One definition does not fit all.
Why does a patient with AN resist treatment? According to Dr. Hassan Nagy, clinical researcher at the Larkin Health System, Miami Beach, FL, a combination of many factors is involved. These include familiar factors found in an AN diagnosis itself, including intense fear of gaining weight and dietary restrictions, excessive exercise, critical perceptions by others, and genetic factors, to name but a few (Avicenna J Med. 2023.13:1)
Resistance to treatment has no set definition, say Dr. Nagy and his colleagues, but treatment-resistant AN is usually identified as persistent AN lasting from 7 to 10 years. The Diagnostic and Statistical Manual-5 classifies treatment-resistant anorexia in relation to BMI, severity of symptoms, need for additional supervision, and inability to perform daily functions. Broomfield et al. classified repeated failed treatment efforts as the second most common diagnostic criteria for a diagnosis of severe and enduring AN (SE-AN). Severe BMI, according to the DSM-5, is a BMI <15 kg/m2. Hospitalization is called for when the patient has a heart rate <50 beats/minute in the day and <45 beats/minute at night. Body fat <10%, body temperature <96°F, arrhythmias, refusing food, and unsuccessful outpatient treatment all factor into the diagnosis.
Dr. Nagy and his colleagues report that many patients, particularly those who fall into a pattern of obsessive and restrictive behavior, are very prone to refuse treatment. Environmental and genetic risk factors with a more susceptible neurobiology are also at play in the resistance to treatment in AN and BN (BMC Psychiatry. 2013.13:292). Resistance is a common ordeal among AN patients. Many express that they do not want to physically mature into an adult female body to avoid being separated from their parents and given added responsibilities, Others don’t have the experience of being autonomous, which can lead to poorer self-esteem. It is also thought that the cycle of compulsive and restrictive actions gives an anorexic patient a sense of control, and raises his or her self-worth.
Treating the treatment-resistant patient
One size does not fit all, say the authors. Those who work with chronic AN patients view quality of life the most important goal. Treatment requires a balance between interventions that focus on physical safety and weight restoration and treating psychological stress first.
The authors suggest five ways to help manage a patient with treatment-resistant AN.
- Provide a course of carefully measured intensity with palliative care. First, assure the patient that weight is not the objective of managing AN, and the patient can negotiate and collaborate with the entire treatment team-this will prevent panic and regression.
- Encourage the patient to explore intellectual pursuits or hobbies that stimulate mastery and cognitive function.
- Encourage patients to find a social activity that will prevent isolation. This could be spending more time with a family member or friend, going to church or spending time at a favorite spot, such as a restaurant or museum, or attending a support group.
- Improving nutrition that does not cause weight gain.
- Educate the family and relevant others about the psychopathology underlying treatment resistant AN, and provide solace and support so they can avoid showing anger and irritation towards the patient.
- Perform regular physical examinations, so the clinician and the team, along with the patient, can be kept up to date about the medical status and can make informed decisions about supportive steps to be taken.