This is, by far, the most interesting article that I’ve read in a long time: Caring for the Chronically Remitting Anorexia Nervosa Patient

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.

I think this highlights an important point — that you can’t be severely malnourished for years. There have to be points of better physical health in there… why? Because something is bound to happen that requires medical attention. I’m not even referring to all the scary medical risks that come with a chronic malnourished condition (passing out, heart attack, etc.)… but at some point you’re going to have to see someone for a birth control prescription, or you’re going to have strep throat and need antibiotics, or have to go to the dentist or something. It’s easy to identify someone who is visibly ill, and any decent professional is going to say something to you.

Maybe being at this low point is the most dangerous time… but it’s also the time you’re most likely to get help. It’s the rest of your life when you’re not dangerously (or as visibly) sick that contributes to chronic anorexia.

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.”

These “people with long-term illness” are in limbo — not really sick, but not really well, either. It’s a state of doing “okay enough.” You’re thinking, “Okay, well I’m eating and my weight isn’t dangerous. My vitals and labs are fine. I have friends and more of a life than I used to. Maybe I still obsess over food and worry about my weight, but lots of people in the world do that.” There’s this comparison between where you are right now and where you were at the height of your disorder. Maybe you know you’re not really okay right now… but you’re not sick… so treatment seems unnecessary.

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.”

This is where I start to disagree with Dr. Strober… I don’t think that treatment needs to be completely different for someone with chronic AN. What, are you going to wait for the patient to feel like she’s okay eating different food or gaining weight? I’ve said it again and again in my posts, but you get stuck in ED limbo — and I think that it takes a significant force to move you out of that state. I had a nutritionist refer to some people as “functional anorexics” — capable of maintaining their disorder, career, and relationships. I almost feel like you need the opposite treatment. You need to be told, “Hello, this is important. I don’t care if you’re functioning and doing ‘well enough’ — you need to take care of this and make it a priority.”

I think that spending 10 years in ED limbo is a clear sign that you are not capable of managing your recovery. Someone else needs to be in charge — there is no way that you can objectively judge your condition. I don’t think that chronic anorexia needs any less aggressive of a treatment plan, but I do think you have to be prepared for more of a fall-out. More panic attacks, resistance, depression, etc. These patients have been holding on to the ED for a long time… but you’re not going to get to a point where you can work through all of that until you push them. More passive treatment is probably the worst that you could do — you’re just going to contribute to the apathy, and eventually the patient is going to include that this treatment (like the previous treatments) is not helpful.