Complex Anorexia: When to Move to a Higher Level of Care

One of the most challenging aspects of treating complex cases of anorexia is cutting through the day-by-day storm and stress of treatment, to clearly see the arc of the disorder and make the right decision about when it’s time to move to a higher level of care.

How do you assess a chaotic picture that includes incremental improvements followed by backsliding, pleading, anger, cajoling, broken promises, emotional outbursts and parental pleas that accompany the refeeding process?

As promised in my last post, here I’ll summarize a set of benchmarks created by Drs. Michael Strober and Craig Johnson, in a recent paper published in The International Journal of Eating Disorders. The two doctors followed their paper up with a workshop at The Renfrew Foundation Conference for Professionals on the complexities of anorexia and how to treat it.

In their paper the authors explain their benchmarks are a “frame of reference” derived from scientifically supported observations and “an immense amount of clinical experience.” Here are their guidelines, directly quoted:

Consider inpatient care as a first intervention when there is:

1. A steeply declining trajectory in body weight, especially when weight is already below 75% of expected weight for age and height.

2. Irrefutable insistence by patient that further weight loss is needed, or justifiable, because of an over- weight or ‘‘obese’’ appearance.

3. History of an extreme degree of regimentation or compulsiveness in behavioral routines from early in life; extreme fear of maturational challenge; a history of trauma, extreme hyperactivity (multiple hours of unrestrained activity), or comorbidity with major depression or obsessive compulsive disorder when their symptom intensity results in impairment on their own, or is compromising weight restoration.

When to End Outpatient Care and Step Up to Hospital Care:

[These benchmarks apply to the scenario involving an underweight child, adolescent, or a young adult, regardless of her or his previous treatment history.]

1. If weight declines steadily over the first 3 weeks of treatment (or following consultation if no treatment was initiated). In our experience, this trajectory becomes difficult to interrupt thereafter.

2. Weight is initially stable, but there is a negligible average weight gain (or a waxing and waning pattern of increases and decreases) by the end of month two of treatment (or following an initial consultation). In our experience, a steady, uninterrupted increase in weight back to normal body mass becomes increasingly less likely after this point.

3. There is initial weight gain, but the slope of the increase levels off prior to the patient achieving full weight restoration, and this flattened pattern remains unaltered for at least 6 continuous weeks.

[The authors note that if there is a change of therapist, these benchmark algorithms start over.]

These benchmarks apply to older adults at low body weight who have been ill for at least five years:

1. Weight is declining steadily in the first three weeks after commencing treatment.

2. Weight is initially stable, but the patient is unable to initiate, and then sustain, a steady increase in weight by the end of month three of treatment; in our experience, uninterrupted weigh gain after this point is increasingly unlikely with such a patient.

3. Weight increases initially, but the slope of this increase then levels off and remains so for 3 continuous months.

The authors preface their guidelines by repeating their warnings that these benchmarks have to be applied within the context of seeing anorexia as a highly complex disease. In summary, their caveats:

• Though a patient may exhibits “noteworthy” improvements, the continuation of even mild symptoms should not be taken lightly.
• Lack of early weight gain in outpatient therapy may indicate a limit on what can be achieved over time.
• Single interventions will not suffice when a disease as complex as anorexia is at issue, and psychological care should be present at all times in conjunction with other treatments.
• Beware of therapist inexperience, which can result in either an overly lax approach when more oversight is needed, or excessively rigid control when more time is needed to let the treatment course evolve.
• A patient’s “avowed enthusiasm for eating,” the doctors ask us not to forget, “is often the last refuge” in an attempt to avoid a more intense level of treatment. “The appearance of change is not necessarily meaningful change,” and failure to recognize the difference can have serious consequences.
• The longer the illness goes on, so will it’s damaging effects on the physical health and the independence of the patient.

I look forward to hearing your reactions and feedback to these guidelines.