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The Need for Complex Ideas in Anorexia Nervosa: Why Biology, Environment, and Psyche All Matter, Why Therapists Make Mistakes, and Why Clinical Benchmarks Are Needed for Managing Weight Correction

Michael Strober, PhD, ABPP1, 2* Craig Johnson, PhD3, 4

Benchmark Algorithms

When to Consider Inpatient Care as a First-Line Intervention

No attempt has yet been made to determine if there is a specific clinical boundary that warrants inpatient versus outpatient care; neither is there a specific weight threshold (below 75% of ideal body weight is frequently cited) nor an infallible course indicator that supports the imperative of hospitalization, beyond, of course, trending signs of cardiac, hematologic, kidney, or liver function abnormality. However, based on experience with patients who enter into outpatient care first, the likelihood of failing this treatment is high when any of the following clinical features are present, and especially when they co-occur.

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 that further weight loss is needed, or justifiable, because of an overweight 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.

Some will ask how these indicators are to be operationalized so they can be applied systematically; but this is where the sort of clinical judgment that experience hones is important. Similarly, it is intuitive that when more than one of the listed features is present concurrently the impairment this results in is too difficult to interrupt in the outpatient setting. For these reasons the rationale for moving sooner rather than later to inpatient care is sound. We are not saying it is absolutely impossible for outpatient care to succeed when very low body weight (or these other clinical features) is present—we know of cases— but it is rare.

When to End Outpatient Care

This is by far the most crucial scenario for benchmark application because it is the more common one. Our recommended algorithms for escalating the level of care are as follows; they are broken down by the presenting circumstance.

Scenario 1: When Outpatient Care Has Been Attempted for an Underweight Child/ Adolescent/Young Adult, Regardless of Previous Treatment History

Beginning treatment de novo with an underweight child or teen is the paradigmatic illustration of benchmarking the level of care needed to minimize risk of a deeper and more entrenched psychopathology. In fact, we are increasingly being asked by parents, ‘‘When do we know what we’re doing is not working?’’ It is a complicated question for several reasons: because the treatment of AN requires time, so changing course too soon isn’t always a good thing; there is no uniformity in how ‘‘low weight’’ is defined; and switching to another therapist, one more skilled, can sometimes reverse the course dramatically. But knowing that a spontaneous remission is extremely rare, that bone demineralization accrues quickly, and that as symptoms intensify self-esteem and adaptive competency suffer, we urge that outpatient therapy be stepped up to hospital care when any of the following circumstances apply:

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.

If, per chance, there is a change of therapist, the algorithms recycle immediately.

Scenario 2: Initiating Outpatient Treatment for the First Time in an Older Adult at Low Body Weight

Here, we are presuming the patient has been ill for at least 5 years. It might be argued that because illness duration is longer the urgency of more intensive treatment is proportionately greater; but so is the patient’s language of resistance, and since time will be needed before we have a good sense of the precise issues involved in the history of such a patient a more lenient algorithm is prudent. So assuming the patient is judged by a physician’s examination to be medically stable, the algorithm needs to allow greater time for the patient’s struggle to play out. Accordingly, we recommend the transition to a higher level of care when:

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.

Scenario 3: Initiating Outpatient Treatment with a Young Adult Who Has Had a Prior Failed Treatment

Here we recommend the same criteria as in Scenario 1.

It is also legitimate to ask whether these should be explicit rules; but it should be remembered that the time points derive from experience. Beyond the questions that naturally arise about algorithms, what these address in a fundamental sense, and we think reasonably given the material reviewed, is the danger of passivity in decision making; because over time, the pull of irrational habits, conflicted motivation, and the mind’s attitude in AN grow stronger and as they do the resistance to change becomes more formidable.

What to Do When Patients/Families Reject the Recommendation of a Higher Level of Care?

As Vandereycken and Meerman note,27 therapists have as much ‘‘right’’ to discontinue treatment as patients do; except here, the rationale is stronger as it is informed by an important clinical wisdom. Patients withdraw from treatment due to fear of what they are being asked to confront and the emotional discomfort that results (we are not speaking here of ending a treatment that is poorly executed or one attempted by an unskilled therapist). But for therapists, the decision comes after a lack of meaningful progress over an extended period, or upon a patient’s refusal to step up their level of care when it is deemed acutely necessary. There is no question these are difficult, sometimes painful, decisions; we consider them reluctantly because of the original commitment we made to the patient’s wellbeing and our abiding hope that one day our patient will enjoy a future less encumbered by withering self-deprivation. But returning to an earlier caution, continuing a level of care that is unprofitable and not likely to have benefit in the foreseeable future is not treatment, and to carry on as if it is carries significant risk. For this reason, discontinuing treatment may well be the only action persuasive enough to convey the urgency of what the therapist feels, and what the patient needs, regardless of what they ultimately decide to do.

But it is not a finite decision, and this is an important point. Instead, we recommend for the time being only a temporary interruption of care; specifically, if an impasse has been reached we recommend reconvening in 1 month’s time for further assessment of the patient’s circumstances. The rationale of the interruption is explained by incorporating the premises discussed throughout this article; hope is expressed that the patient (and/or family) will soon reconsider the refusal of a higher level of care; the risks of further refusal are discussed straightforwardly; interim follow-up with a physician is strongly recommended; possible underlying reasons for the patient’s reluctance to contemplate treatment of greater intensity are outlined, emphasizing the psychopathological issues involved, including as much detail in the explanation as possible; and finally, the possibility that the treatment may end at this time is acknowledged. Should the patient return, laboratory results and symptom intensities are reviewed and signs indicating a worsening of the patient’s physical or clinical state are discussed in detail, along with the patient’s/family’s current worries, or, perhaps, their professed lack of concern (but rarely is a blase´ attitude seen). If the original recommendation is rebuffed at the 1.month follow-up, a second follow-up in 3 months is offered and if the patient agrees the therapist again expresses hope that the return visit will take place. Yet a third, but final, 3-month follow-up is scheduled if the refusal persists.

In our experience, the outcomes are entirely unpredictable: some patients reconsider quickly, accepting the higher level of care because their condition has worsened, or the intensity of their misery has greatly increased; some continue to refuse, but ultimately reconsider at a later time; others seek treatment elsewhere, sometimes showing noteworthy improvement; and still others never return and we never hear from them again. Finally, as discussed elsewhere,28 for some adult patients the only recourse is a supportive management where the interventions and objectives are carefully measured.