Abstract
For severe cases of anorexia nervosa (AN), including when poor prognostic factors like low body mass index (BMI) and longer illness duration are present, intermediate levels of care are often indicated. Current guidelines call for treatment programs to use an evidence-based practice approach to individualize treatment and optimize outcomes. Research supports the effectiveness of intermediate levels of care, including remote programs which increase access to treatment. However, conflicting evidence exists regarding the ability to safely weight restore clients during remote care, necessitating further research. This case report highlights the viability of treating clients with AN remotely using an evidence-based practice approach, resulting in weight restoration and symptom remission. The client presented with a longstanding history of severe binge-eating/purging AN with numerous medical complications but was motivated and treatment-compliant. Her eating disorder (ED) was conceptualized using a biopsychosocial perspective and treated using a multidisciplinary, evidence-based practice approach encompassing individual, group, and supportive interventions. She was successfully discharged from treatment after 150 days, having restored weight to a healthy range and showing substantial improvements in ED, depressive, and anxiety symptoms based on validated measures. This case contributes to the evidence that remote care can be an accessible and effective treatment option, even in cases of severe AN. The case highlights how an evidence-based practice approach can enable safe weight restoration via a personalized treatment plan that emphasizes the use of remote devices and self-monitoring.
1 Theoretical and Research Basis for Treatment
Anorexia nervosa (AN) is a debilitating eating disorder (ED) characterized by body image disturbance, intense fear of weight gain, food restriction, and low body weight (American Psychiatric Association, 2013). Without effective treatment, AN can lead to serious consequences including medical complications, impaired functioning, and reduced quality of life (Van Hoeken & Hoek, 2020). Furthermore, AN is second only to opioid use disorder for excess mortality among psychiatric disorders (Chesney et al., 2014). While recovery is possible, approximately one-third continue to struggle with a chronic course (Eddy et al., 2017). Factors such as lower body mass index (BMI), binge/purge behaviors, and longer illness duration, have been identified as predictors of poor outcomes for AN (Miskovic-Wheatley et al., 2023).
Severe and persistent cases of AN may require more intensive treatment than a general outpatient setting. The American Psychiatric Association (2006; 2023) provides guidelines for determining level of care, considering medical status, body weight, and extent and controllability of ED behaviors. When 24-h supervision is not necessary, intermediate levels of care, including Intensive Outpatient (IOP) or Partial Hospitalization (PHP) programs, may be indicated. American Psychiatric Association (2023) guidelines underscore person-centered care delivered through a coordinated, multidisciplinary treatment team, with the Residential Eating Disorder Consortium (2021) recommending treatment components including individual/family therapy, nutritional counseling, psychiatric management, medical monitoring, meal supervision/support, and group therapy. The effectiveness of intermediate level of care for EDs has been supported by studies showing positive treatment outcomes in terms of weight restoration, depressive and anxiety symptoms, eating pathology, and quality of life that were largely sustained for adult clients at follow-up (de Boer et al., 2023; Friedman et al., 2016).
While results of these studies are promising, findings may not generalize to all intermediate level of care programs due to heterogeneity in programming (Anderson et al., 2017). Hence, standardization of care is imperative, with existing guidelines emphasizing an evidence-based practice approach. According to the American Psychological Association (2006), evidence-based practice involves integrating clinical expertise, the best available research evidence, and client factors (i.e., preferences, characteristics, values, and circumstances) to inform individualized treatment decisions and optimize care (Peterson et al., 2016). Importantly, evidence-based practice is not synonymous with evidence-based treatment; rather it is a more comprehensive approach that considers what available research evidence, including but not limited to randomized controlled trials, may be useful in achieving the best outcome for a client (American Psychological Association, 2006). Within this framework, providers are expected to recognize the limitations of research evidence and flexibly incorporate research-supported treatments as appropriate while also accounting for client factors and the impact of other determinants, like common factors, on outcomes. Given that psychotherapy efficacy studies for adults with AN have yielded modest at best results, evidence-based practice guidelines recommend the use of ED-focused psychotherapeutic interventions that aim to restore weight, normalize eating, reduce weight control behaviors, and address psychological aspects of the disorder by drawing upon evidence-based treatments (e.g., Cognitive-Behavioral Therapy; CBT) along with emerging treatments (e.g., mindfulness approaches) and other therapeutic strategies (e.g., psychoeducation, support) (American Psychiatric Association, 2023; American Psychological Association, 2006). This process of matching therapeutic models and techniques to client factors was shown to be beneficial in a case of a personality disorder, where strong research support for a specific psychotherapy was also lacking (Chan et al., 2015).
Still, limited access to evidence-based care remains a significant barrier to AN recovery (Kaye et al., 2021). Emerging technology-based or -enabled treatment options offer promise in addressing this need (Kazdin et al., 2017). While limited research exists, findings have supported the feasibility, acceptability, and effectiveness of remote treatment at intermediate levels of care for adults with AN (Blalock et al., 2020; Carr et al., 2022; Levinson et al., 2021; Ortiz et al., 2023; Penwell et al., 2023). Specifically, these studies show positive outcomes for ED symptoms, quality of life/impairment, and co-occurring symptoms like depression and anxiety. Studies have also found that digital tools, such as mobile applications, can serve as beneficial adjuncts in managing ED symptoms (Anastasiadou et al., 2018).
Despite these promising findings, concerns remain regarding the ability to successfully and safely weight restore in remote treatment. Results are conflicting, with some studies showing comparable weight-related outcomes for in-person and remote treatment (Levinson et al., 2021; Ortiz et al., 2023) and others showing greater improvements for in-person (Carr et al., 2022; Penwell et al., 2023). One potential explanation for this discrepancy is the use of self-reported weights in remote treatment, which could cause data quality issues and/or iatrogenic awareness of weight interfering with the ability to restore (Froreich et al., 2020). In terms of safety, a possible complicating factor is refeeding syndrome, a rare but severe and acute hormonal-metabolic disturbance that can occur for chronically malnourished individuals during the weight restoration process (Skowrońska et al., 2019). Typically, concerns about refeeding syndrome prompt close medical monitoring (National Institute for Health and Clinical Excellence, 2006), questioning the safety of remote weight restoration for those at risk. Thus, clarity regarding if and how weight restoration can be achieved remotely without negative consequences is needed.
To our knowledge, this is the first case report to illustrate how remote intermediate level of care can be a viable and effective option for adults with longstanding AN. Specifically, this report provides a detailed examination of clinical presentation and treatment trajectory as well as the role of an evidence-based practice approach. Moreover, this case addresses weight restoration and demonstrates that this can be safely accomplished remotely through close monitoring. By showcasing the comprehensive treatment and successful outcomes of this case, we aim to highlight the potential for increased access to high-quality treatment via remote options.
2 Case Introduction
“Gertrude” (a pseudonym used to maintain anonymity), a 46-year-old self-identified White, heterosexual, Jewish woman, signed a HIPAA waiver and consent form allowing for the use of health information for the purposes of this case report. She resided with her husband, 4-year-old daughter, and their live-in nanny. Gertrude had several advanced degrees but was currently unemployed by choice. She was seeking treatment at the encouragement of her parents who expressed concern about her recent weight loss and marital tension. Due to the COVID-19 pandemic, she reached out to Within Health, an intentionally remote ED treatment program offering PHP and IOP levels of care, to inquire about at-home treatment options.
3 Presenting Complaints
Gertrude presented with a longstanding history of body image issues and disordered eating, dating back to adolescence. She indicated that her symptoms recently worsened due to the pandemic isolation. She described daily restriction of food intake and nightly bingeing and purging via self-induced vomiting, with approximately five cycles per night. She also reported heavy daily laxative use to alleviate “severe constipation”, including stimulants, stool softeners, bulk-forming laxatives, and magnesium. She reported daily exercise (i.e., elliptical machine for 30 minutes and either Pilates class, swimming 50 laps, or strength training/abdominal exercises) and stated that she feels “lethargic” and “grumpy” if she is unable to engage. She rated her current body dissatisfaction as 8.5/10. She listed a number of medical complications related to her ED including amenorrhea (i.e., no natural period during adulthood), infertility, dental issues, osteopenia, esophageal damage, acid reflux, and hypotension. At intake, she reported being at her lowest weight (i.e., 87 lbs) due to a recent loss of 8 lbs. She shared that her motivation for treatment was to “stop bingeing and purging” and “get better mentally”.
4 History
Gertrude denied any developmental concerns, history of abuse, or traumatic experiences. She grew up living with her married parents and one sister; her mother was a “homemaker” and her father was an attorney. She identified her paternal aunts as having a history of EDs. She reported having close, supportive relationships with several friends and her sister. Although she identified as Jewish and participated in major holidays, Gertrude said that she was not a regular attendee of religious services and did not identify any relevant cultural or spiritual impacts on her ED nor specific considerations for her care. Gertrude described an increase in marital difficulties associated with the pandemic. She indicated that her husband struggles with obsessive-compulsive tendencies and had instituted strict isolation and decontamination protocols, resulting in heightened conflict.
Gertrude reported that her ED began at the age of 15, precipitated by body changes during puberty. In an effort to maintain a smaller frame as a gymnast, she started bingeing and purging, which “spiraled and never stopped”. She stated that her highest adult weight was approximately 125 lbs in college. She had one prior ED IOP admission during college where she started a selective serotonin reuptake inhibitor; she later withdrew from the program citing “non-effectiveness” and discontinued her medication due to “feeling drained and drowsy”. She reported a history of depressive and anxiety symptoms, exacerbated by the pandemic, but denied any other psychiatric history, treatment, or psychotropic medication use.
Although she did not report having received a specific diagnosis, Gertrude likely met criteria for Bulimia Nervosa initially according to the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). As is common for individuals with EDs, Gertude appeared to experience diagnostic crossover in young adulthood (Miskovic-Wheatley et al., 2023), developing symptoms consistent with an AN presentation that persisted until the present time (i.e., for more than 20 years). She described engaging in restrictive eating resulting in significant low body weight (i.e., < 85% of ideal body weight; IBW), with no more than 1–3 weeks at a time of refraining from bingeing and purging.
5 Assessment
Clinical Interviews
As part of the admissions process, Gertrude was assessed by a multidisciplinary team consisting of a psychotherapist, psychiatric nurse practitioner, registered nurse (RN), and registered dietitian (RD) using a HIPAA-compliant videoconferencing platform. She arrived on time for all assessments and was noted to be compliant and motivated for treatment. Mental status exams were “unremarkable”, revealing that she was oriented times four, cooperative, had a linear/goal directed thought process and normal speech, and showed fair insight/judgment into the nature and severity of her condition and treatment needs. She rated her typical mood and anxiety level both as a 5/10. No safety concerns, suicidality risk, or psychosocial risk factors were identified. She reported a history of tobacco and alcohol use as well as current alcohol consumption; however, substance use was not identified as a target for treatment.
The frequency, intensity, and severity of her ED symptoms were further evaluated by multiple providers. Gertrude reported restricting the amount and variety of food during the day, limiting herself to fat-free and low-calorie foods (e.g., vegetables, protein powder, low-calorie breads, fat-free dips). She identified what she described as “fattening” and “rich” foods (e.g., desserts, fried foods, foods with higher fat or carbohydrates) as those that she tried to avoid. During binge episodes, Gertrude would consume these “unsafe” foods, such as a “giant bowl” of leftovers, a loaf of buttered bread, or a large bag of candy. The RD noted that Gertrude’s caloric, protein, carbohydrate, fat, and calcium intake were all inadequate based on her 24-h diet recall. Precipitants for bingeing included interpersonal conflict, being alone, life stressors, and overhunger. She endorsed feeling numb, out of control, losing track of time, and feeling disconnected during binges. She rated her awareness of hunger and fullness cues as a 6/10 and her level of preoccupation with food/weight/appearance as between 90–100%, remarking “that’s all I’m doing all day”. Gertrude also endorsed several other ED behaviors including body checking (e.g., daily self-weighing), micro-biting, and eating slowly so as not to “overeat”.
Based on her reported symptoms, Gertrude met criteria for Anorexia Nervosa, binge-eating/purging type (AN-BP), severe (i.e., BMI between 15–15.99), in accordance with the DSM-5 (American Psychiatric Association, 2013).
Medical Records Review
Prior to admitting to the treatment program, clients are required to be cleared for treatment by their existing medical provider. Gertrude’s primary care provider (PCP) completed the medical clearance form, which included conducting an in-person exam as well as obtaining an electrocardiogram (ECG) and labwork, which was then reviewed by the team as part of the admissions process. Based on her medical clearance form, Gertrude’s admitting weight was 90 lbs (BMI = 15.94), placing her at 78.26% of her IBW based on the Hamwi (1964) method. Her recent labwork showed elevated amylase, cholesterol, and non-HDL cholesterol with all other values being within normal limits including glucose, phosphorus, and magnesium. Additionally, her blood pressure, heart rate, and temperature were all normal. Her ECG conducted during the medical clearance process was designated “borderline” due to sinus bradycardia, sinus arrhythmia, and low voltage QRS. In addition, her DEXA scan from the prior year showed moderate osteopenia of her right hip and mild osteopenia of her left hip.
Standardized Assessment Battery
Baseline, Discharge, and One-Month Follow-Up Assessment Results.
Note. EDE-Q, Eating Disorder Examination-Questionnaire; EDQOL, Eating Disorder Quality of Life questionnaire; IES-2, Intuitive Eating Scale-2; UPE, Unconditional Permission to Eat subscale; EPR, Eating for Physical Reasons subscale; RHSC, Reliance on Hunger and Satiety Cues subscale; BFCC, Body-Food Choice Congruence subscale; PHQ-9, Patient Health Questionnaire-9; STAI-S, State Trait Anxiety Inventory-State; STAI-T, State Trait Anxiety Inventory-Trait.
aScore was in clinical range based on reported clinical cutoff and norm values.
bMagnitude of change in scores from baseline to discharge represents a clinically significant treatment response.
To assess ED symptoms over the last 28 days, she completed the Eating Disorder Examination-Questionnaire (EDE-Q; Fairburn & Beglin, 1994; 2008). The EDE-Q yields a global score and four subscale scores including restraint, eating concern, shape concern, and weight concern. Respondents also report the frequency of specific ED behaviors including binge eating, purging via vomiting, and laxative use. Gertrude’s global score was above the clinical cutoff (i.e., ≥ 2.8; Velkoff et al., 2023) and, along with her subscale scores, was within the range expected for adult women with AN (Dahlgren et al., 2017). She reported 25 episodes of eating an unusually large amount, with 12 of those episodes including a loss of control. She also reported 25 episodes each of purging via vomiting and using laxatives to control shape and weight.
She completed the Eating Disorder Quality of Life questionnaire (EDQOL: Engel et al., 2006) to measure the perceived impact of the ED on her quality of life over the last 30 days. The EDQOL has a total score and four subscales covering psychological, physical/cognitive, financial, and work/school domains. The work/school subscale was not used since Gertrude was not working or attending school. Her total EDQOL, psychological, and financial scores were all within the range expected for someone with moderate to severe ED symptoms (Engel et al., 2006). The impact of her ED on physical/cognitive quality of life was in the range for those with minor symptoms.
To measure her ability to intuitively eat, the Intuitive Eating Scale-2 (IES-2; Tylka & Kroon Van Diest, 2013) was used. The IES-2 includes a total score along with four subscales: unconditional permission to eat (UPE), eating for physical rather than emotional reasons (EPR), reliance on hunger and satiety cues (RHSC), and body-food choice congruence (BFCC). Her IES-2 scores were all comparable to reported norms for those with AN-BP (Babbott et al., 2022).
Gertrude recorded her symptoms of depression and anxiety using the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) and the State Trait Anxiety Inventory (STAI; Spielberger et al., 1983), respectively. Her total PHQ-9 score was in the moderate range and she indicated that her symptoms made it “somewhat difficult” to function (Kroenke et al., 2001). Her state and trait anxiety scores were both in the clinically elevated range (Knight et al., 1983).
6 Case Conceptualization
The development and maintenance of Gertrude’s ED can be understood through an integrative biopsychosocial lens.
Presenting Problem
Gertrude presented with a history of ED symptoms, including body image disturbance, restricting, bingeing, and purging, dating back to adolescence. At her husband’s insistence, her family remained isolated during the pandemic, which contributed to increased marital conflict and stress, thus exacerbating her symptoms. She described her ED as increasingly ego-dystonic, recognizing how her health and relationships were affected, resulting in her seeking treatment.
Predisposing Factors
From a biological perspective, Gertrude’s family history suggests a possible genetic predisposition, likely rendering her vulnerable to develop an obsessive or persistent temperament, which has been linked to EDs (Atiye et al., 2015; de Jorge Martínez et al., 2022). Sociocultural factors may have played a role, namely dominant Western cultural narratives around thinness and dieting and participation in gymnastics, which have been associated with heighted ED risk (Chapa et al., 2022; Culbert et al., 2015). Moreover, both of Gertrude’s parents modeled attitudes and behaviors that could promote unhealthy body image and disordered eating including focusing on weight/appearance, having “control” over one’s eating, and being high-achieving. Psychologically, Gertrude developed core beliefs within her family about “not being good enough” and “pleasing others to be valued”, relying on external validation to define her self-worth. In particular, she received praise and acceptance for her small body as a gymnast, latching onto this as her identity and source of pride. This emphasis may have contributed to an overvaluation of shape and weight and their control, considered the core psychopathology of EDs (Fairburn, 2008). Finally, Gertrude demonstrated perfectionistic tendencies, which has been documented as a potential risk factor for EDs (Stackpole et al., 2023).
Precipitating Factors
The onset of Gertrude’s disordered eating symptoms and body image disturbance coincided with puberty, highlighting the potential role of hormonal influences and associated body changes as a precipitant (Ma et al., 2019). During adolescence, she experienced body dissatisfaction along with concurrent difficulties navigating peer interactions, leading to her engaging in weight control behaviors as a means of regaining her sense of self and “fitting in” with her social group. Gertrude experienced approval and a feeling of “specialness” for her ability to eat more than others but remain small, thus fueling her ED behaviors.
Perpetuating Factors
Gertrude’s ED was perpetuated by the reinforcement she received from others for maintaining a small body. She learned to view weight/body size as indicative of success and distortedly attributed her successes to her size. Gertrude also developed self-defeating patterns that perpetuated her core beliefs, further solidifying her ED as a source of identity. For instance, she pursued goals that were based on external validation rather than her own interests, leading to feeling unfulfilled and not “good enough”. She also developed relationships based on pleasing and obtaining validation from others, leaving her feeling disconnected and undervalued. Remaining small and envied may have provided a feeling of worthiness and social-connectedness. Additionally, ED behaviors functioned as a coping mechanism for managing stress, anxiety, and conflict, such as she was experiencing related to the pandemic.
Protective Factors
Gertrude possessed protective factors and strengths suggesting the potential for a positive treatment outcome. First, she had financial resources and the ability to access specialized care. In addition, while she did seem to struggle with depressive and anxiety symptoms, she did not have any comorbid psychiatric diagnoses that would impede recovery. Finally, she appeared to be driven in her desire to recover and willing to follow treatment recommendations.
7 Course of Treatment and Assessment of Progress
Overview of Treatment
Within Health’s treatment program embraces an evidence-based practice model whereby clients engage in individual and supportive interventions with their multidisciplinary team and attend selected groups based on their presentation, interest, and needs. This evidence-based practice approach is especially relevant to this case given that there are currently no treatments with strong research support for adults with AN. The program is facilitated by a mobile application with an integrated HIPAA-compliant videoconferencing platform and support features including a chat message function and check-ins (e.g., meal logs, mindfulness). Clients are provided with remote monitoring devices (i.e., blood pressure cuff, thermometer, and screenless scale) to enable RNs to obtain and track vitals as well as closed (i.e., not viewable by clients) weights. Additionally, the program ensures access to the necessary technology to complete remote treatment, such as by loaning smartphones and WIFI hotspot devices.
Because Gertrude was able to self-pay, no initial insurance authorization or oversight was required, thus allowing for more flexibility in her schedule. Overall, she spent 104 days at the PHP level, averaging 26.37 hours per week (range: 21–30.75) spread between six and seven days. She then stepped-down to IOP, at which point she elected to utilize her insurance benefits. She spent 46 days in IOP, averaging 13.13 hours per week of programming (range: 10.5–17) over the course of between four and seven days. She was discharged after 150 days total in the program.
Treatment Plan and Progress
According to the American Psychiatric Association (2006) level of care guidelines, which were still in use at the time of assessment, Gertrude’s multidisciplinary team determined that she was appropriate for admission to PHP. Her team considered whether residential treatment might be more appropriate given several factors: (1) admitting weight of around 78% of her IBW, which is slightly lower than is typical for this level of care (i.e., generally > 80%), (2) preoccupation with intrusive, repetitive thoughts for the majority of the day, (3) prior inability to reduce restriction or manage compulsive exercise behaviors, (4) long history of significant purging and laxative use with some evidence of potential medical abnormalities, and (4) marital conflict that might interfere with her spouse offering support and structure. Given that Gertrude presented as highly motivated and cooperative, was stable enough that extensive medical monitoring was not required, did not present with suicidality or comorbid disorders, and was unable to leave her home due to the pandemic, PHP was deemed the appropriate level.
Although most of the criteria for high risk for refeeding syndrome were not met (e.g., recent weight loss >10–15%, little or no food intake for > 5–10 days, and low electrolyte levels), her low admitting BMI (i.e., <16) did put Gertrude at greater risk (National Institute for Health and Clinical Excellence, 2006). Therefore, her initial meal plan started with a lower caloric amount and gradually increased with her rate of weight gain in line with recommendations (Mehler et al., 2010). She was monitored for signs of refeeding syndrome, including conducting remote weight and vitals checks three times per week and reviewing bloodwork obtained via her PCP (i.e., potassium, phosphorus, magnesium, and glucose levels) as needed.
Treatment Goals, Objectives, and Example Strategies.
Note. Example treatment strategies are marked as follows to illustrate how psychotherapeutic models and techniques were matched to treatment goals and objectives; C, Cognitive-behavioral; H, Humanistic, P, Psychodynamic.
Amount and Approximate Frequency of Individual, Group, and Supportive Interventions.
Additionally, Gertrude received nutrition counseling sessions from her RD and check-ins with her RN (see Table 3). Intuitive eating principles serve as the foundation for nutritional rehabilitation in the program (Tribole & Resch, 2020), with Gertrude’s RD incorporating education, motivation-enhancement, skill-building, and behavioral techniques. Gertrude’s appointments with her RN focused on managing medical aspects of her ED, including decreasing her laxative use to normalize bowel movements. Since she was not taking any psychotropic medications, Gertrude did not require ongoing psychiatric care; thus, she only had one follow-up appointment with a psychiatric provider during her time in PHP.
Gertrude attended a variety of weekly groups including psychoeducational (e.g., nutrition, anatomy and physiology, nervous system regulation), skills-based (e.g., CBT, ACT, DBT), process-oriented (e.g., general ED process group, parent process group), experiential (e.g., art therapy, movement, mindfulness), and support-focused groups (e.g., journal sharing, treatment successes, self-care) (see Table 3). Groups were conducted with specific guidelines intended to approximate in-person sessions (e.g., requiring clients to have cameras on and be seated upright) while also leveraging the videoconferencing platform to enhance the experience. For example, breakout rooms were used to offer opportunities for more intimate, small group interactions when appropriate, including providing space and privacy for anyone in need of individualized attention. Additionally, clients could use emojis while other clients were speaking, thereby showing respect by not interrupting them while also non-verbally conveying support.
The frequency and specific types of groups to which Gertrude was assigned/elected to participate in changed throughout her treatment based on her current concerns, preferences, and overall program hours, illustrative of an evidence-based practice approach. For instance, Gertrude demonstrated a strong grasp of the critical reasoning skills (e.g., cognitive restructuring, problem solving) typically taught in CBT group. As a result, she did not find this group helpful and instead, gravitated towards psychoeducational groups, where she could gather information and apply her knowledge in individual sessions, as well as skills-based groups with strategies that were less familiar to her (e.g., ACT, DBT). Given her isolation during the pandemic, she also requested to attend more process-oriented and support-focused groups where she could hear from and connect with peers in a supportive, non-judgmental environment. When she stepped-down to IOP, Gertrude’s utilization of skills-based and process-oriented groups decreased as she had gained skills and insight to better manage her ED symptoms and found the reinforcement that she received through psychoeducation and support groups most beneficial at this next stage.
The remainder of Gertrude’s program hours consisted of supportive interventions including meetings with an RN for remote weight and vitals monitoring. She also attended sessions with a care partner (i.e., clinical support staff) for support, to complete reflective exercises (e.g., journaling), and/or to engage in real-world exposure interventions, the last of which has demonstrated some benefit for EDs in research (Butler & Heimberg, 2020). Typically, clients participate in supported meals/snacks as part of the program as well, but Gertrude chose not to attend any, expressing a desire to eat with her family instead. In lieu of attendance, Gertrude completed meal/snack logs via the mobile application to help monitor completion, hunger/fullness levels, and thoughts, emotions, and urges associated with eating. She complied with treatment recommendations logging nearly all of her meals/snacks in the early phase of treatment and then intentionally decreasing in frequency as her symptoms improved (see Table 3 for percentage completion and frequency). Gertrude also used other app-based features including mindfulness check-ins and 1:1 chats with staff. She completed 56 mindfulness check-ins during PHP, beginning daily and then tapering such that she no longer used this feature in IOP. Similarly, she chatted with staff daily for the first five weeks of PHP (averaging 18 messages per day), tapering down to five days per week for the remainder of PHP (averaging three messages per day), and finally three days per week throughout IOP (averaging three messages per day).
Post-Treatment Outcomes
Gertrude’s weight at discharge was 112.66 lbs, representing a total gain of 22.66 lbs from her baseline weight during medical clearance. Her discharge BMI (i.e., 19.96) was in the healthy weight range and she was within the expected range according to her IBW (i.e., 97.97%) (see Table 1). She showed a fairly steady weight gain trajectory with a total average rate of 1.06 lbs per week; her rate was slightly faster in PHP (i.e., 1.12 lbs per week) compared to IOP (i.e., .81 lbs per week). This overall rate is consistent with the American Psychiatric Association (2023) recommendations suggesting approximately 1–3 lbs gained per week for those in PHP or outpatient care. Her vitals remained within acceptable ranges throughout treatment and her bloodwork showed no signs of refeeding syndrome or other abnormalities.
Gertrude’s scores on patient-reported outcome measures demonstrated improvements as well (see Table 1 for discharge scores). Her global EDE-Q score was below the clinical cutoff by discharge (Velkoff et al., 2023) and only her shape concern subscale score remained in range for those with AN; all other scores were in the non-clinical range (Dahlgren et al., 2017). She denied engaging in any binge eating or compensatory behaviors over the past 28 days. Her EDQOL total and subscale scores were all in the range expected for those without an ED (Engel et al., 2006). Similarly, her scores on the IES-2 were all outside of the range expected for those with an ED, with the exception of EPR, which remained in the clinical range (Babbott et al., 2022). Gertrude’s depressive symptoms decreased to the none/minimal range according to the PHQ-9 (Kroenke et al., 2001), indicating a clinically significant change (i.e., more than 5 points) as well as a full treatment response (i.e., at least 50% reduction) and remission of symptoms (i.e., scores < 5). Both her state and trait anxiety remained in the clinically significant range (Knight et al., 1983) but she showed a clinically significant decrease (i.e., more than 10 points) in trait anxiety.
According to Gertrude’s team, she showed “good progress” and “global improvement” on her goals by discharge. Based on the DSM-5 criteria (American Psychiatric Association, 2013), her AN-BP was considered to be in “partial remission” due to having a healthy body weight (i.e., at least 90% IBW) for a sustained period of time (i.e., approximately 80 days) and not engaging in behaviors that interfere with weight gain as evidenced by her EDE-Q restraint score and frequency items. Her elevated shape concern subscale showed that she did continue to struggle with shape disturbance. Medically, she was able to experience normal bowel movements without laxatives and her bloodwork showed signs of restored reproductive (i.e., menstruation and ovulation) functioning. She was discharged with the recommendation to continue with an outpatient team consisting of a psychotherapist, a dietitian, and medical provider.
8 Complicating Factors
One complicating factor in this case was the ongoing pandemic and quarantine protocols instituted within Gertrude’s home. While Within Health’s treatment is designed to enable individuals to pursue treatment from home, the unprecedented circumstances of the pandemic introduced issues beyond those typically encountered. For instance, Gertrude may have had more opportunities to engage in meaningful activities and social interactions as part of her treatment plan if not for her confinement. Relatedly, Gertrude’s husband was described as having an extreme reaction to the pandemic within the context of untreated obsessive-compulsive disorder, which seemed to make it difficult for him to fully participate and support Gertrude in treatment.
Another complicating aspect of this case was the fact that Gertrude’s distorted beliefs and coping responses are embraced by her society. The pervasiveness of diet-culture and perfectionistic striving in Western culture may normalize and even encourage these views and behaviors. The pressure to eat and look a certain way to be successful reinforced and perpetuated Gertrude’s deeply ingrained beliefs, making them challenging to modify. Persisting shape and weight concerns have been identified as a predictor of relapse, with studies showing approximately 30% of those with AN relapsing following treatment (Berends et al., 2018). Data beyond one-month post-discharge were not available for this case report; however, Gertrude’s ability to weight restore and follow her meal plan may protect her within this environment given research showing that higher BMI at the end of treatment (Frostad et al., 2022) and adoption of normative eating patterns (Cooper et al., 2021) are predictive of positive, long-term outcomes. With cases similar to Gertrude’s, post-treatment relapse prevention programs, such as the novel in-home adjunctive intervention described in this case study (Sproch & Anderson, 2018), might be warranted.
9 Access and Barriers to Care
Gertrude did not experience financial or insurance-related barriers to accessing care. She had adequate resources to self-fund part of her treatment as well as sufficient insurance coverage for the remainder. She had the tools necessary to participate in a remote treatment program including reliable Internet and digital equipment. Furthermore, Gertrude was able to hire a nanny, allowing her to focus on her treatment. Financial difficulties and limited availability and flexibility have been cited as barriers to ED treatment (Ali et al., 2017). In addition, digital exclusion has been recognized as a barrier to telehealth-based solutions, especially for those from rural areas or marginalized backgrounds (Piers et al., 2023). The treatment program described in this case report has addressed many of these barriers, for instance, by obtaining insurance coverage for clients when possible, thereby making the cost comparable to in-person intermediate level of care. Since cost-effectiveness analyses have suggested that intermediate levels of care, and PHPs in particular, are likely to yield savings for those with more severe EDs, these programs may be a cost-effective option (Deloitte Access Economics, 2020). In addition, the remote nature of the program allows for increased flexibility; clients save time by not commuting and are able to allocate programming around other responsibilities. Finally, the treatment program decreases the digital divide by providing technology to clients in need.
10 Follow-Up
Gertrude was contacted via email at one-month post-discharge to obtain follow-up data using the same patient-reported outcome measures that she completed during treatment. Gertrude’s scores demonstrated maintained improvements over time (see Table 1). Her global ED symptoms remained below the clinical threshold (Velkoff et al., 2023), her shape concern subscale score dropped into the non-clinical range (Dahlgren et al., 2017), and she did not report any bingeing, purging, or laxative use. She denied any impact of her ED on quality life and only her EPR subscale score was still in the clinical range (Babbott et al., 2022). Her depressive symptoms remained in the none-minimal range (Kroenke et al., 2001) while her anxiety was relatively unchanged and still slightly elevated above the clinical cutoff (Knight et al., 1983). No additional follow-up measures were obtained beyond one-month post-discharge; thus, Gertrude’s current status and extent to which gains were maintained is unknown.
11 Treatment Implications of the Case
This case demonstrates that longstanding severe AN can be successfully treated in a remote intermediate level of care setting using an evidence-based practice approach. The positive outcomes of this case are particularly noteworthy given prior research suggesting that lower baseline BMI, engagement in binge/purge behaviors, and longer illness duration are poor prognostic factors (Miskovic-Wheatley et al., 2023). Although Gertrude’s team initially considered residential treatment, she was admitted at the PHP level of care, stepped down to IOP, and then discharged having completed her goals for intermediate level of care. Thus, this case establishes this model of care as a viable option for individuals with similar presentations.
The findings from this case contribute to the growing body of evidence supporting the effectiveness of remote care at the intermediate level (Blalock et al., 2020; Carr et al., 2022; Levinson et al., 2021; Ortiz et al., 2023; Penwell et al., 2023) as well as the potential to reach individuals who may otherwise not be able to access treatment (Kazdin et al., 2017). The circumstances of this case are unusual in that as the pandemic has subsided, this exact scenario may be less likely to occur for others. In particular, Gertude cited her desire to engage in social interaction and activities with others outside of her household as a driver of her pursuit of treatment and an enabler of her recovery. Nevertheless, this case highlights the benefit of being able to receive intensive, evidence-based care within one’s home when pursuing brick-and-mortar options is not possible or preferred. Remote treatment offers a valuable alternative for individuals facing practical obstacles to in-person care, such as geographical distance, transportation limitations, or time-related inconvenience (Ali et al., 2017). In particular, this case shows that it is possible for individuals with low admitting BMI and risk for refeeding syndrome to weight restore safely in a remote setting with the use of remote monitoring devices, appropriately paced meal plan increases, and careful medical attention. The client’s adherence to meal log completion may also be key to her weight restoration given evidence of self-monitoring as a core mechanism linked to reduced dietary restraint in CBT (Spangler et al., 2004).
This case also illustrates how an evidence-based practice approach can offer the necessary flexibility to tailor treatment plans according to a client’s unique situation while still ensuring high-quality care. For instance, rather than requiring strict adherence to a protocol, as may be the case with evidence-based treatments, the client’s desire to have meals with her family was accommodated in this case. This accommodation was crucial in aligning treatment with her personal values, thereby fostering a therapeutic environment that promoted engagement, adherence, and motivation. The utilization of mobile application-based meal logs allowed the client to receive the necessary oversight and support from her team. Additionally, the eclectic psychotherapeutic approach along with group-based and supportive interventions created a comprehensive, holistic treatment experience, addressing the multifaceted aspects of Gertrude’s condition. By embracing an evidence-based practice model and harnessing technology, effective personalized care can be made available for those with severe and persistent EDs.
12 Recommendations to Clinicians and Students
This case report demonstrates how weight restoration and symptom remission can be achieved for an individual with longstanding AN using a remote, evidence-based practice approach. In accordance with existing guidelines (American Psychiatric Association, 2023; Residential Eating Disorder Consortium, 2021), this case illustrates how a comprehensive evaluation incorporating multidisciplinary interviews, medical records review, and patient-reported outcome measures can be used to determine appropriate diagnosis and level of care for similar ED presentations. This case describes special considerations for working with clients on the cusp of needing a higher level of care, including how to mitigate risk for refeeding syndrome. Using an integrative biopsychosocial lens, this report exemplifies how cases can be conceptualized to align with diverse treatment modalities and strategies.
In terms of the treatment process, this case shows how technology can be leveraged in ED treatment, including through a HIPAA-compliant videoconferencing platform for sessions, a mobile-application for meal logging, and remote monitoring devices for checking weight and vitals in a closed manner. Although not meant to be prescriptive, this case provides insight into the length of stay that may be required to achieve comparable outcomes as well as the frequency of treatment components. Furthermore, this case describes how patient-reported outcome measures can be used to track progress and functioning. Finally, this report outlines a treatment plan, including goals, objectives, and strategies drawn from cognitive-behavioral, humanistic, and psychodynamic psychotherapies that could be used in similar cases.
Footnotes
Acknowledgments
The authors sincerely thank the client in this case for her willingness to share her story through this report. We would also like to thank all members of her clinical team who supported her treatment.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Wendy Oliver-Pyatt is the sole owner and President of Within Health Provider Services FL PLLC. She is a co-founder, co-owner, and the Chief Executive Officer of Within Health Group, Inc., an affiliate of Within Health Provider Services FL PLLC. Caitlin Shepherd and Katie Piel are employees of Within Health Provider Services FL PLLC. Christine Stockert, Shaun Riebl, and Rebecca Brumm are employees of Within Health Provider Services FL PLLC and are consultants to and hold stock options issued by Within Health Group, Inc. Jessica Genet is a consultant to Within Health Provider Services FL PLLC and Within Health Group, Inc. and is an investor, and holds equity, in Within Health Group, Inc. Rebecca Boswell receives consulting fees from Within Health Provider Services FL PLLC.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
