Each recommendation is identified as meriting one of three
categories of endorsement, based on the level of clinical confidence
regarding the recommendation, as indicated by a bracketed Roman
numeral after the statement. The three categories are as follows:
[I] Recommended
with substantial clinical confidence
[II] Recommended with moderate clinical
confidence
[III] May be recommended on the basis
of individual circumstances
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1. Psychiatric management
Psychiatric management begins with the establishment of a
therapeutic alliance, which is enhanced by empathic comments and
behaviors, positive regard, reassurance, and support [I].
Basic psychiatric management includes support through the provision
of educational materials, including self-help workbooks; information
on community-based and Internet resources; and direct advice to
patients and their families (if they are involved) [I].
A team approach is the recommended model of care [I].
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a) Coordinating care and collaborating with other
clinicians
In treating adults with eating disorders, the psychiatrist
may assume the leadership role within a program or team that includes
other physicians, psychologists, registered dietitians, and social
workers or may work collaboratively on a team led by others. For
the management of acute and ongoing medical and dental complications,
it is important that psychiatrists consult other physician specialists
and dentists [I].
When a patient is managed by an interdisciplinary team in
an outpatient setting, communication among the professionals is
essential to monitoring the patient's progress, making necessary adjustments
to the treatment plan, and delineating the specific roles and tasks
of each team member [I].
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b) Assessing and monitoring eating disorder symptoms
and behaviors
A careful assessment of the patient's history, symptoms,
behaviors, and mental status is the first step in making a diagnosis
of an eating disorder [I]. The complete assessment
usually requires at least several hours and includes a thorough
review of the patient's height and weight history; restrictive
and binge eating and exercise patterns and their changes; purging
and other compensatory behaviors; core attitudes regarding weight,
shape, and eating; and associated psychiatric conditions [I].
A family history of eating disorders or other psychiatric disorders, including
alcohol and other substance use disorders; a family history of obesity;
family interactions in relation to the patient's disorder;
and family attitudes toward eating, exercise, and appearance are
all relevant to the assessment [I]. A clinician's
articulation of theories that imply blame or permit family members
to blame one another or themselves can alienate family members from
involvement in the treatment and therefore be detrimental to the
patient's care and recovery [I]. It is
important to identify family stressors whose amelioration may facilitate recovery [I].
In the assessment of children and adolescents, it is essential to
involve parents and, whenever appropriate, school personnel and
health professionals who routinely work with the patient [I].
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c) Assessing and monitoring the patient's
general medical condition
A full physical examination of the patient is strongly recommended
and may be performed by a physician familiar with common findings
in patients with eating disorders. The examination should give particular
attention to vital signs, physical status (including height and
weight), cardiovascular and peripheral vascular function, dermatological
manifestations, and evidence of self-injurious behaviors [I].
Calculation of the patient's body mass index (BMI) is also
useful (see http://www.cdc.gov/nccdphp/dnpa/bmi/00binaries/bmi-tables.pdf [for
ages 2–20] and http://www.cdc.gov/nccdphp/dnpa/bmi/00binaries/bmi-adults.pdf [for
adults]) [I]. Early recognition of eating
disorder symptoms and early intervention may prevent an eating disorder
from becoming chronic [I]. During treatment, it
is important to monitor the patient for shifts in weight, blood
pressure, pulse, other cardiovascular parameters, and behaviors
likely to provoke physiological decline and collapse [I]. Patients
with a history of purging behaviors should also be referred for
a dental examination [I]. Bone density examinations
should be obtained for patients who have been amenorrheic for 6
months or more [I].
In younger patients, examination should include growth pattern,
sexual development (including sexual maturity rating), and general
physical development [I]. The need for laboratory analyses
should be determined on an individual basis depending on the patient's
condition or the laboratory tests' relevance to making
treatment decisions [I].
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d) Assessing and monitoring the patient's
safety and psychiatric status
The patient's safety will be enhanced when particular
attention is given to suicidal ideation, plans, intentions, and
attempts as well as to impulsive and compulsive self-harm behaviors [I].
Other aspects of the patient's psychiatric status that
greatly influence clinical course and outcome and that are important
to assess include mood, anxiety, and substance use disorders, as
well as motivational status, personality traits, and personality
disorders [I]. Assessment for suicidality is of
particular importance in patients with co-occurring alcohol and
other substance use disorders [I].
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e) Providing family assessment and treatment
For children and adolescents with anorexia nervosa, family
involvement and treatment are essential [I].
For older patients, family assessment and involvement may be useful
and should be considered on a case-by-case basis [II].
Involving spouses and partners in treatment may be highly desirable [II].
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2. Choosing a treatment site
Services available for treating eating disorders can range
from intensive inpatient programs (in which general medical
care is readily available) to residential and partial hospitalization programs
to varying levels of outpatient care (in which the patient receives
general medical treatment, nutritional counseling, and/or
individual, group, and family psychotherapy). Because specialized
programs are not available in all geographic areas and their financial
requirements are often significant, access to these programs may
be limited; petition, explanation, and follow-up by the psychiatrist
on behalf of patients and families may help procure access to these
programs. Pretreatment evaluation of the patient is essential in
choosing the appropriate treatment setting [I].
In determining a patient's initial level of care
or whether a change to a different level of care is appropriate,
it is important to consider the patient's overall physical
condition, psychology, behaviors, and social circumstances rather
than simply rely on one or more physical parameters, such as weight [I].
Weight in relation to estimated individually healthy weight, the
rate of weight loss, cardiac function, and metabolic status are
the most important physical parameters to be considered when choosing
a treatment setting; other psychosocial parameters are also important [I].
Healthy weight estimates for a given individual must be determined
by that person's physicians [I]. Such
estimates may be based on historical considerations (often including
that person's growth charts) and, for women, the weight
at which healthy menstruation and ovulation resume, which may be
higher than the weight at which menstruation and ovulation became
impaired. Admission to or continuation of an intensive level of
care (e.g., hospitalization) may be necessary when access to a less
intensive level of care (e.g., partial hospitalization) is absent
because of geography or a lack of resources [I].
Generally, adult patients who weigh less than approximately
85% of their individually estimated healthy weights have
considerable difficulty gaining weight outside of a highly structured
program [II]. Such programs, including inpatient
care, may be medically and psychiatrically necessary even for some
patients who are above 85% of their individually estimated
healthy weight [I]. Factors suggesting that hospitalization
may be appropriate include rapid or persistent decline in oral intake,
a decline in weight despite maximally intensive outpatient or partial
hospitalization interventions, the presence of additional stressors
that may interfere with the patient's ability to eat, knowledge
of the weight at which instability previously occurred in the patient,
co-occurring psychiatric problems that merit hospitalization, and
the degree of the patient's denial and resistance to participate
in his or her own care in less intensively supervised settings [I].
Hospitalization should occur before the onset of medical instability
as manifested by abnormalities in vital signs (e.g., marked orthostatic
hypotension with an increase in pulse of 20 bpm or a drop in standing
blood pressure of 20 mmHg, bradycardia <40 bpm, tachycardia >110
bpm, or an inability to sustain core body temperature), physical
findings, or laboratory tests [I]. To avert potentially
irreversible effects on physical growth and development, many children
and adolescents require inpatient medical treatment, even when weight
loss, although rapid, has not been as severe as that suggesting
a need for hospitalization in adult patients [I].
Patients who are physiologically stabilized on acute medical
units will still require specific inpatient treatment for eating
disorders if they do not meet biopsychosocial criteria for less
intensive levels of care and/or if no suitable less intensive
levels of care are accessible because of geographic or other reasons [I].
Weight level per se should never be used as the sole criterion for
discharge from inpatient care [I]. Assisting patients
in determining and practicing appropriate food intake at a healthy
body weight is likely to decrease the chances of their relapsing
after discharge [I].
In shifting between levels of care, it is important to establish
continuity of care [II]. If the patient is going
from one treatment setting or locale to another, transition planning
requires that the care team in the new setting or locale be identified
and that specific patient appointments be made [I].
It is preferable that a specific clinician on the team be designated as the
primary coordinator of care to ensure continuity and attention to
important aspects of treatment [II].
Most patients with uncomplicated bulimia nervosa do not require
hospitalization; indications for the hospitalization of such patients
include severe disabling symptoms that have not responded to adequate
trials of outpatient treatment, serious concurrent general medical problems
(e.g., metabolic abnormalities, hematemesis, vital sign changes,
uncontrolled vomiting), suicidality, psychiatric disturbances that
would warrant the patient's hospitalization independent
of the eating disorder diagnosis, or severe concurrent alcohol or
drug dependence or abuse [I].
Legal interventions, including involuntary hospitalization
and legal guardianship, may be necessary to address the safety of
treatment-reluctant patients whose general medical conditions are
life threatening [I].
The decision about whether a patient should be hospitalized
on a psychiatric versus a general medical or adolescent/pediatric
unit should be made based on the patient's general medical
and psychiatric status, the skills and abilities of local psychiatric
and general medical staff, and the availability of suitable programs
to care for the patient's general medical and psychiatric
problems [I]. There is evidence to suggest that
patients with eating disorders have better outcomes when treated
on inpatient units specializing in the treatment of these disorders
than when treated in general inpatient settings where staff lack
expertise and experience in treating eating disorders [II].
Outcomes from partial hospitalization programs that specialize
in eating disorders are highly correlated with treatment
intensity. The more successful programs involve patients in treatment
at least 5 days/week for 8 hours/day; thus, it
is recommended that partial hospitalization programs be structured
to provide at least this level of care [I].
Patients who are considerably below their healthy body weight
and are highly motivated to adhere to treatment, have cooperative
families, and have a brief symptom duration may benefit from treatment
in outpatient settings, but only if they are carefully monitored
and if they and their families understand that a more restrictive
setting may be necessary if persistent progress is not evident in
a few weeks [II]. Careful monitoring includes
at least weekly (and often two to three times a week) weight determinations
done directly after the patient voids and while the patient is wearing
the same class of garment (e.g., hospital gown, standard exercise
clothing) [I]. In patients who purge, it is important
to routinely monitor serum electrolytes [I]. Urine
specific gravity, orthostatic vital signs, and oral temperatures
may need to be measured on a regular basis [II].
In an outpatient setting, patients can remain with their families
and continue to attend school or work. Inpatient care may interfere
with family, school, and work obligations; however, it
is important to give priority to the safe and adequate treatment
of a rapidly progressing or otherwise unresponsive disorder for
which hospital care might be necessary [I].
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3. Choice of specific treatments for anorexia nervosa
The aims of treating anorexia nervosa are to 1) restore patients
to a healthy weight (associated with the return of menses and normal
ovulation in female patients, normal sexual drive and hormone levels
in male patients, and normal physical and sexual growth and development
in children and adolescents); 2) treat physical complications; 3)
enhance patients' motivation to cooperate in the restoration
of healthy eating patterns and participate in treatment; 4) provide
education regarding healthy nutrition and eating patterns; 5) help patients
reassess and change core dysfunctional cognitions, attitudes, motives,
conflicts, and feelings related to the eating disorder; 6) treat
associated psychiatric conditions, including deficits in mood and
impulse regulation and self-esteem and behavioral problems; 7) enlist
family support and provide family counseling and therapy where appropriate;
and 8) prevent relapse.
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a) Nutritional rehabilitation
The goals of nutritional rehabilitation for seriously underweight
patients are to restore weight, normalize eating patterns, achieve
normal perceptions of hunger and satiety, and correct biological
and psychological sequelae of malnutrition [I].
For patients age 20 years and younger, an individually appropriate
range for expected weight and goals for weight and height may be
determined by considering measurements and clinical factors, including current
weight, bone age estimated from wrist X-rays and nomograms, menstrual
history (in adolescents with secondary amenorrhea), mid-parental
heights, assessments of skeletal frame, and benchmarks from Centers
for Disease Control and Prevention (CDC) growth charts (available
at http://www.cdc.gov/growthcharts/) [I].
For individuals who are markedly underweight and for children
and adolescents whose weight has deviated below their growth curves,
hospital-based programs for nutritional rehabilitation should be
considered [I]. For patients in inpatient or residential
settings, the discrepancy between healthy target weight and weight
at discharge may vary depending on patients' ability to
feed themselves, their motivation and ability to participate in
aftercare programs, and the adequacy of aftercare, including partial
hospitalization [I]. It is important to implement
refeeding programs in nurturing emotional contexts [I].
For example, it is useful for staff to convey to patients their
intention to take care of them and not let them die even when the
illness prevents the patients from taking care of themselves [II].
It is also useful for staff to communicate clearly that they are
not seeking to engage in control battles and have no punitive intentions
when using interventions that the patient may experience as aversive [I].
In working to achieve target weights, the treatment plan should
also establish expected rates of controlled weight gain. Clinical
consensus suggests that realistic targets are 2–3 lb/week
for hospitalized patients and 0.5–1 lb/week for
individuals in outpatient programs [II]. Registered
dietitians can help patients choose their own meals and can provide
a structured meal plan that ensures nutritional adequacy and that
none of the major food groups are avoided [I].
Formula feeding may have to be added to the patient's diet
to achieve large caloric intake [II]. It is important
to encourage patients with anorexia nervosa to expand their food
choices to minimize the severely restricted range of foods initially
acceptable to them [II]. Caloric intake levels
should usually start at 30–40 kcal/kg per day
(approximately 1,000–1,600 kcal/day). During the
weight gain phase, intake may have to be advanced progressively to
as high as 70–100 kcal/kg per day for some patients;
many male patients require a very large number of calories to gain
weight [II].
Patients who require much lower caloric intakes or are suspected
of artificially increasing their weight by fluid loading should
be weighed in the morning after they have voided and are wearing
only a gown; their fluid intake should also be carefully monitored [I].
Urine specimens obtained at the time of a patient's weigh-in
may need to be assessed for specific gravity to help ascertain the
extent to which the measured weight reflects excessive water intake [I]. Regular
monitoring of serum potassium levels is recommended in
patients who are persistent vomiters [I]. Hypokalemia
should be treated with oral or intravenous potassium supplementation
and rehydration [I].
Physical activity should be adapted to the food intake and
energy expenditure of the patient, taking into account the patient's
bone mineral density and cardiac function [I].
Once a safe weight is achieved, the focus of an exercise program
should be on the patient's gaining physical fitness as
opposed to expending calories [I].
Weight gain results in improvements in most of the physiological
and psychological complications of semistarvation [I].
It is important to warn patients about the following aspects of
early recovery [I]: As they start to recover and
feel their bodies getting larger, especially as they approach frightening,
magical numbers on the scale that represent phobic weights, they
may experience a resurgence of anxious and depressive symptoms,
irritability, and sometimes suicidal thoughts. These mood
symptoms, non-food-related obsessional thoughts, and compulsive
behaviors, although often not eradicated, usually decrease with sustained
weight gain and weight maintenance. Initial refeeding may be associated
with mild transient fluid retention, but patients who abruptly stop
taking laxatives or diuretics may experience marked rebound fluid
retention for several weeks. As weight gain progresses, many patients
also develop acne and breast tenderness and become unhappy and demoralized
about resulting changes in body shape. Patients may experience abdominal
pain and bloating with meals from the delayed gastric emptying that
accompanies malnutrition. These symptoms may respond to pro-motility
agents [III]. Constipation may be ameliorated with
stool softeners; if unaddressed, it can progress to obstipation
and, rarely, to acute bowel obstruction.
When life-preserving nutrition must be provided to a patient
who refuses to eat, nasogastric feeding is preferable to intravenous
feeding [I]. When nasogastric feeding is necessary,
continuous feeding (i.e., over 24 hours) may be better tolerated
by patients and less likely to result in metabolic abnormalities
than three to four bolus feedings a day [II].
In very difficult situations, where patients physically resist and
constantly remove their nasogastric tubes, feeding through surgically
placed gastrostomy or jejunostomy tubes may be an alternative to
nasogastric feeding [II]. In determining whether
to begin involuntary forced feeding, the clinician should carefully
think through the clinical circumstances, family opinion, and relevant
legal and ethical dimensions of the patient's treatment [I].
The general principles to be followed in making the decision are
those directing good, humane care; respecting the wishes of competent
patients; and intervening respectfully with patients whose judgment
is severely impaired by their psychiatric disorders when such interventions
are likely to have beneficial results [I]. For
cooperative patients, supplemental overnight pediatric nasogastric
tube feeding has been used in some programs to facilitate weight
gain [III].
With severely malnourished patients (particularly those whose
weight is <70% of their healthy body weight) who undergo
aggressive oral, nasogastric, or parenteral refeeding, a serious
refeeding syndrome can occur. Initial assessments should include
vital signs and food and fluid intake and output, if indicated,
as well as monitoring for edema, rapid weight gain (associated primarily
with fluid overload), congestive heart failure, and gastrointestinal
symptoms [I]. Patients' serum levels
of phosphorus, magnesium, potassium, and calcium should be determined
daily for the first 5 days of refeeding and every other day for several
weeks thereafter, and electrocardiograms should be performed as
indicated [II]. For children and adolescents who
are severely malnourished (weight <70% of healthy body weight),
cardiac monitoring, especially at night, may be desirable [II].
Phosphorus, magnesium, and/or potassium supplementation
should be given when indicated [I].
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b) Psychosocial interventions
The goals of psychosocial interventions are to help patients
with anorexia nervosa 1) understand and cooperate with their nutritional
and physical rehabilitation, 2) understand and change the behaviors
and dysfunctional attitudes related to their eating disorder, 3)
improve their interpersonal and social functioning, and 4) address
comorbid psychopathology and psychological conflicts that reinforce
or maintain eating disorder behaviors.
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(i) Acute anorexia nervosa
During acute refeeding and while weight gain is occurring,
it is beneficial to provide anorexia nervosa patients with individual
psychotherapeutic management that is psychodynamically informed
and provides empathic understanding, explanations, praise for positive efforts,
coaching, support, encouragement, and other positive behavioral
reinforcement [I]. Attempts to conduct formal
psychotherapy with starving patients who are often negativistic, obsessional,
or mildly cognitively impaired may be ineffective [II].
For children and adolescents, the evidence indicates that
family treatment is the most effective intervention [I].
In methods modeled after the Maudsley approach, families become actively
involved, in a blame-free atmosphere, in helping patients eat more
and resist compulsive exercising and purging. For some outpatients,
a short-term course of family therapy using these methods may be
as effective as a long-term course; however, a shorter course of therapy
may not be adequate for patients with severe obsessive-compulsive
features or nonintact families [II].
Most inpatient-based nutritional rehabilitation programs create
a milieu that incorporates emotional nurturance and a combination
of reinforcers that link exercise, bed rest, and privileges to target
weights, desired behaviors, feedback concerning changes in weight,
and other observable parameters [II]. For adolescents
treated in inpatient settings, participation in family group psychoeducation
may be helpful to their efforts to regain weight and may be equally
as effective as more intensive forms of family therapy [III].
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(ii) Anorexia nervosa after weight restoration
Once malnutrition has been corrected and weight gain has begun,
psychotherapy can help patients with anorexia nervosa understand
1) their experience of their illness; 2) cognitive distortions
and how these have led to their symptomatic behavior; 3) developmental, familial,
and cultural antecedents of their illness; 4) how their illness
may have been a maladaptive attempt to regulate their emotions and
cope; 5) how to avoid or minimize the risk of relapse; and 6) how to
better cope with salient developmental and other important life
issues in the future. Clinical experience shows that patients may
often display improved mood, enhanced cognitive functioning, and
clearer thought processes after there is significant improvement
in nutritional intake, even before there is substantial weight gain [II].
To help prevent patients from relapsing, emerging data support
the use of cognitive-behavioral psychotherapy for adults [II].
Many clinicians also use interpersonal and/or psychodynamically
oriented individual or group psychotherapy for adults after their
weight has been restored [II]. For adolescents
who have been ill <3 years, after weight has been restored, family
therapy is a necessary component of treatment [I].
Although studies of different psychotherapies focus on these interventions
as distinctly separate treatments, in practice there is frequent
overlap of interventions [II].
It is important for clinicians to pay attention to cultural
attitudes, patient issues involving the gender of the therapist,
and specific concerns about possible abuse, neglect, or other developmental
traumas [II]. Clinicians need to attend to their
countertransference reactions to patients with a chronic eating
disorder, which often include beleaguerment, demoralization, and
excessive need to change the patient [I]. At the
same time, when treating patients with chronic illnesses, clinicians
need to understand the longitudinal course of the disorder and that
patients can recover even after many years of illness [I].
Because of anorexia nervosa's enduring nature, psychotherapeutic
treatment is frequently required for at least 1 year and may take
many years [I].
Anorexics and Bulimics Anonymous and Overeaters Anonymous
are not substitutes for professional treatment [I].
Programs that focus exclusively on abstaining from binge eating, purging, restrictive
eating, or excessive exercising (e.g., 12-step programs) without
attending to nutritional considerations or cognitive and behavioral
deficits have not been studied and therefore cannot be recommended
as the sole treatment for anorexia nervosa [I].
It is important for programs using 12-step models to be equipped
to care for patients with the substantial psychiatric and general
medical problems often associated with eating disorders [I].
Although families and patients are increasingly accessing
worthwhile, helpful information through online web sites, newsgroups,
and chat rooms, the lack of professional supervision within these
resources may sometimes lead to users' receiving misinformation
or create unhealthy dynamics among users. It is recommended that
clinicians inquire about a patient's or family's
use of Internet-based support and other alternative and complementary approaches
and be prepared to openly and sympathetically discuss the information
and ideas gathered from these sources [I].
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(iii) Chronic anorexia nervosa
Patients with chronic anorexia nervosa generally show a lack
of substantial clinical response to formal psychotherapy. Nevertheless,
many clinicians report seeing patients with chronic anorexia
nervosa who, after many years of struggling with their disorder,
experience substantial remission, so clinicians are justified in
maintaining and extending some degree of hope to patients and families [II].
More extensive psychotherapeutic measures may be undertaken to engage
and help motivate patients whose illness is resistant to treatment [II] or,
failing that, as compassionate care [I]. For patients
who have difficulty talking about their problems, clinicians have
reported that a variety of nonverbal therapeutic methods, such as
the creative arts, movement therapy programs, and occupational therapy,
can be useful [III]. Psychosocial programs designed
for patients with chronic eating disorders are being implemented
at several treatment sites and may prove useful [II].
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c) Medications and other somatic treatments
The decision about whether to use psychotropic medications
and, if so, which medications to choose will be based on the patient's
clinical presentation [I]. The limited empirical data
on malnourished patients indicate that selective serotonin reuptake
inhibitors (SSRIs) do not appear to confer advantage regarding weight
gain in patients who are concurrently receiving inpatient treatment
in an organized eating disorder program [I]. However,
SSRIs in combination with psychotherapy are widely used in treating
patients with anorexia nervosa. For example, these medications may
be considered for those with persistent depressive, anxiety, or
obsessive-compulsive symptoms and for bulimic symptoms in weight-restored patients [II].
A U.S. Food and Drug Administration (FDA) black box warning concerning the
use of bupropion in patients with eating disorders has been issued
because of the increased seizure risk in these patients. Adverse
reactions to tricyclic antidepressants and monoamine oxidase inhibitors
(MAOIs) are more pronounced in malnourished individuals, and these
medications should generally be avoided in this patient population [I].
Second-generation antipsychotics, particularly olanzapine,
risperidone, and quetiapine, have been used in small series and
individual cases for patients, but controlled studies of these medications
are lacking. Clinical impressions suggest that they may be useful
in patients with severe, unremitting resistance to gaining weight;
severe obsessional thinking; and denial that assumes delusional
proportions [III]. Small doses of older antipsychotics
such as chlorpromazine may be helpful prior to meals in very disturbed
patients [III]. Although the risks of extrapyramidal
side effects are less with second-generation antipsychotics than
with first-generation antipsychotics, debilitated anorexia nervosa
patients may be at a higher risk for these than expected. Therefore,
if these medications are used, it is recommended that patients be
carefully monitored for extrapyramidal symptoms and akathisia [I].
It is also important to routinely monitor patients for potential
side effects of these medications, which can result in insulin resistance,
abnormal lipid metabolism, and prolongation of the QTc interval [I].
Because ziprasidone has not been studied in individuals with anorexia
nervosa and can prolong QTc intervals, careful monitoring of serial
electrocardiograms and serum potassium measurements is needed if
anorexic patients are treated with ziprasidone [I].
Antianxiety agents used selectively before meals may be useful to
reduce patients' anticipatory anxiety before eating [III],
but because eating disorder patients may have a high propensity to
become dependent on benzodiazepines, these medications should be
used routinely only with considerable caution [I].
Pro-motility agents such as metoclopramide may be useful for bloating
and abdominal pains that occur during refeeding in some patients [II].
Electroconvulsive therapy (ECT) has generally not been useful except
in treating severe co-occurring disorders for which ECT is otherwise
indicated [I].
Although no specific hormone treatments or vitamin supplements
have been shown to be helpful [I], supplemental
calcium and vitamin D are often recommended [III].
Zinc supplements have been reported to foster weight gain in some
patients, and patients may benefit from daily zinc-containing multivitamin
tablets [II].
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(ii) Relapse prevention
Some data suggest that fluoxetine in dosages of up to 60 mg/day
may help prevent relapse [II]. For patients receiving
cognitive-behavioral therapy (CBT) after weight restoration, adding
fluoxetine does not appear to confer additional benefits with respect
to preventing relapse [II]. Antidepressants and
other psychiatric medications may be used to treat specific, ongoing
psychiatric symptoms of depressive, anxiety, obsessive-compulsive, and
other comorbid disorders [I]. Clinicians should
attend to the black box warnings in the package inserts relating
to antidepressants and discuss the potential benefits and risks
of antidepressant treatment with patients and families if such medications
are to be prescribed [I].
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(iii) Chronic anorexia nervosa
Although hormone replacement therapy (HRT) is frequently prescribed
to improve bone mineral density in female patients, no good supporting
evidence exists either in adults or in adolescents to demonstrate
its efficacy [II]. Hormone therapy usually induces
monthly menstrual bleeding, which may contribute to the patient's
denial of the need to gain further weight [II].
Before estrogen is offered, it is recommended that efforts be made
to increase weight and achieve resumption of normal menses [I].
There is no indication for the use of bisphosphonates such as alendronate
in patients with anorexia nervosa [II]. Although
there is no evidence that calcium or vitamin D supplementation reverses
decreased bone mineral density, when calcium dietary intake is inadequate
for growth and maintenance, calcium supplementation should be considered [I],
and when the individual is not exposed to daily sunlight, vitamin
D supplementation may be used [I]. However, large
supplemental doses of vitamin D may be hazardous [I].
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4. Choice of specific treatments for bulimia nervosa
The aims of treatment for patients with bulimia nervosa are
to 1) reduce and, where possible, eliminate binge eating and purging;
2) treat physical complications of bulimia nervosa; 3) enhance patients' motivation
to cooperate in the restoration of healthy eating patterns and participate
in treatment; 4) provide education regarding healthy nutrition and
eating patterns; 5) help patients reassess and change core dysfunctional
thoughts, attitudes, motives, conflicts, and feelings related to
the eating disorder; 6) treat associated psychiatric conditions,
including deficits in mood and impulse regulation, self-esteem,
and behavior; 7) enlist family support and provide family counseling
and therapy where appropriate; and 8) prevent relapse.
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a) Nutritional rehabilitation counseling
A primary focus for nutritional rehabilitation is to help
the patient develop a structured meal plan as a means of reducing
the episodes of dietary restriction and the urges to binge and purge [I].
Adequate nutritional intake can prevent craving and promote satiety [I].
It is important to assess nutritional intake for all patients, even
those with a normal body weight (or normal BMI), as normal weight
does not ensure appropriate nutritional intake or normal body composition [I].
Among patients of normal weight, nutritional counseling is a useful part
of treatment and helps reduce food restriction, increase the variety
of foods eaten, and promote healthy but not compulsive exercise
patterns [I].
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b) Psychosocial interventions
It is recommended that psychosocial interventions be chosen
on the basis of a comprehensive evaluation of the individual patient
that takes into consideration the patient's cognitive and
psychological development, psychodynamic issues, cognitive style,
comorbid psychopathology, and preferences as well as patient age
and family situation [I]. For treating acute episodes
of bulimia nervosa in adults, the evidence strongly supports the
value of CBT as the most effective single intervention [I].
Some patients who do not respond initially to CBT may respond when
switched to either interpersonal therapy (IPT) or fluoxetine [II] or
other modes of treatment such as family and group psychotherapies [III].
Controlled trials have also shown the utility of IPT in some cases [II].
In clinical practice, many practitioners combine elements
of CBT, IPT, and other psychotherapeutic techniques. Compared with
psychodynamic or interpersonal therapy, CBT is associated with more
rapid remission of eating symptoms [I], but using
psychodynamic interventions in conjunction with CBT and other psychotherapies
may yield better global outcomes [II]. Some patients,
particularly those with concurrent personality pathology or other
co-occurring disorders, require lengthy treatment [II].
Clinical reports suggest that psychodynamic and psychoanalytic approaches
in individual or group format are useful once bingeing and purging
improve [III].
Family therapy should be considered whenever possible, especially
for adolescent patients still living with their parents [II] or
older patients with ongoing conflicted interactions with parents [III].
Patients with marital discord may benefit from couples therapy [II].
A variety of self-help and professionally guided self-help
programs have been effective for some patients with bulimia nervosa [I].
Several innovative online programs are currently under investigation
and may be recommended in the absence of alternative treatments [III].
Support groups and 12-step programs such as Overeaters Anonymous
may be helpful as adjuncts in the initial treatment of bulimia nervosa
and for subsequent relapse prevention, but they are not recommended
as the sole initial treatment approach for bulimia nervosa [I].
Issues of countertransference, discussed above with respect
to the treatment of patients with anorexia nervosa, also apply to
the treatment of patients with bulimia nervosa [I].
Antidepressants are effective as one component of an initial
treatment program for most bulimia nervosa patients [I],
with SSRI treatment having the most evidence for efficacy and the
fewest difficulties with adverse effects [I].
To date, fluoxetine is the best studied of these and is the only
FDA-approved medication for bulimia nervosa. Sertraline is the only
other SSRI that has been shown to be effective, as demonstrated
in a small, randomized controlled trial. In the absence of therapists
qualified to treat bulimia nervosa with CBT, fluoxetine is recommended
as an initial treatment [I]. Dosages of SSRIs
higher than those used for depression (e.g., fluoxetine
60 mg/day) are more effective in treating bulimic symptoms [I].
Evidence from a small open trial suggests fluoxetine may be useful
for adolescents with bulimia [II].
Antidepressants may be helpful for patients with substantial
concurrent symptoms of depression, anxiety, obsessions, or certain
impulse disorder symptoms or for patients who have not benefited
from or had only a suboptimal response to appropriate psychosocial
therapy [I]. Tricyclic antidepressants and MAOIs
have been rarely used with bulimic patients and are not recommended
as initial treatments [I]. Several different antidepressants
may have to be tried sequentially to identify the specific medication
with the optimum effect [I].
Clinicians should attend to the black box warnings relating
to antidepressants and discuss the potential benefits and risks
of antidepressant treatment with patients and families if such medications
are to be prescribed [I].
Small controlled trials have demonstrated the efficacy of
the anticonvulsant medication topiramate, but because adverse reactions
to this medication are common, it should be used only when other
medications have proven ineffective [III]. Also,
because patients tend to lose weight on topiramate, its use is problematic
for normal or underweight individuals [III].
Two drugs that are used for mood stabilization, lithium and
valproic acid, are both prone to induce weight gain in patients [I] and
may be less acceptable to patients who are weight preoccupied. However,
lithium is not recommended for patients with bulimia nervosa because
it is ineffective [I]. In patients with co-occurring
bulimia nervosa and bipolar disorder, treatment with lithium is
more likely to be associated with toxicity [I].
Limited evidence supports the use of fluoxetine for relapse
prevention [II], but substantial rates of relapse
occur even with treatment. In the absence of adequate data, most
clinicians recommend continuing antidepressant therapy for a minimum
of 9 months and probably for a year in most patients with bulimia
nervosa [II]. Case reports indicate that methylphenidate may
be helpful for bulimia nervosa patients with concurrent attention-deficit/hyperactivity disorder
(ADHD) [III], but it should be used only for patients
who have a very clear diagnosis of ADHD [I].
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(iii) Combining psychosocial interventions and medications
In some research, the combination of antidepressant therapy
and CBT results in the highest remission rates; therefore, this
combination is recommended initially when qualified CBT therapists are
available [II]. In addition, when CBT alone does
not result in a substantial reduction in symptoms after 10 sessions,
it is recommended that fluoxetine be added [II].
Bright light therapy has been shown to reduce binge frequency
in several controlled trials and may be used as an adjunct when
CBT and antidepressant therapy have not been effective in reducing bingeing
symptoms [III].
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5. Eating disorder not otherwise specified
Patients with subsyndromal anorexia nervosa or bulimia nervosa
who meet most but not all of the DSM-IV-TR criteria (e.g., weight
>85% of expected weight, binge and purge frequency less
than twice per week) merit treatment similar to that of patients
who fulfill all criteria for these diagnoses [II].
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a) Binge eating disorder
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(i) Nutritional rehabilitation and counseling
Behavioral weight control programs incorporating low- or very-low-calorie
diets may help with weight loss and usually with reduction of symptoms
of binge eating [I]. It is important to advise
patients that weight loss is often not maintained and that binge
eating may recur when weight is gained [I]. It
is also important to advise them that weight gain after weight loss
may be accompanied by a return of binge eating patterns [I].
Various combinations of diets, behavior therapies, interpersonal
therapies, psychodynamic psychotherapies, non-weight-directed psychosocial
treatments, and even some "nondiet/health at every
size" psychotherapy approaches may be of benefit for binge
eating and weight loss or stabilization [III]. Patients
with a history of repeated weight loss followed by weight gain ("yo-yo" dieting)
or patients with an early onset of binge eating may benefit from
following programs that focus on decreasing binge eating rather
than on weight loss [II].
There is little empirical evidence to suggest that obese binge
eaters who are primarily seeking weight loss should receive different
treatment than obese individuals who do not binge eat [I].
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(ii) Other psychosocial treatments
Substantial evidence supports the efficacy of individual or
group CBT for the behavioral and psychological symptoms of binge
eating disorder [I]. IPT and dialectical behavior
therapy have also been shown to be effective for behavioral and
psychological symptoms and can be considered as alternatives [II].
Patients may be advised that some studies suggest that most patients
continue to show behavioral and psychological improvement at their
1-year follow-up [II]. Substantial evidence supports
the efficacy of self-help and guided self-help CBT programs and
their use as an initial step in a sequenced treatment program [I].
Other therapies that use a "nondiet" approach and
focus on self-acceptance, improved body image, better nutrition
and health, and increased physical movement have been tried, as
have addiction-based 12-step approaches, self-help organizations,
and treatment programs based on the Alcoholics Anonymous model,
but no systematic outcome studies of these programs are available [III].
Substantial evidence suggests that treatment with antidepressant
medications, particularly SSRI antidepressants, is associated with
at least a short-term reduction in binge eating behavior but, in
most cases, not with substantial weight loss [I].
The medication dosage is typically at the high end of the recommended
range [I]. The appetite-suppressant medication
sibutramine is effective for binge suppression, at least in the
short term, and is also associated with significant weight loss [II].
The anticonvulsant medication topiramate is effective for binge reduction
and weight loss, although adverse effects may limit its clinical
utility for some individuals [II]. Zonisamide
may produce similar effects regarding weight loss and can also cause
side effects [III].
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(iv) Combining psychosocial and medication treatments
For most eating disorder patients, adding antidepressant medication
to their behavioral weight control and/or CBT regimen does
not have a significant effect on binge suppression when compared
with medication alone. However, medications may induce additional weight
reduction and have associated psychological benefits [II].
Adding the weight loss medication orlistat to a guided self-help
CBT program may yield additional weight reduction [II].
Fluoxetine in conjunction with group behavioral treatment may not
aid in binge cessation or weight loss but may reduce depressive
symptoms [II].
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b) Night eating syndrome
Progressive muscle relaxation has been shown to reduce symptoms
associated with night eating syndrome [III]. Sertraline
has also been shown to reduce these symptoms [II].
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II. Formulation and Implementation of a Treatment Plan
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A. Psychiatric Management
Psychiatric management includes a broad range of therapeutic
actions that are performed by the psychiatrist or that the psychiatrist
ensures are provided to all patients with eating disorders in combination
with other specific treatment modalities. Psychiatric management
begins with the establishment of a therapeutic alliance, which is
then enhanced by empathic comments and behaviors, positive regard,
reassurance, and support. Basic psychiatric management includes
support through the provision of educational materials, including
self-help workbooks (4), information on community and Internet resources
(5, 6), and direct advice to patients and their families (when they
are involved) (7). It is important to caution patients and families
about Internet sites that encourage eating disorder lifestyles ("pro-ana" sites).
Although many service providers have made attempts to police and
encourage elimination of these sites, they still continue to appear,
to the concern of families and professionals (8, 9). In some settings,
judicious use of e-mail contact with patients has been increasingly
used (5, 10). Some resources for patients and families are presented
in Table 1.
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1. Establish and maintain a therapeutic alliance
At the very outset and through ongoing interactions with the
patient, it is important for clinicians to attempt to build trust,
establish mutual respect, and develop a therapeutic relationship
that will serve as the basis for ongoing exploration and treatment
of the problems associated with the eating disorder. Eating disorders
are frequently long-term illnesses that can manifest themselves
in different ways at different points during their course; treating them
often requires the psychiatrist to adapt and modify therapeutic
strategies. Many patients with anorexia nervosa are initially reluctant
to enter treatment and may feel invested in their symptoms. Many
are secretive and may withhold information about their behavior because
of shame. During the course of treatment, they may resist looking
beyond immediate symptoms to possible coexisting psychiatric disorders,
comorbid psychopathology, and underlying psychodynamic issues. Conversely,
some patients may resist discussing eating disorder symptoms and
want to focus on only "core issues," apparently
to avoid relinquishing their symptoms. Psychiatrists should be mindful
of the fact that the recommended interventions create extreme anxieties
for individuals with anorexia nervosa. Encouraging patients to gain
weight asks them to do the very thing of which they are most frightened.
Patients may believe that the psychiatrist just wants to make them
fat and does not understand or empathize with their underlying emotions.
Consequently, by recognizing and acknowledging an awareness of patient
anxieties, psychiatrists can assist in building the therapeutic alliance.
The clinician may foster rapport by letting patients know that eating
disorder symptoms often serve a number of important functions, such
as providing a sense of accomplishment or a way to feel looked after
or protected (11, 12). Addressing patients' resistance
to treatment and enhancing their motivation for change may be important
in allowing therapy to proceed through impasses as well as helping
to ameliorate factors that serve to aggravate and maintain eating
disorders (13–18). Finally, letting patients know that
full recovery from anorexia nervosa takes time (19) may help build
rapport, as the patient senses that the clinician is not expecting
a magical, rapid turnaround, which the patient may sense is unrealistic.
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2. Coordinate care and collaborate with other clinicians
Professionals from several disciplines may collaborate in
the patient's care. The specific role of each professional
may vary with the organizational structure of the eating disorders program
and the professional qualifications of those working within the
program. The psychiatrist may assume the leadership role in the
patient's treatment program or the patient's treatment
team or work collaboratively on a team led by other health professionals,
including other physicians or psychologists. Registered dietitians
with specialized training in eating disorders often provide nutritional
counseling. Therapists from a variety of professional fields may
provide family, individual, or group psychotherapy, including CBT.
Other physician specialists and dentists may be consulted for management
of acute and ongoing medical and dental complications. Often in
the treatment of children and adolescents, school coaches, teachers,
and school counselors may be asked to collaborate in a patient's
treatment. In treatment settings where staff do not have the training
or experience to deal with patients with eating disorders, the provision
of education, supervision, and leadership by a qualified psychiatrist
can be crucial to the success of treatment.
Although a variety of management models are used for adult
patients with eating disorders, no data exist on their comparative
efficacies. Psychiatrists who choose to manage both general medical
and psychiatric issues should have appropriate medical backup to
treat the medical complications associated with eating disorders.
Some programs routinely arrange for interdisciplinary teams to manage
treatment (sometimes called split management).
In this model, the psychiatrist handles administrative and general
medical requirements, prescribes medications when clinically necessary
and appropriate, and recommends interventions aimed at normalizing
disturbed cognitions and eating and weight-reducing behaviors. Other
clinicians then provide individual and/or group psychotherapeutic
interventions (e.g., CBT, psychodynamic psychotherapy, family therapy).
For this management model to be effective and to avoid reinforcing
some patients' tendencies to play staff off each other
(i.e., split the staff), all personnel must work closely together
and maintain open communication and mutual respect.
For children and adolescents, the recommended treatment model
is the team approach (3). In this interdisciplinary management approach,
general medical care clinicians (e.g., specialists in internal medicine,
pediatrics, adolescent medicine, or nutrition) manage general medical
issues, such as nutrition, weight gain, exercise, and eating patterns,
whereas the psychiatrist addresses the psychiatric issues (3, 20, 21). The biopsychosocial nature of anorexia nervosa and bulimia
nervosa dictates the need for interdisciplinary treatment, and each
aspect of care must be developmentally tailored to the treatment
of adolescents (22). In unusual circumstances, psychiatrists may
be qualified to act as the primary provider of comprehensive medical
care.
When a patient is managed by an interdisciplinary team in
an outpatient setting, communication among the professionals is
essential so that all team members have a clear understanding of
each other's responsibilities and approaches. For example,
in team management of outpatients with anorexia nervosa, one professional
must be designated to consistently monitor weights so that this
essential function is not inadvertently omitted from care.
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3. Assess and monitor eating disorder symptoms and
behaviors
It is important for the psychiatrist to carefully assess the
patient's eating disorder symptoms and behaviors (23).
Such an assessment will assist the clinician in identifying target symptoms
and behaviors that will be addressed in the treatment plan as well
as determining whether a DSM-IV-TR diagnosis of anorexia nervosa
or bulimia nervosa is present (Tables 2 and 3).
+
+
It is important to note that a significant number of patients
are relegated to the heterogeneous diagnostic group referred to
as eating disorders not otherwise specified because they have not
been amenorrheic for 3 months and consequently do not meet current
criteria for anorexia nervosa. In terms of their clinical course,
treatment response, or level of impairment, such patients do not
differ from those who fulfill the DSM-IV-TR criteria for anorexia nervosa
(24, 25). These observations have important implications with respect
to making clinical treatment decisions. They also imply that patients
with continued menses who fulfill other criteria for anorexia nervosa
should be eligible for the same levels of care as patients with
anorexia nervosa.
Obtaining a detailed report of food intake during a single
day in the patient's life or using a calendar as a prompt
may help elicit specific information about a patient's
eating behaviors, particularly regarding perceived intake. A clinician
may also obtain useful information by sharing a meal with the patient
or observing the patient eating a meal; in this way, the clinician
can observe any difficulties the patient may have in eating particular
foods, anxieties that erupt in the course of a meal, and rituals
concerning food (such as cutting, separating, or mashing) that the
patient feels compelled to perform.
+
It is important to explore the patient's understanding
of how the illness developed and the effects of any interpersonal
problems at the onset of the eating disorder. A family history should
be obtained regarding eating disorders and other psychiatric disorders,
alcohol and other substance use disorders, obesity, family interactions
in relation to the patient's disorder, and family attitudes
toward eating, exercise, and appearance. It is essential that the
clinician avoid articulating theories that imply blame or permit
family members to blame one another or themselves for the patient's
disorder. No evidence exists to prove that families cause eating
disorders. Furthermore, blaming family members harms their psychological
well-being and often impairs their desire, willingness, and capacity
to be helpful to patients and to participate actively and constructively
in treatment and recovery. Rather, the point is to identify family
stressors whose amelioration may facilitate recovery.
In the assessment of young patients, it is always helpful
to involve parents and, whenever appropriate, school and health
professionals who routinely work with children. The complete assessment
usually requires several hours. Even when directly questioned, patients
and their families may not initially reveal pertinent information
about sensitive issues; important information may be uncovered only
after a trusting relationship has been established and the patient
is better able to accurately identify inner emotional states.
Formal measures are available for the assessment of eating
disorders, including self-report questionnaires and semistructured
interviews. Examples are listed in Table 4. Clinical decisions about
a diagnosis cannot be made on the basis of self-report screening
instruments. Patients who are identified on initial screening as
likely to have an eating disorder must be followed up in a second-stage
determination by trained clinical interviewers. The instruments
shown in Table 4, used by clinicians to interview patients
in a structured format, are generally taken as "gold standards" to
determine clinical diagnoses.
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4. Assess and monitor the patient's general
medical condition
A full physical examination should be performed by a physician
familiar with common findings in patients with eating disorders,
with particular attention to vital signs; physical status (including
height and weight); heart rate and rhythm; jugular venous pressure;
heart sounds (especially midsystolic clicks or murmurs from mitral
valve prolapse); acrocyanosis; delayed capillary refill; lanugo;
salivary gland enlargement; scarring on the dorsum of the hands
(Russell's sign); evidence of self-injurious behaviors,
such as ecchymoses, linear scars, and cigarette burns; muscular
weakness; indications of muscular irritability due to hypocalcemia,
such as in Chvostek's and Trousseau's signs; and
gait and eye abnormalities (40–43). The patient should
also be referred for a dental examination if necessary or indicated
by the patient's history (44). In younger patients, examination
should include growth pattern and sexual development, including
sexual maturity rating, as well as general physical development.
The use of a growth chart of standardized values for pediatric populations
may allow the clinician to identify patients who have failed to
gain weight and have growth retardation (3, 45); such charts are
available on the web site of the CDC (http://www.cdc.gov/growthcharts/).
BMI, in conjunction with weight and height, has gained increasing
attention in research and clinical settings as a tool for assessing
eating disorder patients. BMI is calculated as weight (in kilograms)
divided by height (in meters squared) and is particularly useful
for comparing groups according to index percentiles that take into
account height, sex, and age (46). It is important to remember that
BMI is a calculation based only on height and weight and does not
provide any further measure of body composition. Except in individuals
who are extremely under- or overweight, it is often not useful in
estimating nutritional status. Furthermore, considerable debate
in the scientific community exists about appropriate BMI ranges
for various ethnic groups. Among Caucasian women, for example, the
range of a healthy BMI may be higher than for some groups of Asian
women (47). Adults with a BMI <18.5 kg/m2 are
considered to be underweight. In addition, abnormal muscularity,
body frame size, fluid status, marked constipation, and fluid loading
can decrease the validity of BMI as an indicator of the patient's
nutritional status (48–52). In children and adolescents,
an age-adjusted BMI is used (see http://www.cdc.gov/nccdphp/dnpa/bmi/00binaries/bmi-tables.pdf). Children
with a BMI <5th percentile for age are considered to be underweight.
Commonly found signs, symptoms, and associated laboratory
abnormalities for anorexia nervosa and bulimia nervosa are shown
in Table 5 and Table 6, respectively. Although patients treated
in outpatient practice may report few symptoms and show few obvious physical
signs or abnormal laboratory test results, significant occult abnormalities
may be present (e.g., in bone, heart, and brain).
+
+
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 (43). Some of the
laboratory assessments that may be indicated for patients with eating
disorders appear in Table 7.
+
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5. Assess and monitor the patient's psychiatric
status and safety
In addition to assessing patients' physiological
and nutritional status as well as their behaviors, cognitions, and
emotions associated with eating and exercise, it is essential that
clinicians attend to the overall psychiatric status and safety of
patients. Associated psychiatric issues that bear close monitoring
include historical evidence, signs, and symptoms related to psychiatric
conditions that are often comorbid with eating disorders (e.g.,
mood, anxiety, and substance use disorders) as well as personality
traits and personality disorders that greatly influence patients' clinical
course and outcome (78–82). Patients' motivational
status also bears monitoring, as it is likely to determine their
capacity to engage in treatment (15). Safety issues for patients
with eating disorders include both physiological and psychiatric parameters.
Many of the physiological safety parameters are described in
Section
II.B.1, "Choice of a Treatment Site."
Clinicians
must be vigilant regarding shifts in patients' weight,
blood pressure, pulse, other cardiovascular parameters, and behaviors
that are likely to provoke physiological decline and collapse. General
psychiatric safety issues that bear constant attention include suicidal
ideation and suicide attempts as well as impulsive and compulsive
self-harm behaviors (83, 84).
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6. Provide family assessment and treatment
The available evidence affirms the importance of family involvement
and treatment in the management of children and adolescents with
anorexia nervosa (85–87). In addition, clinical consensus
supports the value of family assessment and involvement in the treatment
of both younger and older patients with other eating disorders (88, 89). Since eating is a quintessential family activity, the opportunity
to observe patterns of family interaction around the eating and particularly
around the eating problems can be useful in assessment (89a). Family
members can provide useful perspectives on factors contributing
to the onset of the disorders and issues that may aid or hamper
efforts at recovery. Family members are often distressed by difficulties in
understanding and interacting with the patient. Clinicians need
to empathically listen to family members, advise them on their interactions
with the patient, and, when indicated, involve them in conjoint
or individual treatment so that the patient and family all stand
the best chance of achieving a good outcome (90). Patients with
anorexia nervosa who are in a relationship may present with a higher
motivation to change (91), and the involvement of spouses and partners
in treatment may be highly desirable. Families of adolescents with
anorexia nervosa may be directed to the Maudsley approach, which
focuses on the family as a resource for recovery and puts parents
in charge of refeeding their affected child (87, 92, 93). Although this
approach is promising, additional data are required to determine
if it is the best approach for adolescents with anorexia nervosa.
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B. Developing a Treatment Plan for the Individual Patient
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1. Choice of a treatment site
Services available for the treatment of eating disorders can
range from intensive inpatient settings (in which subspecialty general
medical consultation is readily available) to residential and partial
hospitalization programs to varying levels of outpatient care (in which
the patient can receive general medical treatment, nutritional counseling,
and/or individual, group, and family psychotherapy). Because
specialized programs are not available in all geographic areas and
financial considerations are often significant, access to these
programs may be difficult. The resources listed in Table 1 may provide
guidance to patients and families for accessing suitable programs.
Pretreatment evaluation of the patient is essential for determining
the appropriate treatment setting. Patient weight, rate of weight
loss, cardiac function, and metabolic status are the most important
physical parameters for making this choice. Eating disorders should
be recognized and early treatment implemented as soon as possible
after the onset of symptoms. This is especially true in children,
adolescents, and young adults, to avoid the disorder becoming chronic.
As a general rule, patients who weigh less than approximately
85% of their individually estimated healthy weights have
considerable difficulty gaining weight outside of a highly structured program
that includes inpatient care; such a program may be medically and
psychiatrically necessary even for patients above that weight level.
It is important to underscore that these are individually estimated
healthy weights, not weights simply listed in a standard insurance
table. Healthy weight estimates for a given individual must be determined
by that person's physicians on the basis of historical
data (e.g., growth charts) (3) and, for women, the weight at which
healthy menstruation and ovulation resume, which may be higher than
the weight at which menstruation and ovulation became impaired (94–96).
It is equally important that the decision to hospitalize a
patient be based on psychiatric and behavioral factors, including
a rapid or persistent decline in oral intake; a decline in weight
despite maximally intensive outpatient or partial hospitalization
intervention; the presence of additional stressors, such as dental
procedures, that may interfere with the patient's ability
to eat; the weight at which the patient was medically unstable in
the past; and co-occurring psychiatric problems that merit hospitalization.
The degree of a patient's denial and resistance to participate
in his or her own care in less supervised settings is critical in deciding
whether to hospitalize the patient. Once weight loss is
severe enough to indicate the need for immediate hospitalization,
treatment may be less effective, refeeding may entail greater risks,
and prognosis may be more problematic than if intervention had been
provided earlier. Because cortical gray matter deficits result from
malnutrition and persist after refeeding (97–99), earlier
(rather than later) interventions may be important to minimize the
persistent effects of these physiological impairments. Therefore,
hospitalization should occur before the onset of medical instability
as manifested by vital signs, physical findings, or laboratory test
results outside of the normal range.
Vital sign changes that indicate a need for immediate medical
hospitalization include marked orthostatic hypotension, with an
increase in pulse of 20 bpm or a drop in blood pressure of 20 mmHg
standing; bradycardia, with a heart rate <40 bpm; tachycardia,
with a heart rate >110 bpm; or the patient's inability
to sustain his or her body core temperature (e.g., body temperatures
<97.0°F) (3). Most severely underweight
patients, particularly those with physiological instability, require
inpatient medical management and comprehensive treatment to support
their weight-gaining efforts. To avert potentially irreversible
effects on physical growth and development, many children and adolescents
require inpatient medical treatment, even when weight loss, although
rapid, has not been as severe as that suggesting a need for hospitalization
in adult patients (3). If children refuse fluids or food out of
concern about gaining weight, they may become dehydrated quickly.
Also, a child's small size may mean that relatively smaller
reductions in weight will result in greater physiological danger.
In determining a patient's initial level of care
or suitability for change to a different level of care, expert consensus
indicates that it is important to consider a patient's
overall clinical and social picture rather than simply rely on weight
criteria. Furthermore, weight level per se should never be used
as the sole criterion for discharge from inpatient care. Patients
need to both gain healthy body weight and learn to maintain that
weight prior to discharge; patients who reach a healthy body weight
but are discharged before this learning occurs are likely to immediately
decrease their caloric intake to excessively low levels that are
often insufficient to sustain their healthy body weight. Assisting
patients in determining and practicing appropriate food intake at
a healthy body weight is likely to decrease the chances of their
relapsing. Patients who are medically stabilized on acute medical
units will still require inpatient treatment for eating disorders
if they do not meet biopsychosocial criteria for partial hospitalization
programs or if no suitable partial hospitalization program for eating
disorders treatment is accessible because of geographic or other
reasons. Patients with inadequate motivation or support who are
discharged from inpatient to partial hospitalization programs before
they are clinically ready often have high rates of early relapse,
greater struggles with recovery, and slower rates of progress, necessitating
longer future inpatient stays.
In shifting between levels of care, it is important to establish
continuity of care. Stepping down from one level of care to a less
intensive level may be destabilizing for a patient and can be even
more so when this involves a change in physician, therapist, or
treatment team. At times, patients may erroneously conclude that
moving to a less restrictive treatment setting means that they are
suddenly fully improved. The patient's ability to continue
treatment with familiar and trusted staff in a partial hospitalization
or outpatient setting may contribute to the success of aftercare
planning. Consequently, if the patient is moving from one treatment
setting or locale to another, transition planning requires that
the care team in the new setting or locale be identified and that
specific patient appointments be made. It is preferable that a specific
clinician on the team be designated as the primary coordinator of
care to ensure continuity and attention to important aspects of
treatment. Guidelines for treatment settings are provided in Table 8.
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Although most patients with uncomplicated bulimia nervosa
do not require hospitalization, indications for hospitalization
can include severe disabling symptoms that have not responded to
adequate trials of outpatient treatment, serious concurrent general
medical problems (e.g., metabolic abnormalities, hematemesis, vital
sign changes, uncontrolled vomiting), suicidality, psychiatric disturbances
that would warrant patients' hospitalization independent
of the eating disorder diagnosis, or severe concurrent substance
use.
Legal interventions, including involuntary hospitalization
and legal guardianship, may be necessary to address the safety of
patients who are reluctant to receive treatment but whose general
medical conditions are life threatening (102). On a short-term basis
at least, outcomes for those patients who are hospitalized involuntarily
are comparable with outcomes of those hospitalized voluntarily with
respect to rates of weight restoration (103). The decision to hospitalize
on a psychiatric versus a general medical or adolescent/pediatric
unit depends on the patient's general medical status, the
skills and abilities of local psychiatric and general medical staff,
and the availability of suitable programs to care for the patient's
general medical and psychiatric problems (104). There is evidence
to suggest that patients treated in specialized inpatient eating
disorder units have better outcomes than patients treated in general
inpatient settings where staff lack expertise and experience in
treating patients with eating disorders (105).
Partial hospitalization and day hospital programs are being
increasingly used in attempts to decrease the length of inpatient
stays or even in lieu of hospitalization for individuals with milder
symptoms. However, such programs may not be appropriate for patients
with lower initial weights. The failure of outpatient treatment
is one of the most frequent indications for the more intensive treatment
provided in a day, partial hospitalization, or inpatient program.
In deciding whether a patient requires a partial hospitalization
program, the patient's motivation to participate in treatment
and ability to work in a group setting should be considered (106, 107). A growing body of evidence suggests that partial hospitalization outcomes
are highly correlated with treatment intensity and that more successful
programs involve patients at least 5 days/week for 8 hours/day
(101).
Patients who are considerably below their healthy body weight
but who are highly motivated to adhere to treatment, have cooperative
families, and have brief symptom duration may benefit
from treatment in outpatient settings, but only if they are carefully
monitored and if they and their families understand that a more
restrictive setting may be necessary if persistent progress
is not evident within a few weeks (108, 109). Careful monitoring
includes at least weekly (and often twice or thrice weekly) weight
determinations done immediately after the patient voids and while
the patient is wearing the same class of garment (e.g., hospital
gown, standard exercise clothing). Measurement of urine specific
gravity, orthostatic vital signs, oral body temperature, and, in
purging patients, electrolytes may also need to be monitored on
a regular basis. Although child and adolescent patients treated
in the outpatient setting can remain with their families and continue
to attend school or work, these advantages must be balanced against
the risks of failure to progress in recovery.
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2. Choice of specific treatments for anorexia nervosa
Anorexia nervosa is a complex, serious, and often chronic
condition that may require a variety of treatment modalities at
different stages of illness and recovery. Specific treatments include
nutritional rehabilitation, psychosocial interventions, and medications.
The aims of treatment are to 1) restore the patient to a healthy
weight (associated with the return of menses and normal ovulation
in female patients, normal sexual drive and hormone levels in male
patients, and normal physical and sexual development in children
and adolescents); 2) treat the patient's physical complications;
3) enhance the patient's motivation to cooperate in the
restoration of healthy eating patterns and participate in treatment;
4) educate the patient regarding healthy nutrition and eating patterns;
5) help the patient reassess and change core dysfunctional cognitions,
attitudes, motives, conflicts, and feelings related to the eating
disorder; 6) treat the patient's associated psychiatric
conditions, including deficits in mood and impulse regulation, self-esteem,
and behavior; 7) enlist family support and provide family counseling
and therapy where appropriate; and 8) prevent the patient from relapsing.
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a) Nutritional rehabilitation
The goals of nutritional rehabilitation for seriously underweight
patients are to restore weight, normalize eating patterns, achieve
normal perceptions of hunger and satiety, and correct biological
and psychological sequelae of malnutrition (110, 111).
Healthy target weights should be established as part of the
initial treatment plan and discussed explicitly with the patient,
but with considerable sensitivity to how generally fearful patients
are of gaining weight. On occasion it may be judicious to delay
this discussion until the patient is less likely to be terrified
of his or her ultimate weight goal. In general, a healthy goal weight
for female patients is the weight at which normal menstruation and ovulation
are restored and, for male patients, the weight at which normal
testicular function is resumed. For female patients who previously
had a healthy menses and ovulation, the clinician can estimate their
healthy weight as approximately the same weight at which full physical
and psychological vigor were present. In one study of 100 adolescent
patients with anorexia nervosa (94), the resumption of menses occurred
at a weight approximately 4.5 pounds greater than the weight at
which menses was lost; at 90% of healthy weight, 86% of
patients resumed menses. In children and adolescents, growth curves
should be followed and are most useful when longitudinal data are
available, given that extrapolations from cross-sectional data at
one point in time can be misleading. Therefore, for most clinical work,
it is reasonable to simply weigh patients and gauge how far they
are from their individually estimated healthy body weight (112).
Bone age may be accurately estimated from wrist X-rays and nomograms.
In conjunction with bone measurements, menstrual history in adolescents
with secondary amenorrhea, mid-parental heights, and assessments
of skeletal frame, CDC growth charts (available at http://www.cdc.gov/growthcharts/) may be used to accurately estimate
individually appropriate ranges for "expected" weights
for current age and to set individually realistic expectations and
goals for weight and height for patients up to age 20 years.
For individuals who are markedly underweight and for children
and adolescents whose growth is substantially less than that predicted
by growth curves, hospital-based programs for nutritional rehabilitation
should be considered. For those in inpatient or residential settings,
the weight at which it is appropriate to discharge a patient may
vary in relation to the patient's healthy target weight
and will depend on the patient's ability to feed him- or
herself, the patient's motivation and ability to participate
in aftercare programs, and the adequacy of aftercare, including
partial hospitalization. In general, the closer a patient is to
his or her healthy body weight before discharge, the less the risk
he or she has of relapsing and being readmitted. Having patients
maintain their weight for a period of time before they are discharged
from inpatient treatment probably decreases the risk of their relapsing
as well.
Refeeding programs should be implemented in nurturing emotional
contexts. Staff should convey to patients their intention to take
care of them and not let them die even when the illness prevents
the patients from taking care of themselves. Staff should clearly
communicate that they are not seeking to engage in control battles
and have no punitive intentions when using interventions that the
patient may experience as aversive. Some positive reinforcements
(e.g., privileges) and negative reinforcements (e.g., required bed
rest, exercise restrictions, restrictions of off-unit privileges)
should be built into the program; negative reinforcements can then
be reduced or terminated and positive reinforcements accelerated
as target weights and other goals are achieved.
As patients work to achieve their target weights, their treatment
plan should also establish expected rates of controlled weight gain.
Clinical consensus suggests that realistic targets are 2–3
lb/week for hospitalized patients and 0.5–1 lb/week
for individuals in outpatient programs, although an intensive partial
hospitalization, stepped-down program has reported gains of up to
2 lb/week (113). Occasionally some patients may gain as
much as 4–5 lb/week, but these individuals must
be carefully monitored for refeeding syndrome and fluid retention.
Dietitians can help patients choose their own meals and provide
a structured meal plan that ensures nutritional adequacy and inclusion
of all the major food groups. Formula feeding may have to be added
to achieve large caloric intake. Some authorities advocate that
the amount of solid food eaten should not exceed the amount that patients
would ordinarily be eating at their target weight. Expanding cuisine
options is important to avoid the severely restricted food choices frequently
seen in eating disorder patients. Legitimate food allergies and
patients' religious and cultural practices must be considered
and discussed to limit patient rationalizations for restricted eating.
Intake levels should usually start at 30–40 kcal/kg
per day (approximately 1,000–1,600 kcal/day).
During the weight gain phase, intake may have to be advanced progressively
to as high as 70–100 kcal/kg per day for some
patients; many male patients require a very large number of calories
to gain weight. Patients who require significantly higher caloric
intakes may be discarding food, vomiting, or exercising frequently
or they may engage in more nonexercise motor activity such as fidgeting;
others may have a truly elevated metabolic rate. Patients requiring
much lower caloric intakes or those suspected of artificially increasing
their weight by fluid loading should be weighed in the morning after
voiding while they are wearing only a gown; their fluid intake also
should be carefully monitored. Assessing urine specimens obtained
at the time of weigh-in for specific gravity may help ascertain
the extent to which the measured weight reflects excessive water
intake.
Particularly in residential or hospital treatment programs,
it may initially be difficult to obtain the cooperation of patients
who do not wish to be there. In addition, many patients have delayed
gastric emptying that initially impairs their ability to tolerate
1,000 calories/day. Under such circumstances, it is often
more effective to begin with 200–300 calories above the
patient's usual caloric intake (e.g., a patient consuming
400 calories/day may need to start at 600–700 calories/day).
During hospitalization, giving patients a liquid feeding formula
in the early stages of weight gain and then gradually exposing them
to food and slowly increasing their activity level can be a very
effective strategy for inducing weight gain (114). As patients are
able and as their cooperation improves, a 2–3 lb/week
gain in residential or hospital programs can be expected without
compromising the patients' safety.
In addition to an increased caloric intake, patients also
benefit from vitamin and mineral supplements. Serum potassium levels
should be regularly monitored in patients who are persistent vomiters.
Hypokalemia should be treated with oral or intravenous potassium
supplementation and rehydration.
Physical activity should be adapted to the food intake and
energy expenditure of the patient, taking into account bone mineral
density and cardiac function. For the severely underweight patient,
exercise should be restricted and always carefully supervised and monitored.
Once a safe weight is achieved, the focus of an exercise program
should be on physical fitness as opposed to expending calories.
The focus on fitness should be balanced with restoring patients' positive
relationship with their bodieshelping them to take back control
and get pleasure from physical activities rather than being compulsively
enslaved to them. An exercise program should involve exercises that
are not solitary, are enjoyable, and have endpoints that are not
determined by time spent expending calories or changing weight and
shape. Sports such as soccer, basketball, volleyball, or tennis
are examples (115).
Staff should help patients deal with their concerns about
weight gain and body image changes, given that these are particularly
difficult adjustments for patients to make. In fact, there is general
agreement among clinicians that distorted attitudes about weight
and shape are the least likely to change and that excessive and
compulsive exercise may be one of the last of the behaviors associated
with an eating disorder to abate. Although it is by no means certain
that patients' abnormal eating habits will improve simply
as a function of weight gain (116), there is considerable evidence
to suggest that other eating disorder symptoms diminish as weight
is restored with nutritional rehabilitation. For example, clinical
experience indicates that with weight restoration, food choices
increase, food hoarding decreases, and obsessions about food decrease
in frequency and intensity, although they do not necessarily disappear.
Providing anorexia nervosa patients who have associated binge
eating and purging behaviors with regular structured meal plans
may also enable them to improve. For some patients, however, giving
up severe dietary restrictions and restraints appears to increase binge-eating
behavior, which is often accompanied by compensatory purging.
As weight is regained, changes in associated mood and anxiety
symptoms as well as in physical status can be expected (117). Clinicians
should advise patients of what changes they can anticipate as they
start to regain weight. In the initial stages, the apathy and lethargy
associated with malnourishment may abate. However, as patients start
to recover and feel their bodies becoming larger, and especially
as they approach frightening magical numbers on the scale that represent
phobic weights, they may experience a resurgence of anxious and
depressive symptoms, irritability, and sometimes suicidal thoughts.
These mood symptoms, non-food-related obsessional thoughts, and
compulsive behaviors, although often not eradicated, usually decrease with
sustained weight gain.
Weight gains result in improvement in most of the physiological
complications of semistarvation, including improvement
in electrolyte levels, heart and kidney function, and attention
and concentration. Initial refeeding may be associated with mild
transient fluid retention, and patients who abruptly stop taking
laxatives or diuretics may experience marked rebound fluid retention
for several weeks, presumably from salt and water retention caused
by elevated aldosterone levels associated with chronic
dehydration. Refeeding edema and bloating occur frequently.
Patients may experience abdominal pain and bloating with meals
from the delayed gastric emptying that accompanies malnutrition.
Constipation, which may be ameliorated with stool softeners, can
progress to obstipation and, rarely, acute bowel obstruction. As
weight gain progresses, many patients also develop acne
and breast tenderness. Many patients become unhappy and demoralized
about resulting changes in body shape. Management strategies for
dealing with these milder adverse effects include careful refeeding,
frequent physical examinations, and forewarnings to patients about
mild refeeding edema.
A severe refeeding syndrome may occur when severely malnourished
patients (generally those weighing <70% of their healthy
body weight) are re-fed too rapidly, particularly in the context
of enteral or parenteral feedings but also with vigorous oral refeeding
regimens. This syndrome consists of hypophosphatemia, hypomagnesemia,
hypocalcemia, and fluid retention. Thiamine deficiency may also
be seen as a feature of this syndrome. In some case series, the
refeeding syndrome has been reported to occur in roughly 6% of
hospitalized adolescents (118). Excessively rapid refeeding and
nasogastric or parenteral feeding may be particularly dangerous because
of their potential for inducing severe fluid retention, cardiac arrhythmias,
cardiac failure, respiratory insufficiency, delirium, seizures,
rhabdomyolysis, red cell dysfunction, and even sudden death, especially
in the lowest-weight patients (118, 119). In such cases, phosphorus,
magnesium, and/or potassium supplementation will be necessary
(118, 120). In one series of hospitalized adolescents, moderate
hypophosphatemia occurred in 5.8% and mild hypophosphatemia
in 21.7% of patients, requiring some degree of phosphorus
replacement in 27.5% of these patients (120).
Besides monitoring of mineral and electrolyte levels, general
medical monitoring during refeeding should include assessment of
vital signs, monitoring of food and fluid intake and output (if
indicated), and observation for edema, rapid weight gain (associated
primarily with fluid overload), congestive heart failure, and gastrointestinal
symptoms. For children and adolescents who are severely malnourished
(weigh <70% of their standard body weight), cardiac
monitoring, especially at night, may be advisable (120).
Some patients are completely unable to recognize their illness,
accept the need for treatment, or tolerate the guilt that would
accompany eating, even when performed to sustain their lives. On
the rare occasions when staff have to take over the responsibilities
for providing life-preserving care, nasogastric feedings
are preferable to intravenous feedings. In some programs, supplemental
overnight pediatric nasogastric tube feedings have been used to
facilitate weight gain in cooperative patients. This practice is
not routinely recommended at present, although it appears to be
well tolerated, may slightly decrease hospital stays in children,
and may be experienced positively by some patients, particularly
younger patients, who may feel relieved to know that they are being
cared for and who, while they cannot bring themselves to eat, are
willing to allow physicians to feed them (121). If used, such interventions
should never supplant expectations that the patient will resume
normal eating patterns on his or her own. Total parenteral feeding
is required only rarely and for brief periods in life-threatening
situations.
Forced nasogastric or parenteral feeding can each be accompanied
by substantial dangers. When nasogastric feeding is necessary, clinical
experience suggests that continuous feeding (i.e., over 24 hours)
may be less likely than three to four bolus feedings a day to result
in metabolic abnormalities or patient discomfort and may be better
tolerated by patients. As an alternative to nasogastric feedings,
in very difficult situations where patients physically resist and
constantly remove their nasogastric tubes, gastrostomy or jejunostomy tubes
may be surgically inserted. As described above, rapid refeeding
can be associated with the severe refeeding syndrome, and infection
is always a risk with parenteral feedings in emaciated and potentially immunocompromised
patients with anorexia nervosa. Consequently, these interventions
should not be used routinely but should be considered only when patients
are unwilling or unable to cooperate with oral feedings or when
the patients' health, physical safety, and recovery are
being threatened. In situations where involuntary forced feeding
is considered, careful thought should be given to clinical circumstances,
family opinion, and relevant legal and ethical dimensions of the
patient's treatment.
If using interventions that patients with anorexia nervosa
may experience as coercive, the clinician should consider the potential
impact on the therapeutic relationship, especially since maintaining
a sense of control is often a key dynamic in these patients. The
setting of limits is developmentally appropriate in the management
of children and adolescents and may help shape the patient's
behavior in a healthy direction. It is essential for caregivers
to be clear about their own intentions and empathic capacities regarding
the patient's impression of being coerced. Caregivers should
not be seen as using techniques intended to be coercive. Rather, caregivers' interventions
should always be clearly seen as components of a general medical
treatment required for the patient's health and survival.
During the last few years, there has been considerable debate
about the ethics of involuntarily feeding patients with anorexia
nervosa (122, 123). There is general agreement that children and
adolescents who are severely malnourished and in grave medical danger should
be re-fed, involuntarily if necessary, but that every effort should
be made to gain their cooperation as cognitive function improves.
Ethical as well as clinical dilemmas often confront clinicians
dealing with adult patients with chronic anorexia nervosa and their
families. The general principles to be followed are those directing
good, humane care; respecting the wishes of competent patients;
and intervening respectfully with patients whose judgment is severely
impaired by their psychiatric disorders when such interventions
are likely to have beneficial results (124, 125).
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b) Psychosocial interventions
The goals of psychosocial interventions in patients with anorexia
nervosa are to help them 1) understand and cooperate with their
nutritional and physical rehabilitation, 2) understand and change
the behaviors and dysfunctional attitudes related to their eating
disorder, 3) improve their interpersonal and social functioning,
and 4) address comorbid psychopathology and psychological conflicts
that reinforce or cause them to maintain eating disorder behaviors.
Efforts to achieve these goals often benefit from an initial enhancement
of a patient's motivation to change along with ongoing
efforts to sustain this motivation.
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(i) Acute anorexia nervosa
Few controlled studies offer guidance for the psychosocial
treatment of anorexia nervosa. Clinical consensus suggests that
during the acute refeeding and weight gain stages, it is beneficial
to provide patients with individual psychotherapeutic management
that is psychodynamically informed and that provides empathic understanding,
explanations, praise for positive efforts, coaching, support, encouragement,
and other positive behavioral reinforcement. During all phases of
treatment, seeing patients' families is also helpful, particularly
for children and adolescents, for whom controlled trials suggest
that family treatment is the most effective intervention (86, 126).
For patients who initially lack motivation, their awareness and
desire for recovery may be increased by psychotherapeutic techniques
based on motivational enhancement, although solid evidence for this
contention is lacking.
At the same time, clinical consensus suggests that psychotherapy
alone is generally not sufficient to treat severely malnourished
patients with anorexia nervosa. Although the value of establishing
and maintaining a psychotherapeutically informed relationship is
clearly beneficial and psychotherapeutic sessions to enhance patient
motivation and further patient weight gain are likely to be helpful,
the value of formal psychotherapy during the acute refeeding stage
is uncertain (127). Attempts to conduct formal psychotherapy may
be ineffective with starving patients, who are often negativistic,
obsessional, or mildly cognitively impaired, presumably in relation
to the known cortical atrophy seen in nutritionally compromised
patients. One study documented the difficulty researchers have had
in initiating and sustaining cognitive-behavioral therapies for
patients with anorexia nervosa (128).
Most nutritional rehabilitation programs incorporate emotional
nurturance and one of a variety of behavioral interventions that
link exercise, bed rest, and privileges with target weights, desired
behaviors, and informational feedback. Several studies of individual
therapy have shown modest success, sometimes in only a small percentage
of patients (7, 85). In one controlled trial, nonspecific supportive
clinical management appeared to be at least as effective as CBT
or IPT in some patients. However, 70% of patients either
did not complete or made only small gains from the active psychotherapies
they received (7). In this study, clinical management included education,
care, support, and the fostering of a therapeutic relationship designed
to promote adherence to treatment through the use of praise, reassurance,
and advice.
The accumulated evidence strongly supports the value of family
therapy for the acute treatment of children and adolescents in outpatient
settings. Studies show that whether patients and parents are seen
together or are treated separately in ongoing treatment, the results
are better than when families are not involved at all (86, 126).
This approach begins with the therapist's attempting to
unite the parents in developing a consistent approach to refeeding,
sympathizing with their plight, and explicitly disclaiming the notion
that the parents have caused the eating problem. When families are
involved in treatment, sibling subsystems can be engaged to support
the affected sibling. Parents can determine for themselves how best
to refeed their child with anorexia nervosa with the therapist's
ongoing support and consultation. For some outpatients, a short-term
course of family therapy may be as effective as a long-term course;
however, a shorter course of therapy may not be adequate for patients
with severe obsessive-compulsive features or nonintact families
(129). In these studies (129), inpatient care was used briefly for medical
stabilization. For adolescents treated in inpatient settings, participation
in family group psychoeducation may help promote weight gain and
may be as effective as more intensive forms of family therapy (130).
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(ii) Anorexia nervosa after weight restoration
Clinical consensus suggests that psychotherapy can be helpful
for patients with anorexia nervosa once their malnutrition has been
corrected and they have begun gaining weight (131). Because of the
enduring nature of many of the psychopathological features of anorexia
nervosa and the patient's need for support during recovery,
ongoing individual psychotherapeutic treatment is frequently required
for at least 1 year and may take many years (132, 133).
Although there have been few formal studies of its effectiveness
(134, 135), psychotherapy is generally thought to help patients
understand 1) what they have been through; 2) developmental, familial,
and cultural antecedents of their illness; 3) how their illness
may have been a maladaptive attempt to cope and emotionally self-regulate;
4) how to avoid or minimize the risk of relapse; and 5) how to better
deal with salient developmental and other important life issues
in the future. At present there is no absolute weight or percentage
of body fat that indicates when a patient is actually ready to begin
formal psychotherapy. In addition, patients often display improved
mood, enhanced cognitive functioning, and clearer thought processes
once their nutritional status has significantly improved and even
before they make substantial weight gains.
Little evidence from controlled studies exists to guide clinicians
in the use of specific therapies for adults with anorexia nervosa.
Nonetheless, some data are emerging in support of individual CBT
(136–138) for helping patients maintain healthy eating
behaviors and CBT or IPT for inducing cognitive restructuring and
promoting more effective coping (139, 140). After a patient has
begun to gain weight, CBT may be helpful in reducing the risk of relapse
and improving outcome, as demonstrated in a small randomized controlled
trial (136). In that study, patients who received CBT were more
likely to remain in treatment (78%) and have a good outcome after
a year (44%) than those assigned to nutritional counseling
(7%).
Many clinicians also use psychodynamically oriented individual
or group psychotherapy to address underlying personality disorders
that may hamper treatment and help sustain the illness and to foster
psychological insight and maturation in patients who have made strides
toward weight restoration (141–148). Clinical consensus
suggests that psychosocial interventions should incorporate an understanding
of the patient's developmental traumas, cognitive development,
psychodynamic conflict and defense styles, disorders of self-esteem,
self-regulation, and "sense of self," as well
as other psychological deficits, the presence of other psychiatric
disorders, and the complexity of family relationships (149–152). Although
studies of psychotherapies focus on different interventions as distinctly
separate treatments, in practice there is frequent overlap among
treatments. Indeed, most experienced clinicians report using interventions
that cross theoretical boundaries when treating patients with eating
disorders (153).
In adolescents, controlled studies have shown that for patients
who are younger than age 19 years, have been ill for 3 years or
less, and have restored their weight, family therapy is more beneficial
than individual therapy, whereas individual therapy is more beneficial
for patients with later-onset disorders (154). At 5-year follow-up
of patients who received these therapies, much of the improvement
could be attributed to the natural outcome of the illness, but it
was still possible to detect long-term benefits of the psychological
therapies (155).
Regardless of the clinical or theoretical approach used in
treatment, some patients with eating disorders challenge clinicians' understanding
and in some instances provoke countertransference reactions, particularly
in response to patients' communications of aggression and defiance
(140, 147, 156–162). Clinical consensus suggests that eating
disorders are often difficult to ameliorate with short-term interventions,
at least in older adolescents and adults; for this reason, clinicians
often feel they have not done enough to change the patient's
plight. Countertransference feelings often include beleaguerment,
demoralization, and excessive need to change patients with a chronic eating
disorder. At the same time, when treating patients with chronic
illnesses, clinicians need to understand the longitudinal course
of the disorder and that patients can recover even after many years
of symptoms. Such awareness may help clinicians maintain a degree
of therapeutic optimism and deal with the feelings of pessimistic
demoralization that may arise (13, 163).
Some observations suggest that the gender of the clinician
may play a role in the particular kind of countertransference reactions
that come into play (156, 157). A patient's concerns about
the gender of a clinician may be tied to concerns about potential
boundary violations and should be attended to when selecting clinicians,
including psychiatrists (164, 165). In addition, cultural differences
between patients and clinicians or patients and other aspects of
the care system may also influence the course and conduct of treatment
and require attention. Ongoing processing of one's countertransference
reactions, sometimes with the help of a supervisor or
consultant, can be useful in helping the clinician persevere and reconcile
intense, troublesome countertransference reactions.
When a patient with an eating disorder has been sexually abused
or has felt helpless in other situations of boundary violations,
this may stir up needs in the clinician to rescue the patient, which
can occasionally result in a loosening of the therapeutic structure,
the loss of therapeutic boundary keeping, and a sexualized countertransference
reaction. In some cases, these countertransference responses have
led to overt sexual acting out and unethical treatment on the part
of the clinician that have not only compromised treatment but also
severely harmed the patient (166). The maintenance of clear boundaries
is critical in treating all patients with eating disorders, not
only those who have been sexually abused but also those who may
have experienced other types of boundary intrusions regarding their
bodies, eating behaviors, and other aspects of the self by family
members or others. Regular meetings with other team members and/or
formal supervision can also help clinicians avoid boundary violations
with eating disorder patients. Particularly with some adolescents,
a clinician's obvious warmth and direct educational approach
may facilitate initiating and sustaining the patient's
trust. However, the license to be informal may create a climate
in which a clinician is at a greater risk to violate therapeutic
boundaries; such an occurrence must be consistently and carefully
prevented. At the same time, according to some clinicians, a clinician's
excessively rigid, cold manner and formal distancing behaviors (e.g.,
avoiding even benign pats on the shoulder that a patient might seek
for reassurance) may be disconcerting to some patients and inhibit
them from fully engaging in treatment.
Some clinicians use group psychotherapy as an adjunctive treatment
for anorexia nervosa; in such cases, however, caution must be taken
that patients do not compete to be the thinnest or sickest patient
in the group or become excessively demoralized by observing the ongoing
struggles of other patients in the group. For that reason, clinicians
sometimes prefer heterogeneous groups that combine patients with
bulimia nervosa and those with anorexia nervosa. Although there
has been little formal study of group psychotherapy in the treatment
of anorexia nervosa, one naturalistic study suggests that CBT may
have promise (137).
Some clinicians consider that eating disorders may be usefully
treated through addiction models, but no data from short- or long-term
outcome studies using these methods have been reported. Literature
from Anorexics and Bulimics Anonymous and Overeaters Anonymous emphasizes
that these programs are not substitutes for professional treatment.
These organizations specifically recommend that members seek appropriate
medical and nutritional guidance. Nevertheless, there are concerns
about zealous and narrow application of the 12-step philosophy in
addiction-oriented programs for eating disorders. Programs that focus
exclusively on abstaining from binge eating, purging, restrictive
eating, and exercise (e.g., 12-step programs) without attending
to nutritional considerations or cognitive and behavioral deficits
have not been studied and therefore cannot be recommended as the
sole treatment for anorexia nervosa. Clinicians frequently report
encountering patients who, while attempting to resolve anorexia
nervosa by means of a 12-step program alone, might have been greatly
helped by concurrent conventional treatment approaches such as nutritional
counseling and rehabilitation, medications, and psychodynamic or
cognitive-behavioral approaches. By limiting their attempts to recover
to their participation in a 12-step program alone, patients not
only deprive themselves of the potential benefits of conventional
treatments but also may expose themselves to misinformation
about nutrition and eating disorders offered by well-intended nonprofessionals
participating in and sometimes running these groups. Attempts have
been made to integrate traditional and 12-step approaches into treatment;
such approaches can offer a strong sense of community, but the effectiveness
and potential adverse effects of these combined interventions have
not been systematically studied (167). It is important for programs
using a 12-step model to be equipped to care for patients with the
substantial psychiatric and general medical problems often associated
with eating disorders.
Selective support groups led by professionals and advocacy
organizations may be beneficial as adjuncts to other psychosocial
treatment modalities. However, clinicians should remain cognizant
of the idiosyncratic recommendations made in some self-help groups. Sometimes,
participants or leaders will eschew clinician-recommended treatments
such as psychotropic medication or insist that a participant follow
a particular kind of meal structure. These recommendations may conflict
with other treatment recommendations and potentially increase the
patient's resistance to treatment.
Patients and their families are increasingly using online
web sites, news groups, and chat rooms as resources. Although substantial
amounts of worthwhile information and support are available in this
fashion, the lack of professional supervision of these sources may
sometimes lead to misinformation and unhealthy dynamics among users.
Clinicians should ask patients about their use of electronic support
and other alternative and complementary approaches and be prepared
to openly and sympathetically discuss the information and ideas
they and their families have gathered from these sources.
As with any form of intervention, various psychosocial interventions
may generate adverse effects; however, these have not been systematically
studied with regard to treating anorexia nervosa. Some that have
been observed by clinicians, patients, and families include 1) fostering
negative attitudes in patients and/or families toward health
care professionals without adequate discussion and reflection, thereby
increasing the risk that patients will drop out of treatment and
become less willing to seek or engage in professional treatment;
2) delaying referral to more appropriate interventions; and 3) generating
burdensome costs without reasonable or expected benefits (13, 168).
Patients often have difficulty with certain elements of psychotherapy.
For example, among patients receiving CBT, some are quite resistant
to self-monitoring, whereas others have difficulty mastering cognitive
restructuring. Most patients are initially resistant to changing
their eating behaviors, particularly when it comes to increasing
their caloric intake or reducing exercise. However, the complete
lack of acceptance of a psychotherapeutic approach appears to be
rare, although this has not been systematically studied.
Management strategies to deal with potential negative effects
of psychotherapeutic interventions include 1) conducting a careful
pretreatment evaluation, during which the therapist must assess and
enhance the patient's level of motivation for change and
determine the most appropriate therapeutic approach and format (e.g.,
individual versus group); 2) being alert to a patient's
reactions to and attitudes about the proposed treatment and listening to
and discussing the patient's concerns in a supportive fashion;
3) ongoing monitoring of the quality of the therapeutic relationship;
and 4) identifying patients for whom another treatment should be
co-administered or given before psychotherapy begins (e.g.,
substance use disorder treatment for those actively abusing alcohol
or other drugs, antidepressant treatment for patients whose depression
makes them unable to become actively involved, more intensive psychotherapy
for those with severe personality disorders, group therapy for those
not previously participating). Alternative strategies may be necessary
to facilitate the therapeutic process and prevent the abrupt termination
of therapy (13). As with all therapeutic interventions, it is essential
that the therapist be alert to potential countertransference phenomena
toward these often difficult-to-treat patients. If unresolved, these
reactions have a high potential for disrupting or hastening the
termination of treatment.
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(iii) Chronic anorexia nervosa
Available studies of patients with chronic anorexia nervosa
typically show a lack of substantial clinical response to psychotherapy.
For example, in the study of Dare et al. (85), 84 patients, ill
for an average of 6.3 years and with an initial average BMI of 15.4
kg/m2,
were assigned to one of three individual psychotherapies or a control
group. The results after 1 year of psychotherapy were modest in
all groups, although the psychoanalytic psychotherapy and family
therapy groups fared better than those in the low-contact, routine-care
control group. Nevertheless, many clinicians report seeing patients
with chronic anorexia nervosa who, after many years of struggling
with their disorder, experience substantial remission; thus clinicians
are justified in maintaining and extending some degree of hope to
patients and families.
For patients whose anorexia nervosa continues to be resistant
to treatment despite substantial trials of nutritional rehabilitation,
medications, and hospitalizations, more extensive psychotherapeutic
measures may be undertaken in a further effort to engage and help motivate
them or, failing that, as compassionate care. This difficult-to-treat
subgroup may represent an as-yet poorly understood group of patients
with malignant, chronic anorexia nervosa. Efforts to understand
the unique plight of such patients may sometimes lead to engagement
in the therapeutic alliance, thereby allowing the nutritional protocol
to be initiated (125, 141, 142, 169, 170). With patients who have
difficulty talking about their problems, clinicians have reported
a variety of nonverbal therapeutic methods, such as creative arts
and movement therapy programs, to be useful (171), but these methods
have not been formally studied. At various stages of recovery, occupational
therapy programs may also enhance self-concept and self-efficacy
(172, 173), but again these programs have not been formally studied.
Although psychotropic medications should not be used as the
sole or primary treatment for anorexia nervosa, they have been used
as an adjunct treatment when nutritional rehabilitation programs
alone are ineffective in restoring patients' normal weight
or when patients demonstrate significant comorbid psychopathology
such as disabling obsessive-compulsive, depressive, or anxiety symptoms. However,
because anorexia nervosa symptoms and associated features such as
depression may remit with weight gain, decisions concerning the
use of medications should be deferred if possible until patients' weight
has been restored. The decisions about whether to use psychotropic
medications and which medications to choose will be determined by
the remaining symptom picture (e.g., antidepressants are usually considered
for those with persistent depression, anxiety, or obsessive-compulsive
symptoms and for bulimic symptoms in weight-restored patients; second-generation
antipsychotics are usually considered for those with severe, unremitting
resistance to gaining weight, severe obsessional thinking, and denial
that assumes delusional proportions). Many patients with anorexia
nervosa are extremely reluctant to take medications and often refuse those
that they know to specifically affect weight. These issues must be
discussed sympathetically and comprehensively with patients and,
for children and adolescents, with their families.
The efficacy of SSRI antidepressants for anorexia nervosa
appears to vary with the phase of treatment. On the basis of several
studies, fluoxetine does not appear to confer significant benefits
during weight restoration (174, 175), nor did citalopram increase
the rate of weight gain in a small study (176). In contrast, in
weight-restored patients, fluoxetine in dosages of up to 60 mg/day
may decrease relapse episodes and has been associated with better maintenance
of weight and fewer symptoms of depression (177). However, for weight-restored
patients with anorexia nervosa who are receiving CBT to help prevent
relapse, adding fluoxetine to their treatment does not further decrease
the risk of relapse (138).
Although higher dosages of fluoxetine have been found to
impair appetite and cause weight loss in normal-weight and obese
patients, this effect has not been reported in anorexia nervosa
patients treated with lower dosages. Many clinicians report that
malnourished depressed patients are less responsive to the beneficial
effects of tricyclics, SSRIs, and other antidepressant medications
than normal-weight depressed patients. These findings are consistent
with those showing that SSRIs are not as effective for depression,
when patients without an eating disorder undergo dietary restrictions
(178, 179).
Malnourished patients are also much more prone to the side
effects of medications. For example, the use of tricyclic
antidepressants may be associated with greater risk of hypotension,
increased cardiac conduction times, and arrhythmia, particularly
in purging patients whose hydration may be inadequate and whose
cardiac status may be nutritionally compromised. Given the availability
of other antidepressant treatments, tricyclic antidepressants should
be avoided, particularly in underweight patients and in patients
who are at risk for suicide. In patients for whom there is a concern
regarding potential cardiovascular effects of medication, medical
specialty consultation can help evaluate the patient's
status and advise on the use of medication. With all antidepressants,
strategies to manage side effects include limiting the use of medications
to patients with persistent depression, anxiety, or obsessive-compulsive
symptoms; using low initial doses in underweight patients; and remaining
vigilant about early manifestations of side effects.
Several other antidepressants have also been associated with
significant side effects that are of relevance to the treatment
of anorexia nervosa patients. Bupropion has been associated with
an increased likelihood of seizures in patients with bulimia nervosa
(180, 181); although the reason for this is unknown, it is suspected
that patients with anorexia nervosa, binge-purge type, may also
be at increased risk for seizures. Thus, this medication is not recommended
for patients with anorexia nervosa, particularly those who purge.
Mirtazapine, an antidepressant associated with weight gain, has
also been associated with neutropenia. In addition, the only published
case report of using mirtazapine to treat anorexia nervosa described
a patient also taking fluvoxamine who developed the serotonin syndrome
(182). Thus, mirtazapine may not be suitable for use in underweight
anorexia nervosa patients.
Clinicians must attend to the black box warnings concerning
antidepressants and conduct appropriate informed consent with patients
and families if antidepressants are to be prescribed (183–189).
It has been suggested that antipsychotic medications, particularly
second-generation antipsychotics, can be potentially useful during
the weight-restoration phase or in treatment of other associated
symptoms of anorexia nervosa, such as marked obsessionality, anxiety, limited
insight, and psychotic-like thinking. Although no controlled studies
have been reported in patients with anorexia nervosa, controlled
trials of olanzapine and risperidone are under way. Evidence from
case reports, case series, and open-label uncontrolled trials suggests
that the second-generation antipsychotic olanzapine may
promote weight gain in adults and in adolescent patients (190–193)
and that olanzapine (190–194) and quetiapine may improve
other associated symptoms (195–197). A small open-label
study of low-dose haloperidol also showed improved insight and weight
gain in severely ill patients (198). The quality of the available
evidence on using antipsychotic medications is also limited by the
fact that studies rarely include male patients and have included
only small numbers of adolescents; in addition, only case reports
are available regarding prepubertal children. If antipsychotic medications
are used, the possibility of extrapyramidal symptoms, especially in
debilitated patients, should be considered and routinely assessed.
Also, appropriate attention must be given to the potential adverse
impact of these medications on insulin sensitivity, lipid metabolism,
and length of QTc interval.
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(iii) Other medications and somatic treatments
Other somatic treatments, ranging from vitamin and hormone
treatments to ECT, have been tried in uncontrolled studies. None
has been shown to have specific value in the treatment of anorexia
nervosa symptoms (199).
Other medications have been used to address associated features
of anorexia nervosa. For example, antianxiety agents have been used
selectively before meals to reduce anticipatory anxiety concerning
eating (200, 201), and pro-motility agents, such as metoclopramide,
are commonly offered for the bloating and abdominal pains that result
from gastroparesis and that contribute to the premature satiety
seen in some patients. However, before prescribing metoclopramide,
clinicians should consider the fact that extrapyramidal symptoms
are more likely to be seen in underweight anorexia nervosa patients.
In
anorexia nervosa patients with prolonged amenorrhea, hormone replacement
therapy (HRT) is frequently prescribed to improve patients' bone
mineral density. However, no good supporting evidence exists to
demonstrate the efficacy of this treatment (202, 203). In women with
anorexia nervosa, the evidence supporting the use of HRT is marginal
at best. HRT has not been demonstrated to increase bone mineral
density over and above standard treatment in adults (204) or in
adolescents (203). Only in a subset of very-low-weight women (<70% average
body weight) did it prevent further bone loss (204). Estrogen can
cause the fusion of the epiphyses and should not be administered
to girls before their growth is completed (3). HRT usually induces
monthly menstrual bleeding, obscuring the major sign that indicates weight
normalization in women. This, in turn, may cause the patient to
misunderstand that her body is functioning normally and
therefore contribute to denial of the need to gain more weight.
Clinicians stress that efforts should be made to allow patients
to increase their weight and achieve resumption of normal menses
before they are offered estrogen (205). There is no indication for
the use of biphosphonates such as alendronate in patients with anorexia
nervosa. In fact, long-term use of alendronate may oversuppress
bone turnover (206). Thus, the recommended treatment for low bone
mineral density includes weight gain and calcium with vitamin D
supplementation (207).
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3. Choice of specific treatments for bulimia nervosa
The aims of treatment for patients with bulimia nervosa are
to 1) reduce and, where possible, eliminate binge eating and purging;
2) treat physical complications of bulimia nervosa; 3) enhance the
patient's motivation to cooperate in the restoration of
healthy eating patterns and participate in treatment; 4) provide
education regarding healthy nutrition and eating patterns; 5) help
the patient reassess and change core dysfunctional thoughts, attitudes,
motives, conflicts, and feelings related to the eating disorder;
6) treat associated psychiatric conditions, including deficits in
mood and impulse regulation, self-esteem, and behavior; 7) enlist
family support and provide family counseling and therapy where appropriate;
and 8) prevent relapse.
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a) Nutritional rehabilitation and counseling
Bulimia nervosa is associated with nutritional chaos characterized
by alternating cycles of dietary restriction, bingeing, and purging.
A primary focus for nutritional rehabilitation is to help patients
develop a structured meal plan that will allow them to reduce the
episodes of dietary restriction and the urge to binge and purge.
Nutritional intake should be sufficient to promote satiety. Because
most bulimia nervosa patients who have been studied are of normal
weight, nutritional restoration will not be a central focus of treatment.
However, normal body weight (or normal BMI) does not ensure normal
body composition, nor does it ensure that nutritional intake is
appropriate. In addition, even if their weight is within statistically
normal ranges, many patients with bulimia nervosa weigh less than
their appropriate biologically determined set points (or ranges)
and may have to gain some weight to achieve physiological and emotional
stability. Although many patients with bulimia nervosa report irregular
menses, improvement in menstrual function has not been systematically
assessed in the available outcome studies. Thus, even among patients
of normal weight, nutritional counseling may be a useful adjunct
to other treatment modalities in reducing behaviors related to the
eating disorder, minimizing food restrictions, increasing the variety
of foods eaten, and encouraging healthy but not compulsive exercise
patterns (208). Those patients for whom some weight gain is indicated
similarly require the establishment of a pattern of regular, non-binge
meals, with attention on increasing their caloric intake and expanding
macronutrient selection. Patients with bulimia nervosa who are overweight or
obese have not been well studied.
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b) Psychosocial interventions
The goals of psychosocial interventions for patients with
bulimia nervosa vary and can include the following: reducing or
eliminating binge eating and purging behaviors; improving attitudes
related to the eating disorder; minimizing food restriction; increasing
the variety of foods eaten; encouraging healthy but not compulsive
exercise patterns; treating co-occurring conditions and clinical
features associated with eating disorders; and 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, sex role expectations, family dysfunction,
coping styles, and problem solving. Consequently, psychosocial interventions should
be chosen on the basis of a comprehensive evaluation of the individual
patient and take into consideration the patient's cognitive and
psychological development, psychodynamic issues, cognitive style,
comorbid psychopathology, and preferences as well as age and family situation.
With respect to short-term interventions for treating acute
episodes of bulimia nervosa in adults, the available evidence indicates
that CBT is the most efficacious. CBT may effect improvements in
psychological functioning of bulimia nervosa patients as well as
ameliorate binge eating and purging symptoms. For example, studies
have shown that bulimia nervosa patients who improved with CBT also
showed improvements in self-directedness and harm avoidance (209, 210). Among patients who do not initially respond to CBT, a small number
do respond to IPT or fluoxetine (211) or other modes of treatment
such as family and group psychotherapies. Some controlled trials
(212) have also shown the effectiveness of IPT as an initial therapy.
Behavioral techniques, such as planned meals and self-monitoring,
may also be helpful for managing initial symptoms and interrupting
binge-purge behaviors (213, 214). It should be pointed out that
these study results may not be generalizable to typical clinical
situations. For example, to maximize the "clean" experimental
nature of some of the CBT/IPT controlled studies mentioned
above, the CBT intentionally avoided dealing with interpersonal
issues and the IPT intentionally avoided talking about eating issues,
which is quite different than how these therapies are conducted
in clinical practice (215). It is also possible that the narrow
inclusion criteria of some studies limit the generalizability of
the study results (216).
Some clinical reports indicate that psychodynamic and psychoanalytic
approaches in individual or group format are useful once bingeing
and purging symptoms improve (217–219). These approaches
address developmental issues; identity formation; body image concerns;
self-esteem; conflicts surrounding sexuality, anger, or aggression;
affect regulation; gender role expectations; interpersonal conflicts;
family dysfunction; coping styles; and problem solving. In a recent
naturalistic study of treatment as practiced by experienced clinicians
in the community, both CBT and psychodynamic psychotherapy
led to decreased rates of bingeing and purging similar to those
seen in controlled trials (roughly 50%). However, although
CBT has been reported to be associated with a more rapid remission
of eating symptoms, some therapists note that more integrative treatments
that include psychodynamic approaches are useful in targeting both
eating symptoms and broader personality, comorbidity, and quality-of-life
issues (153).
Some bulimia nervosa patients, particularly those with concurrent
personality pathology or other co-occurring disorders, may require
substantially longer treatment. In one study, the clinicians reported
that their average CBT treatment for bulimia nervosa lasted 69 sessions (81).
However, just how closely these clinicians adhered to formal CBT
methods is unknown. Also unknown is how the length and characteristics
of the treatments varied according to other clinical dimensions
of these patients. Exactly what is required over the long run to
best help patients resolve lingering preoccupations with body image
and the more subtle but impairing psychological dimensions that
may be associated with eating disorders requires additional study.
These concerns are often approached in practice through a variety
of longer-term psychotherapies.
Family therapy should be considered whenever possible, especially
for adolescents still living with parents or for older patients
with ongoing conflicted interactions with parents. Patients with
marital discord may benefit from couples therapy.
A variety of self-help and professionally guided self-help
programs have been effective for a small number of patients with
bulimia nervosa (220–222) and have been piloted in some
stepped-care approaches. Several innovative online programs are
currently being studied (5). Support groups and 12-step programs
such as Overeaters Anonymous may be helpful as adjuncts to initial
treatment of bulimia nervosa and for subsequent relapse prevention
but are not recommended as the sole initial treatment approach for
bulimia nervosa (168, 223). As noted above, these support organizations
emphasize in their literature that their programs are not substitutes
for professional treatment and specifically recommend that members
seek appropriate medical and nutritional guidance. However, clinicians should
remain cognizant of the idiosyncratic recommendations made in some
self-help groups.
Patients with bulimia nervosa occasionally have difficulties
with certain elements of psychotherapy similar to what was discussed
above for patients with anorexia nervosa. Possible adverse effects
of psychotherapeutic and psychosocial interventions, steps that
clinicians might take to minimize negative therapeutic reactions,
and issues concerning countertransference (as discussed in
Section
II.B.2.b
) apply to the treatment of patients with bulimia nervosa.
Antidepressants are effective as one component of an initial
treatment program for most bulimia nervosa patients. Although various
classes of antidepressant medications can reduce symptoms of binge
eating and purging, SSRIs have the most evidence for efficacy and
the fewest difficulties with adverse effects (224–226).
To date, the only medication approved by the FDA for the treatment
of bulimia nervosa is fluoxetine. The only other SSRI shown to be effective
is sertraline, which was studied in a small randomized controlled
trial (227). Available studies also suggest that antidepressants
may be helpful for patients with substantial symptoms of depression
or anxiety, obsessions, or certain impulse disorder symptoms or
for patients who have not responded or had a suboptimal response
to previous attempts at appropriate psychosocial therapy (228, 229).
Dosages of SSRIs that are higher than those used for depression
(e.g., fluoxetine 60 mg/day) are more effective in treating
bulimic symptoms (224, 226, 230), but high dropout rates may also
be seen in patients using these drugs (226). A small open trial
demonstrated the safety and effectiveness of 60 mg/day
of fluoxetine for treating bulimia nervosa in adolescents (225).
Thus, many clinicians initiate fluoxetine treatment for bulimia
nervosa at the higher dosage, titrating downward if necessary to
manage side effects. Tricyclic and MAOI antidepressants are rarely
used to treat bulimia nervosa, but if they are used, the dosages
are similar to those used to treat depression (231).
Often, several different antidepressants may have to be tried
sequentially to identify the specific medication with the optimum
effect in a particular patient. In the bulimia nervosa patient whose
symptoms do not respond to medication, it is important to assess
whether the patient has taken the medication shortly before vomiting.
Correlations between serum levels and response have not been identified;
however, if serum levels of the medication are available, they may
help determine whether presumably effective levels of the drug have
actually been achieved. Treatment adherence will also enhance the
patient's response to treatment, and subtle interpersonal
and psychodynamic factors in the physician-patient relationship
may contribute to treatment resistance if left unaddressed (232).
As in most clinical situations, careful education of the patient
regarding possible side effects of medications and their symptomatic
management (e.g., stool softeners for constipation) is important.
Side effects vary widely across studies depending on the type of antidepressant
medication used. In the multicenter fluoxetine trials (224, 230),
sexual side effects were common, and at the dosage of 60 mg/day,
insomnia, nausea, and asthenia were seen in 25%–33% of
patients. For the tricyclic antidepressants, common side effects
include sedation, constipation, dry mouth, and, with amitriptyline,
weight gain (233–238).
The toxicity and potential lethality of tricyclic antidepressant
overdosage also dictate caution in prescribing this class of drug
for patients who are at risk for suicide. Practitioners should also
avoid prescribing MAOIs to patients with chaotic binge eating and
purging behaviors. The risk of spontaneous hypertensive crises in
patients with bulimia nervosa taking MAOIs is not insignificant
(239). This risk and the importance of eating a tyramine-free diet
while taking MAOIs should be discussed with patients
for whom this type of medication is contemplated.
There are few reports on the use of antidepressant medications
in the maintenance phase of treating bulimia nervosa patients. Although
there are data indicating that fluoxetine can be effective in preventing
relapse in these patients (226), other data suggest that high rates of
relapse occur while antidepressants are being taken and possibly
higher rates are seen when the medication is withdrawn (240). In
the absence of more systematic data, most clinicians recommend continuing
antidepressant therapy for a minimum of 9 months and probably for
1 year in most patients with bulimia nervosa.
Clinicians must attend to the black box warnings concerning
antidepressants and conduct appropriate informed consent with patients
and families if these medications are to be prescribed (183–189).
For patients with bulimia nervosa who require mood stabilizers,
the use of lithium carbonate is problematic, because lithium levels
may shift markedly with rapid volume changes. Lithium is not effective
in the treatment of bulimia nervosa (241). Both lithium carbonate and
valproic acid frequently lead to undesirable weight gains that may
limit their acceptability to bulimia nervosa patients. Selecting
a mood stabilizer that avoids these problems may result in better
patient adherence and medication effectiveness. Topiramate is not
an effective mood stabilizer but may be potentially useful for bulimia
nervosa and binge eating disorder (242, 243). However, in contrast
to the low rates of adverse effects observed in clinical trials
with topiramate, practitioners have reported several patients experiencing
adverse effects with the drug, such as word-finding difficulties
and paresthesias in a sizable minority of patients, although these
may have been related to excessively rapid rates of dosage increases
(242, 243). Also of note, patients receiving topiramate for bulimia
nervosa lost an average of 1.8 kilograms, so this medication may
be problematic for normal- to lower-weight individuals (243). No
data are available regarding the use of these medications for treating
bulimia nervosa or binge eating in children or adolescents, but
safety and tolerability data have been reported for children and
adolescents with other disorders for which lithium (244), valproic
acid (245), and topiramate (246) have been prescribed.
Several case reports indicate that methylphenidate may be
helpful for bulimia nervosa patients with concurrent ADHD (247–249).
In these situations, particular attention should be given to a range
of potential adverse effects, including abuse.
+
d) Combinations of psychosocial interventions and
medications
Although not all psychotherapies have been well studied, there
is general consensus among clinicians regarding the efficacy of
a combined psychotherapeutic/medication approach; such
an approach is worth considering when initiating treatment. In some
research, the combination of antidepressant therapy and CBT has
resulted in the highest remission rates of bulimia nervosa (250–252).
Other studies suggest that target symptoms such as binge eating
and purging and attitudes related to the eating disorder generally
respond better to CBT than to pharmacotherapy (253–255),
with at least two studies (251, 254) showing that the combination
of CBT and medication is superior to either alone. Two of the studies
suggested a greater improvement in mood and anxiety variables when
antidepressant therapy is added to CBT (251, 253, 256). Of note,
some experienced clinicians do not find rigidly defined and doctrinally
practiced CBT to be as useful as methods that integrate CBT with
other psychotherapeutic techniques. This may be due to several factors,
including clinician inexperience or discomfort with the methods
of CBT or differences among patients seen in the community and those
who have participated as research subjects in these studies (81, 153).
Bright light therapy has been shown to reduce binge frequency
in several controlled trials (257–259). Case reports suggest
that repeated transcranial magnetic stimulation may be effective
in treating patients with major depression and bulimia nervosa (260, 261). One controlled trial (719) showed odansetron, a peripheral
5-hydroxytryptamine type-3 (5-HT3) receptor
antagonist that reduces vagus nerve activity, to be effective in
decreasing symptoms of bulimia nervosa, and its use may be considered
in unusual circumstances.
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4. Eating disorder not otherwise specified
The eating disorder not otherwise specified (EDNOS) category
is a conceptually problematic one and comprises a clinically heterogeneous
group of diagnoses (262, 263). This "everything else" category
currently consists largely of individuals with subsyndromal anorexia
nervosa or bulimia nervosa who do not meet DSM-IV-TR criteria of
being 15% below expected weight or who binge and purge
slightly less than twice per week. Such individuals merit treatment
similar to that of full-syndrome patients. In addition, the EDNOS category
lumps together normal-weight patients who purge, individuals who
chew and spit out their food without swallowing it to prevent weight
gain, and patients with binge eating disorder. Also perhaps suitable
for this "other" category are individuals who
experience psychiatric impairment related to the abuse of diet pills
and diuretics (264), individuals who are obsessively preoccupied
with liposuction (265) to deal with issues of shape and
weight, and certain new-onset postgastrectomy eating disorder patients
(266). The EDNOS diagnosis covers a wide spectrum, so no easily
generalizable comments can be made for the entire group regarding
course or prognosis (267). In addition, over time, considerable
movement occurs from one eating disorder diagnostic category to
another, including EDNOS (263).
Binge eating disorder is the most discrete and well-studied
EDNOS subgroup. Although binge eating disorder is currently not
an approved DSM-IV-TR diagnosis, research criteria listed in
DSM-IV-TR consist of disturbances in one or more of the following
spheres: behavioral (e.g., binge eating), somatic (obesity is common,
although not required), and psychological (e.g., body image dissatisfaction,
low self-esteem, depression). Empirically supported strategies for
the treatment of binge eating disorder include nutritional counseling and
dietary management; individual or group behavioral, cognitive behavioral,
dialectical behavioral, psychodynamic, or interpersonal psychotherapy;
and medications. In reviewing the available information on treating
binge eating disorder, it is important to consider the focus of
treatment. Most programs using nutritional rehabilitation and counseling
focus on weight loss as the primary outcome, whereas studies of
psychotherapy and medication generally consider reduction of binge
eating as the primary outcome measure, with weight loss as a secondary
outcome. Clinical consensus suggests that psychodynamic psychotherapy may
also be helpful to reduce binge eating in some patients.
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a) Nutritional rehabilitation and counseling: effect
of diet programs on weight and binge eating symptoms
The literature on treating binge eating disorder suggests
that 1) behavioral weight control programs incorporating low- or
very-low-calorie diets may help patients lose weight and usually reduce
symptoms of binge eating; 2) at least some degree of weight gain
often follows weight loss; 3) weight gain after weight loss may
be accompanied by a return of binge eating patterns; and 4) various
combinations of diets, behavior therapies, non-weight-directed psychosocial
treatments, and even some "nondiet/health at every
size" psychotherapy approaches may be of benefit in reducing
binge eating and promoting weight loss or stabilization in various
circumstances (268).
Some believe that patients with a history of repeated weight
loss followed by weight gain ("yo-yo" dieting)
or patients with an early onset of binge eating might benefit from following
programs that focus on decreasing binge eating rather than losing
weight (269, 270). However, at this point, there is little empirical
evidence to suggest that obese binge eaters who are primarily
seeking weight loss should receive different treatment than obese individuals
who do not binge eat.
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b) Other psychosocial treatments: effects on binge
eating disorder
CBT is the most widely studied treatment for binge eating
disorder, and there is substantial evidence supporting its efficacy
for behavioral and psychological symptoms, whether it is delivered
in the individual or group format. IPT and dialectical behavior
therapy have also been shown to be effective for behavioral and
psychological symptoms and can be considered as alternative therapies.
There is less consensus regarding the long-term effects of treatment;
however, some studies suggest that most patients continue to show
behavioral and psychological improvement at 1-year follow-up (271, 272). There is a substantial body of evidence supporting the efficacy
of self-help and guided self-help CBT treatment programs (273–277)
and their use as an initial low-burden step in a sequenced treatment
program.
Because severe dieting may disinhibit eating and lead to
compensatory overeating and binge eating (278), and because chronic
calorie restriction can also increase symptoms of depression, anxiety,
and irritability (279), alternative therapies have been developed
that use a "nondiet" approach and focus on self-acceptance,
improved body image, better nutrition and health, and increased
physical movement (280–282). Addiction-based 12-step approaches,
self-help organizations, and treatment programs based on the Alcoholics Anonymous
model have been tried, but no systematic outcome studies of these
programs are available.
In sum, there appear to be several good psychotherapeutic
options for treating binge eating disorder when a reduction in binge
eating is the primary goal. Weight loss, particularly in the long
term, is a much more elusive goal, not only for obese patients with
binge eating disorder but for obese patients in general. However,
several studies suggest that at least for some patients at certain
stages of recovery, behavioral weight control may be a useful treatment
component. Also, because studies have found that binge eating may
begin before obesity or dieting (283), specific approaches are needed
for nonobese patients struggling with binge eating symptoms. The
optimal sequencing of treatmentsthat is, whether the treatment
of binge eating should precede or occur concurrently with weight
control treatmenthas yet to be definitively determined.
There is substantial evidence to suggest that treatment with
antidepressant medications, particularly SSRI antidepressants, is
associated with at least a short-term reduction in binge eating,
in most cases without substantial weight loss. The dosage of medication
is typically at the high end of the recommended range. The appetite-suppressant
medication sibutramine also appears to be effective in suppressing
binge eating, at least in the short term, and is additionally associated
with significant weight loss (284). Heart rate and blood pressure need
to be monitored closely in patients taking sibutramine, and the
medication should be discontinued if there are significant elevations
in these parameters, although these side effects seem to be uncommon
(285). Finally, the anticonvulsant medication topiramate appears
to be effective in reducing binge eating and promoting weight loss
in the short (286) and long (287) term, although side effects such
as cognitive problems, paresthesias, and somnolence may limit its
clinical utility for some individuals. The anticonvulsant zonisamide may
produce similar effects (288). Dexfenfluramine, although effective
for reducing binge eating (289), has been removed from the market
because of increased risk of primary pulmonary hypertension and
heart valve abnormalities. Patients who report having used fenfluramine
and phentermine in the past should be screened for potential cardiac
and pulmonary complications.
It is important to note that in several studies, the placebo
response rate has been reported to be quite high. The clinical implications
of this finding are that controlled studies are extremely important,
as a positive response in an open study may be nonspecific, and
short-term beneficial responses to treatment should be viewed cautiously,
given that a transient "honeymoon" effect of initiating
treatment is common.
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d) Combined psychosocial and medication treatment
strategies
There have been few studies of combined treatment for binge
eating disorder, so the clinical recommendations are preliminary.
Overall, it appears that for most patients, the addition of antidepressant
medication to behavioral weight control and/or CBT does
not significantly augment binge suppression but may confer additional
benefits in weight reduction (290–294). One study reported
that the addition of the weight-loss medication orlistat to a guided
self-help CBT program yielded additional weight loss (295). Another study
found that fluoxetine in the setting of group behavioral treatment
did not augment binge cessation or weight loss but did reduce depressive
symptoms (294). Thus, the addition of medication to psychotherapy
for binge eating disorder is not, in most cases, associated with
additional benefit on the core symptom of binge eating, perhaps
because psychosocial treatments are quite effective for this symptom.
However, medication augmentation may have additional benefits.
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e) Treatment strategies for night eating syndrome
The phenomenon of wakeful nighttime eating, variously characterized
as night eating syndrome, nocturnal eating/drinking syndrome,
or nocturnal sleep-related eating disorders, is currently an area
of active research (296). Although formal agreed-upon definitions
for these syndromes do not yet exist, the construct of night eating
syndrome, first described by Stunkard et al. (297), generally includes
morning anorexia, evening hyperphagia, and insomnia. In contrast,
the construct of nocturnal eating/drinking syndrome emphasizes
a sleep disorder with recurrent awakenings often accompanied by
eating or drinking, and the construct of nocturnal sleep-related
eating disorders adds to this a reduced level of awareness or recall
of nocturnal eating episodes. Sleep-related eating disorders, including
somnambulism, have reportedly been induced by risperidone, olanzapine,
and bupropion, among other medications (298–300). The literature
does not, at this point, support the recommendation of particular
treatments for these disorders. However, there is preliminary evidence
supporting the utility of progressive muscle relaxation (301) and
sertraline (302, 303). Further studies of the phenomenology and
treatment of these disorders are needed.
+
III. Clinical Features Influencing the Treatment Plan
+
A. Chronicity of Eating Disorders
In some patients with eating disorders, the illness course
becomes chronic, lasting for a decade or more. The care of chronically
ill patients is challenging, and modifications in treatment goals
may be needed for these patients to benefit. For example, the goals
of psychological interventions may be to make small, progressive
gains and achieve fewer relapses. Throughout the outpatient care
of such patients, communication among professionals is especially
important. In addition, more frequent outpatient contact and other
supports may sometimes help prevent hospitalizations.
Among patients with a chronic course of anorexia nervosa,
many are unable to maintain a healthy weight and experience chronic
depression, obsessionality, and social withdrawal. Treatment may
require consultation with other specialists; repeated hospitalizations,
partial hospitalizations, or residential care; individual or group
therapy; other social therapies; trials of various medications;
and, occasionally, ECT for patients with severe or treatment-resistant
depression. During hospitalizations, expectations for weight gain
may be more modest; achieving a safe weight compatible with the
patient's life rather than a healthy weight may be all
that is possible. The focus of treatment may be on addressing quality-of-life
issues (rather than on weight changes or more normal eating habits)
and providing compassionate care, with the recognition that patients
can realistically achieve only limited goals (125, 304, 305).
Even for patients who have been ill for 20–30 years,
there is some evidence that significant benefits can still be derived
from treatment. Here too the clinician's approach may need
to be modified by relying more on the emotional resources of the
patient and much less on the resources of the family. Therapy may
need to focus on patients' recognition that their eating
disorder has cost them decades of their lives; their therapists
may then help them use their energy to improve the remainder of
their lives. Some older patients maintain accurate images of their
body and recognize that they are too thin but still need significant help
with actually gaining the needed weight or relinquishing a strongly
established habit of binge eating or purging. The family work often
revolves around helping the family adjust to the positive changes
that occur with symptom and behavioral changes in the patient (306).
+
B. Other Psychiatric Factors
+
1. Substance use disorders
Substance use disorders are common among both women and men
with eating disorders (106, 307, 308). Among individuals with bulimia
nervosa, 22.9% meet criteria for alcohol abuse (309). Alcohol
and other substance use disorders appear to be less common among patients
with the restricting type of anorexia nervosa than among those with
the binge eating/purging type (310, 311). Binge eating
disorder is also associated with high rates of lifetime co-occurring
substance abuse, which is more prevalent in male (57%)
than in female (28%) patients (313). Patients with co-occurring
substance abuse and anorexia or bulimia nervosa appear to have more
severe problems with impulsivity in general, including greater risk
of shoplifting, suicidal behaviors, self-injurious behaviors, and
laxative abuse (83, 314–316). The relation between bulimia
nervosa and alcohol abuse/dependence may be indirect and
may be influenced by associations with major depression and posttraumatic stress
disorder (PTSD) (317).
Available data indicate that patients with eating disorders
who have a history of prior but currently inactive substance use
disorder respond to standard therapies in the same manner as those
without such a history (318–320) and do not appear to experience
exacerbation of their substance use after their eating disorder
is successfully treated (319). Furthermore, co-occurring alcohol
abuse increases the risk of mortality in anorexia nervosa (321).
The presence of an active substance use disorder does have implications
for the treatment of eating disorders. Patients with co-occurring
eating and substance use disorders require longer inpatient stays
and are less adherent with treatment after hospitalization than
those with substance use disorders alone (322). In everyday clinical
practice, substance use shows a strong association with length of
treatment required for remission (81). A study of 70 patients with
co-occurring eating disorders and substance abuse found that the
associated axis III medical disorders reflected complications of
both eating and substance use disorders. Where treatment staff are
skilled in treating both disorders, concurrent treatment should
be attempted.
+
2. Mood and anxiety disorders
A high percentage of treatment-seeking patients with eating
disorders report a lifetime history of major depression (313, 323–327).
Nutritional insufficiency and weight loss often predispose these
patients to symptoms of depression (279). Depressed individuals
with an eating disorder experience higher levels of anxiety, guilt,
and obsessionality but lower levels of social withdrawal and lack
of interest than depressed individuals without eating disorders (328).
The presence of co-occurring depression at initial presentation
has minimal or no predictive value for treatment outcome (329).
Although antidepressant medications may be relatively ineffective
in treating depressive symptoms before a patient has gained weight (174)
and are typically not helpful in weight restoration (see
Section
II.B.2.c.i.
), their use has sometimes been associated with reduced
symptoms of depression and anxiety during the weight restoration
phase (176). In addition, the experience of many clinicians suggests that
severe depression can impair a patient's ability to become
meaningfully involved in psychotherapy and may dictate the need
for medication treatment for the mood symptoms from the beginning
of treatment.
Lifetime prevalence rates for anxiety disorders also appear
to be higher for patients with anorexia or bulimia nervosa. In a
controlled study with a large sample, 71% of women with anorexia
or bulimia nervosa had at least one anxiety disorder, a rate significantly
higher than that found in the control group (330), although rates
for specific anxiety disorders varied (331). Social phobia
and obsessive-compulsive disorder (OCD) are the anxiety disorders most
commonly described in patients with anorexia nervosa. For those
with bulimia nervosa, co-occurring presentations of social phobia,
OCD, PTSD, or simple phobia are most often described (332, 333).
Patients with binge eating disorder also have high rates of lifetime anxiety
disorders (29%), with simple phobia and panic disorder
being the most commonly described (334–340). Overanxious
disorders of childhood are also common in conjunction with anorexia
and bulimia nervosa, and anxiety disorders often precede the onset
of these eating disorders (82, 341). Youngsters with anorexia nervosa
may have co-occurring OCD more frequently than adults with anorexia
nervosa (342). Although there is no clear evidence that co-occurring
anxiety disorders significantly affect eating disorder treatment
outcome, such comorbid problems should be addressed in treatment
planning.
Available data on the extent of PTSD among patients with eating
disorders suggest an association between childhood trauma and bulimia
nervosa (333, 343–346). Although specific causal links
have not been demonstrated and the mechanisms of association and
potential transmission remain unclear, it is thought that early
trauma may sensitize some individuals to later traumatic experiences
and an array of impulsive behaviors, including eating disorder symptoms.
The lifetime rate of PTSD among women with bulimia nervosa reported
in studies has varied between 6% and 45% (330,
332, 346, 347). Clinical consensus suggests that the extent of trauma
history and the possible presence of PTSD should be taken into consideration in
treatment planning.
+
3. Personality disorders
Temperament, genetics, family pathologies, and other dimensions
of personality appear to be involved in the occurrence and manifestations
of eating disorders (348–350). In all cases, personality
types and the extent of personality pathology have implications
for treatment (79, 351, 352). As with mood and anxiety disorders,
the presence of comorbid personality pathology (whether or not it
is severe enough to meet DSM criteria for a personality disorder)
is the norm rather than the exception (353). Patients with eating
disorders should routinely be assessed for concurrent personality
disorders. The reported prevalence of personality disorders has
varied widely across eating disorders and studies. Individuals with
anorexia nervosa tend to have higher rates of Cluster C personality
disorders, particularly obsessive-compulsive, perfectionistic, and
avoidant and histrionic traits, whereas normal-weight
patients with bulimia nervosa are more likely to display features
of Cluster B disorders, particularly impulsive, affective, and narcissistic
traits (354–361). The presence of borderline personality disorder
seems to be associated with a greater disturbance in eating attitudes,
a history of more frequent hospitalizations, and the presence of
other problems such as suicidal behaviors and self-injurious behaviors
(356, 360). The presence of borderline personality disorder is also
associated with poorer treatment outcome and higher levels of psychopathology
at follow-up (362, 363). The improvement of axis I eating disorder
symptoms may produce concurrent improvement in traits associated
with these personality disturbances (364). Although this approach
has not yet been systematically studied, clinical consensus strongly suggests
that the presence of a co-occurring personality disorder, particularly
borderline personality disorder, dictates the need for longer-term
therapy that focuses on the underlying personality structure, coping
strategies, and interpersonal relationships in addition to the symptoms
of the eating disorder. Recent naturalistic research documents the
generally poorer outcome and longer treatment required for bulimia
nervosa patients with borderline, avoidant, or more broadly emotionally
dysregulated personality pathology, although many such patients
do improve substantially with longer-term treatment (365).
+
C. Concurrent General Medical Conditions
Eating disorders may be more common among patients with type
1 or type 2 diabetes than among nondiabetic patients (366, 367),
but this contention is not strongly supported by research (368).
It has been suggested that type 1 diabetic patients are more likely
to have anorexia nervosa or bulimia nervosa (368a) and type 2 diabetic
patients are more likely to have binge eating disorder (367). Although
patients with both an eating disorder and diabetes are more likely
to be female, males with both disorders are also commonly found,
particularly among type 2 diabetic patients. The presentation of
eating disorders in the context of diabetes may be substantially
more complex than that seen with an eating disorder alone. In addition,
these concurrent diagnoses may present as numerous general medical
crises before the presence of the eating disorder is diagnosed and
treated, particularly among patients with type 1 diabetes. Evidence
suggests that rates of diabetic complications are higher when insulin-dependent
diabetes mellitus co-occurs with bulimia nervosa or EDNOS (369).
Mortality rates are much higher with combined anorexia nervosa and
type 1 diabetes than with either condition alone (370). Patients
with uncontrolled diabetes who also have bulimia nervosa may require
a period of inpatient treatment for stabilization of both illnesses
(371, 372). Treatment of these concurrent disorders may also require
more interaction with general medical specialists. Lengthy inpatient
treatment for adult diabetic patients with eating disorders (primarily
bulimia nervosa) is promising but has been studied in only a few
patients (373).
Diabetic patients with eating disorders often underdose their
insulin to lose weight. Throughout the studies undertaken to date,
insulin omission has been found to be common (374). It has been
suggested that insulin omission be considered a specific type of
purging behavior in the next DSM revision.
Eating disorders may begin de novo during pregnancy, but many
patients become pregnant even while they are actively symptomatic
with an eating disorder. Behaviors associated with eating disorders,
including inadequate nutritional intake, binge eating, purging by various
means, and the use or misuse of some teratogenic medications (e.g.,
lithium, benzodiazepines, divalproex, diet pills), can all result
in fetal or maternal complications (375). The care of a pregnant
patient with an eating disorder is difficult and usually requires
the collaboration of a psychiatrist and an obstetrician who specializes
in high-risk pregnancies (376–379).
In a recent study of 49 nulliparous women previously diagnosed
with an eating disorder (24 with anorexia nervosa, 20 with bulimia
nervosa, 5 with EDNOS), 22% had a verified relapse of eating
disorder during pregnancy. Compared with a control group, women
with past or current eating disorders were at increased risk of
hyperemesis, infants with significantly lower birth weight, smaller
head circumference (including microcephaly), and small-for-gestational-age infants
(380). Women with active symptoms of anorexia or bulimia nervosa
are at higher risk for Cesarean section and postpartum depression
(381). Yet another study linked the presence of an eating disorder
before pregnancy or an eating disorder (or dieting or fasting) during
the first trimester with an increased risk to the infant, including
a greater risk of low birth weight, preterm delivery, a small-for-gestational-age size,
and neural tube defects (382).
Data on the impact of pregnancy on eating disorder symptoms
are conflicting. One study has shown that among treated bulimia
nervosa patients, childbirth is not associated with increased symptoms
(383). Another study found that anorexia and bulimia nervosa patients had
a decreased severity of eating disorder symptoms during pregnancy
and that patients with bulimia nervosa, but not patients with anorexia
nervosa, maintained this improvement through 9 months postpartum
(384).
Prepregnancy counseling of eating disorder patients and their
families should be detailed and cautionary. Although some patients
may be able to eat normally and decrease binge eating and purging
during their pregnancy, it is best for the eating disorder to be
treated before the pregnancy if possible. Although women with a
lifetime history of anorexia nervosa may not have reduced fertility,
they do appear to be at risk for a greater number of birth complications
than comparison subjects and of giving birth to babies of lower
birth weight, whether or not the anorexia nervosa is active at the
time of pregnancy (312). Mothers with eating disorders may have
more difficulties than others in feeding their babies and young
children than mothers without eating disorders and may need additional
guidance, assistance, and monitoring of their mothering (385–388).
In one study, primiparous mothers with an episode of eating disorder
during the first postpartum year often expressed negative emotions
toward their infants during meals, the infants' emotional
tone was more negative, and the infants' mealtimes were
more conflictual than those of control infants (388).
Active bulimia nervosa may be associated with polycystic ovaries
or other follicular abnormalities. In a study of eight women with
bulimia nervosa, six of the seven women with active bulimic symptoms
showed polycystic ovaries; at follow-up, the five who continued to
have bulimic symptoms all had polycystic ovaries, whereas normal
ovaries were seen in the three whose bulimia nervosa had remitted
(389).
Some patients with an eating disorder may present to fertility
clinics and request medications to facilitate conception. Although
little is known about the consequences of fertility drugs in patients
with anorexia nervosa, the simultaneous multiple pregnancies that
often occur with these drugs may be even more difficult for patients
with an eating disorder to contend with than for women without an
eating disorder.
+
D. Demographic Variables
Although eating disorders are more prevalent in women, males
with eating disorders are not rare, and case series often report
on hundreds of male patients (390, 391). The stereotype that eating
disorders are female illnesses may limit a full understanding of
the scope and nature of problems faced by male patients with eating
disorders.
There continues to be a paucity of information regarding males
with eating disorders (392). However, more males may be seeking
treatment (393). The most common form of eating disorders among
males may be EDNOS (394).
In community samples, males with eating disorders have more
psychiatric comorbidity and psychosocial morbidity than females
with eating disorders (395). Studies of national samples of girls
and boys exposed to physical and sexual abuse have shown that although binge
and purge behaviors were nearly twice as prevalent among girls (13%)
as boys (7%), boys who had experienced both physical and
sexual abuse were nearly twice as likely as girls to report these
behaviors (odds ratios 8.25 and 4.28, respectively) (396). Especially
in the bulimia nervosa and binge eating disorder subgroups, males
with eating disorders who present to tertiary care centers may have
greater rates of co-occurring substance use disorders and more frequently
have a history of having premorbid obesity or being overweight (397).
As in women, there is a higher risk of osteoporosis in men with
eating disorders (398, 399).
Although many similarities exist between males and females
with different types of eating disorders, notable differences have
been reported. Females with anorexia or bulimia nervosa score higher
on the Drive for Thinness subscale than do males, and this appears
to be a real difference; females also score higher on the body dissatisfaction
subscale than do males, but this may result from a failure of these
scales to address the specific ways in which males are dissatisfied
with their bodies (e.g., males seem to be more concerned with upper
torso and muscular development than are females). Studies of binge
eating disorder patients demonstrate that women have greater body
image dissatisfaction and are more likely to cope with negative
affect by binge eating, whereas men have higher rates of drug and
alcohol use disorder histories (400).
Body dysmorphic disorder (BDD), a severe form of body image
disturbance seemingly related to OCD, is common among patients with
anorexia nervosa (401) and appears to be increasing in prevalence.
Although BDD is nearly as common in men as in women, the focus of
body preoccupations may differ by gender (402, 403). Muscle dysmorphia,
a distressing or impairing preoccupation with the idea that one's
body is not sufficiently lean and muscular, is a form of BDD that
occurs primarily in men, often involves abnormal eating behavior,
and appears to overlap in other ways with eating disorders. The
relation of BDD to eating disorders other than anorexia nervosa
is poorly understood (404). In one small inpatient study, anorexia
nervosa patients with BDD were found to have significantly poorer functioning,
more episodes of psychiatric hospitalization, and three times the
rate of lifetime suicide attempts compared with anorexia nervosa
patients without BDD (401).
Although a patient's gender per se does not appear
to influence the outcome of treatment, some aspects of treatment
may need to be modified on the basis of gender. For example, with
regard to personality traits, males with eating disorders have somewhat
less perfectionism, harm avoidance and reward dependence behaviors,
and cooperativeness than females (405). Open-blind studies suggest
that bringing testosterone levels to within normal ranges in males
during nutritional rehabilitation for anorexia nervosa may be helpful
in increasing lean muscle mass, but definitive studies on this have
not been completed.
Although studies in clinical samples have suggested that a
higher prevalence of homosexuality may exist among males with eating
disorders (390), this finding has not yet been confirmed epidemiologically.
Nevertheless, because issues concerning sexual orientation are not
uncommon among males with eating disorders seen in clinical settings,
these issues should be considered in treatment (390).
Where possible, therapy groups restricted to male patients
may address some of these patients' specific needs and
help them deal with potential stigmatization of male patients by
female patients in treatment. Male patients with anorexia nervosa
may require higher energy intakes (up to 4,000–4,500 kcal/day)
during nutritional rehabilitation because they normally have higher
lean body mass and lower fat mass compared with female patients. Further,
because they are generally taller and larger framed to begin with,
males with anorexia nervosa often require much larger weight gains
to return to a healthy weight (391, 399).
Although most eating disorders start while patients are in
their teens and 20s, earlier and later onsets have been observed
as well. Among the youngest patients with early onset (i.e., ages
7–12 years), obsessional behavior and depression are common
(406). Children often present with physical symptoms such as having
nausea, experiencing abdominal pain, feeling full, or being unable
to swallow (all conditions requiring evaluation to investigate a
variety of potential etiologies) (407). Their weight loss can be
rapid and dramatic. Similarly, their lack of expected weight gain
is problematic. Food avoidance for primarily psychological reasons
that results in weight loss (food avoidance emotional disorder [FAED])
has been delineated and differentiated from anorexia nervosa in
young children. These young patients know that they are underweight,
would like to be heavier, may not know why this goal is hard to
achieve, and usually show more generalized anxiety unrelated to
food. A small number of FAED patients go on to develop eating disorders,
but direct continuity between the two types of disorders has not
been demonstrated (408). Other syndromes to be considered are selective
eating disorder, functional dysphasia, and pervasive refusal syndrome
(407).
Children with early-onset anorexia nervosa may have delayed
growth (3, 97, 98, 409–412) and be especially prone to
osteopenia and osteoporosis (413, 414). In a few cases, exacerbations
of anorexia nervosa and OCD-like symptoms have been associated with
pediatric infection-triggered autoimmune neuropsychiatric disorders
(415), but further research is needed to determine the nature of
this association (416). Bulimia nervosa is rarely seen in children
under age 12 years (417–420).
With respect to middle-aged patients, case reports and clinical
consensus now suggest that as the baby boomer generation grows older,
body image concerns and eating disorders are becoming more prevalent.
One case report from an established residential program noted a
shift in the age of its patients and reported treating more middle-aged
women than a decade ago (417–420).
At the other end of the age spectrum, incidence rates for
anorexia nervosa among women over age 50 years are low, accounting
for <1% of patients with newly diagnosed anorexia nervosa
(421). Anorexia nervosa has been reported in elderly patients in
their 70s and 80s; these are generally women in whom the illness
has been present for 40 or 50 years. In many cases, the illness
started after age 25 (so-called anorexia tardive). In some case
reports, adverse life events such as deaths, a marital crisis, or
a divorce have been found to trigger these older-onset syndromes.
The fear of aging has also been described as a major precipitating
factor in some patients (142, 422). Rates of co-occurring depression
have been reported to be higher among these patients in some studies
but not in others (423). Regardless of the age at onset, concerns
about comorbid medical conditions, especially osteopenia and osteoporosis,
take on greater significance with older patients.
Specific pressures and values concerning weight and shape
vary among different cultures. The quest for beauty and acceptance
in accordance with the stereotypes women perceive in contemporary
media is leading increasing numbers of women around the world to develop
attitudes and eating behaviors associated with eating disorders.
Despite initially higher prevalence rates of this phenomenon in
Western and postindustrial societies, disordered eating behaviors
now appear to be globally distributed (424–427).
Popkin and Gordon-Larsen (428) have described a phenomenon
called the "nutritional transition" in economically
emerging countries. In some Asian and Middle Eastern countries, the
decrease in activity levels and increase in access to high-fat,
high-calorie foods have occurred much more rapidly than in the United
States; likewise, this trend has led to a faster rate of increase
in the number of individuals becoming overweight or obese than that
seen in the United States. Consequently, the pressure to lose weight
or remain slender may ultimately affect an even wider group of people
more quickly in these regions than it has in the United States.
Emerging population data suggest that transnational migration and
modernization may increase the risk of disordered eating and body
dissatisfaction across diverse ethnic and social contexts (427,
429–432).
Clinicians should engage female patients from non-Western
cultures in informed and sensitive discussions regarding their struggles,
experiences, and personal perceptions about what it means to be
attractive and satisfied with their bodies (433). Clinicians should
be sensitive to and inquire about how weight and shape concerns
are experienced by patients, especially those who are from minority
populations or non-Western or other cultural backgrounds or are
transitioning and assimilating into Western societies. Transcultural
differences in the meanings of terms and concepts are considerable
(434). It is not uncommon to find Asian patients with atypical behaviors,
such as denying a fear of weight gain, appraising their bodies as
malnourished, denying distorted perceptions of their bodies, and
specifically denying a drive for thinness (435). (Atypical patients
who specifically deny a drive for thinness are also seen among North
American and European populations [436].)
Although little information exists on cross-cultural differences
among males with regard to eating disorders, male patients with
anorexia nervosa, bulimia nervosa, and binge eating disorder have
been described in non-Western populations. Some population differences across
cultures among males have been found with regard to attitudes about
eating, body shape, and weight (437, 438).
+
4. Eating disorders in athletes
The risk for eating disorders is greater among competitive
athletes than in the general age-matched population (439–441).
Female athletes in competitive sports that emphasize a thin body
or appearance, such as gymnastics, figure skating, and distance
running, are especially at risk, as are female ballet dancers. Male
athletes in sports such as bodybuilding and wrestling are also at
greater risk. Certain antecedent factors such as cultural preoccupation
with thinness, performance anxiety, and athlete self-appraisal may
predispose a female athlete to body dissatisfaction, which may mediate
the development of eating disorder symptoms (442). Parents and coaches
of young athletes may support distorted shape and eating attitudes
in the service of guiding the athlete to be more competitive. Although
competitive college athletes appear to be at greater risk for eating
disorders than nonathlete peers, this has not been demonstrated
among high school athletes (443). Girls as young as age 5 years
who participate in aesthetic sports, such as ballet or figure skating,
have exhibited greater weight concerns than girls who participate
in nonaesthetic sports or who do not participate in sports (444).
Participation in sports may protect some young athletes from developing
eating disorders if, for example, they approach their sports in
a sensible way and derive appropriate pride and self-esteem from
their achievements (443, 445).
Physicians working with adolescent and young adult athletes,
particularly competitive athletes participating in the at-risk sports
mentioned above, must be alert to early symptoms of eating disorders.
Simple screening questions about weight, possible dissatisfaction
with appearance, amenorrhea, and nutritional intake on the day before
a physical evaluation may help identify an athlete who is developing
an eating disorder. Early general medical and psychiatric intervention
is key to prompt recovery from the disorder.
Extreme exercise appears to be a risk factor for developing
anorexia nervosa, especially when combined with dieting (446–448).
A "female athlete triad" has been identified,
consisting of disordered eating (including the full spectrum of
eating-related problems from simple dieting to clinical eating disorders),
amenorrhea, and osteoporosis (449). The exact relation between the
triad and clinical eating disorders is not fully understood, but
athletes with the triad would meet diagnostic criteria for EDNOS.
The prevalence of the triad among collegiate athletes has been studied;
menstrual irregularity has been found in nearly one-third of female
athletes not using oral contraceptives, and athletes participating
in aesthetic sports (e.g., gymnastics) have higher scores on the
26-item Eating Attitudes Test (31, 32) than athletes in endurance
or team sports (450). Similarly, an "overtraining syndrome," described
as a state of exhaustion, depression, and irritability in which
athletes continue to train but their performance diminishes, has
been observed (451, 452). Both the female athlete triad and the
overtraining syndrome parallel the "activity anorexia" syndrome
that has been observed in animal models (453, 454).
+
5. Eating disorders in high school and college students
Eating disorders are common among female high school and college
students. From a primary prevention perspective, health professionals
may be called on to provide information and education about eating
disorders in classrooms, athletic programs, and other extracurricular
venues. However, the efficacy of such educational programs in reducing
eating disorders is still uncertain (455, 456). Health professionals
who serve as trainers, coordinators, and professional supports for
peer counseling efforts conducted at school, in dormitories, and
through other campus institutions may help in early intervention.
Through student health and psychological services, health professionals
may serve as initial screeners and diagnosticians and help manage
the treatment of students with eating disorders of varying levels
of severity (457).
Psychiatrists may be occasionally called on as clinicians
and agents of the school administration to offer guidance in the
management of impaired students with serious eating disorders. In
such situations, the suggested guidelines for levels of care described
in Table 8 should be followed. According to the guidelines, students
must be treatable as outpatients to stay in school. It is advisable
that students be required to take a leave of absence if they are
severely ill (457, 458). Students should be directed to inpatient
hospital care if their weight is considerably below an expected
healthy weight and they meet the other indications for hospitalization
listed in Table 8.
For students with serious eating disorders who remain in school,
it is useful for the psychiatrist and other health care professionals
to work with the school's administration toward developing
policies and programs that make student attendance contingent on
participation in a suitable treatment program. When the psychiatrist
and other health care professionals serve as "dual agents" for
the school and whenever information must be shared among health care
professionals, appropriate consents must be obtained and the requirements
of the Health Insurance Portability and Accountability Act followed.
For severely ill students, the clinical team must include a general
medical clinician who can gauge patients' physical safety
and monitor their weight, vital signs, and laboratory indicators.
For the student to be permitted to continue in school, these clinicians
may require a minimum weight and other physical, behavioral, or
laboratory target measures to ensure basic medical safety. An explicit
policy should be developed specifying that clinicians have the final
say regarding the student's participation in physically
demanding activities (e.g., organized athletics). Restrictions must
be based on actual medical concerns. Procedures should be in compliance
with the school's policies regarding management of students
with psychiatric disabilities and the Americans With Disabilities
Act (458).
+
6. Identification of risk and protective factors
Many efforts have been made to understand how eating disorders
develop. Overall, our understanding of risk and vulnerability still
outweighs our knowledge of protective factors and resilience. Temperamental
factors, eating dysregulation, attachment issues, deficient self-regulation,
childhood abuse in the case of bulimia nervosa, and sociocultural
ideals of health and beauty may all contribute to risk and pathogenesis
(367, 459, 460). High rates of childhood anxiety disorders precede
eating disorders, especially overanxious disorder and OCD for anorexia
nervosa and overanxious disorder and social phobia for bulimia nervosa; this
could be of potential clinical relevance, especially when treating
children and adolescents (341). A history of childhood obsessive-compulsive
traitsnotably perfectionism, rigidity, and rule-bound
behaviormay also be associated with an increased risk
for the development of an eating disorder (461). Richly documented
clinical histories of patients with anorexia nervosa followed over
30 years from infancy to early midlife suggest several potential
risk factors related to early perceived body image distortions,
body regulatory problems, and academic and interpersonal problems
(146).
Because it is well known that the risk of eating disorders
is transmitted in families, it is important to offer particular
help to patients with eating disorders who are themselves mothers.
Attention should be paid to their mothering skills and attachment
styles and to their offspring to minimize the risk of eating disorders
being transmitted (386–388, 462, 463).
In some patients, increasingly compulsive exercise may precipitate
anorexia and bulimia nervosa (447, 464). Female athletes in certain
physical activities such as ballet and gymnastics are especially
vulnerable (465). Unlike habitual runners, ballet dancers exhibit
eating pathology similar to that of individuals with eating disorders
(466). Male bodybuilders are also at risk, although the symptom
picture often differs because bodybuilders may emphasize a wish
to "get bigger" and may also abuse anabolic steroids
to reach their goal (467, 468). This has been called the "Adonis
complex" (469, 470).
Programs have been designed to influence these risk factors
and thus prevent eating disorders. A recent meta-analysis (471)
of prevention programs suggests that programs vary significantly
in their impact, ranging from an absence of any effect to a reduction
in current and future eating pathology. Some effects persist as
long as 2 years and are superior to minimal-intervention
control conditions. Larger effects occur for selected (versus universal), interactive
(versus didactic), and multisession (versus single-session) programs;
programs offered solely to female patients and to participants over
age 15 years; programs without psychoeducational content; and trials
that use validated measures. Several of these programs have resulted
in enhanced knowledge about eating disorders and healthy eating.
A few have resulted in improved attitudes toward size, shape, eating,
and weight, and some have addressed self-esteem and "weightism" and
stressed normal/healthy attitudes and behaviors. Other
approaches have resulted in modest changes in eating- and weight-related behaviors
(472–474), but these changes are not always sustained (455, 456, 475). Because some studies even suggest that certain preventive
efforts actually increase the likelihood that maladaptive eating
behaviors would be attempted, particularly among adolescents (455),
caution is recommended in selecting target populations for such
intervention and proper follow-up is necessary.