Adult Women (age 25+) with Chronic Anorexia Nervosa
There is no agreed upon definition for what constitutes “chronic” anorexia nervosa. Among those that have been offered are: the affected person has been suffering from an eating disorder for 10 or more years (Noordenbos et al, 1998); the presence, for 5 or more years, of strong anorexic symptoms (Levenkron, 2000); and onset before age 25 and continuation of the illness after age 25 (Mynors-Wallis et al, 1992). In part due to this discrepancy, there are no specific statistics on the prevalence of chronic anorexia nervosa in adult women. It is documented, however, that 2% of adult women meet current diagnostic criteria for anorexia or bulimia nervosa (APA) and the lifetime prevalence for anorexia is women is 3.7%. Up to 25% of all patients with anorexia can be considered chronic (Hsu, 1996).
It is estimated that with treatment, about 60% of people with eating disorders fully recover thanks to eating disorder resources; approximately 20% make partial recoveries, and the remaining show little improvement. A number of predictors of chronicity have been determined: co-morbidity (the presence of affective or anxiety disorders, substance abuse, etc.); a Body Mass Index of less than 13.0 at referral (Hebebrand et al, 1997); delayed diagnosis and treatment (i.e., the longer abnormal eating behaviors persist, the more difficult it is to overcome the disorder and its effects on the body); high level of purging behavior; disturbances in family relationships; compulsive exercise; and social isolation prior to onset (Costin, 1999). Also, if someone is discharged from an inpatient program below 90% of her normal weight, the risk of relapse jumps tenfold (Chase, 1999).
In general, clients with anorexia have a reputation for being “treatment resistant.” The experiences of chronic patients give insight to one reason for that phenomenon, that of the treatment itself. Chronic anorexic women report more negative experiences with treatment, especially behavior therapy, tube feeding, and frightening hospitalizations, leading many to lose faith in any further treatment (Noordenbos et al, 1998). Noted specialist in anorexia, Hilde Bruch, related that many of her clients had previously been “exposed to numerous contradictory treatment plans” (1988). And Steven Levenkron argues that, “Someone who has been repeatedly exposed to the standard accepted treatments for anorexia nervosa is not likely to respond to yet another exposure to them” (2000).
In addition to a general lack of trust in treatment on the part of the chronic anorexic woman, there are a number of other factors that may serve as barriers to effective counseling. Primary among them is poor insurance coverage for mental illness. Full recovery from anorexia is estimated to take 57-79 months of treatment (Strober et al, 1997). Inpatient or residential stays of several months are often needed to combat severe anorexia, followed by intensive outpatient therapy. Yet insurers often cut off coverage, many providing a maximum of 30 inpatient days and 20 outpatient visits per year. Other problems include a lack of communication between family members, therapists, psychiatrists, and other treatment providers of chronic patients (Jack, 2000) and the mechanism by which the physical consequences of the eating disorder may serve to perpetuate the disorder (Treasure and Szmukler, 1995).
Levenkron details how the chronicity itself and enabling factors add to the difficulty of successfully treating the adult chronic anorexic woman. Of one client, he says, “…The sheer length of time Graham had lived a life consisting of no responsibility, no connection to others, made her eating disorder the only structure in her life that she was organized around and could depend on.” Essentially, when symptomatic thinking and acting become ingrained and natural to a woman, they stop being an illness and evolve into her sense of identity. Also, significant others often come to adjust to and accept the woman’s illness rather than continuing what seems to be ineffective interference. In contrast to the agitation her family might have gone through during the first few years of a woman’s anorexia, “those around her all used up and she’s still alive.”
Unfortunately, however, without intervention, that may not be true for long. Anorexia has a higher mortality rate than that of any other psychiatric disorder. There are many physical consequences that can result from extended states of malnutrition and emaciation, which intensify over time. Osteoporosis, for instance, is a relatively common complication in long-term anorexia, and appears to persist after weight gain and recovery (Serpell and Treasure, 1997). More significantly, without treatment, up to 20% of people with eating disorders will die from the effects of their illness, most commonly from organ failure (heart, liver, kidney) or suicide. With treatment that number falls to 2-3%. The mortality rate for anorexia is 5.6% per decade, meaning that for each decade of chronic anorexia, sufferers face an addition 5.6% risk of dying from it.
The research results for current treatment methods for anorexia, mainly focused on cognitive-behavioral therapy, remain disappointing. Relatively little research has been devoted to developing improved methods for its treatment. (APA) Results for older and more chronic patients are generally only mentioned in passing, and no treatment for chronic forms of eating disorders has proved to be effective in the research literature (Treasure, 1991). Clinical literature, meanwhile, focuses more on psychodynamic and feminist oriented psychotherapy, quite distinct from the types of treatment chronic patients indicate have failed them, and expresses a significantly more positive outlook on the prospect of full recovery. “A special requirement for the adult, long-term patient is a therapeutic relationship that has a personal connection that exceeds previous therapies.” (Levenkron, 2000)
References
Bruch, H. (1988). Conversations with anorexics: A compassionate and hopeful journey through the therapeutic process. Northvale, NJ: Jason Aronson, Inc.
Chase, M. (1999). Insurers are obstacles for anorexics. The Kansas City Star.
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business/30dadac.325,.html.”
Chronic diseases—Research agenda for psychosocial and behavioral factors in women’s health. American Psychological Association Public Interest Directorate. “www.apa.org/pi/wpo/chronic.html”.
Costin, C. (1999). The eating disorder sourcebook. Los Angeles: Lowell House.
Hebebrand, J., Himmelman, G., Herzog, W., Herpertz, & Dahlmann, B. M. (1997). Prediction of low body weight at long-term follow-up in acute anorexia nervosa by low body weight at referral. American Journal of Psychiatry, 154 (4), 566-569.
Hsu, L. K. G. (1996). Outcome of early onset anorexia nervosa: What do we know? Journal of Youth and Adolescence, 25 (4), 563-568.
Jack, S. M. (2000). The social construction of chronic anorexia nervosa: A qualitative investigation of patients, parents, therapists, and psychiatrists. Dissertation Abstracts International Section A: Humanities and Social Sciences, 60 (9-A), 3543
Levenkron, S. (2000). Anatomy of anorexia. New York: W. W. Norton & Company
Mynors-Wallis, L., Treasure, J., & Chee, D. (1992). Life events and anorexia nervosa: Differences between early and late onset cases. International Journal of Eating Disorders, 11 (4), 369-375.
Noordenbos, G., Jacobs, M. E., & Hertzberger, E. (1998). Chronic eating disorders: The patients’ view of their treatment history. Eating Disorders: The Journal of Treatment and Prevention, 6 (3), 217-223.
Serpell, L., & Treasure, J. (1997). Osteoporosis—A serious health risk in chronic anorexia nervosa. European Eating Disorders Review, 5 (3), 149-157.
Strober, M., Freeman, R., & Morrell, W. (1997). The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. International Journal of Eating Disorders, 22 (4), 339-360
Treasure, J. (1991). Long-term management of eating disorders. International Review of Psychiatry, 3 (1), 43-58.
Treasure, J. & Szmukler, G. I. (1995). Medical complications of chronic anorexia nervosa. In G. I. Szmukler & C. Dare (Eds.), Handbook of eating disorders: Theory, treatment, and research (pp. 197-220). New York: John Wiley & Sons.
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