Conference Coverage

What’s best for patients who are dying of anorexia?


AT APA 2023

– The patient at a Florida eating disorder clinic said she was eating plenty even though she acknowledged purging once a week. But her vitals told a different story: Her body mass index (BMI) was 12.2, down from 14.8 a couple of years before – a dangerously low value.

Dr. Nadia Surexa Cacodcar, psychiatrist at the University of Florida, Gainesville University of Florida

Dr. Nadia Surexa Cacodcar

The pandemic had disrupted her care, said Nadia Surexa Cacodcar, MD, a resident psychiatrist at the University of Florida, Gainesville, in a presentation at the annual meeting of the American Psychiatric Association. To make matters more challenging, coordinating with the patient’s primary doctor was difficult because her electronic health records couldn’t communicate with one another.

While the woman agreed that she needed to gain weight, she refused advice to pursue residential or inpatient treatment. This left her team with a big dilemma: Should they force her into care because she wouldn’t eat? Was that even possible under the law? Did she have the capacity to make decisions about her future? What other alternatives were there?

Determining the best course of action in cases like this is anything but simple, Dr. Cacodcar said. To make matters more complicated, there are numerous hurdles facing clinicians as they try to help their patients with advanced and severe anorexia nervosa (AN).

“At least in my state of Florida, we know that it can be very, very hard to get patients expert care,” said Dr. Cacodcar. And, she said, it can be even tougher for certain types of patients, such as those that are LGBTQ and those who have severe illness but don’t meet the criteria.

As Dr. Cacodcar noted, the APA released new practice guidelines regarding eating disorders earlier this year, marking their first update since 2006. The guidelines highlight research that suggests nearly 1% – 0.8% – of the U.S. population will develop AN over their lifetimes. Recent studies also suggest that eating disorder numbers rose during the pandemic, with one analysis finding that patients under inpatient care doubled in 2020.

“Mortality rates are high for anorexia nervosa, up to 10 times higher than matched controls,” Dr. Cacodcar said. “It has the highest mortality rate of the psychiatric diseases with the exception of opioid use disorder.”

As for outcomes, she pointed to a 2019 study that surveyed 387 parents who had children with eating disorders, mostly AN. Only 20% made a full recovery. “The farther you get out from the onset of anorexia, the less likely you are to achieve recovery,” Dr. Cacodcar said. “A lot of the control behaviors become very automatic.”

Determining capacity

In some cases of AN, psychiatrists must determine whether they have the capacity to make decisions about treatment, said Gabriel Jerkins, MD, a chief resident of psychiatry at the University of Florida. At issue is “the ability of the individual to comprehend the information being disclosed in regard to their condition, as well as the nature and potential risks and benefits of the proposed treatment alternatives. They include of course, no treatment at all.”


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