Approximately 20% of patients with anorexia nervosa develop severe and enduring anorexia nervosa (SE-AN), manifest by decades-long illnesses. At certain points, demoralized and/or based on judicious appraisals of the seeming futility of further professional treatment to radically alter their course, some SE-AN patients decide that “enough is enough” and opt out of intensive treatment. This article considers courses and treatment options available at these stages for patients, families, and clinicians.
The author uses clinical illustrations, Socratic questioning, and available literature to explore questions of treatment strategies with patients struggling with SE-AN.
SE-AN patients have frequently received care in varieties of medical, psychiatric, and specialized eating disorders inpatient, residential, partial hospital, and outpatient treatment settings. Patients may reject further high-intensity treatment for judicious or capricious reasons, but may still accept lower intensity treatments. Some may reject any and all offers of treatment. Clinicians' treatment recommendations, not always coinciding with patients' wishes, are influenced by numbers of clinical, social, and professional pressures, including those from families, treatment settings, regulatory bodies, and payors.
When managing patients with decades-long disease and multiple comorbidities, clinicians must be realistic about the low odds of effecting cure and adjust treatment expectations accordingly. For patients with SE-AN, a variety of low-intensity treatment approaches, at times extending to palliative and hospice care, may be useful. Clinicians should always strive to provide humane comfort and support, as closely aligned to patients' judicious wishes as realistically possible.