Treatment Resistance: Anorexia Nervosa in a Middle-Aged Woman

When it comes to treatment resistence, clinicians must be prepared to accept the possibility that their most important function is to provide genuine human contact that focuses on quality of life and removes the sense of isolation these patients feel. Here we offer a vignette that of a patient with an eating disorder. This case briefly outlines a treatment approach using a community-based, patient-centered model of care.

We invite your comments below. The authors will review your responses and give their feedback in coming weeks.

Question to consider when reading the case:

As a physician, what are some of the challenges you might anticipate in adopting a palliative care approach to this patient with treatment refractory anorexia nervosa (AN)?

CASE VIGNETTE

Miss A, 45 years old, lives alone and does volunteer work. She has been receiving medical disability and has supported herself through social assistance. She has had AN, the restricting subtype, since she was 18 years old and has been hospitalized 17 times for her illness. At entry into the program, she weighed 63 lb (body mass index, 11). She had chronic suicidal ideation and had no interest in intensive inpatient eating disorder treatment.

Our team followed her in the community with the goal of improving her quality of life and trying to maintain some degree of medical stability (as opposed to disease management and weight gain). Treatment included ongoing psychosocial support, working with Miss A to develop a detailed safety plan for her chronic suicidal risk, and assessing and managing her considerable medical instability: she has severe osteoporosis and has sustained 4 fractures in the recent past. She is severely constipated, extremely weak, and tired, and has frequent episodes of dizziness and fainting and a history of seizures. On presentation, she had abnormal laboratory values, including elevated liver enzyme levels; decreased creatinine clearance; and decreased levels of albumin, white blood cells, and serum glucose. Her heart rate was 40 beats per minute.

The clinicians in the program spent a significant amount of time liaising with other supports, including her primary care physician and her family. They also set up a meal support program that was acceptable to the patient: it included liquid supplements and twice-weekly supervised lunches in her apartment.

Outcome: With this support, Miss A has been maintained out of hospital for the past 2 years and is able to continue her volunteer work.

For further reading, seeChronic Eating Disorders: A Different Approach to Treatment Resistance, from which this case was adapted.