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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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Table 1. Self-Help Books and Internet Resources on Eating Disorders  

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Table Reference Number
Table 1. Self-Help Books and Internet Resources on Eating Disorders  
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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).

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Table Reference Number
Table 2. DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa
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Table 3. DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa

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.

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Table Reference Number
Table 4. Representative Instruments for the Assessment of Eating Disorders

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).

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Table Reference Number
Table 5. Physical Complications of Anorexia Nervosa 
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Table 6. Physical Complications of Bulimia Nervosa 

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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Table 7. Laboratory Assessments for Patients With Eating Disorders 
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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.

Table Reference Number
Table 1. Self-Help Books and Internet Resources on Eating Disorders  
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Table 2. DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa
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Table 3. DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa
Table Reference Number
Table 4. Representative Instruments for the Assessment of Eating Disorders
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Table 5. Physical Complications of Anorexia Nervosa 
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Table 6. Physical Complications of Bulimia Nervosa 
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Table 7. Laboratory Assessments for Patients With Eating Disorders 

References

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