severe and enduring anorexia nervosa is a persistent dietary restriction , underweight and over evaluation-of weight , history of more than 3 years and exposure to at least two evidence based treatments delivered

1. SEVERE AND ENDURING ANOREXIA
NERVOSA : CLINICAL AND
NEUROPSYCHOLOGICAL ASPECTS
By Heba Essawy MD., CEDS.,
Prof of psychiatry
Head of Eating Disoreders unit
Egyptian International chapter chair . Iaedps –USA
Okasha Institute of psychiatry.
Ain Shams University , Egypt

2. Introduction
■ Anorexia Nervosa (AN) is a severe psychiatric illness associated
with various medical complications that arise as a result of
weight loss and malnutrition,
■ Increased mortality rates
■ Even receiving treatment, many patients do not recover or
remain symptomatic.
■ Approximately 20–30% of people with AN do not recover fully
despite treatment but develop an enduring form of the disorder

3. Road Map
■ Proposed Criteria /Diagnosis for severe and Enduring AN
■ Severe and Enduring Anorexia Nervosa :Developmental stages
■ Why do people not get better ?
■ Severe and Enduring Anorexia Nervosa :Neurophysiological aetiology
■ Severe and Enduring Anorexia Nervosa :Neurobiological model
■ Severe and Enduring Anorexia Nervosa : Treatment Challenges
■ Severe and Enduring Anorexia Nervosa : psychotherapeutic treatments

4. Case Z
■ Late fourties sinle lady with restriction of food intake , lives with her family , not
been able to work for last 15 years due to her illness
■ Multiple admission , not able to maintain her weight in community over longer
period of time , BMI 13
■ Multiple psychotherapy attempts , different modalities
■ Current care plan : short term , planned admissions for limited weight restoration

5. Severe and Enduring Anorexia Nervosa
: Known Data
■ Chronic eating Disordrers , consisting on AN , restricting or binging/ purging type,
EDNOS.
■ Being consistentently ill for than 7 years (10 years)
■ Undergoing at least one unsuccessful evidence –based tratment
■ Common criteria used to define this final stage of the staging model include
previously failed treatment attempts,
■ Having severe impairment across a number of life domains
■ Having a strong motivation to hold onto AN, and thus a relectance to continue
active treatment

6. Proposed Criteria /Diagnosis for severe
and Enduring AN
■ A persistent state of dietary restriction, underweight ,and
overvaluation of weight /shape with functional impairment .
■ A history of more than 3 years of AN
■ Exposure to at least two evidence –based treatments appropriately
delivered , with a diagnostic assessment and formulation that
incorporates an assessment of the person s eating disorder health
literacy and stage of change
Drs. Phillipaand stephen touyz-proposed for ICD-11 2022

7. Severe and Enduring Anorexia Nervosa
:Developmental stages
■ Initial phase -1-2 years of duration
- Extreme medical instability ( body adapting to starvation )
-Low body weight
- Increase risk of death
 Middle phase -10-30 years of duration “stable sick”
- Bioadapted
- Stable weight at low level
- Death less likely ( if occurs often accident Na, K, suiccide)

8. Severe and Enduring Anorexia Nervosa
:Developmental stages
■ Terminal phase-duration 2-5 years
- Return of medical instability
- Unexpected /nondelibrate weight loss
- Becomes impossible to return to “stable sick”
- Final effort or death

9. Why do people not get better ?
 Psychological /Social
1. Trauma and attachementdisorders ( Trust)
2. Primary/ secondary gain ( conflict theory)
3. Family ( role of illness in family conflicts)
4. Fear of becoming adult ( intamicy /responsibility )
5. Inability for change

10. Why do people not get better ?
■ Biological/Genetic
1. Predisposition to a particular cognitive style or personality
Characterstics ( Narcissism )
2. Comorbidities make it more likely that the Eds become chronic (
Depression Anwxiety/OCD/ personalty Disorders
3. Reward / addictive behavior ( repeated cycles of starvation/binging
may impact on reward system)

11. Severe and Enduring Anorexia Nervosa
:Neurophysiological aetiology
■ Abnormal Reward processing in AN
■ Set Shifting
■ Information Processing Speed

12. Severe and Enduring Anorexia Nervosa :
Abnormal Reward processing in AN
■ AN is an illness characterised by behaviours that become reinforced in a manner
that become pathological .
■ Development of reward linked behaviors ( involving conditioning and reinforcement
) ex patients find skiny body and self starvation reinforcing and rewarding
■ Patients engage in starvation to relive anhedonia and thus develop dependence on
this mechanism ( reward dysfunction become addicted to starvation)
■ Eating rituals reduce anxiety/fear (negative reinforcement or reduced bad feelings,
as OCD)
■ Abnormalities in reward systems and in fronto-striatal systems and have paved the
way for “top-down,” approach that probes the neural activity related to
disturbances in eating behavior.
■ “top-down rely on : some aspect of dieting behavior is initially rewarding, but that
this behavior persists in individuals with AN as maladaptive behavior because it is
ultimately mediated by neural circuits linked to habit formation.

13. Severe and Enduring Anorexia Nervosa :
Neuropsychological abnormalities : Set
Shifting
■ In severe and enduring cases are significantly impaired on Set-
shifting .
■ Set-shifting has been consistently found to be negatively impacted by
the AN illness
■ In investigated set-shifting using the WCST :
Severe and enduring participants demonstrated significantly
more perseverative errors compared to healthy control participants in
the data set
Roberts et al., 2007; Tchanturia et al., 2011; Talbot et

14. Severe and Enduring Anorexia Nervosa :
Neuropsychological abnormalities
:Information Processing Speed
■ The speed at which information is processed in the brain has been proposed as
having a key function in facilitating higher order cognitive abilities such as
executive functioning
■ Utilising the Processing Speed Index of the Wechsler Adult Intelligence Scale
IV
■ Some cases reported low average range on attention and within the average
range in respect to information processing speed.
■ Further research suggested that these two processes may represent low
information processing speed
Hemmingsen et al. (2020)

15. Severe and Enduring Anorexia Nervosa
:Neurobiological model
■ Neurobiology of food decision :
- Dorsal fronto- striatal circuits play a greater role in guiding decisions
regarding what to eat than among healthy individuals.
- Habit formation is the process by which a behavior associated with a reward,
if repeated frequently (“practiced”), becomes almost automatic and far less
dependent on the receipt of the reward
■ Neurobiology of reward :
- Mesolimbic neural systems of reward processing encompass the
midbrain/ventral tegmental area, ventral striatum (including nucleus accumbens ),
and orbitofrontal cortex (OFC).

16. Severe and Enduring Anorexia Nervosa
:Structural and Functional studies
■ Functional studies:
- PET studies have shown hypermetabolic abnormalities in the caudate
among patients with AN,
- PET dopamine binding study also reported that dopamine binding
potential in the dorsal caudate correlated with harm avoidance, a trait commonly
found in individuals with AN
■ Structural studies:
- Decreased volume in the caudate among individuals with AN
- fMRI study using food pictures for symptom provocation found greater
caudate activation among individuals who had recovered from AN as compared
with HC

17. Severe and Enduring Anorexia Nervosa
: Treatment Challenges
■ In severe and enduring illness, after several years of eating
disorder, treatments that have not yet led to recovery factors such
as
* Treatment burnout
*Deep ambivalence about recovery
*sense of powerlessness
*Sense of loss of hope may be present .
These factors must be considered and addressed when making
decisions about when to strive for full weight restoration and
recovery.

18. Severe and Enduring Anorexia Nervosa
: Aim of Treatment
■ In the treatment of SE-AN
*Place the focus on improving quality of life
* Medical safety
*Overall functioning in the presence of an enduring illness.
rather than always focusing on full weight restoration and recovery
Touyz et al 2020

19. Severe and Enduring Anorexia Nervosa
: What Might work
It is important that:
■ The team that is planning, coordinating, and implementing the treatment have
adequate training and experience
■ Impact of the disorder on QOL- primary target of interventions
■ Gaining an understanding of their values
■ Weight gain encouraged but not mandated or primary focus .
■ In a study by Jenny Jordan identified that 3 things helped in recovery: finding
God , having a baby and falling in love
■ Never gave up , accept the small victories and believe that things will change

20. Severe and Enduring Anorexia Nervosa :
psychotherapeutic treatments
■ In the only randomized controlled trial (RCT) of psychotherapeutic treatments for
SE-AN, Touyz et al. found that SE-AN patients benefited from both
*Outpatient cognitive behavioral therapy (CBT)
*Specialist supportive clinical management (SSCM)
both treatments were modified to prioritize. Harm minimization and quality of life.
 Both CBT and SSCM resulted in positive changes regarding
 Quality of life
 Mood disorder symptoms
 Social adjustment
 Body mass index (BMI),
 Eating disorder symptoms
 Motivation for change.

21. Take Home Messages
■ Explore the clinical utility of illness duration at presentation for treatment in AN,
■ Consider clinical impairment as a marker of severity.
■ Patients with longer duration of illness and higher impairment secondary to ED
may require more individualized and specific treatment.
■ Close monitoring and fast access to treatment to ED cases at early stage in
order to prevent the development of an enduring course with associated functional
impairment.
■ Addressing patient goals , and quality of life and impairment secondary to the
ED can be used as an important clinical strategy to motivate patients to change.

22. Heba Essawy MD.,CEDS.,
essawi_h@yahoo.com
www.heba Essawy.com