Caring for the Chronically Remitting Anorexia Nervosa Patient

Franklin Mint Chair in Eating Disorders, Professor of Psychiatry, Director, Eating Disorders Program, UCLA Semel Institute for Neuroscience and Human Behavior, Resnick UCLA Neuropsychiatric Hospital

First published in Psychiatry Weekly, Volume 3, Issue 28, on August 18, 2008

This interview was conducted on July 10, 2008 by Lonnie Stoltzfoos

There are no empirical data regarding the number of people who develop treatment-resistant anorexia nervosa, ie, those who have a strong aversion to treatment resulting in steadfast avoidance of care. One can, however, approach the question of prevalence indirectly by turning to long-term follow-up data that indicate the number of people with anorexia nervosa who remain unremittingly ill for extended periods of time, which ranges from 3%-5% overall. According to Dr. Michael Strober, most people who develop anorexia nervosa will not remain in an acute malnourished state throughout their entire lives, although a significant minority of people have varying levels of illness over decades.

Symptomatic and Clinical Profile

“Although most cases of anorexia nervosa develop around the ages of 13–18 years, no strong relationship has been established between age of illness onset and the likelihood of chronic illness,” says Dr. Strober. “There is now a question in the literature as to whether people who develop it earlier—as children—are more likely to have chronic long-term, unremitting illness compared to those who develop it in adolescence. There is no indication, however, that this is the case.”

Other partial conclusions or inferences drawn from existing literature suggest that the greater the family conflict that is present in association with onset, the greater the likelihood of non-recovery or poor outcome. Also, some evidence suggests that people who engage in severe compulsive exercise early on are more likely to have chronically resistant course. Dr. Strober cautions that, “these data do not allow for an absolute statement about these relationships. It is suggestive evidence, and I would not put it in any stronger terms.”

Treatment-resistance in anorexia nervosa is best defined by patients with anorexia nervosa who have been unremittingly ill for decades—including those who have made attempts at treatment, yet relapsed—despite exposure to high-quality care. “It is reasonable to say that people who have never had treatment have actively avoided treatment,” Dr. Strober explains. “That does not mean that people with long-term illness deny it or fail to recognize their condition. The overwhelming majority of patients who rationalize their illness will, when pushed, admit that there is something abnormal about their thinking and their behavior.”

Ideal Treatment Approaches

People who tend to steadfastly deny and avoid treatment are characterized, overall, by a much greater fear of change, and, perhaps, a fear of engagement and involvement with other individuals, according to Dr. Strober. “Since psychotherapy implies engaging with other individuals, a willingness and tolerance to change and discomfort, it stands to reason that one’s reluctance to engage in treatment is going to be greater,” he says.

Compared to more typical cases of anorexia nervosa where the assumption is that there can be a measurable, significant change to the point of clinical recovery, Dr. Strober emphasizes that treatment must be administered through a completely separate framework when working with anorexia nervosa patients who have been ill for long periods of time.

“The discussion of weight gain and approaches to weight have to be very cautious and very deliberate,” says Dr. Strober. “The goal has to be weight maintenance as opposed to weight increase; the patient must be kept socially active to prevent malaise and isolation; clinicians must stress that the goal of care is to stabilize the patient’s condition and to reassure him or her that the issue of weight gain will not be forced.”

It is also important to educate this particular subset of patients on the possibility that eating more is possible without gaining weight, and to emphasize that experiementing with increases in calories does not have the purpose of weight gain, but simply to improve their cognitive and emotional stability while keeping weight stable.

“Chiefly, the goal when working with these patients is stabilization, paying very close attention to issues of transference and counter-transference that can arise, and at working with people whose prospect for change is very little,” Dr. Strober says. “The work is very difficult, very tedious, and clinicians must be prepared to attend to the emotions is may evoke.”

The role of pharmacotherapy in anorexia nervosa, in general, is rather limited, although SSRIs and atypical neuroleptics are potentially helpful in terms of working with agitation, stress, rumination, and anxiety. Presumably, the same is true in working with chronically ill patients, although there is no pharmacotherapy that produces robust results in anorexia nervosa.

Future Research

“Over the past several years, I have been particularly interested in the various forms of anxiety-related emotionality that are present in people with anorexia nervosa well before the onset of dieting and weight-loss,” says Dr. Strober. “We can therefore hypothesize that those influences are relevant to anorexia nervosa whether or not they allow for the identification of individuals who are going to go on to have long-term, treatment-resistant illness. Translational research in the area of anxiety and fear mechanisms deserves our attention for its potential application to research in anorexia nervosa.”

Disclosure: Dr. Strober reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.