An intriguing paradox 

I stood by her side as she held the tiny green fruit with shaking hands. Her fingers trembled as she brought it closer, hesitating each time it neared her lips. This grape, so small and so insignificant to others, represented an enormous struggle for her, a struggle that could mean betraying her eating disorder . . . 

Anorexia nervosa is one of the most challenging psychiatric conditions to treat. At the core of this disorder lies an intriguing paradox: unlike most other mental health disorders, individuals with anorexia nervosa often embrace their condition and are resistant to treatment. While disorders such as depression and anxiety are generally perceived by patients as conditions they want to actively overcome, those with anorexia might desire recovery but usually form a strong attachment to their illness. This resistance makes it not only difficult to establish therapeutic rapport between healthcare professionals and their patients but also intensifies the clinical challenge of effectively guiding those patients toward recovery. The need to address this challenge is underscored by the fact that anorexia nervosa carries the highest mortality rate among psychiatric disorders, an alarming reality that adds urgency to developing effective treatment approaches. 

After working with adolescents with anorexia nervosa, I realized that several principles are essential: First, it’s crucial to push oneself to truly empathize with the patients’ experience, no matter how perplexing it may seem. For individuals with anorexia, their perception of being “fat” is as real as any concrete reality, and they often describe feeling the impact of each calorie they consume in an almost visceral way. I’ll never forget the time a patient refused to drink her milk because “I can feel the drop of milk dissolve on my lips and go straight to my arms.” Accepting the genuineness of this perception helps establish a therapeutic alliance, reducing the chances of patients feeling misunderstood or dismissed. In addition, it helps build trust in the clinicians, who in the patients’ eyes are complete strangers with one goal only: making them gain weight and lose control (anorexia nervosa’s worst enemies).  

Second, it’s extremely important to avoid phrases like “you’re too skinny” or “gaining a few kilos won’t hurt” at all costs. Such comments may seem like reassurances, but to someone with anorexia nervosa, they are unrelatable at best and dismissive at worst. Patients often interpret these remarks as invalidations of their reality and might respond by retreating further into their disorder and resisting treatment. On the other hand, phrases such as “Luckily, you’ve never required hospitalization,” or, “Thankfully you’re not too ill,” though often intended as words of encouragement, can be deeply distressing for someone struggling with anorexia. These comments imply that the patients haven’t fully adhered to the expectations of their eating disorder (or have “betrayed” their eating disorder), reinforcing a dangerous cycle of comparison with other patients, who are perceived as more ill and are therefore “better anorexics.” Instead of providing support, such remarks can heighten feelings of inadequacy and guilt, leading to an even stronger desire to restrict and meet those harmful standards of the eating disorder. It’s crucial to avoid making comments about physical appearance altogether, as this only perpetuates the societal emphasis on looks, something we are actively trying to combat in the journey towards recovery. 

Finally, it’s essential to remember that healthcare professionals are dealing with a chronically starved brain, one that isn’t always capable of rational thought due to severe, and sometimes chronic, malnutrition. Trying to negotiate with the eating disorder itself can be futile; instead, focus on nutrition as the cornerstone of treatment. Re-nourishing the brain is fundamental to improving cognitive abilities, which can lay the groundwork for a more meaningful therapeutic engagement at a later point. More importantly, clinicians should NEVER (and I can’t stress this enough) compromise with the eating disorder and should always be consistent with the message they’re sending: nutrition is non-negotiable. Allowing the patient to refuse eating the bread crumb, as harmless as it might sound, can in fact reinforce the eating disorder and only strengthen it; after all, the disorder was able to “trick” the clinician and get away with what it wants: less nutrition. Anorexia is skilled at exploiting and seizing any opportunity for manipulation, and only through a unified, compassionate, and firm approach can healthcare professionals offer the patient the best chance at healing. 

At some point, nearly every healthcare professional, be it a psychiatrist, psychologist, dietitian, pharmacist, nurse, medical student, family physician, pediatrician, emergency physician, endocrinologist, cardiologist, obstetrician, you name it, will encounter a patient with anorexia nervosa. Even parents, families, and friends inevitably find themselves part of this journey, often feeling unprepared for the intensity of supporting someone with this complex disorder. Regardless of their role, everyone involved must practice a deep level of empathy, acknowledging the patient’s very real struggle without being dismissive of their experience. At the same time, they must remain firm and consistent, never negotiating with the eating disorder itself. With compassion, patience, and an unwavering focus on nutrition, clinicians can support these patients through their long, challenging journey toward recovery. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.