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Establish goals for seriously underweight patients:
Normalize eating patterns.
Achieve normal perceptions of hunger and satiety.
Correct biological and psychological sequelae of malnutrition.
Help the patient to resume eating and to gain weight.
Establish a target weight and rates of weight gain: a healthy goal weight is the weight at which normal menstruation and ovulation are restored or, in premenarchal girls, the weight at which normal physical and sexual development resumes.
Usually begin intake at 30–40 kcal/kg per day (approximately 1,000–1,600 kcal/day); intake may be increased to as high as 70–100 kcal/kg per day.
Reserve nasogastric feeding for rare patients with extreme difficulty recognizing their illness, accepting the need for treatment, or tolerating guilt accompanying active eating even when done to sustain life.
Help the patient limit physical activity and caloric expenditure according to food intake and fitness requirements.
Monitor vital signs; food and fluid intake/output; electrolytes; signs of fluid overload (e.g., presence of edema, rapid weight gain, congestive heart failure); or other evidence of a serious refeeding syndrome.
Address gastrointestinal symptoms, particularly constipation, bloating, and abdominal pain.
Provide cardiac monitoring, especially at night, for children and adolescents who are severely malnourished.
Add vitamin and mineral supplements; for example, phosphorus supplementation may be particularly useful to prevent serum hypophosphatemia.
Create a milieu that incorporates emotional nurturance and a combination of reinforcers that link exercise, bed rest, and privileges to target weights, desired behaviors, and feedback concerning changes in weight and other observable parameters.
Help the patient to maintain weight.
Once desired weight is achieved, calculate ongoing caloric intake based on weight and activity. For children and adolescents, intake levels at 40–60 kcal/kg per day are often needed for growth and maturation.
Help the patient cope with concerns about weight gain and body image changes.
Educate about the risks of eating disorders.
Provide ongoing support to the patient and the family.
Establish goals, including to help the patient
understand and cooperate with nutritional and physical rehabilitation,
understand and change the behaviors and dysfunctional attitudes related to the eating disorder,
improve interpersonal and social functioning, and
address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors.
Establish and maintain a psychotherapeutically informed relationship with the patient.
This includes understanding the following:
Psychodynamic issues, including deficits in sense of self and interpersonal and intrapsychic conflicts
Complexity of family relationships
Influence of other psychiatric disorders that may be present
Provide formal psychotherapy once weight gain has started.
Is usually required for at least 1 year and may take many years because of the enduring nature of the illness and the need for support during recovery.
Cognitive-behavioral, interpersonal, and psychodynamic approachesor a combination of these approacheshave the most evidence and consensus for use in adults.
Family and couples therapy
Is useful when family or marital problems are contributing to the maintenance of the disorder.
Family approaches are most effective with children and adolescents, particularly with illnesses lasting less than 3 years.
Typically has a cognitive-behavioral, interpersonal, and/or psychodynamic focus.
Care must be taken to help patients avoid competition to be the thinnest or the sickest and cope with demoralization from observation of the difficult, chronic course of the illness.
Self-help, online resources, 12-step models
Can be helpful adjuncts for some and patients.
Lack of professional supervision can sometimes perpetuate misinformation or unhealthy dynamics.
Use psychotropic medications in conjunction with psychosocial interventions, not as a sole or primary treatment for patients with anorexia nervosa.
Whenever possible, defer making decisions about medications until after weight has been restored.
Be aware of and manage general side effects.
Malnourished, depressed patients are more prone to side effects.
Cardiovascular consultation may be helpful if there is concern about potential cardiovascular effects of a medication.
Consider antidepressants to treat persistent depression or anxiety following weight restoration.
Selective serotonin reuptake inhibitors (SSRIs) have the most evidence for efficacy and the fewest difficulties with adverse effects.
SSRIs may also be useful in patients with bulimic or obsessive-compulsive symptoms.
Bupropion should be avoided in patients with eating disorders because of increased risk of seizures.
Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) should be avoided in underweight patients; their potential lethality and toxicity in overdose should be taken into consideration.
Clinicians should attend to the black box warnings in the package inserts relating to antidepressants and discuss the potential benefits and risks of treatment with patients and families if such medications are to be prescribed.
Consider second-generation and low-potency antipsychotics for selected patients with severe symptoms.
Evidence from controlled trials is limited. Clinical impression suggests these agents may be useful for patients with severe unremitting resistance to gaining weight, severe obsessional thinking, and denial that approaches delusional proportions.
If these agents are used, monitor for side effects, including laboratory abnormalities.
Consider approaches to restore lost bone mineral density.
Calcium supplementation should be considered when dietary calcium intake is inadequate for growth and maintenance.
Vitamin D supplementation can be added in patients without daily sunlight exposure, but excessive doses should be avoided.
Hormone replacement therapy is sometimes given, but there is no good evidence for efficacy and its use can enhance patient denial of illness by creating regularly occurring "pseudomenses" (pharmacologically induced menses).
Biphosphonates such as alendronate are generally not indicated.