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From:

http://www.psych.org/psych_pract/treatg/pg/eating_revisebook_2.cfm?pf=y

I. EXECUTIVE SUMMARY

A. Coding System
Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendations:

[I] recommended with substantial clinical confidence.
[II] recommended with moderate clinical confidence.
[III] may be recommended on the basis of individual circumstances.

B. General Considerations
Patients with eating disorders display a broad range of symptoms that frequently occur along a continuum between those of anorexia nervosa and bulimia nervosa. The care of patients with eating disorders involves a comprehensive array of approaches. These guidelines contain the clinical factors that need to be considered when treating a patient with anorexia nervosa or bulimia nervosa.

1. Choosing a site of treatment
Evaluation of the patient with an eating disorder prior to initiating treatment is essential for determining the appropriate setting of treatment. The most important physical parameters that affect this decision are weight and cardiac and metabolic status [I]. Patients should be psychiatrically hospitalized before they become medically unstable (i.e., display abnormal vital signs) [I]. The decision to hospitalize should be based on psychiatric, behavioral, and general medical factors [I]. These include rapid or persistent decline in oral intake and 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., intercurrent viral illnesses), prior knowledge of weight at which instability is likely to occur, or comorbid psychiatric problems that merit hospitalization.

Most patients with uncomplicated bulimia nervosa do not require hospitalization. However, the indications for hospitalization for these patients can include 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), suicidality, psychiatric disturbances that warrant hospitalization independent of the eating disorders diagnosis, or severe concurrent alcohol or drug abuse.

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, and the availability of suitable intensive outpatient, partial and day hospitalization, and aftercare programs to care for the patient's general medical and psychiatric problems.

2. 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. Important components of psychiatric management for patients with eating disorders are as follows: establish and maintain a therapeutic alliance; coordinate care and collaborate with other clinicians; assess and monitor eating disorder symptoms and behaviors; assess and monitor the patient's general medical condition; assess and monitor the patient's psychiatric status and safety; and provide family assessment and treatment [I].

3. Choice of specific treatments for anorexia nervosa
Goals in the treatment of anorexia nervosa include 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; and preventing relapse.

a. Nutritional rehabilitation/counseling
A program of nutritional rehabilitation should be established for all patients who are significantly underweight [I]. 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. Patients who have higher caloric intake requirements may be discarding food, be vomiting, be exercising frequently, have increased nonexercise motor activity (e.g., fidgeting), or have truly higher metabolic rates. Vitamin and mineral supplements may also be beneficial for patients (e.g., phosphorus supplementation may be particularly useful to prevent serum hypophosphatemia).

It is essential to monitor patients medically during refeeding [I]. Monitoring should include assessment of vital signs as well as food and fluid intake and output; electrolytes (including phosphorus); and 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 [I].

b. Psychosocial interventions
The establishment and maintenance of a psychotherapeutically informed relationship is beneficial [II]. Once weight gain has started, formal psychotherapy may be very helpful. There is no clear evidence that any specific form of psychotherapy is superior for all patients. Psychosocial interventions need to be informed by understanding psychodynamic conflicts, cognitive development, psychological defenses, and complexity of family relationships as well as the presence of other psychiatric disorders. Psychotherapy alone is generally not sufficient to treat severely malnourished patients with anorexia nervosa. 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.

Both the symptoms of eating disorders and problems in familial relationships that may be contributing to the maintenance of disorders may be alleviated by family and couples psychotherapy [II]. Group psychotherapy is sometimes added as an adjunctive treatment for anorexia nervosa; however, 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.

c. Medications
Treatment of anorexia nervosa should not rely on psychotropic medications as the sole or primary treatment [I]. 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 [II].

4. Choice of specific treatments for bulimia nervosa

a. Nutritional rehabilitation/counseling
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 [I].

b. Psychosocial interventions
A comprehensive evaluation of individual patients, their cognitive and psychological development, psychodynamic issues, cognitive style, comorbid psychopathology, patient preferences, and family situation is needed to inform the choice of psychosocial interventions [I]. Cognitive behavioral psychotherapy is the psychosocial treatment for which the most evidence for efficacy currently exists, but controlled trials have also shown interpersonal psychotherapy to be very useful. Behavioral techniques (e.g., planned meals, self-monitoring) may also be helpful. Clinical reports have indicated that psychodynamic and psychoanalytic approaches in individual or group format may be useful once bingeing and purging are improving. Patients with concurrent anorexia nervosa or severe personality disorders may benefit from extended psychotherapy.

Whenever possible, family therapy should be considered, especially for adolescents still living with parents or older patients with ongoing conflicted interactions with parents or other family members [II].

c. Medications
For most patients, antidepressant medications are effective as one component of an initial treatment [I]. Selective serotonin reuptake inhibitors (SSRIs) are currently considered to be the safest antidepressants and may be 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 can reduce the symptoms of binge eating and purging and may help prevent relapse among patients in remission.

While tricyclic and monoamine oxidase inhibitor (MAOI) antidepressants can be used to treat bulimia nervosa, tricyclics should be used with caution for patients who may be at high risk for suicide attempts, and MAOIs should be avoided for patients with chaotic binge eating and purging.

Emerging evidence has shown that a combination of psychotherapeutic interventions and medication results in higher remission rates and therefore should be considered when initiating treatment for patients with bulimia nervosa [II].