REVIEW ARTICLE

Minimizing and Treating Chronicity in the Eating

Disorders: A Clinical Overview

Stephen Wonderlich, PhD1,2,3* ABSTRACT

Objective: The purpose of this article is
James E. Mitchell, MD1,2,3 to review the available literature regard-
Ross D. Crosby, PhD1,2 ing treatment and management of eating
Tricia Cook Myers, PhD3 disorder patients who fail to change over
Kelly Kadlec, EdD3 protracted periods of time.
Kim LaHaise, PhD3 Method: Literature was reviewed per-
Lorraine Swan-Kremeier, PsyD3 taining to approaches to promoting
change in treatment-resistant cases and
Julie Dokken, MS3 the treatment of chronic eating disor-
Marnie Lange, MSW3 dered individuals.
Janna Dinkel, RN3 Results: Although there are a number
Michelle Jorgensen, MD3 of clinical perspectives on the treatment
Linda Schander, LRD3 of chronic eating disorder patients, fun-
damental studies defining the concept of
‘‘chronicity’’ and standardized treatment
approaches do not exist. Empirical stud-
ies of chronic cases are needed, given the
absence of investigation of maintenance
factors in chronic eating disorders and
evidence-based approaches for treat-
ment. An integrative and practical clini-
cal protocol is provided.
Discussion: The results of this review
suggest that a significant number of eat-
ing disorder patients display a chronic
course, which is poorly understood.
Treatments for these individuals are not
based on evidence-based findings.
VC 2012 by Wiley Periodicals, Inc.
(Int J Eat Disord 2012; 45:467–475)

Introduction for protracted periods of time (i.e., years) with

Treatment studies of eating disordered individuals
indicate that the majority of individuals with ano-
rexia nervosa (AN) or bulimia nervosa (BN) do not
fully recover during short-term, focused psycho-
therapy or pharmacotherapy trials.1–4 Moreover,
long-term follow-up studies suggest that a substan-
tial number of AN and BN patients continue to dis-
play clinically significant levels of eating disorder
symptoms for years and, in some cases, for deca-
des.5–7 Robinson8 summarizes a series of longitudi-
nal studies of clinical cases of AN,9–12 which to-
gether suggest that after !6 or 7 years of eating
disorder duration, the likelihood of people recover-
ing reaches a plateau and fails to reach zero,
although some evidence suggests that such a pla-
teau does not appear until 10–20 years after the
onset of the disorder.13 These findings support the
well-known clinical observation that a significant
number of eating disordered individuals will con-
tinue to display eating disorder symptomatology
Accepted 6 November 2011
*Correspondence to: Stephen Wonderlich, Ph.D., University of
North Dakota School of Medicine and Health Sciences, Fargo, ND
58107. E-mail: stephenw@medicine.nodak.edu.
1 cuss strategies for treating individuals with long-
University of North Dakota School of Medicine and Health Sci-
ences, Fargo, North Dakota
2
Neuropsychiatric Research Institute, Fargo, North Dakota
3
Sanford Health System, Fargo, North Dakota
Published online 23 January 2012 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.20978
C 2012 Wiley Periodicals, Inc.
V focus on active change of eating disorder symptoms
some ultimately recovering, but others experienc-
ing chronic, lifelong eating disorders that do not
resolve. Unfortunately, the scientific evidence base
for such eating disordered individuals who do not
respond to initial treatment and experience multi-
ple treatment failures is exceedingly limited.
Consequently, clinicians are faced with the reality
that most patients receiving eating disorder treat-
ment continue to receive care well beyond the 6–12
months outlined in most empirically based treat-
ment manuals.14–16 In such situations, clinicians of-
ten modify treatment, perhaps address alternative
treatment goals, target comorbid complicating dis-
orders, switch to intermittent supportive treatments,
or intensify treatments with higher levels of care, all
of which are based on clinical decision making with
minimal scientific guidance. Unfortunately, treat-
ments may devolve into relatively unfocused, inter-
mittent, supportive interventions, where goals
become unclear and monitoring of clinical status
becomes impressionistic and imprecise.
Over the last 30 years, a small literature on the
treatment of chronic eating disordered individuals
has also developed.17–20 This literature tends to dis-
standing eating disorders who have experienced
multiple treatment failures and a complex array of
mental health and medical problems. Most often,
these clinical perspectives propose reducing the

International Journal of Eating Disorders 45:4 467–475 2012 467

WONDERLICH ET AL.
and instead emphasize an effort to reduce harm,
maintain symptom stability, and enhance quality of
life for the patient.
The present work focuses on the issue of eating
disorder chronicity. We will provide a brief overview
of this literature and also discuss some problems or
concerns with the definition of chronicity and
approaches taken to address chronicity in other
areas of mental health. Also, we will review practi-
cal issues embedded in the treatment of chronic
patients and strategies to assist such individuals
and their families.
Clinical Perspectives on Treatment of
the Chronic Eating Disorder Patient
Previous Perspectives on Treating Chronic or
Treatment Resistant Eating Disorder Patients
Hamberg, Herzog, Brotman, and Stasior.21 Hamberg
et al.21 describe a team-oriented approach to deal-
ing with treatment resistance in AN, which they
view as common in these patients. They suggest
that the idea of a shared or collaborative commit-
ment between patient and clinician in the treat-
ment of AN is rare or nonexistent, and such com-
mitment only comes with careful establishment of
the therapeutic alliance. The first step in this
approach is to establish clear guidelines that are
shared among the patient, the clinical team, and
the family regarding issues of safe weights and cri-
teria for medical stabilization treatment. These
authors view this team-oriented approach with
explicit guidelines as optimal and describe the
team as a ‘‘therapeutic envelope,’’ which protects
the safety of the patient and the integrity of the
treatment. They note that AN patients commonly
‘‘test’’ the ability of the therapeutic envelope to
respond according to the guidelines.
In essence, Hamberg et al.21 offer an early and
clear recommendation that team-oriented treat-
ment for complex and treatment-resistant eating
disorders is essential and that the patient’s ambiva-
lence about recovery is likely to result in multiple
tests of the treatment team’s ability to maintain the
medical safety of the patient.
Goldner.17 Goldner17 provides another discussion
of treatment refusal in patients with AN and high-
lights that the clinical dilemmas noted by Lasegue
and Charcot, in their early reports regarding strat-
egies for treatment resistance in AN, persist in
more contemporary treatment. He discusses other
early debates between clinicians who thought that
468
the clinician’s acceptance and tolerance of treat-
ment resistance were essential versus other clini-
cians who suggested that directly confronting the
absence of weight restoration was a sine qua non
of treatment. Interestingly, he also recommends
that clinicians may need to refuse treatment in
exceptional cases as an ‘‘ultimatum’’ to provide a
confrontation regarding the lack of collaboration in
the treatment. Further acknowledging the com-
plexities of treatment resistance and treatment re-
fusal, Goldner notes that legal policy often cannot
be avoided in the treatment of chronic AN patients,
most notably involving cases of involuntary com-
mitment, legal incompetency, and patients below
the age of majority. Goldner17 makes the interesting
point, however, that there is considerable variabili-
ty among clinicians regarding their imposition of
legal mechanisms, given the complexity of the
assessment of the overall risk versus benefit of
treatment for such patients.
Goldner17 offers a thoughtful discussion of prac-
tical suggestions for managing treatment refusal in
patients with AN that carefully addresses issues of
control versus autonomy as well as the collabora-
tive engagement of the patient in treatment versus
treatment imposition. He also raises the issue that
clinicians treating chronic AN patients who are
refusing treatment may need to modify typical
treatment goals and protocols used in more acute
cases and prepare for what is likely to be a long-
term process.
Yager.18 In another early work on this topic, Yager18
outlines a comprehensive framework for thinking
about working with chronic and recalcitrant eating
disordered patients. After providing a brief over-
view of empirically derived prognostic factors in
eating disorder patients and a rich clinical descrip-
tion of typical chronic eating disorder cases, he
offers a list of recommendations that can be sum-
marized as follows:
1. Establish a heartfelt connection with the
patient and attempt to identify true goals and
avoid counter-productive battles with the
patient over control of the treatment.
2. Review with the patient and her/his family
what treatments have been tried in the past
and what treatments they think might be use-
ful to pursue in the future.
3. Establish a multidisciplinary treatment team
that outlines a collaborative behavioral con-
tract that is flexible and avoids ‘‘dehuman-
izing, rigidly monitored control battles around
eating behavior.’’ Although the clinician should
not be overzealous in trying to engage the
International Journal of Eating Disorders 45:4 467–475 2012
 MINIMIZING AND TREATING CHRONICITY IN EATING DISORDERS
chronic eating disorder patient into a tightly
controlled behavioral plan, clinicians should
not deviate from basic requirements regarding
medical monitoring and criteria for hospitali-
zation.
4. If untried, discuss particular psychotherapeu-
tic or pharmacotherapeutic interventions.
5. If possible, include family members in treat-
ment planning.
6. Avoid expensive, time-consuming treatments
that have been repeatedly shown to be inef-
fective or instill hope in the patient or family
that is unfounded.
7. Consider legal procedures only in life threat-
ening situations.
Overall, Yager18 describes an approach that paral-
lels Goldner’s emphasis on the application of
humanistic treatment principles that respect the
patient’s self-determination and autonomy, but
also mandates clinicians to impose interventions in
the case of potentially harmful circumstances.
However, he adds the additional recommendation
to carefully examine previous treatments that have
failed and others that have not been attempted.
Vitousek, Watson, and Wilson.22 Vitousek et al.22 pro-
vide a thoughtful consideration of an approach
designed to enhance the level of engagement and
increase motivation in treatment resistant eating
disorder patients. Unlike Goldner or Yager,18 this
approach does not explicitly address chronic, treat-
ment refusing cases, but focuses on the related topic
of treatment resistance. The approach outlined in
the work emphasizes the significance of clinicians
attempting to gain a clear understanding of the sub-
jective experience of the reluctant eating disorder
patient, their concerns about weight gain and other
behavioral changes, and an appreciation of the diffi-
culty of this behavioral change. Vitousek et al.22 rec-
ommend a very empathically oriented, cognitive-
behavioral approach that relies on Socratic ques-
tioning to promote a collaborative examination of
the patients ambivalence about recovery.
In contrast to other authors writing on chronicity
of eating disorders, the authors carefully avoid
moving in the direction of differential treatment
planning for chronic patients. They state, ‘‘the con-
clusion that a patient cannot give up her AN should
be reached slowly, reluctantly, and above all tenta-
tively since apparently intractable cases sometimes
evolve toward recovery.’’ It is suggested that when
persistent efforts fail to promote change, therapists
should apply the same motivational principles, but
reduce the magnitude of the goals. Thus, these
International Journal of Eating Disorders 45:4 467–475 2012
authors would recommend engaging in the same
motivationally oriented treatment in the most
treatment-resistant cases, but collaboratively seek
to identify goals that are consistent with the
patient’s clinical history and previous treatment ex-
perience. In other words, Vitousek et al.22 recom-
mend continuation of the fundamental treatment
approach with modified goals.
Strober.19,20 Strober19,20 offers two unique works
regarding chronicity in AN. His perspective is
couched in the concepts of his earlier writings
regarding personality traits, conditioning proc-
esses, and environmental pressures as risk factors
for AN. He describes the development of AN as a
conflict between a temperament characterized by
emotional restraint, interpersonal inhibition, per-
fectionistic standards, and the stresses associated
with the developmental uncertainties of adoles-
cence, which is resolved through a retreat into an
obsessional focus on weight, eating, and self-con-
trol. His conceptual model is relevant, because it
clearly informs his treatment. Specifically, Strober19
views these personality/temperament traits as
essential for AN both in terms of its onset and
maintenance. Furthermore, these traits are thought
to propel a person toward symptomatic stability
and avoidance of change, which he believes needs
to be considered and respected in the treatment of
the chronic AN patient. Precisely because treat-
ment involves change, and some degree of loss of
control, the AN patient is compelled to avoid
engagement in treatment. Clinicians are advised to
avoid aggressive, therapeutically zealous
approaches to treatment that promote excessive
change and overwhelm the patient. In contrast,
Strober19 suggests that clinicians create ‘‘a pallia-
tive, holding management of carefully measured
intensity.’’
Strober’s19,20 treatment of such patients begins
with a thorough understanding of his neurodeve-
lopmental model of AN and a strong reassurance
that weight gain will not be a principle objective of
the treatment. He requires that the patient obtains
regular physical examinations and encourages
increases in nutrition that do not risk significant
increases in weight. Regarding the patients’ social
life, he encourages the patients to develop routines
of social activity and engagement in hobbies, intel-
lectual pursuits, and any activity that promotes a
sense of pleasure, mastery, or cognitive stimulation.
Finally, Strober19 recommends meeting adjunc-
tively with family members to teach them about
the psychopathology of AN and to provide general
support to the family. Strober19,20 believes that the
treatment of such patients is best done in the con-
469
WONDERLICH ET AL.
text of the hospital environment, but discourages
the use of general psychiatric inpatient units or
medical units.
Robinson.23 Robinson23 provides a unique perspec-
tive on the treatment of complex and chronic pre-
sentations of AN and BN, which he refers to as
‘‘severe and enduring eating disorder’’ (SEED). He
makes the point that long-term eating disorder
cases should be considered serious disorders with
major psychiatric, medical, social, occupational,
and familial complications. Each of these domains
of impairment is discussed and elaborated in terms
of the typical impact of enduring eating disorders.
Also, Robinson23 has conducted a series of quanti-
tative studies in which symptom measures, life skill
assessments, and quality of life measurements are
compared between different psychiatric disorders.
Importantly, patients with SEED (AN type) scored
similarly to severely depressed patients in quality of
life scores. Additionally, the life skill scores of the
eating disorder group were as impaired as patients
with schizophrenia. Drawing on the parallels
between SEED and other serious psychiatric disor-
ders, Robinson considers how psychiatric rehabilita-
tion models may be useful in terms of treating
SEED. Using multidisciplinary team models, similar
to that seen in psychiatric rehabilitation approaches,
Robinson23 outlines an intervention strategy that
includes long-term follow-up of psychiatric issues,
crisis intervention, specific psychological interven-
tions, and substance misuse. Furthermore, basic
self-care needs, including nutrition, housing consid-
erations, financial issues, daily recreation, and voca-
tional issues are considered.
Community Outreach Partnership Program
(COPP24) was designed for eating disorder patients
who have not responded to recovery oriented treat-
ment. Primary goals include enhancing quality of
life and increasing independence rather than
decreasing eating disorder symptoms. It is an inte-
grated program including staff from a hospital-
based eating disorder program and a community-
based mental health rehabilitation team. Clinical
contact with the patient may take place in the
community (e.g., home, restaurant, or other com-
munity agencies) rather than a hospital or clinic
environment. Interactions with the patient are
practical, but also significantly influenced by moti-
vational interviewing techniques. COPP also
emphasizes the importance of environmental
resources and attempts to assist the patient in
developing a broad-based community of individu-
als and institutions that support the patient’s well
being. Additionally, the COPP team establishes
470
‘‘non-negotiables’’ that refer to essential agree-
ments that the patient must make in order to be
seen by the COPP team (e.g., attendance at medical
appointments). Interestingly, COPP is not consid-
ered to be palliative care. Preliminary outcome
data reveal that patients in the program have had
an eating disorder for an average of 15 years and
have been followed in the COPP program for
!3 years. From baseline to end of treatment
(!3 years), there were significant decreases in
global distress, hopelessness, and eating disorder
symptoms. Relationships and self-concept indica-
tors also improved. Quality of life, somewhat sur-
prisingly, did not improve.
Unresolved Issues in Defining and
Assessing Chronicity
There is no hard and fast algorithm, rule, or crite-
ria for designating a patient as having a chronic
eating disorder. Furthermore, there is no strong
empirical evidence that suggests that there is a
demarcation or boundary separating chronic cases
from other cases which guides differential treat-
ment planning. The complexity of such a definition
was seen in a recent DELPHI study in the United
Kingdom,25 in which 53 professionals who work in
the area of eating disorders and represent numer-
ous disciplines completed a series of question-
naires that were analyzed to determine the group’s
consensus opinion about definitions for chronic
AN and its treatment. Interestingly, these individu-
als failed to find consensus on the utility of ‘‘dura-
tion of the disorder’’ or ‘‘number of failed treat-
ments’’ as indicators of chronicity. Rather, the data
revealed that the group viewed entrenched patterns
of behavior, eating disordered identity, and a BMI
under 17.5 as comprising the best definition of
chronicity. Other indicators that professionals have
identified over the years as possible indicators of
chronicity include duration of the disorder that is
greater than 10 years, extremely limited social life
and vocational impairments, poor quality of life,
and repeat treatment failures.
Attempting to provide definitions of ‘‘chronicity’’
for eating disorders may be complicated by several
problems. First, at a behavioral level, chronicity
implies an absence of change. However, an absence
of change is a complicated concept. Eating disor-
dered individuals may vary along dimensions of
body weight, binge eating, purging, and various
cognitions about body, shape, and weight. Fre-
quently, patients will change on a given dimension,
but fail to change on another. Consequently, multi-
faceted assessment of change produces a more
complicated clinical picture than simply determin-
International Journal of Eating Disorders 45:4 467–475 2012
 MINIMIZING AND TREATING CHRONICITY IN EATING DISORDERS
ing whether the person has an eating disorder or
not. Second, it is unclear how long a person must
display an ‘‘absence of change’’ along some key clin-
ical dimension before being considered chronic.
Longitudinal analyses suggest that the likelihood of
change after 5–7 years of eating disorder symptoms
is significantly reduced.5,6 As described previously,
Robinson’s8 analyses suggest that somewhere
around 7 years the number of individuals recovering
from their eating disorders reaches a plateau,
although there is variability among studies. These
estimates, however, are based on group data, and
any given patient may ultimately be a ‘‘statistical
outlier’’ who responds long after the data suggests
that he or she will recover. Third, is the considera-
tion of patient age and developmental level in the
designation of a patient as chronic. For example,
would a 42-year-old AN patient with a 10-year his-
tory of the disorder and a 22-year-old AN patient
with an equivalent 10-year history be equally
chronic? Fourth, how does treatment history affect
the definition of chronicity? Would a 40-year-old BN
patient with a 25-year history of the disorder, but no
history of treatment, be considered chronic?
In general, there remain significant unanswered
questions about the nature of the concept of chron-
icity. As growing numbers of eating disorder
patients display treatment nonresponse, it will
become increasingly important to refine the defini-
tion of chronicity, particularly given the trend
toward differential treatment approaches for acute
versus chronic eating disorder patients. One meth-
odological suggestion for studying the validity of a
potential class of chronic eating disorder patients is
a more rigorous examination of variables mea-
suring duration of disorder or frequency of treat-
ment failures in descriptive studies of eating disor-
der diagnoses. In particular, taxonomic research
methods, such as latent class analysis or latent pro-
file analysis, could be conducted with duration of
disorder or number of treatment failures included
as an indicator in the analyses. If the inclusion
of such indicators produces additional classes
that might be considered chronic, external valida-
tion studies could be conducted that would clarify
the actual nature of these conditions. Also, an
enhanced understanding of maintaining factors in
the eating disorders will improve conceptual mod-
els and associated treatments for individuals with
longstanding or chronic eating disorders. Research
designs, which identify symptom persistence among
initially symptomatic individuals, are needed to elu-
cidate maintenance factors.26 There have been neu-
roscientifically informed theoretical developments
surrounding the role of emotion, interpersonal, and
International Journal of Eating Disorders 45:4 467–475 2012
cognitive factors as possible maintenance factors for
eating disorders.27–29 Furthermore, consideration of
the impact of starvation effects on the central nerv-
ous system broadens the scope of potential mainte-
nance models of eating disorders, in part through its
impact on brain reward systems.28,30
Summary. This small clinical literature appears to
be characterized by several common themes
regarding treatment of the chronic eating disor-
dered individual:
1. To the greatest extent possible, rely on a mul-
tidisciplinary team that is extremely cohesive
and familiar with chronic eating disorder
patients.
2. Review the treatment history to identify any
possible interventions that have not been used.
3. Carefully establish goals that are appropriate
for a patient with a chronic course and
include medical stability and appropriate
contingencies (e.g., hospital admission) when
medical stability is compromised.
4. Adopt a genuinely collaborative therapeutic
relationship that is both empathic and vali-
dating, but firm and clear in terms of bounda-
ries and expectations for the treatment.
5. Do not aggressively pursue significant reduc-
tion of eating disorder symptoms beyond
what is necessary for medical stability; rather
focus on quality of life, social adjustment,
vocational issues, and interpersonal/family
relationships.
6. Where possible, include family members and
assist families to adjust to the chronic nature
of the patient’s disorder and the implications.
Unfortunately, there is currently little empirical
evidence to support any of these recommenda-
tions. Furthermore, conducting such studies will be
significantly limited by the absence of a coherent
definition of chronicity. A related issue has to do
with identifying the most useful terminology to
refer to this group of patients. Are these individuals’
best viewed as chronic, treatment resistant, ambiva-
lent, nonresponsive, recovering, or some other
term? Each of these labels carries meaning regarding
a clinician’s conceptualization of the patient, which
may impact approaches to treatment.
Finally, it may be useful to consider how other
branches of mental health treatment conceptualize
and address patient nonresponse. For example, in
mood disorders, the concept of ‘‘treatment-resistant’’
depression is frequently used,31,32 but also has been a
source of considerable debate regarding definitional
471
WONDERLICH ET AL.
issues.33,34 Furthermore, Parker et al.35 suggest that
what appears to be treatment resistance is often
‘‘pseudo-resistance’’ referring to a variety of failures
to consider diagnostic factors, which, if addressed,
may alter treatment (e.g., organic determinants
and failure to diagnose melancholic depression). In
spite of these definitional issues and in contrast to
the eating disorder field, a large number of studies
of treatment-resistant depressed individuals has
been conducted, which have produced a wide array
of therapeutic options to be considered for treat-
ment resistant or chronic cases.36
Another model that may have utility for the eat-
ing disorder patient is the recovery model or recov-
ery movement.37,38 This approach to mental health
care, which has been particularly applied to severe
and persistent mental disorders such as schizo-
phrenia and psychoses, includes a range of inter-
ventions, including the promotion of culturally
appropriate independence in relationship to family,
the development of strong support systems, the
stabilization of symptoms and improvement of
social skills, and the enhancement of strengths
while minimizing deficits.39 This approach relies
heavily on broadening the concept of recovery to
include not only symptom reduction, but the
‘‘consumers’’ performance of instrumental role
functions and notions of empowerment and self-
directedness.40 This approach has not been with-
out critics.41 Most often, these criticisms focus on
the possibility that the recovery model places too
much emphasis on hope, empowerment, and
human rights and fails to take advantage of scien-
tifically supported treatment options, although
integrations of evidence-based ideas and the re-
covery model have emerged.42 In many ways, the
treatments for chronic eating disorder patients
reviewed previously seem to have identified
themes which are consistent with such a model.
For example, a significant de-emphasis on elimi-
nating eating disorder symptoms,20,24 a greater
emphasis on social adaptation,20,23,24 and the
negotiations of issues of autonomy in relation-
ship to family17,18,20 are all themes that may be
consistent with such a recovery model. Further-
more, the increasing attention paid to working
with caregivers and family members of eating dis-
order patients43,44 is consistent with such a bur-
geoning recovery oriented approach to mental
health care.
Undoubtedly, the treatment of eating disordered
individuals who fail to recover will continue to
evolve over time. However, clinicians are currently
faced with treatment and management of such
cases on a daily basis with little in the way of em-
472
pirical guidance. Consequently, we now describe
an approach to treating such individuals, which is
informed by the available clinical literature and
offers practical guidance to clinicians.
Practical Team Oriented Care of the Chronic
Eating Disorder Patient
Based on clinical experience, we would recom-
mend that long-standing eating disorder cases that
have not responded to treatment are best treated
within the context of a multidisciplinary eating dis-
order treatment team. Typical team composition
may include a mental health provider, dietitian,
medical provider, social worker, pharmacothera-
pist, and immediate access to hospital-based medi-
cal services with expertise in eating disorders (i.e.,
acute medical, inpatient, and partial hospital eating
disorders programs). Each patient should be
assigned to an outpatient team providing the fun-
damental range of services required for that
patient. It is worth noting that many patients with
a chronic eating disorder may intermittently use
various services provided by the team. For example,
a patient may only see a psychologist twice a
month, their medical provider every 2 months, a di-
etitian monthly, and a pharmacotherapist every
few months. What seems most critical is that the
team is integrated in their approach to treatment
and committed to a well-articulated plan, in spite
of the fact that treatment may be minimally inten-
sive. Practically speaking, it is often wise to arrange
appointments, so that patients do not go more than
1–2 weeks without being seen by one member of the
team. This helps to prevent serious periods of deteri-
oration outside of the awareness of the team mem-
bers. Furthermore, each outpatient team providing
services for a chronic eating disorder patient should
have good access to a hospital-based treatment
team, preferably one that is already familiar with the
patient, but at minimum is skilled in working with
chronic patients. Next, we will discuss outpatient
and hospital-based services for the chronic, treat-
ment-resistant eating disorder patient.
Outpatient Treatment. When an outpatient team has
determined that a particular patient appears
unlikely to engage in a change-oriented treatment
plan, but persists with behaviors that are clinically
significant, a full team staffing with the patient (and
relevant family members if possible) should be con-
ducted. In preparation for the team meeting, staff
should carefully review the treatment history; deter-
mine if there are any possible maintenance factors
that have been overlooked, or treatment options that
have not been tried.18 Such a meeting will generally
produce one of several possible outcomes. The first
International Journal of Eating Disorders 45:4 467–475 2012
 MINIMIZING AND TREATING CHRONICITY IN EATING DISORDERS
is that the patient (or the family) indicates that they
wish to persist in intensive, change-oriented treat-
ment, because some important obstacle has been or
could be modified or the patient and family demon-
strate renewed motivation and commitment to
change. These are difficult moments for treatment
teams. On one hand, the team does not want to give
up too quickly,22 but they also must appreciate the
history of the patient’s disorder and the limited effec-
tiveness of treatment to date. At the same time, fami-
lies may wish that the patient persists in treatment
and makes behavioral changes, even though the
patient remains ambivalent about treatment and
recovery. If the team elects to continue with an
active, change-oriented treatment approach, estab-
lishing goals, and a clear structure for the treatment
with an appropriate timeline become particularly im-
portant. What are the treatment goals for this next
phase? How often will the patient be seen and by
which members of the team? What makes this treat-
ment plan different, and more likely to succeed, than
past treatment plans? How long will this change-ori-
ented treatment effort be implemented and how will
it be evaluated? In certain cases, such an approach
may be justified, particularly if there is a meaningful
change that could modify the previous treatment
nonresponse. However, in other cases, where similar
team meetings have been held repeatedly over a pro-
tracted period of time with little benefit, further
extension of active, change-oriented treatment likely
creates a scenario that is unrealistic and disadvanta-
geous to all parties involved.
A second option for the team is a decision to
move to a more supportive model of treatment
with less emphasis on marked behavioral change
and weight gain and greater emphasis on maximiz-
ing medical stability, quality of life, and enhancing
social relationships (i.e., similar to Strober’s19 ‘‘pal-
liative holding management’’). Some patients may
benefit from case management services offered
through institutions or agencies who work with
other long-term psychiatric patients. Establishment
of reasonable goals that are acceptable to the
patient and the team is essential before launching
such a maintenance-oriented treatment plan.20,24
Furthermore, regular review of the plan by the mul-
tidisciplinary team, similar to that recommended
by Robinson,23 is critical. It is also important to
have clear guidelines regarding symptom status
and changes in the treatment plan. For example,
severity markers for admission to the hospital need
to be established and procedures identified that
will be instituted if the patient does not regularly
attend sessions.17,24 Also, conditions under which
family members would be contacted (i.e., inability
International Journal of Eating Disorders 45:4 467–475 2012
to contact the patient when the patient’s welfare is
in question), and circumstances leading to an
imposition of treatment involuntarily should be
clearly understood by all members of the team, the
patient, and the family.17
A third possible outcome of such a team staffing
is that the patient will elect to leave treatment. The
severity of some patient’s disorder, needs for
autonomy, or difficulty collaborating with a particu-
lar team may be sufficiently pronounced to make
long-term collaboration impossible.17 Treatment
teams are encouraged to be collaborative and com-
promising, but obviously cannot create treatment
plans that are unethical or ill advised in terms of
atypical burden on team members or founded on
treatment agreements that are not ultimately in the
patient’s best interest. If the patient elects to leave
the treatment, appropriate recommendations and
referrals should be provided, and appropriate
administrative or legal contact made to insure that
acceptable termination protocols are followed.17,18
Hospital-Based Care. Relatively little is known about
the efficacy of hospital-based care. Two random-
ized control trials suggested that hospital treatment
confers no benefit beyond outpatient treatment in
terms of long-term eating disorder outcome.2,45
However, case series across different clinical set-
tings reveal that both inpatient and day hospital
eating disorder treatment provide significant
reduction in core eating disorder symptoms.46–48
Even less is known about the optimal role and effi-
cacy of the hospital in treating chronic, treatment
nonresponsive patients. On one hand, such
patients are likely to need intensive care. On the
other hand, hospital-based programs are often ori-
ented toward intensive and active behavioral
change and acute medical stabilization, which may
be inconsistent with the overall treatment plan
(i.e., harm reduction) of some chronic patients.
Regardless of continued uncertainty about the
long-term effectiveness of hospital-based care,
chronic eating disorder patients will be hospital-
ized occasionally. When the chronic eating disorder
patient, who is not focused on active symptom
change, is hospitalized, hospital-based teams may
have to consider a highly individualized treatment
plan for such patients, which take into account
their goals of maintenance. This can be compli-
cated, given that many hospital-based programs
are intensely focused on weight restoration and
psychotherapeutic modalities, which encourage
active behavioral change (e.g., CBT and IPT). The
potential impact of such modifications on the
milieu of the unit should be carefully considered.
473
WONDERLICH ET AL.
The risk that such patients may complicate motiva-
tion for more recovery-oriented patients is possible
and may require modifications in group therapies
and other components of treatment in which
patients interact. Furthermore, clinical staff’s reac-
tion to such patients and their maintenance goals
may be important to monitor, particularly in terms
of aggressive reactions, excessive caregiving, or
exaggerated expectations for change.
Chronic eating disorder patients may also require
short-term hospitalizations on medical units.
Ideally, medical units who accept eating disorder
patients for medical stabilization should have avail-
able staff who are well trained in eating disorders
and understand chronic eating disorder cases and
associated reduced goals and expectations for full
recovery. Alternatively, with proper supervision,
most medical complications can be managed in an
inpatient eating disorder treatment setting. If medi-
cal units are used, once medical stabilization is
reached, these patients should be transferred to an
eating disorder unit where appropriate psychiatric
and nutritional interventions are offered, and the
patient is stepped down to an eating disorder hos-
pital-based program and ultimately returned to
outpatient care.
In summary, we believe that the ideal environ-
ment for chronic eating disorder patients is a fully
integrated treatment system with outpatient clini-
cians, medical providers, and hospital-based eating
disorder personnel working together to recognize
the unique needs of the chronic eating disorder
patient and deliver levels of care that are appropri-
ate for this relatively unique population. Risks of
unnecessary or ineffective hospital treatments are
substantial and should be considered in planning
strategic hospitalizations that are optimal for
patients with chronic eating disorders.
Overall Summary
Many eating disordered individuals do not respond
to acute, short-term treatment models. Many of
these patients will ultimately respond to treatment,
but this may take years of engagement with treat-
ment providers offering a wide range of interven-
tions. In the end, a significant number of patients
will not respond, but continue to be treated in eat-
ing disorder programs because of serious eating
disorder psychopathology and medical instability.
There is no generally accepted definition of a
‘‘chronic’’ eating disordered individual, and such
definitions are complicated by factors such as the
474
patient’s age, length of disorder, or histories of
treatment failure in the prediction of long-term
course of a disorder. Studies of maintenance proc-
esses in the eating disorders are needed to enhance
our understanding of chronicity. Finally, there
appears to be a fundamental uncertainty in the
field about approaches to the treatment of chronic
patients, and a lack of incorporation of chronicity-
related ideas developed in the treatment of other
forms of psychopathology. There is currently a
randomized controlled trial being conducted in
Australia, which may significantly inform clinicians
and scientists about treating this population (Le
Grange and Touyz, personal communication). Pres-
ently, however, we know very little about ‘‘chronic’’
patients and the most appropriate approaches to
treating this group of patients.
References
1. Agras WS, Walsh T, Fairburn CG, Wilson GT, Kraemer HC. A mul-
ticenter comparison of cognitive-behavioral therapy and inter-
personal psychotherapy for bulimia nervosa. Arch Gen Psychia-
try 2000;57:459–466.
2. Gowers SG, Clark A, Roberts C, Griffiths A, Edwards V, Bryan C,
et al. Clinical effectiveness of treatments for anorexia nervosa
in adolescents. Br J Psychiatr 2007;191:427–435.
3. McIntosh VVW, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik
CM, et al. Three psychotherapies for anorexia nervosa: A
randomized, controlled trail. Am J Psychiatr 2005;162:741–747.
4. Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter JC,
et al. Fluoxetine after weight restoration in anorexia nervosa: A
randomized controlled trial. J Am Med Assoc 2006;295:2605–2612.
5. Herzog DB, Dorer DJ, Keel PK, Selwyn SE, Ekeblad ER, Flores AT,
et al. Recovery and relapse in anorexia and bulimia nervosa: A
7.5-year follow-up study. J Am Acad Child Adolesc Psychiatr
1999;38:829–837.
6. Keel PK, Brown TA. Update on course and outcome in eating
disorders. Int J Eat Disord 2010;43:195–204.
7. Fichter MM, Quadflieg N. Long-term stability of eating disorder
diagnoses. Int J Eat Disord 2007;40:S61–S66.
8. Robinson P. Severe and enduring eating disorders: A need for
some new ideas. Paper presented at the Eating Disorders Inter-
national Conference, London, 2010.
9. Theander S. Outcome and prognosis in anorexia nervosa and
bulimia: Some results of previous investigations, compared
with those of a Swedish long-term study. J Psychiatr Res 1985;
19:493–508.
10. Deter HC, Herzog W. Anorexia nervosa in a long-term perspec-
tive: Results of the Heidelberg-Mannheim study. Psychosom
Med 1994;56:20–27.
11. Fichter MM, Quadflieg N, Hedlund S. Twelve-year course and
outcome predictors of anorexia nervosa. Int J Eat Disord 2006;
39:87–100.
12. Wentz E, Gillberg IC, Anckarsater H, Gillberg C, Rastam M. Ado-
lescent-onset anorexia nervosa: 18-year outcome. Br J Psychiatr
2009;194:483–491.
13. Steinhausen HC. The outcome of anorexia nervosa in the 20th
century. Am J Psychiatr 2002;159:1284–1294.
14. Fairburn CG. Cognitive Behavior Therapy and Eating Disorders.
Washington, DC: Guilford Press, 2008.
International Journal of Eating Disorders 45:4 467–475 2012
 MINIMIZING AND TREATING CHRONICITY IN EATING DISORDERS
15. Lock J, le Grange D, Agras WS, Dare C. Treatment Manual for Treat-
ing Borderline Personality Disorder. New York: Guilford, 2001.
16. Pike KM, Walsh BT, Vitousek K, Wilson GT, Bauer J. Cognitive
behavior therapy in the posthospitalization treatment of ano-
rexia nervosa. Am J Psychiatr 2003;160:2046–2049.
17. Goldner E. Treatment refusal in anorexia nervosa. Int J Eat Dis-
ord 1989;8;297–306.
18. Yager J. Patients with chronic recalcitrant eating disorders. In:
Yager J, Gwirtsman HE, Edelstein CK, editors. Special Problems
in Managing Eating Disorders. Washington, DC: American Psy-
chiatric Press, 1992.
19. Strober M. Managing the chronic, treatment resistant patient
with anorexia nervosa. Int J Eat Disord 2004;36:245–255.
20. Strober M. The chronically ill patient with anorexia nervosa. In:
Grilo CM, Mitchell JE, editors. The Treatment of Eating Disor-
ders. New York: Guilford Press, 2009.
21. Hamburg P, Herzog DB, Brotman AW, Stasior JK. The treatment
resistant eating disordered patient. Psychiatr Ann 1989;19:
494–499.
22. Vitousek K, Watson S, Wilson GT. Enhancing motivation for
change in treatment-resistant eating disorders. Clin Psychol Rev
1998;18:391–420.
23. Robinson P. Severe and Enduring Eating Disorder (SEED). West
Sussex, UK: Wiley-Blackwell, 2009.
24. Williams KD, Dobney T, Geller J. Setting the eating disorder
aside: An alternative model of care. Eur Eat Disord Rev 2010;
18:90–96.
25. Tierney S, Fox JRE. Chronic anorexia nervosa: A Delphi study to
explore practitioners’ views. Int J Eat Disord 2009;42:62–67.
26. Stice E. Risk maintenance factors for eating pathology: A meta-
analytic review. Psychol Bull 2002;128:825–848.
27. Strober M. Pathologic fear conditioning and anorexia nervosa: On
the search for novel paradigms. Int J Eat Disord 2004;35:504–508.
28. Hatch A, Madden S, Kohn M, Clarke S, Touyz S, Williams LM. An-
orexia nervosa: Towards an integrative neuroscience model.
Eur Eat Disord Rev 2010;18:165–179.
29. Schmidt U, Treasure J. Anorexia nervosa: Valued and visible. A
cognitive-interpersonal maintenance model and its implications
for research and practice. Br J Clin Psychol 2006;45:343–366.
30. Treasure J, Russell G. The case for early intervention in anorexia
nervosa: Theoretical exploration of maintaining factors. Br J
Psychiatr 2011;199:5–7.
31. Souery D, Papakostas GI, Trivedi MH. Treatment-resistant
depression. J Clin Psychiatr 2006;67 (Suppl 6):16–22.
32. Trivedi MH, Kleiber BA. Using treatment algorithms for the
effective management of treatment-resistant depression. J Clin
Psychiatr 2001;62 (Suppl 18):25–29.
33. Sackeim HA. The definition and meaning of treatment-resistant
depression. J Clin Psychiatr 2001;62 (Suppl 16):10–17.
International Journal of Eating Disorders 45:4 467–475 2012
34. Greden JF. The burden of disease for treatment-resistant
depression. J Clin Psychiatr 2001;62 (Suppl 16):26–31.
35. Parker GB, Malhi GS, Crawford JG, Thase ME. Identifying ‘‘para-
digm failures’’ contributing to treatment-resistant depression.
J Affect Disord 2005;87:185–191.
36. Shelton RC, Osuntokun O, Heinloth AN, Corya SA. Therapeutic
options for treatment-resistant depression. CNS Drugs 2010;24:
131–161.
37. Beale V, Lambric T. The recovery concept: Implementation in
the mental health system: A report by the Community Support
Program Advisory Committee. Columbus, OH: Ohio Depart-
ment of Mental Health, 1995, pp.1–20.
38. Jacobson N, Greenley D. What is recovery? A conceptual model
and explication. Psychiatr Service 2001;52:482–485.
39. Glynn SM, Cohen AN, Dixon LB, Niv N. The potential impact of the
recovery movement on family interventions for schizophrenia:
Opportunities and obstacles. Schizophr Bull 2006;32:451–463.
40. Sullivan P. Recovery from schizophrenia: What we can learn
from the developing nations. Innovat Res Clin Service Commun
Support Rehabil 1994;3:7–15.
41. Peyser H. What is recovery? A commentary. Psychiatr Service
2001;52:486–487.
42. Frese FJ, Stanley J, Kress K, Vogel-Scibilia S. Integrating evi-
dence-based practices and the recovery model. Psychiatr Serv-
ice 2001;52:1462–1468.
43. Treasure J, Smith G, Crane A. Skill-Based Learning for Caring for
a Loved One with an Eating Disorder. The New Maudsley
Method. London: Routledge, 2007.
44. Treasure J, Sepulveda AR, Whitaker W, Todd G, Lopez C, Whit-
ney J. Collaborative care between professionals and non-profes-
sionals in the management of eating disorders: A description
of workshops focused on interpersonal maintaining factors. Eur
Eat Disord Rev 2007;15:24–34.
45. Crisp AH, Norton K, Gowers S, Halek C, Bowyer C, Yeldham D,
et al. A controlled study of the effects of therapies aimed at
adolescent and family psychopathology in anorexia nervosa.
Br J Psychiatr 1991;159:325–333.
46. Carter JC, Woodside DB, Kaplan AS. Inpatient treatment for an-
orexia nervosa: Response and predictors of outcome. Paper
presented at the Ninth International Conference on Eating Dis-
orders, New York, 2000.
47. Treat TA, McCabe EB, Gaskill JA, Marcus MD. Treatment of ano-
rexia nervosa in a specialty care continumm. Int J Psychiatry
2008;41:564–572.
48. Olmsted MP, Woodside DB, Carteer JC, McFarlane TL, Staab
R, Colton PA. Intensive treatments for eating disorders. In:
Gabbard, GO, editor. Treatments of Psychiatric Disorders,
4th ed. Washington, DC: American Psychiatric Association,
2007, pp.709–722.
475