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Throughout the process of assessment, diagnosis, and formulation and implementation of a treatment plan, the following principles of psychiatric management should be kept in mind:

  • Establish and maintain a therapeutic alliance.

    • Enhance development of the alliance through empathic comments and behaviors, positive regard, reassurance, and support.

    • Recognize and acknowledge anxieties that patients with anorexia nervosa have about gaining weight.

    • Be aware that many patients may withhold information about their behaviors because of shame.

    • Set clear boundaries.

    • Be aware of countertransference reactions.

    • Adapt and modify therapeutic strategies as the disorder and the therapeutic alliance change over time.

  • Collaborate with other clinicians.

    • Provide and/or coordinate care.

    • Collaborate with other individuals who are involved in the patient'€™s treatment, including other physicians, registered dietitians, mental health professionals, and school personnel.

    • Consult with other physician specialists and dentists.

    • Educate and supervise inexperienced staff.

  • Assess and monitor eating disorder symptoms and behaviors.

    • Use DSM-IV-TR criteria to guide diagnosis and identification of target symptoms and behaviors.

    • Obtain history of previous episodes of eating disorder, including previous treatment response.

    • Assess specific eating-related behaviors by

      • obtaining a detailed report of food intake during a single day,

      • observing the patient during a meal, and

      • recording food and/or fluid intake and output as part of nutritional management.

    • Consider the use of formal measures (e.g., semistructured interviews, rating scales, self-report questionnaires).

    • Assess related psychological symptoms (e.g., obsessional thoughts related to weight, shape, and eating).

    • Explore the patient'€™s understanding of how the illness developed and the effects of interpersonal issues on onset, including aspects of sexual history and psychological, physical, or sexual abuse.

    • Identify stressors that exacerbate the symptoms of the eating disorder.

    • Identify relevant psychodynamic and interpersonal conflicts.

    • Determine the patient'€™s insight into the presence of the disorder and the patient'€™s motivation for change.

  • Ensure that the patient'€™s general medical status is assessed and monitored.

    • Ensure that a physical examination is conducted by a physician knowledgeable about eating disorders:

      • Vital signs

      • Weight and height, including calculation of BMI

      • Physical and sexual growth and development

      • Cardiovascular system, including evidence of dehydration, cardiac arrhythmias, or congestive heart failure

      • Lanugo

      • Salivary gland enlargement

      • Russell'€™s sign (scarring on dorsum of hand)

      • Muscular irritability or weakness

      • Evidence of self-injurious behaviors

    • Review dental examination results.

    • Conduct laboratory analyses, as indicated. For laboratory assessments and their patient indications, see Table 1.

    • For commonly found signs, symptoms, and associated laboratory abnormalities, see Table 2.

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TABLE 1. Laboratory Assessments for Patients With Eating Disorders

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Table Reference Number
TABLE 1. Laboratory Assessments for Patients With Eating Disorders
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TABLE 2. Physical Complications of Eating Disorders

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Table Reference Number
TABLE 2. Physical Complications of Eating Disorders

  • Assess and monitor the patient'€™s psychiatric status, including co-occurring conditions and safety.

    • Determine whether the patient is at potential risk of self-harm.

      • Assess current suicidal ideation, plan, or intent, including access to means for suicide.

      • Obtain history of suicidal ideation, suicide attempts, and self-injurious behavior.

    • Identify the presence of co-occurring psychiatric signs, symptoms, or conditions, including

      • mood symptoms and disorders,

      • anxiety symptoms and disorders,

      • obsessions/compulsions,

      • substance abuse,

      • impulsive behaviors (including shoplifting), and

      • personality disturbances.

  • Assess family issues and enlist family support.

    • Identify any family history of eating disorders, other psychiatric disorders, and obesity.

    • Assess family dynamics (e.g., guilt, blame) and attitudes toward eating, exercise, and appearance.

    • Identify family reactions to the patient'€™s disorder and the burden of illness for the family.

  • Provide education about the patient'€™s eating disorder and its treatment.

    • Give direct advice and information to the patient and to involved family members.

    • Suggest resources such as self-help workbooks and community- and Internet-based information.

    • Caution about potentially detrimental Internet sites that encourage eating-disordered lifestyles.

Table Reference Number
TABLE 1. Laboratory Assessments for Patients With Eating Disorders
Table Reference Number
TABLE 2. Physical Complications of Eating Disorders

References

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