The long-standing eating disorder

Eating disorders have become one of the most prevalent disorders in adolescence, especially among women (9 out of 10). Their incidence and prevalence have increased considerably in recent years, worsening after the COVID-19 pandemic .

The severity of this disorder requires specialized treatment by an interdisciplinary team as early as possible to minimize the consequences (both physical and mental) and improve the prognosis. Although recovery rates vary considerably (likely due to the diverse and broad definitions of the term "recovery"), most people recover completely. In the case of anorexia nervosa (AN), 60% achieve complete remission within 2-3 years, and in bulimia nervosa (BN), the figure is 45%. Some individuals achieve remission but experience psychological or physical aftereffects (20% in the case of AN and 27% in BN).

However, there are around 20% of people who end up living with the eating disorder throughout their lives, making it a chronic condition.

The long duration of eating disorders is often associated with a loss of confidence in one's own ability to recover, demoralization, and distrust of professionals and treatment, which places the person in a situation of hopelessness and disability.

There is no established definition for the concept of long-term eating disorders , with only partial consensus regarding the duration and set of unsuccessful treatments received, giving rise to the concept known as severe and persistent eating disorder (SEED).

We speak of a SEED when:

• An eating disorder with more than 7 years of evolution is presented, with neurobiological impact due to prolonged malnutrition and loss of social capital.
• At least 2 evidence-based treatments have been received, with an evolution of more than 3 years.

There are a number of common patterns in people who have a severe and persistent eating disorder (SEED):

• They have established patterns of food restriction.
• They have deeply ingrained anorexic cognitions (rigid thinking about weight, shape, food; persistent anorexic thoughts and feelings, often accompanied by ritualistic behaviors; dichotomous thinking style).
• Personal identity intertwined (confused) with AN (fear of change without AN, anorexia as the only value in one's personal identity, anorexic ideology).
• BMI less than 17.7 (low BMI from adolescence to adulthood).
• Chronicity understood as "resistance to change": history of previous treatments with few results, people who have not requested treatment, years of illness.
• The seven-year mark on the disorder appears to be a turning point in treatment: those who have received specific treatment and have not improved may need a different approach, a change of goals, and a reconsideration of expectations.
• Especially after 10 years of the disorder's evolution and after having tried several treatments without success, it is considered a long-term eating disorder (LTD).
• Perfection as a compensatory mechanism. A strategy that protects them from a near absence of self-esteem: setting such cruel goals makes them feel superior and balances feelings of inadequacy.
• Feelings of inadequacy lead to a need for external validation, heightened sensitivity to criticism, and a high degree of reactivity to social approval. All of these factors pose difficulties in developing an internal identity and a degree of autonomy.
• Dichotomous thinking style leads to the adoption of rigid and inflexible rules.

What resistance factors exist in eating disorders that prevent or hinder recovery?

Resistance to treatment and change are key problems in eating disorders. Generally speaking, three dimensions need to be considered to understand why this resistance occurs (Liberman 1988): the duration of the disorder, the diagnosis, and social functioning (level of social competence).

There are four factors that prevent or hinder recovery:

• Biological . Genetic factors, comorbidity with other diseases.
• Social deterioration. We know of the influence of the social environment on human behavior and on the prognosis of the evolution of mental disorders.
• Personality and endophenotypes. Eating disorders could be explained as a pathology of control, as a dysfunctional attempt to reduce the unpredictable and invalidate through at least two mechanisms. Perfectionism impacts treatment outcomes, especially regarding body image, the drive for thinness, and the internalization of the aesthetic ideal—dimensions that show greater resistance to treatment. There is a tendency to respond more intensely to aversive stimuli and greater behavioral inhibition.
• Family maintenance factors. The different responses of the immediate environment towards people affected by an eating disorder can interfere and act as perpetuators of the symptoms.

Community approaches to eating disorders

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In the person's daily life, we distinguish deficits that are associated with the severity of the disorder :

• The capacity for self-care (maintaining healthy habits).
• The capacity for autonomy (economic management, leisure and free time, work).
• The ability to self-control (managing stressful situations).
• Lack of social network and deficits in social skills, also affecting the family area.
• Isolation and lack of motivation.
• Feelings of emptiness and existential failure.
• Loss of confidence in their ability to recover, and demoralization and distrust towards professionals and treatment.
• Difficulties with attention, concentration, and information processing. A long-term eating disorder involves neuroprogressive changes, with alterations in brain structure and function, which reinforce the disorder and hinder recovery.

Is recovery possible in cases of long-term eating disorders?

Broadly speaking, there is currently some consensus in assessing the recovery according to three dimensions:

• Physical criteria
• Behavioral
• Psychological/cognitive

As time passes, the chances of recovery decrease, but there is always a possibility. However, the treatment and characteristics of the case, as well as the objectives, must be reassessed, setting realistic expectations.

It is important to focus on the psychosocial consequences and improve the quality of life despite not achieving a full recovery, trying to regain hope and establish a more meaningful life.

Treatment of long-standing eating disorders

There is little literature and few studies on effective interventions. In cases of long-term eating disorders, it is observed that, despite having received different treatments, family relationships continue to behave according to the same patterns that are not conducive to achieving change (Rosa Calvo Sagardoy, 2011). Therefore, the following is recommended:

• Reducing pressure to reduce the risk of treatment abandonment: redefine the objectives, do not focus exclusively on the reduction/elimination of symptoms (weight recovery) because they are not effective.
• Many authors recommend replacing the active approach with a rehabilitative model , with greater emphasis on promoting good functioning in the community and achieving their cognitive and behavioral challenges.

Factors that favor rehabilitation:

• Opportunity to connect with the immediate experience of the here and now.
• Learning to build new life goals, new occupations and roles with a positive impact on health: new relationships, new habits, occupations, etc., that give us new goals and dreams and take us away from thoughts of invalidity and hopelessness.
• Learn to objectively assess the outcome of actions.
• Learn to start something without losing confidence.
• Adapting to relationships with the peer group: sharing.
• Adjusting expectations about oneself.
• Managing and solving the error without resorting to the symptom.
• Develop social, work and domestic skills.
• Developing a future project: maintaining an identity as a person through periods of crisis and conflict.
• Importance of intervention in the family or primary support circle.