The literature on treating refractory patients consists mainly of suggestions based on observations of patients. These studies are mostly uncontrolled and with small samples. Over the past 20 years eating disorder hospital treatment has changed from long term treatment to stabilization of acute episodes. For treatment resistant patients this change has been deleterious and not cost effective as shown in one study with readmissions changing from 0% to 27% of total admissions [
29]. For anorexia nervosa patients contingencies attached to behavioral goals could be changed or the intensity of treatment increased such as residential treatment with a daily structure in careful monitoring to prevent readmissions. At times involuntary hospitalization with enteral feeding may be necessary. Pharmacotherapies that have shown some effectiveness in treating resistant anorexia nervosa include haloperidol [
30] quetiapine and olanzapine [
31,
32] and Duloxetine [
33]. Several novel psychotherapies are being developed for treating resistant anorexia nervosa include the following; 1) Cognitive Behavioral Therapy Extended [
34]: this focuses on addressing predisposing and maintaining factors of the eating disorder as well as involving caregivers to support the patient with matters regarding food, eating and psychological factors. Cognitive Remediation Therapy was developed to treat an inflexible thinking style [
35]. Modest results were obtained. Another 10 session treatment package that primarily addresses emotion processing difficulties in the self and others and includes strategies to manage emotions and the practice of emotion expression has also had modest results. This therapy is called Cognitive Remediation and Emotional Skills Training (CREST) [
36]. Maudsley Model for Treatment of Adults with Anorexia Nervosa (MANTRA) is another form of therapy which addresses rigid thinking styles with perfectionism and obsessive compulsive personality traits and the avoidance of strong emotional responses to others. It includes motivational interviewing and a CBT framework [
37]. Community outreach partnership program (COPP) has a goal of improving quality of life and minimizing harm [
38]. Specialist supportive clinical management (SSCM) emphasizes support for changes that will improve quality of life as well as physical well being. Its aim is to provide a therapeutic match to the chronic patient’s level of ambivalence [
39,
40]. It does this by allowing flexibility in the approach. Strober [
41], advocates a different paradigm in which management replaces traditional objectives of therapy to support the patient in a palliative holding management of carefully measured intensity. Small steps are taken to partially compensate or cushion the effects of the illness. This is done by assuring the patient weight gain will not be a principle objection of the management approach, encouraging the patient to maintain some type of social activity and involvement in hobbies, intellectual pursuits or activities that allow for feelings of pleasure. It also requires regular physical exams and exploring possibilities of improvement in nutrition. In therapy with treatment resistant anorectics Vanderlinden [
42], emphasizes the quality of the therapeutic alliance and the timing of therapeutic strategies as well as focusing less on the content of cognitions and more of the emotional involvement with cognitions. He also emphasizes focusing on dysfunctional cognitions and messages within the family communications and interactions.
In treating resistant bulimia nervosa patients sequential treatment is often effective. In one study [
43], 20% of non responders to cognitive behavioral therapy responded to fluoxetine or interpersonal therapy at the same rate. Resistant bulimics may require a partial hospitalization or inpatient program for a short period of stabilization. Additional or separate treatment for comorbid diagnoses with bulimia may be indirectly helpful. Examples are alcoholics anonymous for those with substance abuse or dialectal behavior therapy for those with borderline personality disorders. Cue exposure was effectively used to treat resistant adolescents with bulimia nervosa [
44]. The authors emphasize that cue exposure prevented the binge itself whereas exposure response therapy prevents post bingeing behaviors and the latter has not been effective in treating resistant bulimics.