Eating disorders as classified by DSM-5 include diagnostic categories for anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive feeding intake disorder, and feeding and eating conditions not otherwise specified. These are serious illnesses associated with numerous psychological and medical comorbidities, including increased risk of death.
Patients with eating disorders are notoriously difficult to treat and are also known to have high relapse rates. Resistance in eating disorders is common and can help explain why treatments often fail and why patients drop out. In general, resistance can refer to the conscious and unconscious factors that prevent a patient from engaging fully in the treatment process. Importantly, patient resistance is not uniform across the different eating disorder diagnoses, and how it is addressed also depends on the age of the individual.
Why patients with eating disorders resist treatment
Safety behaviors. Patients with eating disorders are typically terrified of weight gain and will go to great lengths to avoid this outcome. To decrease anxiety about weight gain, patients sometimes adopt behaviors that they believe will “protect” them from gaining weight—eg, scrutinizing body parts, daily weighing, following strict rules about when and how much to eat, and overexercising. Patients become highly invested in these safety behaviors, which results in decreased willingness to change them and increases therapeutic resistance.
Ego-dystonic vs ego-syntonic. Another key factor that affects resistance to change is whether patients view the disorder as ego-dystonic (ie, part of themselves) or ego-syntonic (ie, separate from themselves). Individuals who experience the behaviors associated with the eating disorder as problematic and incongruent with how they see themselves view their eating disorder as ego-dystonic; this view is typically endorsed in bulimia nervosa and binge eating disorder. As a result, these patients often want help because they are frustrated with unsuccessful weight loss attempts and are ashamed of their binge eating/purging behaviors. This desire for help leads to an improved therapeutic alliance and motivation to change.
In contrast, individuals with eating disorders who experience their behaviors as congruent with their personality and have a certain amount of pride in the ability to diet and exercise to extremes view the eating disorder as ego-syntonic. This ego-syntonic view is most often seen in anorexia nervosa. In most cases, when the eating disorder is experienced as ego-syntonic, there will be little or no motivation to change the behaviors, which results in high levels of treatment resistance that increases with time.
Ego-syntonic patients typically avoid therapy and will often attend only because of outside pressure (eg, to please a loved one). In these cases, it is extremely difficult to form a therapeutic alliance or to agree on goals for treatment. For example, these patients will be opposed to weight gain, although it is necessary in underweight patients with anorexia nervosa. This discrepancy in treatment goals between patient and clinician leads many patients to drop out of therapy, a common problem in anorexia nervosa.
Process and outcome resistance. In general, individuals with eating disorders resist treatment for many reasons. It can be helpful to both patient and clinician to understand and distinguish potential sources of process resistance and outcome resistance as an early step in the therapeutic process.1 Process resistance refers to resistance related to necessary changes for improvement and is associated with high levels of anxiety and discomfort. Examples of process resistance include gaining weight, eating more regularly, and eating larger amounts and/or foods that have been avoided. Outcome resistance, on the other hand, refers to concerns about the ultimate changes that will result once the behaviors and cognitions maintaining the eating disorder are no longer available to use as a coping strategy (eg, cannot binge as a coping strategy and may have to start attending to other unpleasant responsibilities in life that have been avoided because of the eating disorder).
While ultimately not helpful, these eating disorder behaviors and cognitions function as a temporizing measure in ways that the patient may or may not be aware of. For example, the individual with anorexia nervosa may not feel negative emotions as intensely while in a starvation state and thus, when eating normally, will need to learn to tolerate these emotional experiences. Most patients with an eating disorder struggle with both process and outcome resistance.
Dr Aspen is a Postdoctoral Research Fellow and Dr Darcy is an Instructor in behavioral medicine; Dr Lock is Professor of child psychiatry and pediatrics and Director of the Eating Disorder Program for Children and Adolescents in the department of psychiatry and behavioral sciences at Stanford University School of Medicine, Stanford, Calif. The authors report no conflicts of interest concerning the subject matter of this article.
1. Burns D. Tools, Not Schools, of Therapy: Integrating Twelve Treatment Models. May 2013. http:// jackhiroseresources.com/post-one. Accessed August 6, 2014.
2. Lock J, Le Grange D. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. 2nd ed. New York: Guilford Press; 2013.
3. Lock J, Agras WS, Fitzpatrick kk, et al. Is outpatient cognitive remediation therapy feasible to use in randomized clinical trials for anorexia nervosa? Int J Eat Disord. 2013;46:567-575.