Why Medications are so Ineffective for Anorexia

When someone, clinician or layperson, begins to understand the underlying thought process of anorexia, it becomes hard not to see the illness as a fundamental problem in brain function. The medical consequences of starvation make clear that anorexia is a physical illness as well, but the tortured thoughts of the disorder are the most shocking revelation.

The overall treatment plan for anorexia is a treatment team covering all the possible bases: therapist, psychiatrist, dietitian and primary care doctor. Sometimes, attention to the details of recovery and improved nutrition are enough to start reversing the course. Frequently, they are insufficient.

Consequently, it’s reasonable that patients and families turn to psychiatric medication as a possible salve for the psychological wounds inflicted by anorexia. There must surely be a medication that can reverse the nonsensical and distorted view that food is not meant to be eaten and that weight loss is paramount no matter the cost.

The psychiatric community agrees with this assumption. Despite the utter lack of success of any medication and the ignorance of an underlying biological cause of the illness, psychiatrists continue to study any medication for its utility in the treatment of anorexia. Even though all studies have thus far have been futile, desperation for more effective treatment is the driving force for continued clinical research.

As of now, the most salient fact about the cause of anorexia is that genetics account for over 70% of the likelihood that someone develops the illness. There needs to be an initial trigger of starvation in order to assess how someone is programmed to respond to a lack of food.

In our society currently, sanctioned dieting, even for children, allows many communities to serve as breeding grounds for eating disorders. The mere acceptance of dieting as a reasonable decision puts adolescents and adults at risk regularly. Prior to the practically universal acceptance of dieting, eating disorders barely existed in our communities.

Survival is the body’s primary ingrained response to starvation and surely is an adaptation that enabled ancestors not lucky enough to live with an overabundance supply of food to persist. It’s unlikely that there is a pharmaceutical fix for a longstanding genetic adaptation.

Although the crucial step to decrease anorexia and eating disorders is to stop sanctioned dieting, it’s more likely that we can create an environment that helps someone already sick to constantly question the anorexic thoughts. When a trusted clinician combined with the person’s support network repeat that the eating disorder thoughts are lies and only hurt them day after day, week after week, month after month, recovery can be possible. Yes we need more options, but medications aren’t likely to be the solution.

Management of a Chronic Eating Disorder

One topic i have not addressed more clearly is the person who has no true interest or ability to consider full recovery. The idea that people with eating disorders are sick forever is a common misunderstanding in today’s culture. In fact, it is still surprising for many lay people to hear that recovery is even an option, let alone something that occurs on a regular basis, albeit over a period of time and with very difficult, often excruciating work.

Realistically, many people do live with eating disorders for their entire lives. Many of them get professional help, but with the purpose of seeking emotional support from a knowledgeable clinician and perhaps guidance how to manage the illness and still function in life, not to get well. 

The distinction between treatment intended for recovery and management of an eating disorder is significant. As opposed to full treatment, eating disorder management has very different goals: containment of medical conditions associated with the illness, emotional support for the daily struggle of surviving an eating disorder and education about improvements in eating that will manage weight and health within the guidelines allowed by the eating disorder.

Many clinicians refuse to work with people who will not commit fully to recovery. So most of these patients have been ostracized and left to feel alone in their predicament. It’s a mandate for the clinical eating disorder community to commit to helping these people. They shouldn’t be punished because of our lack of effective treatment for the sickest people.

More than anything, people with chronic, intractable eating disorders need compassion. They did not ask for this horrible illness. Many of them have endured long stretches of available treatment with minimal benefit. They deserve kindness and thoughtful care to help them live the best lives available to them. It’s hard to completely ignore my optimistic thought that even in these circumstances, at least partial recovery, if not more, may still be possible. The next post will discuss treatment of these patients more specifically.

The Pros and Cons of Eating Disorder Treatment Teams

The standard of care for an eating disorder, if someone doesn’t need residential or hospital care, is to assemble a treatment team. This involves several components: a therapist, a dietitian, a primary care doctor, a psychiatrist (frequently but not always) and a set of other possible options such as meal support or group therapy.

This team covers all the bases and provides treatment for all different aspects of recovery. It’s almost dogma for clinicians to automatically suggest assembling a team and for many people doing so leads to progress.

However, there is a reflexive element to this process; as if the team itself somehow creates an illusion that recovery and wellness is easily within the grasp of all patients. The reality of eating disorder treatment consistently shows that not everyone gets well quickly and not everyone gets well.

This advice also serves another purpose: to insulate practitioners from responsibility if treatment doesn’t go as planned. Since the team approach is the standard of care for people with eating disorders, it’s easy for treatment providers to tell themselves they did their part. They were part of the team or recommended assembling a team. If the team didn’t help, tacitly blaming the patient is an easy option to fall back on. 

For people early in their treatment, working with a team makes sense. Exposure to all types of eating disorder clinicians will help someone find what works best for them.

After this introductory period, individualized treatment is crucial. Continuing to suggest the exact same thing for someone who already has tried that path with limited benefit deserves more thoughtful care.

It is the responsibility of the clinician to think outside the box for different ideas to help. Relying solely on the standard care only shows a lack of creativity and frankly a lack of caring. Since eating disorder treatment is far from perfect, patients need to know all possible elements of treatment are on the table and that the people in their corner are doing everything they can to make a difference.

The Unfairness of Eating Disorder Recovery

It’s a fine line between blame and responsibility when it comes to eating disorder recovery. I wrote the last post with trepidation that it was too easy to interpret my words as blaming the patient for their illness, something I adamantly oppose.

And certainly the same logic wouldn’t apply to a purely physical illness such as cancer.

Part of the difference lies in the core medical knowledge and treatment options. The science of brain function remains in its infancy. Only a few decades ago, a common misconception was that people only use 10% of their brain, but that factoid reflected justification for our collective ignorance. Even as we learn more about how our mind works, the yawning scientific gaps preclude the large majority of any truly functional knowledge.

However, the medical information available about cancer is also very limited, as is treatment. Why is the discrepancy in attitude towards eating disorders as opposed to cancer so wide?

Cancer is an invasive “other” in one’s body. The psychological component of treatment is one of endurance and maintaining optimism in the face of so much fear and doubt. The goal of treatment is very clear. There is no way for the doctor-patient relationship to be adversarial.

Eating disorder treatment attempts to separate out the eating disorder thought process from one’s own independent thoughts. Although that construct is useful and effective, it is a construct nonetheless. Eating disorder thoughts may be the driver of the illness, but they still feel like one’s own thoughts. The cognitive exercise of learning to identify them as part of the illness, dismiss them and follow a different, often newly acquired set of thoughts is challenging at best.

When an educated, caring, well-meaning clinician urges week after week the patient to follow these new thoughts and ignore a well-worn pattern of daily life, inevitably there will be friction in the treatment. The process of learning new patterns with food and managing the concomitant thoughts is challenging and bumpy. Since no treatment can effectively ease this painful transition, that responsibility to work on new behaviors each day has to lie with the sufferer.

This is certainly a cruel joke. Not only is someone saddled with an eating disorder but the only effective treatment option is a slow and painful struggle against the powerful eating disorder forces. And it’s easy to see why not everyone can get well.

I am always searching for new ways to make this easier, to prevent the suffering and to sidestep the prolonged pain of the process. I remain hopeful because many, many people do get well. In the meanwhile, I also have to accept these realities and communicate them in treatment.