express my
Therapist: What would be the message your body would send if it could voice an opinion? feelings to others.
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Inclusion Family
• Family orientation sessions (no family therapy in the strict sense) Overview
• Diagnostic aspects are in the foreground
– Patients tend to trivialize relationship conflicts and strives for a
Part 4
• Treatment Set-Up
counterproductive harmony
– Confrontation with their family members helps to uncover • Initial Phase of treatment
current relationship conflicts
• Procedure
– All family members of the core family (parents, siblings) are
invited (alternative couple session, if appropriate with children)
• Contradictions for conducting family sessions
– Family violence
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General Principles of Therapy Treatment – Initial Phase

Inclusion Family – Organization of Session Treatment Set-Up
• Joining Phase (connecting with each family member)
– Small talk („How did the family get to the session today“)
• Basic therapeutic stance
• Central topic: relief from any imagined blame, for the parents the – A directive but empathic therapeutic stance
family session is often synonymous with clarifying the question who – Caution: coping with personal helplessness
is to blame for the illness. • Patients should be convinced that treatment is required
– Multifactorial origin of AN, no prototypic anorexic family – Risks and consequences of AN should be discussed
– Involvement of the family is relevant for the course of the
• Additional pressure by suggesting weight gain in the first four
disorder
weeks should be avoided
• To approach the topic of illness
– e. g. agreement during the first four weeks to maintain body
– Circular questioning (e.g. the patient may be asked „What do
you think your farther believes is an important topic“)
weight
• Psychoeducation: information about the characteristics of the • Possible obstacles to success should be addressed
disorder – e.g. fear of gaining weight or fear of becoming dependent
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| Prof.
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Hans-Christoph
Max Mustermann
Friederich
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Therapeutic Stance in the Initial Phase

• Creating a secure framework, giving structure, focusing in on
Treatment Initial Phase
anorexic behavior while explicitly avoiding pressure, Working with the symbolic character of AN
empathizing with the natural fears of the patient, verbalizing • Interventions examples:
inner experiences, coping with personal helplessness. – Therapist: How could you regain your appetite for life?
– Therapist: What message do you think not eating food and
Intervention Examples not swallowing gives?
• Supportive aspects – Therapist: You are conveying a message with your weight –
– Therapist: It really is a shame that your illness kept you namely, a worry that you are not being seen or respected.
from going to college. – Therapist: Is all the pressure you are putting on yourself
– Therapist: I believe that you don’t deserve to be as lonely making you smaller and giving you the feeling of literally
as your anorexia is making you. disappearing?
• Patient’s prolonged silence – Therapist: Does the constant weight loss also express an
– Therapist: Are you having difficulty in finding a way to talk inner exhaustion of resources, as if you were trying to say
about your feelings? “I just can’t anymore”?
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Clinical Vignette
Treatment – Initial Phase
Avoidance of affects and denial of illness
Working on the Therapeutic Alliance
• Therapist: How are things going right now with eating? How do you feel
• Ambivalence is a natural part of the transformation process. while preparing your meals or eating your food?
However, it is not a state worth lingering in. • Patient: Yes, it’s going well. I prepare my meals in the kitchen, and then I
• Strengthen those personality traits that motivate weight gain. take them with me to the balcony. With this wonderful weather we’re
Allow the healthy (not anorexic) voice to get a chance to speak. having, it’s really a treat to eat outside.
• Therapist should avoid to get entangled in argumentation, • Therapist: Does eating represent indulgence and pleasure to you?
i.e. to pursue „dancing not wrestling“. • Patient: Yes, it’s always been that way for me.
• Discuss the mismatch between present and desired state of • Therapist: Is there maybe another side to eating within you? A side of
living eating that has a different connotation? What does that side feel like for
e.g. to anticipate how life could be in 5 years‘ time. you, when you are preparing a meal or getting ready to eat the food
• Focus on the self-worth theme and depressive experiences prepared?
e.g. to question the negative beliefs about the self. • Patient: I prepare my food in such a way that I like eating it. The only
thing is, I always have to leave a little bit leftover. I just can’t seem to eat
the entire portion. I don’t know why that is, I can’t really explain it.
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2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
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Treatment Initial Phase

Working with pictures or metaphors
• Intervention examples: The „inner advisor“ anorexia nervosa
– Therapist: Do you have an inner advisor that forbids you to
eat food? What happens when you ignore this inner
advisor?
– Therapist: How can we succeed in silencing your inner
anorexic advisor and build trust in the therapy? Which positive roles does the anorexic disorder fulfill for the
– Therapist: What is necessary for you to trust me as much patient?
as you trust your inner anorexic voice? QUIZ
Initiate reflection processes
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Treatment – Initial Phase Intervention Examples

Uncovering Proanorexic Beliefs and Thoughts Overassimilation
Emotional security
Control
Attractiveness • Therapist: The people who are always nice and well behaved
Self-confidence aren’t necessarily always appreciated. They notice that other
Avoidance of feelings people are using them, but they’re afraid of peoples’
reactions if they were to say no – as if everything would then
Being special
be lost.
Fitness
Success
Attention
No menstruation
Serpell et al. 1999
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
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Treatment – Initial Phase Intervention Examples

Focusing on the self-worth theme and perfectionist expectations of self
depressive experiences
• Patient: I’m only loved when I’m really perfect. I only have
• Low self-esteem -> drop out rate ↑ value when I don’t make any mistakes.
• Interventions that strengthen the often fragile self-esteem • Therapist: It’s hard to watch how much pressure you put on
• Identification of negative believes about the self yourself. It’s like you’re trying to be superhuman.
• Therapist: What would you lose if you were less self-critical
and less achievement-oriented?
Question these dysfunctional beliefs in order to turn

them ego-dystonic
74 77
Intervention Examples Clinical Pearl

Handling negative beliefs (How?) Avoiding power struggles
• Therapist: If you could slip into someone else’s shoes and look
at yourself from an outsider’s point of view, would you still • In the initial phase of treatment, the greatest danger for the
come to the conclusion that you are unlikeable? How would therapist is getting locked into a power struggle about eating
your friends and relatives judge you? (Outside perspective) behavior and weight. If this occurs, the patient will inevitably
feel helpless and inferior and begin a process of inner
• Therapist: You say that you felt small and helpless in this
devaluation.
situation. In retrospect, what is your assessment of the
situation now? Can you see differences between your feelings
then and your rational evaluation right now? (Contrasting
emotional experience and rational interpretation)
• Therapist: When was the last time that you really felt strong
and resilient when relating to other people? (Identify
exceptional situations)
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Example of a letter to Overview interventions in the Initial Phase

anorexia nervosa as a friend Supportive Interventions
• Constructing a beneficial therapeutic relationship (empathy,
Dear Anorexia,
support, acceptance of affect experience in a nonjudgmental
You were always there for me when others ran out on me or manner)
abandoned me. You are a loyal companion and have often
helped me. • Attempting to identify with their split-off submerged aspect of
Others think that you are injuring me, but the truth is that your life
support helped me survive. • Reinforcing self-esteem (acknowledging, relieving their
Without you, I would have been aimless and lost, like a satellite conscience, modifying demands on the self)
in space. You give me something that I can concentrate on • Supporting situations in which the patient feels like the
when my world threatens to fall apart, and you give me back initiator of competent actions
a bit of the control that I have lost.
• Both patient and therapist should be aware of the possibility
of remission and discuss change (Caution: The therapist must
guard against countertransference of helplessness).
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Inner disruption
Overview
Part 5
• Middle Phase
• Working with the Focus
80 83
80 83
Topics of letters to „Anorexia as an Enemy“ Treatment – Middle Phase

• The feeling of being at the mercy of the illness Therapeutic Stance
• Social withdrawal, together with the loss of friendships and • A less directive, educational and controlling attitude
relationships
– encourage working alliance between patient and therapist
• Abandonment of eduction, employment, and career goals
• Reduction in control of weight goals (if possible)
• Feelings of having wasted time, not taking part in life
• Identifying problematic experiences in relationships (focusing
• Current physical problems and fear of future medical
problems on affective components)
• Depression and irritability • Supporting an exploratory trial and error approach to the
main difficulties
• Feelings of having been tricked by the illness
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2017
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| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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Treatment – Middle Phase Treatment – Middle Phase

Clincial Vignette (Connection emotional experience and eating behaviour)
Interventions that support emotional experience Therapist: It seems difficult for you to address problems that stand between
yourself and your parents.
Weight gain increases the patient‘s ability to perceive their own Patient: Yeah, um, exactly – there are many situations where I don’t dare
emotions.. show my parents the anger that I’m feeling when I talk with them.
Therapist: What is your worry? What could possibly happen if you talked
• Mirroring and clarifying affects about your anger?
• Offering relief from affect (“permission”) Patient: I don’t know, I’ve never thought about that before. Maybe because I
just don’t trust myself and then jump to an overly hasty conclusion about
• Intensifying affect experience (“delving into”) what might hurt my parents. I often feel too heart-broken and angry to talk
• Establishing a connection between affects and relationship about that with my parents.
experiences Therapist: It seems like you are worried that you might hurt your parents?
Patient: Yes, partly I am. I’m worried that I won’t be objective in such an
• Identifying the triggers of affects emotionally strained situation, and so I tell myself that it’s better not to talk
• Assigning affects to the present and the past about it at all.
Therapist: What influence do these situations have on your eating behavior?
• Developing distance from affects Patient: On those days I really have trouble eating anything at all. I think I
punish myself for my intense emotions by not allowing myself to eat.
Therapist: …. November20192017| Prof.
Heidelberg University Hospital | Februar | Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
85 88
Treatment – Middle Phase

Clincial Vignette (Intesifying the emotional expierence)
Focus on Affective-Emotional Experience •Therapist: You seem very aware of what you eat in comparison with what your boyfriend
eats.
•Patient: Yes, I do notice that, that’s true. When he eats more than I do, I’m relieved. However,
when I eat more than he does, I immediately feel uneasy.
•Therapist: How do you experience those situations when your boyfriend eats a small portion?
Is your experience such that you really don’t feel hungry any-more, or do you forbid yourself
from eating more even if you’re still hungry?
•Patient: My throat tightens up, and I feel sad or angry, and I no longer feel like eating. I don’t
feel hunger in these situations.
•Therapist: How can it be understood that you react so intensely in those situations? What are
you afraid of?
•Patient: I don’t know – maybe that I might gain weight, that I won’t be able to stop eating.
• Maladaptive relationship patterns represent important •Therapist: So it’s about control? Let’s suppose that you would eat more than your boyfriend,
what feeling would come up?
material for therapeutic work
•Patient: A fear, a fear of being too greedy – a glutton, a person that doesn’t have herself
• Patients should learn how affect experience is linked to eating under control.
behaviour •Therapist: Where do you have that feeling in your body?
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
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Treatment focus-oriented approach Treatment – Middle Phase

Interventions for work on the relationship focus
If an issue not defined Deactivation of the issue and
in the focus is activation of a theme defined in the • Differentiating the subjective relationship experiences (“What exactly do
activated focus you mean by …”; “I haven’t fully understood what it was that you
experienced when …”)
• Distinguishing between perception of self and the perception of others
Further
(“In this situation you felt as if …; I wonder how X felt?”)
Yes • Determining active and reactive aspects of personal behavior (“Did you act
development of the
problem out of fear, or because you wanted to attain X?”)
Affect tolerance
Yes • Uncovering in part ambivalent paradoxes in the construction of personal
sufficient?
relationships (e.g., fear of closeness in spite of the wish for relationship)
Is an issue defined in Deactivation and
No • Working out the cyclic maladaptive pattern in relationships (self-fulfilling
the focus activated stabilisation
prophecy) and the dysfunctional effects on self-perception
• Working on hidden wishes and fears (in an advanced stage of therapy)
No Instruction, resistance- and
countertransference-analysis
Wöller & Kruse 2007 Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann
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Clincial Vignette (work on the relationship focus) I
Clinical vignette Ms. I– Structural impairments
• Therapist: What is it about your mother that makes you so mad?
• Patient: I’m angry because in my mother’s eyes, I always do everything
wrong: I’m not raising my children right; my house isn’t tidy enough
• Therapist: Mhm (affirmative). So I have the feeling that you are always Ms. I. is in her mid-40s with haggard facial features; she is living
being criticized, no matter what topic you introduce with your mother. with restrictive anorexia nervosa that she has had since her
• Patient: At times I am able to express my anger in some situations. Just youth. At her orientation visit to the outpatient clinic, she
yesterday I told her that it is none of her business how we go about doing
presents with a BMI of 16 kg/m². The recommendation for
things.
further care came from the clinic that had previously treated her
• Therapist: How does your mother react when youx say something
after she was admitted with extreme low weight (BMI at clinical
• like that?
admission: 11 kg/m²). Her current weight is the most she has
• Patient: Then she gets angry. She said, “You can’t keep going on like this.”
weighed since the illness began when she was 13 years old. Even
• Therapist: How is it for you when you vent your anger like that?
though she has usually had a critically low weight of BMI 15
• Patient: On the one hand, I think that I might have been a bit direct and
mean-spirited. I think she is ashamed of my illness, but on the other hand, kg/m², she was, with medical help, able to give birth to three
that is none of her business anymore. It’s my life. She shouldn’t meddle in children.
my life.
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Treatment – Middle Phase Treatment – Middle Phase

Clincial Vignette (work on the relationship focus) II Clinical vignette Ms. I– Structural impairments
• Therapist: So, do you feel relieved, or do you have a guilty conscience? Contact with the patient is difficult; she controls the
• Patient: Afterwards I do have a guilty conscience. conversation and remains pale and inanimate; she regularly ends
• Therapist: How would you wish it to be? the session on her own accord 5 minutes before time is up. Due
• Patient: That she learns to accept me and my life, and that she doesn’t to her excessive control, any flexible handling of wishes or
criticize me nonstop. affects is obviously very constricted. Aggressive impulses are
• ….. countered with self-deprivation or bound up in “masochistic”
• Therapist: In my opinion, a part of you really likes your mother. What appearing excessive exercise. She feels totally overburdened and
would it be like if all of a sudden your mother would approach you and under extreme pressure from her three children, and by her
praise you – praise you for managing your life even with your illness, and
profession and her housework. In addition, her husband is often
ask if there was any way she could help?
away on business. She is unable to care for herself or accept the
• Patient: (Becomes sad and begins to cry.) I always wished that exactly that
would happen. help she needs.
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Treatment – Middle Phase (Structural impairments)

Treatment –Middle Phase Clinical vignette Ms. I: Affect experience & differentiation
Structural impairments Therapist: The weight curve shows multiple episodes over the past 3 months
where you temporarily lost 2–3 kg (4.5–6.5 lb). Can you remember what was
different in those phases?
Patient: Mhm, no, I don’t know.
Therapist: Could it be that those episodes coincided with the business trips that
your husband took overseas?
A low level of structural integration requires a less Patient: Let me think. Yes, that pretty much fits with the dates of his trips.
confrontational approach Therapist: I feel overwhelmed when I think about you having to organize all of
that alone while your husband was overseas.
Patient: That really doesn’t make a difference, since my husband always works
really late and just comes home to sleep.
Therapist: Mhm, regarding your eating behaviour it does seem to make a
difference. I think it could be important to look at what that difference might be.
Patient: I can’t really see any connections.
Therapist: I have the feeling that you often stop eating and do lots of exercise,
when you feel lonely and stressed.
Patient: (Wearily) I haven’t noticed that yet.
Therapist: ….
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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Treatment – Middle Phase (Structural impairments)

Clinical vignette Ms. I: impulse regulation Treatment – Middle Phase (Structural impairments)
Clinical vignette Ms. I: self-worth regulation
• Therapist: Right now you are totally focused on the children and not aware • Patient: I’ll have to think about it. Well, there is this secretary
of your own wishes or needs. Will you be celebrating your birthday this year?
at work. I sometimes lose my patience with her. She always
• Patient: Yes, well. I looked at the calendar already and noticed that the date
is right in the middle of the week. But I don’t want to invite anyone ahead of acts so helpless, you have to explain everything 100 times,
time, whoever thinks of me can come by the house for a piece of cake. and then it’s still better if you do it yourself. How can it be that
• Therapist: How would you feel if a good friend of yours forgot your birthday she has gotten this far in life? Actually, in my eyes, she doesn’t
and didn’t stop by or call on your birthday? deserve it. She is like a dead weight. The rest of us drag her
• Patient: Yes, I would prefer not finding out who hasn’t called, or not even be along. She isn’t even able to organize enough paper and
at home to accept calls. I wouldn’t be mad at her, but I would immediately envelopes for a job. If I were the boss, I would kick her out. I
think: “Oh my, did she forget me?” It is nice if one is remembered on their wouldn’t have any qualms about it. That may sound harsh,
birthday. Well, that has always been somewhat ambivalent for me.
but she is being paid to do nothing; the rest of us are dragging
• Therapist: It sounds like you are experiencing two needs that are in conflict
with one another. On the one hand, you would like to celebrate your birthday her along, and she does nothing. I don’t have any empathy for
and to invite friends over, and on the other hand you are maybe worried that moochers. You know those people that use others.
you might get disappointed and hurt. • Therapist: And are you as strict with yourself as you are with
others?
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Treatment – Middle Phase (Structural impairments) Treatment – Middle Phase (Structural impairments)
Clinical vignette Ms. I: impulse regulation Clinical vignette Ms. I: accepting help
• Therapist: There are people that can accept help, and others that have a
• Patient: Do you celebrate your birthday? problem accepting help. To which group do you think you belong?
• Therapist: Now you are changing the conversation. It seems you are • Patient: I always thought that I was engaging with others and accepting
having difficulty talking about this conflict with me? help from them. But my colleagues offered their opinion, that I am totally
• Patient: Yes, maybe. withdrawn and that they know very little about me. That really surprised
• Therapist: Let’s first address the need that you are more familiar with – me because I had judged myself in a different light.
Agreed? • Therapist: Is your behavior different when you interact with your husband,
• Patient: Okay. friends, colleagues?
• Therapist: What are you closer to right now, celebrating your birthday or • Patient: Well, we are how we are. I probably act to the same towards my
not celebrating? husband, my colleagues, and my parents, but it’s also clear that one has
different topics for different people. You know how it is, when you know
• Patient: Not celebrating my birthday.
that a person only likes hearing one thing or the other, or when you know
• Therapist: Okay, let’s take a closer look at this need. Try to answer this for that he really likes talking about cars, then you talk about that with him
yourself, why would you prefer to not celebrate. more readily.
• Therapist: Do you entrust others with your interests, problems, and ideas?
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Treatment – Middle Phase (Structural impairments) Treatment – Middle Phase (Structural impairments)
Clinical vignette Ms. I: self-worth regulation Clinical Vignette Ms. I : accepting help
• Patient: Now I remember: “unfit to live life.” That was what my mother • Patient: I am interested in other people. Sure, when someone says,
said. I would be unfit to live my life. And in certain respects, she’s right. tell me about yourself, how was your vacation. Then I would tell
• Therapist: That is a harsh opinion coming from your mother’s mouth. If them something about myself and say my vacation was nice or so.
you heard this insulting sentence today – that you are unfit for life – how • Therapist: So you don’t miss disclosing who you really are in
would you answer today? conversations?
• Patient: Being unfit for life could also mean having two left hands; I don’t • Patient: Well, you know if I get a phone call, I really like that. I like
think that is so bad. that a person is interested in me and I think: “I have to give that
• Therapist: Hm, your mother was pretty direct and extreme in her opinion. back,” so that the person calling isn’t hurt and thinking that she’s
• Patient: Yes, my mother can be very strict and critical. never ever calling that conceited cow again, who doesn’t even ask
• Therapist: Do you have that same voice in you? The voice that is how I’m feeling.
• hard and unrelenting towards others? • Therapist: I’m getting the picture that you avoid closeness in
• Patient: (Pause) Yes, I think so, yes. relationships again and again, out of fear that you might lose your
• Therapist: Can you think of an example? real self.
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Treatment – Middle Phase (Structural impairments) Treatment – Closure Phase

Clinical vignette Ms. I: Detachment Stabilizing New Skills
Following the cancer diagnoses of Ms. I.’s mother, a crisis situation of • Reinforcement of patient’s achievements (even small achievement
extreme weight loss ensues. The patient’s weight loss plunges below a should be recognized)
BMI of 14 kg/m2, necessitating a period of temporary clinical – the achievement of goals and subgoals should be attributed to the
treatment. After 2 weeks of inpatient treatment, Ms. I.’s physical patient in order to strengthen self-efficacy
stability is such that she can resume outpatient treatment. On a • In retrospect, the pivotal moments and expierences the patient had
superficial level, the patient seems not to need others. Nevertheless, during therapy should be adressed
an existential dependency exists for supportive objects like her mother. • Applying new skills in day-to-day life during the greater therapy intervals
The anticipated fear of losing her mother is so extreme that she is no toward the endo of treatment
longer able to regulate this fear with positive inner objects or respond
adequately to the help offered her. She reacts with a relapse of • Finally , goals that were not attained should also be adressed and
anorexic symptoms. The crisis represents an important phase in concrete steps should be formulated for the months following treatment
therapy in which the inhibiting affect of fear is replaced with the
Intervention Example: Appreciation of accomplishments
experience of sadness and anger. This contributes to an improvement Therapist: If I compare your reaction today with how the situation
in the patient’s affect competence and affect regulation. was a year ago, I notice that …
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
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Treatment – Closure Phase

Anticipating relapses
• Identification of critical situations
Overview – Analyses of past situations
– A functional schema can be worked out that describes personal and
Part 6 transpersonal experiences that led to the relapse
• Closure Phase – There is often a time frame leading up to the relapse, in which
alterations in mood and behaviour are discernible
• Procedural challenges
• Summarize helpful strategies
– Based on the patient‘s past experience, helpful strategies for handling
relapses are discussed
– Evaluation of coping strategies based on their usefulness
– To look for new and try new coping mechanisms
– It may be helpful to identify peope within the patient‘s social network
that can be contacted in case of a relapse
– Safety net: A weight boundary that is communicated to the general
practioner, falls the weight below the boundary therapy is resumed.
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Treatment – Closure Phase Treatment – Closure Phase

Therapeutic Stance Persistence of symptoms
• Therapist should assume the role of helpful companion
• 40 sessions were adequate for over one third of the patients expressing solidarity with, and support of the patient
• separation fears and feelings of abandonment get reactivated • Feelings of fear and helplessness should be avoided
• Therapeutic Stance: promoting autonomy, implicit messages: • The necessity of further outpatient, day clinic or inpatient
willingness to let go, confidence in the patient. care is discussed with the patient
• Mention the patient‘s success and positive development • Possible support structures within the patient‘ social network
are identified
• At least 10-12 sessions should be reserved for the closure
phase • Affects concerning self-doubt, resignation, or aggressive
impulses directed at the therapist should not be analyzed
Intervention Example: Ending treatment during this therapy phase.
Therapist: What was your experience, and how did you feel when therapy didn’t
take place this past year during vacations or holidays?
– Figuratively speakting, the therapist should stand at the
patient‘s side and adopt the role of a mentor (or coach)
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Treatment – Closure Phase Treatment – Procedural challenges

Follow-up Care Crisis and problems during treatment
• Disorder with a high risk of relapses and chronicity
• Recommendation of a break of at least three months, regardless of • When Patients Hold Onto Their Anorexic Behavior, Even When Negative
whether they show a complete persistence of symptoms (if physically Consequences Escalate
stable) – Possible interventions: Attempting to find a playful rather than an
– The break allows patients to practice new behaviours and implement adversarial approach; encouraging the patient to develop possible
new skills in their day-to-day lives solutions instead of the therapist’s providing them.
– Continuation of treatment avoid the feelings of loss and farewell • Weight Loss in Therapy, Particularly in Regard to Weight Manipulation
– The greatest and most significant changes in behaviour occur after the – Possible interventions: Drawing a boundary, while simultaneously
completion of treatment! showing understanding for the fear-inducing effect of weight gain;
• Even after successful treatment the general practitioner of the patient discussing avoidance as it pertains to therapy (as the only topic being
should monitor the patient for a year (lab tests, weight, eating behaviour, discussed in this case is weight); discussing one’s “guilty conscience”
psychosocial health) toward oneself and the therapist. (Note: A weight of BMI < 14 kg/m²
indicates the need for urgent inpatient treatment.)
• Booster sessions spaced at large intervals may help to prevent relapses by
reactivating therapy themes
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Treatment – Procedural challenges Treatment – Procedural challenges

Crisis and problems during treatment Crisis and problems during treatment
• Weight gain leads to the reactivation of emotions in all their intensity • Newly Emerging Bulimic Behavior
– During this stage the occasional risk of reactively expressing those – Possible interventions: Identify trigger situations, interactions, affects;
activated emotions emerges (e.g., purging behavior, self-injuring strengthen impulse control by developing alternative strategies; avoid
behavior, etc.) acting out countertransference (i.e., disappointment, anger); identify
– Experiencing emotions is coupled with the feeling of total loss of newly activated fears; use metaphors and pictures that establish a
control connection to the relationship dynamic focus.
– Weight gain expressing an acting out of indulgence and a forfeiture of • Self-Injuring Behavior
self-determination – Possible interventions: Along with the process of identifying trigger
– Allowing for the satisfaction of personal needs, such as nourishment situations, it is recommended that the therapist take an empathic but
and feelings of security, sexuality and care is equivalent to forfeating clear stance with regard to this behavior. The therapist should stress
the anorexic identitiy, coupled with a threatening of ego functions that self-injuring behavior is incompatible with the therapeutic setting
(i.e., taking over and strengthening the patient’s selfcare). Important
symptom-oriented actions are contracts that the therapist implements
Not feeling anything is the perfect state of being in cooperation with the patient (e.g., a pact against self-injuring
behavior).
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Treatment – Procedural challenges Treatment – Procedural challenges

Crisis and problems during treatment Crisis and problems during treatment
• Strong Ambivalence • Medical Complications, Such as changes in electrolytes
– Possible interventions: Contrasting the persisting and the – Possible interventions: Close cooperation with a colleague
progressive components of the patient’s personality (this can experienced in the medical complications of starvation is
lead to the patient’s increased self-acceptance of even the more required so that any untoward developments can be
rebellious aspects of their personality).
addressed in a timely manner.
• Setting a Weight Goal (When patients resist to formulate one)
• Meddling by Others – For Example, Family
– Possible interventions: Working with various personality parts:
“What weight goal would that part of you have that doesn’t – Possible interventions: If the patient is not able to establish
want to gain weight?”; clarifying distressing affects: “What is boundaries between themselves and their primary family
your apprehension, what do you think could happen, if you set a and unable to reflect their role as the carrier and mediator
weight goal for yourself?”; exploring fear of commitment and of unreal performance requirements and ideals, then
surrender; and defining the fundamental freedom of choice. indirect work with the family can be tried.
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Treatment – Procedural challenges Efficacy – ANTOP

Primary Outcome BMI
Crisis and problems during treatment
• Handling the Indication for Inpatient Admission
– Possible interventions: From treatment onset, it is important that
boundaries are set for both weight and medical symptoms that require
urgent inpatient admission. These strict boundaries should
consistently be acted upon without necessitating a break in the
therapeutic relationship.
• Excessive Endurance Sports
– Possible interventions: Here too, symptom-oriented measures in the
form of a contract between the patient and therapist can be
implemented. Physical activity should be reduced to a level that is
compatible with the current weight and daily calorie intake, while
sports that strengthen muscles and guard against osteoporosis can be
recommended. Classical endurance sports such as jogging should be
avoided.
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Zipfel et al. 2014 Lancet
118
115 118
Treatment – Adjuvant therapies Efficacy – ANTOP

Secondary Outcome Remission
• Psychopharmacology *
Globale Outcome
– To date, there is no evidence for the efficacy of Focal Psychodynamic Therapy (FPT) Cognitive-Behaviour Therapy (CBT-E) Treatment as usual (TAU-O)
psychotropic drugs on weight gain (NICE 2017)

– Psychiatric comorbidity should be treated as
recommended by guidelines (SSRIs seem to have a limited
efficacy in underweight patients)
– Compulsive behaviour may also prevent weight gain. In
this case adjuvant psychotropic drugs should be discussed
• Intake of high-calorie dietary supplements
– May be helpful during the beginning of treatment and
realimintation (as GIT is unprepared for normal amounts of
Global outcomes, differentiated for the three treatment groups
food) FPT = focal psychodynamic psychotherapy; CBT-E = cognitive behavior therapy – enhanced;
TAU-O = treatment as usual - optimized. T0=after randomization; T2=10 months after T0;
T4=22 months after T0 (one year follow-up). *p<0·037.
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich Zipfel et al. 2014 Lancet
119
116 119
Outpatient dosage of therapy sessions
Overview
Part 7
• Efficacy Outpatient therapy dosage (T0 – T4)
• Research findings FPT CBT-E TAU-E
• Case Example N outpatient 39,9 44,8 41,6 n.s.

sessions
117 120
117 120
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12.11.2019
Efficacy – ANTOP Secondary Analyses – ANTOP

Inpatient admissions Therapeutic Process and Outcome
* Quantitative linguistic Analysis
Mean number of words in % (SD)
Total number of words

Percentage
Initial Session Early treatment phase Middle treatment phase Late treatment phase
Positive words Negative words Body related words Eating related words Total words
BMI at the end of therapy BMI at 1-year FU
B SE B β p B SE B β p
% negative words in the middle phase
of therapy 1.055 0.346 0.307 0.003 0.880 0.454 0.215 .057

November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Zipfel et al. 2014 Lancet Heidelberg University Hospital | Februar
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich Friederich et al. 2017 Psychother Psychosom
121 124
121 124
Secondary Analyses - ANTOP Secondary Analyses – ANTOP

Predictors of outcome (BMI) Cost-of-Illness and Cost-Effectiveness-Analyses
• Negative predictors for BMI and recovery at follow-up were • Anorexia nervosa is characteristically of a chronic nature that requires
– Lower baseline BMI recurrent treatment
• Anorexia nervosa patients have the longest median length of inpatient
– Advanced age at baseline stay of all mental disorders (Thompson et al. 2004)
– Duration of illness > 6 years • Additional indirect costs arise because of sick leave, on-the-job-
– Comorbid current/ lifetime depression (or low self-esteem) productivity-loss, etc.
• -> the cost of illness for anorexia nervosa is substantial
• Anxiety disorders, including OCD, ED-psychopathology and
subtype of disorder showed no significant prediction of
• Cost-effectiveness of outpatient therapy (ANTOP-trial)
treatment outcome (Wild et al. 2016).
– Cost-effectiveness was determined for 10 months of treatment
• Social factors (family, partnership, education and occupational together with 12-month follow-up
situation) showed also no significant prediction of outcome – With regard to recovery and direct costs, FPT proved cost-effective
(Teufel et al. 2017) when compared with CBT-E and TAU-O (Egger et al. 2016).

November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
122 125
Summary
Secondary Analyses – ANTOP FPT and ANTOP trial
Therapeutic Process and Outcome • The manual of focal psychodynamic therapy has been shown to produce
lasting changes in adults with AN
– BMI increases significantly over the course of the treatment & FU-phase
- Computerized text analysis -
– FPT compared to TAU-O showed an advantage for global outcome (i.e.

clinical remission) at 1-year FU (secondary outcome criteria)
• Physically stable adults with a BMI ≥ 15kg/m²can be securely & successfully
treated in an outpatient setting (if hospital back-up can be provided)
• Secondary analyses of data from the ANTOP study underscore
– the relevance of depressive comorbidity and self-esteem in the
Correlation with prediction of outcome
outcome parameters Extraction and – affective comorbidity was closely related to body image dissatisfaction
analyses of word
– the importance of affective-emotional processing in the middle
categories
e.g.. emotional words treatment phase (confrontation with negative emotions should not occur
prematurely!)
– a phased (early, middle, late) course of treatment, each with its own
therapeutic challenges
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
Friederich et al. 2017 Psychother Psychosom Heidelberg University Hospital | Februar
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
123
123 126
21
12.11.2019
Case Example 1 (Ms. P.) Case Example 4 (Ms. P.)

• A tal, slim woman in elegant and figure-flattering • The relationship with her mother was problematic
clothing, 26 years, 50 kg (110Ib), 171 cm (7 ft 7.3 in) • She was often moody, load and discontent with herself and others
(BMI 17.1 kg/m2) • The patient‘s mother had always defended the kitchen as her
domain
• She works in marketing (diploma in business admin.) • The patient recalled baking cookies with her grandmother because
• Eating disorder began, when she was 15 years, her she was afraid dirtying her mother‘s kitchen.
starting weight was 58kg, she lost weight with • A very sad memory was that her mother often secretly threw
presents into the trash that Ms. P made for her
restricting eating until she weighed only 47.5kg.
• Her father worked as a high school teacher and was described by
• Then pronounced binge-purging behaviour develops her as a loving, heartfelt person. He was conservative in his views
(vomiting after every mealtime, during work and in and focused primarily on safety and achievement
the evening, when her boyfriend was not present) • During childhood she showed a highly adapted behaviour. Conflicts
with her parents began to increase with the onset of her disorder.
• Last year she lost weight to a new alltime low of only • The relationship with her sister was one of sibling rivalry, she was
40 kg (BMI 13.7 kg/m2). more succesfull and achievement-oriented than her sister
127
127 130

• History of Psychotherapy
Selecting a focus
– Her first outpatient treatment for AN was when she was 17 • She grew up with a strict, dominant and often critical mother
years old
• Her mother acted in a socially distanced manner toward her
– She permateruly discontinued this treatment after 5 daugthers
months, as her symptoms were not improving
• The maternal grandmother therefore became Ms. P‘s most
• Therapy motivation important psychological parent.
– Her boyfriend was the terminating factor • The atmosphere in the family was tained by competition as
– With his support, she has managed to gain weight from 40 well as sibling rivalry with her sister who was 2 years older
to 50 kg. Her boyfriend monitored her weight and • Exclusion of her peer groups combined with maturation fears,
motivated her gaining weight could potentially have initiated the onset of her AN at age 15
– At 50kg an inner barrier had been reached, she was no • From then on, conflicting points of view and self-assertion in
longer able to continue overcoming the disorder solely the relationship with her mother found their expression in AN
with her boyfriend
128
128 131

• grew up in her primary family with her older sister Selecting a focus
• Maternal grandmother lived in a small apartment in her parent‘s
house. She was like a second mother to her and was always there • OPD 2 Axis II: Central relationship pattern
for her. – Dominant and distanced mother, problems with peers, rivalry
• 6 years ago she moved out of the parent‘s house and began renting with sister, she has difficulties in expressing her wishes for
an apartment with her boyfriend. After moving out her encouragement, acceptance and security. This dynamic was
grandmother fell ill and passed away three years ago. mirrored in the relationship pattern where the patient used
• Her mothers pregnancies had been very difficult. Before the birth of the disorder to get attention from her boyfriend
the older sister, her mother had two miscarriages. While pregnant • OPD 2 Axis III: Dysfunctional conflicts
with the patient, she had pelvic problems (loosening of the pelvic
– Self-worth conflict
ring) and had to lie most of the time in bed. After the patients birth
a gynaecological operation was necessary that hindered further – Self-sufficiency versus need for care conflict
childbearing. • OPD Axis IV: Level of structural integration
• Her father had always wanted four girls („organ pipes“) – Moderate to high level of structural integration across all axes
129 132
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12.11.2019

Beginning Phase of Treatment Beginning Phase of Treatment
• Agreement for weight maintenance in the first four weeks was helpful for • However not much changed in her daily binge-eating attacks
building an therapeutic relationship
nor in her fears of weight gain.
• She was very focused on body weight and daily variances in body weight
• She complained of a disproportionate distribution of her body shape (e.g.
• According to the manual in this phase weight gain was agreed
„bony on top and too curvy around the bottom“) and bodily sensations of 500g (1.1 Ib) per week.
(e.g. „fear, when I feel my thighs rub up against one another“) • Moreover, intense work was done to improve impulse control
• In this early phase the therapeutic stance was one of providing a secure and to develop alternativ behaviours in stressful situations
framework and structure (i.e., standing on the side of the patient)
• Ms. P. gradually developed competencies in identifying the
• A systematic analyses was carried out to identify thoughts and feelings
that preceed her binge eating attacks. Furthermore, psychoeducational interpersonal idiosyncrasies that influenced her eating
interventions were used to set-up a regular meal-structure behaviour.
• She was encouraged to increase her willingness for conflict, and to • The more she tried alternative behaviours in her interpersonal
expresses her needs and whishes to her boyfriend in a more open manner relationships, the more her binge-eating attacks decreased.
133 136
Case Example 11 (Ms. P.)

Middle Phase of Treatment
Beginning Phase of Treatment
• Working on the relationship focus: Allowing for emotion and
offering relief from affect
• Trigger of the binge-eating attacks
– Accept her sadness by crying openly
– Submissive behaviour and adaption to her boyfriend‘s
opinion (e.g. housework) – One of her greatest fears were that her boyfriend might
leave her („if he knew how I really am, he would quit our
– Depressive mood and boredom
relationship“)
– Stressful work environment (initially no awareness for the
– Therefore, she invited her boyfriend to the family session,
pressure and burden at work)
but not her parents
• In the beginning her self-demand was: I have to be able to do
• Couple session
it all alone; she showed an altruistic behaviour
– Partner was emotionally burdened, worried about his
• In the course she gained access to feelings of beeing exploited
girlfriend and helpless
and disappointed by others (at workplace, in the relationship),
learned to differeniate feelings – „Had I known what I was getting into, I would not have
begun this relationship“.
134 137

Beginning Phase of Treatment Middle Phase of Treatment
• Couple Session
• Trigger of the binge-eating attacks – Expressing appreciation for the great job he had done
– Submissive behaviour and adaption to her boyfriend‘s supporting his girlfriend in gaining weight (10kg; 22 Ib)
opinion (e.g. housework) – Pressure of keeping watch over his girlfriend‘s progress
– Depressive mood and boredom was relieved (now under therapeutic monitoring)
– Stressful work environment (initially no awareness for the – Caring and keeping up own interests is a balancing act
pressure and burden at work) – Discovery and cultivation of topics of common interest to
• In the beginning her self-demand was: I have to be able to do the couple – topics distinct from the eating disorder („
it all alone; she showed an altruistic behaviour guinea pig“)
• In the course she gained access to feelings of beeing exploited – -> she responded to the couple sessions (issues of
and disappointed by others (at workplace, in the relationship), dependence and independence in her relationship) by
learned to differeniate feelings losing 2 kg (4.4Ib) before the next session
135 138
23
12.11.2019

Middle Phase of Treatment
• Additional stressor started with the beginning of a new job
ANTOP
– same maladaptive relationship constellations were beeing reenacted study group
at her new workplace (high demands on herself, she avoided to ask
for help and support)
– fears of not meeting new requirements increased binge-eating In this
phase, THANK YOU FOR YOUR
– she developed a strategy to handly mistakes, find a way to ask even
the „troublesome“ colleagues for help and learned to assert herself
ATTENTION
• These success experiences reduced the frequency of binge eating attacks
and supported the weight gain goals
• Her weight gain of 200-500g per week coincided with an increase in
dissatisfaction with her own body (difficult to endure for the therapist)
• Work on the discrepancy between self- and percpetion of others was of
great help (relief from partner, parents, and colleagues)
November2019
2017
| Prof.
| Prof.
Dr.Dr.
Hans-Christoph
Max Mustermann
Friederich
139 142

Closing Phase of Treatment
• She began to occupy herself with wedding plans and the prospect of
starting a family
– Her boyfriend experienced extreme pressure; at the same time he
became uncertain about his feelings for her
• Her boyfriend fall in love with her when she was ill…
• BUT, they talk about their partnership, relationship and not about the
disorder of the patient
• The end of therapy and conflicts in realtionship activated detachment
fears
• She succeeded in broaching difficult emotional topics -> strengthening of
self-efficacy
• It was possible to conclude treatment after 10 months (BMI 19.5kg)
140
Weight Chart
Weight in kg
Treatment duration in weeks

141
141
24

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12.11.

What reactions does this

• The challenges of treating anorexia nervosa are

Spectrum of eating disorders Course and prognosis

• Clinical sample: 50 % recovery, 30 % residual symptoms, 20 % chronic form

Heidelberg University Hospital | November 2017 | Prof. Dr. Max Mustermann

1.0% Increased by obesity

ICD 11 (Beta Version, 2017) DSM-5 (APA 2015)

Recommendations for medical diagnostic methods

What stands out? Psychiatric comorbidity

• Anxiety disorders, including OCD (60-83%)

• Anxiety disorder often precede anorexia nervosa

• Comorbidities should be considered at the beginning and in

Zahnstatus Decision-making aids for inpatient

Assessment of medical risk I Refeeding Syndrom

Assessment of medical risk II Long-term damages

Assessment of medical risk III Dental status

Cave severe hypokalemia in patients from the purging subtype

Normal vs. osteoporotic bone Theories and Models

National Osteoporotic Foundation

Notice: No oestrogen therapy in adolescents!

• The anorexic modus establishes a dysfunctional compromise between extreme

Manualisation of psychodynamic Psychodynamic Understanding

Basic assumption of focal psychodynamic PT Elements of the diagnostic interview II

Heidelberg University Hospital | Februar

Operationalized Psychodynamic Diagnosis OPD – Axis II interpersonal relations

Elements of the diagnostic interview I Operationalized Psychodynamic Diagnosis

OPD – Axis III: Conflicts

Vignette 1 „The good daughter“ Vignette 2

Lead affect: defiant aggression

Conflict: Control versus submission conflict, with an active

Vignette 1 „The good daughter“ Vignette 3

Vignette 3 The „unapproachable beauty“

Conflict: Individuation versus dependency conflict, with an

Axis IV: Structural impairments Research background

• Basic questions in patients with structural impairments

Operationalized Psychodynamic Diagnosis Research Background

ANTOP Nutrition Guidelines for Patients with AN

Treatment General Principles of Therapy

Heidelberg University Hospital | Februar

Treatment General Principles of Therapy

General Principles of Therapy Ambivalence in the relationship

General Principles of Therapy

General Principles of Therapy

General Principles of Therapy Treatment – Initial Phase

Therapeutic Stance in the Initial Phase

Treatment Initial Phase

Initiate reflection processes

Treatment – Initial Phase Intervention Examples

Treatment – Initial Phase Intervention Examples

Question these dysfunctional beliefs in order to turn

Intervention Examples Clinical Pearl

Example of a letter to Overview interventions in the Initial Phase

Topics of letters to „Anorexia as an Enemy“ Treatment – Middle Phase

Treatment – Middle Phase Treatment – Middle Phase

Treatment – Middle Phase

Treatment focus-oriented approach Treatment – Middle Phase

Treatment – Middle Phase

Treatment – Middle Phase Treatment – Middle Phase

Treatment – Middle Phase (Structural impairments)

Treatment – Middle Phase (Structural impairments)

Treatment – Middle Phase (Structural impairments) Treatment – Closure Phase

Treatment – Closure Phase

Treatment – Closure Phase Treatment – Closure Phase