| Treatment |
| Patients with eating disorders display a broad range of symptoms that often occur along a continuum between those of anorexia nervosa and bulimia nervosa. Their care involves a comprehensive array of approaches coordinated among professionals and non-professionals. High quality care is dependent upon a thorough initial assessment, structured goal-oriented treatment, periodic re-assessment and close monitoring of clinical status. In general, the nature and intensity of treatment depends on the symptom profile and severity of impairment, not the DSM-IV diagnosis. General Principles for the Treatment of Eating Disorders Choosing a Site of Treatment Evaluation of the patient prior to initiating treatment is essential for determining the appropriate setting of treatment. Assessment of weight, cardiac and metabolic status are crucial Patients should be psychiatrically hospitalized before they become medically unstable (i.e., display abnormal vital signs). The decision to hospitalize should be based on psychiatric, behavioral, and general medical factors: Rapid or persistent decline in oral intake Decline in weight despite outpatient or partial hospitalization interventions The presence of additional stressors that interfere with the patient's ability to eat (e.g., viral illnesses) Prior knowledge of weight at which instability is likely to occur Comorbid psychiatric problems that merit hospitalization. Factors influencing the decision to hospitalize on a psychiatric versus a general medical or adolescent/pediatric unit include The patient's general medical status The skills and abilities of local psychiatric and general medical staffs The availability of suitable intensive outpatient, partial and day hospitalization, and aftercare programs to care for the patient's general medical and psychiatric problems. Most patients with uncomplicated bulimia nervosa do not require hospitalization unless there are: Severe disabling symptoms that have not responded to outpatient treatment, serious concurrent general medical problems (e.g., metabolic abnormalities, hematemesis, vital sign changes, and the appearance of uncontrolled vomiting), Signs of suicidality (imminent danger to self or others), Psychiatric disturbances that warrant hospitalization independent of the eating disorders diagnosis, Signs of severe concurrent alcohol or drug abuse. Psychiatric Management Psychiatric management forms the foundation of treatment for patients with eating disorders and should be instituted for all patients in combination with other specific treatment modalities. Essential components: Establish and maintain a therapeutic alliance Coordinate care and collaborate with other clinicians Assess and monitor eating disorder symptoms and behaviors Formal measures (self-report questionnaires and semistructured interviews): Diagnostic Survey for Eating Disorders (DSED) Eating Attitudes Test Eating Disorders Examination (EDE) EDE-Q4 Eating Disorders Inventory Eating Disorders Questionnaire Questionnaire of Eating and Weight Patterns Yale-Brown-Cornell Eating Disorder Scale Assess and monitor the patient's general medical condition The need for laboratory analyses should be determined on an individual basis depending on the patient's condition or when necessary for making treatment decisions. Assess and monitor the patient's psychiatric status and safety Substance abuse/dependence Mood and anxiety disorders Suicidality Obsessive and compulsive symptoms Personality disorders Posttraumatic stress disorder (PTSD) Provide family/social support assessment and treatment Anorexia Nervosa - Specific Treatments Goals of Treatment Restoring healthy weight (i.e., weight at which menses and ovulation in females, normal sexual drive and hormone levels in males, and normal physical and sexual growth and development in children and adolescents are restored) Treating physical complications Enhancing patients' motivations to cooperate in the restoration of healthy eating patterns and to participate in treatment Providing education regarding healthy nutrition and eating patterns Correcting core maladaptive thoughts, attitudes, and feelings related to the eating disorder Treating associated psychiatric conditions, including defects in mood regulation, self-esteem, and behavior Enlisting family support and providing family counseling and therapy where appropriate Preventing relapse Treatment Modalities Strategies for the treatment of anorexia nervosa include nutritional counseling and rehabilitation; psychosocial interventions (including psychotherapy in individual or group format); family interventions; and medications. Nutritional rehabilitation/counseling General: A program of nutritional rehabilitation should be established for all patients who are significantly underweight. Most nutritional rehabilitation programs employ a milieu incorporating emotional nurturance and one of a variety of behavioral interventions. Goals of nutritional rehabilitation for seriously underweight patients: Restore weight Normalize eating patterns Achieve normal perceptions of hunger and satiety Correct biological and psychological sequelae of malnutrition Techniques Healthy target weights and expected rates of controlled weight gain (e.g., 2-3 lb/week for most inpatient and 0.5-1 lb/week for most outpatient programs) should be established. Intake levels should usually start at 30-40 kcal/kg per day (approximately 1000-1600 kcal/day) and should be advanced progressively. This may be increased to as high as 70-100 kcal/kg per day during the weight gain phase. Intake levels should be 40-60 kcal/kg per day during weight maintenance and for ongoing growth and development in children and adolescents. Vitamin and mineral supplements may also be beneficial It is essential to monitor patients medically during refeeding. Assessment of vital signs as well as food and fluid intake and output Electrolytes (including phosphorus) The presence of edema, rapid weight gain (associated primarily with fluid overload), congestive heart failure, and gastrointestinal symptoms, particularly constipation and bloating. Cardiac monitoring may be useful, especially at night, for children and adolescents who are severely malnourished (weight <70% of the standard body weight). Physical activity should be adapted to the food intake and energy expenditure of the patient. Nutritional rehabilitation programs should also attempt to help patients deal with their concerns about weight gain and body image changes, educating them about the risks of their eating disorder and providing ongoing support to patients and their families. Psychosocial Interventions General: Once weight gain has started, formal psychotherapy is often beneficial. Goals are to help patients: Understand and cooperate with their nutritional and physical rehabilitation Understand and change the behaviors and dysfunctional attitudes related to their eating disorder Improve their interpersonal and social functioning Address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors. Structured inpatient and partial hospitalization programs Behaviorally formulated interventions Nonpunitive reinforcers (e.g., empathic praise, exercise-related limits and rewards, bed rest) Privileges linked to achieving weight goals and desired behaviors Individual psychotherapy Psychosocial interventions need to consider individual emotional conflicts and defenses, cognitive development, complexity of family relationships and the presence of other psychiatric disorders. Psychotherapy alone is generally not sufficient to treat severely malnourished patients with anorexia nervosa. There is no clear evidence that any specific form of psychotherapy is superior for all patients. Ongoing treatment with individual psychotherapeutic interventions is usually required for at least a year and may take 5-6 years because of the enduring nature of many of the psychopathologic features of anorexia nervosa and the need for support during recovery. Psychotherapy can address both the symptoms of eating disorders and problems in familial relationships that may be contributing to the maintenance of disorders Group Psychotherapy Care must be taken to avoid patients competing to be the thinnest or sickest member or becoming excessively demoralized through observing the difficult, chronic course of other patients in the group. Family Psychotherapy Family therapy and couple psychotherapy are frequently useful for both symptom reduction and dealing with family relational problems that may contribute to maintaining the disorder. Support Groups Groups based on addiction models or exclusively on the need for abstinence (e.g., 12-step programs) without attending to nutritional considerations or cognitive and behavioral deficits are not recommended as the sole initial treatment approach for anorexia nervosa. Medications General: Treatment of anorexia nervosa should not rely on psychotropic medications as the sole or primary treatment. Techniques An assessment of the need for antidepressant medications is usually best made following weight gain, when the psychological effects of malnutrition are resolving. These medications should be considered for the prevention of relapse among weight-restored patients or to treat associated features of anorexia nervosa, such as depression or obsessive-compulsive problems. Antidepressants may be considered after weight gain when the psychological effects of malnutrition are resolving, since these medications have been shown to be helpful with weight maintenance Other medications as needed for comorbid conditions Many clinicians report that malnourished depressed patients are more prone to side effects and less responsive to the beneficial effects of tricyclics, SSRIs, and other novel antidepressant medications than depressed patients of normal weight. Bulimia Nervosa - Specific Treatments Treatment Modalities Strategies for the treatment of eating disorders include nutritional counseling and rehabilitation; psychosocial interventions (including psychotherapy in individual or group format); family interventions; and medications. A combination of psychotherapeutic interventions and medication may be the most effective. Nutritional rehabilitation/counseling Goals: Reducing binge eating and purging are primary goals in treating bulimia nervosa. Weight restoration is usually not a focus of therapy because most patients are of normal weight. Techniques Nutritional counseling as an adjunct to other treatment modalities may be useful for reducing behaviors related to the eating disorder, minimizing food restriction, increasing the variety of foods eaten, and encouraging healthy but not excessive exercise patterns. Psychosocial interventions A comprehensive evaluation is needed to inform the choice of psychosocial interventions. Such evaluation should include their cognitive and psychological development, dysfunctional emotional conflicts, cognitive style, comorbid psychopathology, patient preferences, and family situation. Goals Reduction in, or elimination of, binge-eating and purging behaviors Improvement in attitudes related to the eating disorder Minimization of food restriction Increasing the variety of foods eaten Encouragement of healthy but not excessive exercise patterns Treatment of comorbid conditions and clinical features associated with eating disorders Addressing themes that may underlie eating disorder behaviors such as developmental issues, identity formation, body image concerns, self-esteem in areas outside of those related to weight and shape, sexual and aggressive difficulties, affect regulation, gender role expectations, family dysfunction, coping styles, and problem solving. Individual psychotherapy Cognitive behavioral psychotherapy is the psychosocial treatment of choice. Interpersonal psychotherapy can be very useful. Behavioral techniques (e.g., planned meals, self-monitoring) may also be helpful. Once bingeing and purging have improved, enduring emotional conflicts can be explored through psychotherapy in individual or group format. Patients with concurrent anorexia nervosa or severe personality disorders may benefit from extended psychotherapy. Group psychotherapy Group therapy is moderately efficacious, especially when it includes dietary counseling and management. Family Therapy Such therapy should be considered whenever possible, especially for adolescents who still live with their parents, older patients with ongoing conflicted interactions with parents, or patients with marital discord. Support Groups Twelve-step programs or other approaches that exclusively focus on the need for abstinence without attending to nutritional considerations or behavioral deficits are not recommended as the sole initial treatment approach for bulimia nervosa. Medications Combination of psychotherapy and medication is most likely to be effective. For most patients, antidepressant medications are effective as one component of an initial treatment. Selective serotonin reuptake inhibitors (SSRIs) are currently considered to be the safest antidepressants Especially helpful for patients with significant symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms or for those patients who have had a suboptimal response to previous attempts at appropriate psychosocial therapy Other antidepressant medications from a variety of classes Tricyclics should be used with caution for patients who may be at high risk for suicide attempts Monoamine oxidase inhibitors (MAOIs) should be avoided for patients with chaotic binge eating and purging. Eating Disorder Not Otherwise Specified Eating Disorder Not Otherwise Specified is a commonly used diagnosis, given to nearly 50% of patients with eating disorders who present to tertiary care eating disorders programs. Particularly common among adolescents Largely consists of subsyndromal cases of anorexia nervosa or bulimia nervosa (e.g., those who fail to meet one criterion, such as not having three months of amenorrhea or having fewer binge eating episodes per week than required for strictly defined diagnosis). One variant consists of abusers of weight reduction medications who are trying to lose excessive amounts of weight for cosmetic reasons. |
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