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.
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.
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
Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry.
Ratnasuriya RH, Eisler I, Szmukler GI, Russell GF. Anorexia nervosa: outcome and prognostic factors after 20 years. Br J Psychiatry.
Strober M. Managing the chronic, treatment-resistant patient with anorexia nervosa. Int J Eat Disord.
Kaplan AS, Garfinkel PE. General principles of outpatient treatment. In: Gabbard G, ed. Treatments of Psychiatric Disorders.
3rd ed. Washington, DC: American Psychiatric Press; 2001:2099-2117.
Fairburn CG, Cooper PJ. The epidemiology of bulimia nervosa: two community studies. Int J Eat Disord.
Hoek HW, Bartelds AI, Bosveld JJ, et al. Impact of urbanization on detection rates of eating disorders. Am J Psychiatry.
Garfinkel PE, Lin E, Goering P, et al. Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups. Am J Psychiatry.
Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord
Kaye WH, Frank GK, Bailer UF, Henry SE. Neurobiology of anorexia nervosa: clinical implications of alterations of the function of serotonin and other neuronal systems. Int J Eat Disord.
Keel PK, Dorer DJ, Eddy KT, et al. Predictors of mortality in eating disorders. Arch Gen Psychiatry
Pike KM, Walsh BT, Vitousek K, et al. Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. Am J Psychiatry
McIntosh VV, Jordan J, Carter FA, et al. Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry
Attia E, Haiman C, Walsh BT, Flater SR. Does fluoxetine augment the inpatient treatment of anorexia nervosa? Am J Psychiatry.
Strober M, Pataki C, Freeman R, DeAntonio M. No effect of adjunctive fluoxetine on eating behavior or weight phobia during the inpatient treatment of anorexia nervosa: an historical case-control study. J Child Adolesc Psychopharmacol.
Walsh BT, Kaplan AS, Attia E, et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial [published corrections appear in JAMA.
2006;296:934 and 2007;298:2008]. JAMA
Wilson GT, Fairburn CC, Agras WS, et al. Cognitive-behavioral therapy for bulimia nervosa: time course and mechanisms of change. J Consult Clin Psychol.
Goldstein DJ, Wilson MG, Thompson VL, et al. Long-term fluoxetine treatment of bulimia nervosa: Fluoxetine Bulimia Nervosa Research Group. Br J Psychiatry
Agras WS, Dorian B, Kirkley BG, et al. Imipramine in the treatment of bulimia: a double-blind controlled study. Int J Eat Disord
Walsh BT, Stewart JW, Roose SP, et al. Treatment of bulimia with phenelzine: a double-blind, placebo-controlled study. Arch Gen Psychiatry.
Bacaltchuk J, Hay P. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database Syst Rev.
Kaplan A, Rockert W, Rais H, et al. Assertive community treatment for chronic eating disorders: sample description and treatment outcome. Presented at: the 14th annual meeting of the Eating Disorder Research Society; September 25-27, 2008:159; Montreal.
Kaplan AS, Garfinkel PE. Difficulties in treating patients with eating disorders: a review of patient and clinician variables. Can J Psychiatry.