Psychiatric Times.
No. 8
TREATMENT RESISTANCE
Chronic Eating Disorders
A Different Approach to Treatment Resistance
By Allan S. Kaplan, MD and Kate Strasburg, MD |
July 30, 2009
Dr Kaplan is senior clinician/scientist and director of research training at the Center for Addiction and Mental Health; the Loretta Anne Rogers Chair in Eating Disorders, Toronto General Hospital; and vice chairman for research, professor of psychiatry at the University of Toronto. Dr Strasburg is a resident in psychiatry and in the Clinician Scientist Program at the University of Toronto. The authors report no conflicts of interest concerning the subject matter of this article.
CASE VIGNETTE
Miss A, 45 years old, lives alone and does volunteer work. She has been receiving medical disability and has supported herself through social assistance. She has had anorexia nervosa, the restricting subtype, since she was 18 years old and has been hospitalized 17 times for her illness. At entry into the program, she weighed 63 lb (body mass index, 11). She had chronic suicidal ideation and had no interest in intensive inpatient eating disorder treatment.
Our team followed her in the community with the goal of improving her quality of life and trying to maintain some degree of medical stability (as opposed to disease management and weight gain). Treatment included ongoing psychosocial support, working with Miss A to develop a detailed safety plan for her chronic suicidal risk, and assessing and managing her considerable medical instability: she has severe osteoporosis and has sustained 4 fractures in the recent past. She is severely constipated, extremely weak, and tired, and has frequent episodes of dizziness and fainting and a history of seizures. On presentation, she had abnormal laboratory values, including elevated liver enzyme levels; decreased creatinine clearance; and decreased levels of albumin, white blood cells, and serum glucose. Her heart rate was 40 beats per minute.
The clinicians in the program spent a significant amount of time liaising with other supports, including her primary care physician and her family. They also set up a meal support program that was acceptable to the patient: it included liquid supplements and twice-weekly supervised lunches in her apartment.
With this support, Miss A has been maintained out of hospital for the past 2 years and is able to continue her volunteer work.
Conclusion
Improving our understanding of what contributes to treatment resistance in a patient who has an eating disorder will allow us to target new interventions specifically aimed at enhancing motivation and reducing resistance to behavioral and attitudinal change. As challenging and difficult as they may be, patients with chronic treatment-resistant eating disorders deserve our serious and committed attention. Warmth and genuineness, understanding and acceptance, and openness and honesty are all essential components of the effective and competent long-term care of patients with eating disorders. Especially for patients with chronic illness, clinicians must be prepared to accept the possibility that their most important function is to provide genuine human contact that focuses on quality of life and removes the sense of isolation and aloneness these patients feel.22
Also in this Special Report
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