The Current State of Treating Patients with Severe Anorexia Nervosa

The medical community still struggles enormously to know how to help patients with severe, life-threatening Anorexia Nervosa. Often, hospitals, even ones with experienced doctors, can medically stabilize at best. Residential treatment programs have no long lasting treatment approach to offer other than months of nutrition with the hope that the eating disorder thoughts abate. The field has studied medication after medication to no avail. Various outpatient programs find that harm reduction and long-term medical stabilization are most often the best outcome.

Ethically, the field is often torn between bad outcomes and worse ones. Patients often respond by living outside the medical system and trying their best on their own or with one provider compassionate enough to stand by them and accept the severity of their illness. 

Is a life of chronic illness often without much ability to have a satisfying, fulfilling life worthwhile? Should patients be found mentally incapable and given a legal guardian to force them into treatment even if they are otherwise totally lucid? Are these patients sometimes in a situation worth considering ending one’s own life as Dr. Jennifer Gaudiani wrote about publicly a few years ago? 

These questions represent only part of the ethical dilemma swirling around the treatment of these patients. 

Over the years, I have written multiple times in this blog about the mental health provider’s obligation to stand by these patients and support them them even in difficult situations. Too many of these patients end up abandoned by their providers—typically out of fear of the illness or liability or both. That’s not an acceptable option either. 

The hope is that the field will find new ways to successfully treat Anorexia. Every new drug or new therapeutic approach ends up being tested for Anorexia, thus far to no avail. 

I still believe these patents deserve support and deserve a voice. It can be very hard to do so when medical doctors don’t feel equipped to treat them, when family and practitioners often feel overwhelmed or afraid of their appearance and when treatment options are so limited for a dire, potentially life-ending illness. 

Medicine tends to approach these patients on a case by case basis without clear guidance on a treatment protocol. Even seasoned ethicists struggle to find the right path. Patients rights bump up against a severe and largely misunderstood illness. There are no right answers. 

Even though I come down on the side of patients rights, I’m aware that the choices are limited. The only answer is to find a path towards improved health, not even a cure at this point. It’s a painful and challenging reality for people with severe Anorexia. But that’s where the field is right now.

Managing the Vulnerability and Exposure in Early Stages of Eating Disorder Treatment

Although eating disorders themselves have fairly consistent symptoms, the driving force for eating disorders, and thus the path for recovery, can be quite different.

Eating disorder symptoms tend to be fairly clearcut. The majority include food restriction, binging, purging, over-exercise, chew-spit behaviors and unusual eating behaviors. Although this list is not comprehensive, the actual eating behaviors themselves are easy to pin down.

The first step in any treatment plan involves normalizing eating both discrete meals/snacks and the variety and balance of different types of food. This step is rarely easy, but the goals are clear.

The subsequent therapeutic goals aimed to help patients find new ways to cope with their thoughts, feelings and experiences can be much more varied.

Eating disorders can start from many initial factors such as trauma, anxiety, medical illness, dieting and the need for clear structure and emotional regulation, to name a few. Understanding the initial cause can be helpful, especially if that cause remains relevant in the present.

For other people, the cause of the eating disorder fades as other driving forces for the illness become more central. The list of possible forces are the same as the initial causes, but the need for the eating disorder for each patient can shift through the course of the illness.

Inevitably, any stabilization around food will crumble without sustained attention in therapy to find new ways to cope with what is uncovered by stable eating. People at this stage of recovery describe feeling very exposed, alone, and vulnerable to the world and unable to cope with how they feel inside. Taking away the eating disorder symptoms feels like exposing all their inner turmoil without any new way of coping. That experience is often so painful that people see no other recourse than relapse.

Therapists can use various skills such as calming techniques like breathing, muscle relaxation or somatic tools. They can work with psychological methods to process, identify and experience emotions in new ways. They can also use trauma therapies to start to more fully integrate trauma memories. There are many other ways to help people through this challenging part of recovery.

The goal of therapy at this point is to acknowledge how hard this step is while also maintaining hope that the turmoil will pass. It does pass for people who find a way forward. The first months when food is more regulated is typically the hardest part of recovery. It’s worth the effort and energy to move forward to get to the other side.

Why Doctors and Psychiatrists are Reluctant to Treat People with Eating Disorders

I have a strange experience any time I tell another doctor, especially another psychiatrist, that I specialize in seeing people with eating disorders. The reaction is typically surprise, incredulity and admiration. On the whole, doctors across the board are shocked to know a colleague would choose to build a practice seeing primarily these patients.

My first thought about this reality is that no wonder patients with eating disorders struggle to find adequate, compassionate care. Doctors don’t appear to want to treat this group of patients.

My second thought is what are these colleagues trying to say through their reactions.

I believe there are several aspects of treating patients with eating disorders that scare off many doctors.

First, this cohort of patients is often medically sick, sometimes very ill. When the symptoms of the disorder itself are often intractable, seeing people with eating disorders means ongoing care for people who are chronically medically ill. Even with adequate medical care, which is very hard to find since primary care doctors often reject these patients, psychiatrists are held somewhat responsible for the concomitant medical and psychiatric effects of these illnesses. Recovery is long and slow so psychiatrists end up overseeing a medically ill patient for years. That’s an unusual burden for a psychiatrist.

Second, the family dynamic around these patients is typically complicated. As many books have discussed, patients with eating disorders tend to come from families with challenging emotional structures, poor communication and little room for the patient to express thoughts and feelings. The way they are heard and seen is most often through the eating disorder—a reason why recovery often seems so out of reach. Psychiatrists are then challenged to work on the emotional struggle and dysregulation with a patient reluctant to improve eating and their overall health, specifically due to that family dynamic. Very often this situation applies to adult children in their 20’s and 30’s and even older. The potential consequences are serious.

Last, the families and patients are also typically desperate for the person to just get better. Since eating seems like the most basic human task, it’s hard to explain what makes recovery so hard. Failure is often not tolerated, and psychiatrists can get caught up in the whirlwind of desperation even when the course of recovery is laid out clearly. The emotional needs of the family don’t match the data that getting better is no guarantee, and that situation makes it easy to include the doctor as part of the failure.

These mainstay issues in treating people with eating disorders lands a lot of blame and responsibility, often erroneously or at least in an exaggerated way, on the doctor. These are hard to treat illnesses. People can get better, but recovery is often long and hard. Some people don’t get well. Circumstances around treatment make this population challenging, often more challenging than many doctors and psychiatrists are willing to take on.