Treatment Resistance in Eating Disorders

Clinicians treating patients with eating disorders find the challenge great with many treatment-resistant cases.

To some extent, this is true of any clinical disorder. Outpatient treatment rolls and inpatient samples are over-represented by those failing to respond to initial interventions.

A medical example is helpful here. Endocrinologists specializing in diabetes see more complicated cases where glucose control is difficult and diabetic complications are common.

Diabetics with easy glucose control and no complications do not need to see an endocrinologists. To an endocrinologist, clinical practice seems to point to the disease as a treatment-resistant and clinically challenging disorder.

Nevertheless, treatment resistance in eating disorders is a significant issue that has been recently summarized in a nice review by Dr. Katherine Halmi.

Here are my notes from review of the Halmi manuscript using her key headings:

Core eating disorder psychopathology

• Adolescent eating disorder subjects lack insight into the seriousness of illness
• Many do not acknowledge need for treatment
• Body weight, exercise and dieting provide a distraction from other life problems
• Malnutrition in eating disorders contributes to cognitive impairment, treatment engagement problems
• Bulimia treatment resistance has been linked to greater depression, lower BMI and social adjustment problems

Psychiatric and psychological comorbidity

• U.S. National Survey found high rates of psychiatric comorbidity in eating disorders (56% in anorexia nervosa, 95% in bulimia nervosa and 79% in binge eating disorder)
• Anxiety disorders rates are elevated in eating disorders with obsessive compulsive disorder and social anxiety disorder two common conditions
• Anxiety disorders can contribute to resistance of treatment of eating disorder symptoms
• Cluster B personality disorders are elevated in bulimia nervosa and appear related to higher rates of substance dependence in this disorder
• Perfectionism is common in anorexia nervosa. Early onset and high perfectionism traits contribute to higher treatment resistance

Biological features

• Serotonin receptor and transporter function appear to influence course of illness in eating disoders
• GABA receptor genotype appears to be related to level of trait anxiety in both bulimia nervosa and anorexia nervosa
• GABA receptor abnormalities are also possibly related to treatment resistance

Treating refractory patients

• Quetiapine, olanzapine, haloperidol and duloxetine are drugs with some promise in treatment resistant anorexia nervosa
• Novel psychotherapies including CBT and the Maudsley Model  target key features of resistance in anorexia nervosa
• Treatment resistant bulimia nervosa may respond to sequential treatment strategies that include partial hospitalization, selective serotonin reuptake inhibitor (SSRI) drugs and cue exposure
• Binge eating disorder may respond to high dose SSRI therapy or topiramate in a graduated dosing schedule

This review points to the key elements for treatment of the difficult eating disorder patient.

This population needs access to specialized hospitalization units, psychopharmacology expertise and specialized psychotherapy services.

Dr. Halmi notes advances in the treatment of this population may require advances in understanding the neurobiology and neurocircuitry for the disorder.

Readers with more interest in this summary can find the free full-text manuscript by clicking on the DOI link in the citation below.

Winter snow scene is from the author's files.

Follow the author on Twitter @WRY999

Halmi, K. (2013). Perplexities of treatment resistence in eating disorders BMC Psychiatry, 13 (1) DOI: 10.1186/1471-244X-13-292