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.

More recently, McIntosh and colleagues¹²found that nonspecific supportive clinical management was superior to more specialized psychotherapies, such as CBT and interpersonal psychotherapy, for the treatment of anorexia nervosa. Support for the efficacy of medications in the treatment of anorexia nervosa remains limited. The use of SSRIs, most commonly fluoxetine(Drug information on fluoxetine), has been studied in both open-label trials and double-blind randomized controlled studies; results fail to support a role for these agents in both underweight and weight-restored anorexic patients.^13-15Medications are indicated for treatment of comorbid illness, such as depression and anxiety, in the anorexic population, but the effectiveness of antidepressants is limited in the presence of starvation and emaciation.⁴

There is well-established support for the efficacy of CBT in bulimia nervosa as well as for medications.¹⁶ Antidepressants, including SSRIs (fluoxetine), tricyclic antidepressants, and monoamine oxidase inhibitors have been shown to reduce binge eating and purging in bulimia nervosa.^17-20

Treating chronically ill patients can be difficult for clinicians. However, the nature of the symptoms of a chronic eating disorder makes treatment particularly challenging. Such patients often deny the severity of their illness; as a result, they resist treatment and their symptoms often develop a life of their own. Caloric restriction and binge eating and purging are self-reinforcing behaviors that lead to a starvation state and eventually become symptoms that are intractable and impervious to treatment.

There is an ego-syntonic pursuit of thinness in patients with eating disorders; what clinicians see as symptoms to be treated, patients see as lifestyle choices to be pursued. Issues of trust are prominent in patients with anorexia nervosa. As a consequence, these patients have difficulty in establishing a therapeutic relationship.

The change in focus to quality-of-life issues and away from ego-syntonic symptoms helps solidify the therapeutic alliance with caregivers and tends to decrease the power struggle that so often characterizes the relationship that develops. Strober³ outlines interventions that are useful for clinicians who treat these patients. Most important, he emphasizes the necessity of reassuring the patient that weight gain is not a primary objective and that steps toward weight gain are both collaborative and negotiable. Similarly, nutritional improvement should only be addressed once a therapeutic alliance is well established.

When efforts are made for weight gain, the goal may be to achieve a safe weight that is acceptable to the patient and compatible with medical stability and staying out of the hospital. Collaboration between therapist, dietician, and patient is essential before the implementation of any nutritional changes. A caloric goal of about 1200 kcal per day is often useful because it can be achieved by most patients and will not lead to significant weight gain but may be adequate for medical stabilization.³ Liquid supplements can reduce the osmotic load that accompanies the intake of solid food and that causes bloating and fluid retention in emaciated patients with anorexia nervosa. Such patients require medical monitoring by a primary care physician, including a full medical examination, regular laboratory measures, and ECGs.

The aforementioned strategies underline the importance of collaboration and communication among professionals, setting small achievable goals and, perhaps most important, establishing a strong therapeutic alliance.

A community-based, patient-centered approach

As with many chronic illnesses, the goals and expectations in patients with a treatment-resistant eating disorder shift from a focus on full recovery to symptom alleviation, improving the quality of life, and in the case of anorexia nervosa, the medical stability and a reduction in mortality. At Toronto General Hospital, we have implemented a client-centered, assertive community-based treatment approach for this group of patients.²¹ The approach is modeled after assertive community-based treatment programs that have been established for the seriously and persistently mentally ill, mostly patients with schizophrenia. The goals of this program for patients with a chronic treatment-resistant eating disorder are summarized in Table 1.

The multidisciplinary team that works with the patient is made up of a psychiatrist, a dietician, a nurse, a social worker, and an occupational therapist. The clinicians have both unique discipline-specific roles and shared clinical roles. All of the clinicians provide ongoing psychosocial support and meet with patients wherever they are most comfortable (eg, in the patient’s home, in a park). In addition, discipline-specific roles are clearly defined (Table 2).